Throughout the 2016 presidential campaign and much of the second term of the Obama administration, the Republican stance on the Affordable Care Act (ACA) was “repeal and replace”. After the surprise upset victory by Donald Trump, Republicans are seemingly now the dog that caught the car. Which leaves Americans, and potentially more importantly, physicians wondering what happens next.
Without a specific policy proposal in place, you may think it’s difficult to determine how potential, abstract changes could affect your practice. However, on President Trump’s first day in office, he signed an executive order directing federal agencies to “ease the burden” of the ACA. The IRS took notice and quietly removed the mandatory requirement of healthcare coverage in 1040 filings. This effectively eliminated the individual mandate.
Chris Pittman, M.D., medical director and founder of Vein911 in Tampa, is triple board-certified in Venous and Lymphatic Medicine, Vascular and Interventional Radiology, and Diagnostic Radiology with more than 20 years of experience as a non-surgical vein treatment specialist. He is also past president of the Hillsborough County Medical Association, Immediate Past President of the Florida Medical Association Political Action Committee (FMA PAC), and a Board Manager for the Tampa Bay Integrated Healthcare Network (TBIH), a clinically integrated, fee-for-value network partnered with Florida Blue and Cigna.
Dr. Pittman has advocated for patients and physicians for nearly 30 years at the local, state and national levels and delivered state and national presentations on healthcare policy for physicians and policymakers.
If anyone locally can predict the future in an uncertain and constantly changing healthcare environment, he’s the one to ask.
Dr. Pittman is clear that although there is a new captain at the helm, the ship will remain heading the direction it was already going: away from the fee-for-service payment model and toward a fee-for-value payment model.
“Trumpcare” will have little to no impact on how physicians are paid
“Changes to Obamacare or “Trumpcare” won’t change anything for my practice, and, frankly, probably not for many physicians,” Dr. Pittman says. “A repeal of the ACA won’t materially affect most physicians because the way physicians are paid is now codified in the bipartisan, 2015 MACRA law.”
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the sustainable growth rate (SGR) methodology for determining updates to the Medicare physician fee schedule. This law shifts the paradigm from the traditional fee-for-service model to a fee-for-value model.
MACRA changes to Medicare payments took effect on January 1, 2017, allowing physicians to choose from two quality metrics: the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). Medicare payments based on these quality metrics will not be received until 2019.
Some have alleged that we have a medical (that is, sick) care system—a system that waits until we become ill before it kicks into action—instead of a health care system focused on helping us stay healthy.
“The way we’re paid right now is sick care. We wait for someone to get sick and fix them. Under fee-for-value, we’re going to be paid based on the value we provide our patients,” says Dr. Pittman.
Potential changes to come
Dr. Pittman shared a memo from the Florida Medical Association (FMA) Director of Health Policy and Innovation, Jarrod Fowler, indicating that the prospect of substantially reshaping the federal health care system for the second time in recent history will also offer unprecedented opportunities to advance changes that benefit Florida’s patients and caregivers.
In the memo, it is noted that there is also currently no consensus on the future of Medicaid expansion, which is a crucial component of ACA’s major coverage provisions.
Florida chose not to expand Medicaid, but according to the Kaiser Family Foundation, the uninsured rate in Florida has dropped from around 19% in 2013 to around 13% in 2015.
Whether states like Florida that have yet to expand Medicaid eligibility will continue to have that option available, and whether the current eligibility standards and enhanced matching rate for this population will remain the same are two important questions that need to be decided upon. Given that a number of red states have signed onto expanding Medicaid eligibility, including Vice President Mike Pence’s home state of Indiana, enacting a proposal that would substantially reduce the funding for the newly eligible Medicaid population may prove politically challenging.
On specific policy ideas, Dr. Pittman offers an important take. At face value, the idea of selling health insurance policies across state lines seems like a good idea, but as Dr. Pittman notes, in politics, what seems like a good idea is often a bad idea.
“Selling health insurance across state lines is not a good idea because right now, insurance regulation is a state rights issue. FMA fought really hard and won against egregious practices by health insurance companies, but if we allow selling of policies across state lines, all the political gains against health insurance companies will probably go out the door,” says Dr. Pittman.
At the heart of the health care delivery issue is diversity. A state like Florida is similar in size to many countries. With 20 million people from diverse backgrounds, solutions that fit Floridians may not fit all states. And vice versa, health care solutions that work in Utah may not be ideal in New York.
MACRA is key
Despite all of the theoretical changes, Dr. Pittman notes the key for physicians right now is to pay very close attention to MACRA, specifically, the fee-for-value model of payment.
This is a silver lining in a shifting payment environment. The fee-for-value concept provides a pathway for physicians to do what’s best for patients, lower health care costs, and maintain our integrity as doctors.
“Commercial payers typically follow whatever Medicare does, and right now, they are like ducks on water quickly putting fee-for-value networks together,” says Dr. Pittman. “Local clinically integrated networks like Tampa Bay Integrated Healthcare Network (TBIH) have contracts with these large commercial payers and it’s important to join a network like this.”
Dr. Pittman equates the future for independent physician as similar to a game of musical chairs. Payers are building networks and physicians are choosing whether or not to join.
“It’s my prediction that in 3-5 years, the music may stop and some doctors will have no patients to care for if they don’t start engaging commercial payer fee-for-value networks.”
While this prediction may seem grim, Dr. Pittman is quick to point out the importance of getting onboard.
“MACRA and fee-for-value payment models are the cards we’ve been dealt. We need to understand how to play, or we will not be in a good position in 3-5 years.”