The Patient Protection and Affordable Care Act (ACA) and the Health Care and Education Reconciliation Act (Reconciliation Act), collectively referred to as “healthcare reform,” will implement numerous changes impacting physician providers.  Several of these provisions affect primary care physicians and specialists separately, while other provisions will impact all physician providers with an increased focus on the coordination of patient care.¹

Provisions Affecting All Physician Providers

One of the primary goals of healthcare reform is to improve quality of care and increase patient access to care while controlling healthcare costs.  In order to achieve these goals, the reform legislation has laid out several initiatives, for example: ten percent Medicare bonus payments to primary care physicians as well as general surgeons working in rural areas from 2011 to 2016; implementation of a relative value based modifier to enable physician payments based on quality metrics; and, various expanded regulatory compliance and disclosure requirements.²

Over the next ten years, $250 million has been dedicated by the ACA to fund the expansion of fraud and abuse compliance.  Beyond government “policing,” the ACA requires physicians to actively identify possible Stark Law violations through the Health and Human Services (HHS) designed self-disclosure protocol. Under this provision, physicians who voluntarily disclose potential Stark violations may receive reduced penalties if violations are in fact found.³ Additionally, disclosure under the Physician Payments Sunshine Act, passed within the ACA, requires companies (e.g., pharmaceutical and medical device firms) to record any physician payment over $10 in 2012 and begin reporting these amounts on March 31, 2013.⁴

Beginning in 2011, CMS will launch the “Physician Compare” website, which is designed to disseminate provider quality measures reported through the Physician Quality Reporting Initiative (PQRI).⁵ From 2011 to 2014, participation in the PQRI will be voluntary and CMS will provide Medicare incentive payments (one percent in 2011 and 0.5 percent from 2012-2014) for providers who participate in the program. However, beginning in 2015, failure to participate in the PQRI will result in a 1.5 percent reduction in Medicare payments.⁶

In order to increase quality and lower costs, healthcare reform encourages the coordination of patient care.  Many provisions of the ACA hope to achieve this integration between providers by changing the way in which physician practices are structured. Beginning in 2011 and beyond, the ACA provides for the implementation of various demonstration projects and new delivery models to test the effectiveness of various reform initiatives, including Accountable Care Organizations (ACOs) and bundled payment structures.⁷ For more information on ACOs and bundled payment, see Health Capital Topics Vol. 3, Issue 8: Emerging Healthcare Organizations: Accountable Care Organizations, and Health Capital Topics Vol. 3, Issue 10: Emerging Healthcare Organizations: Bundled Payments. If these small scale endeavors prove successful, the law provides for the extension and expansion of the programs on a national scale.⁸  Industry experts are urging physicians and small group practices to align themselves with other healthcare enterprises now in order to best position themselves to take advantage of the benefits offered by the Medicare Shared Saving Program, which are scheduled to take effect in 2012.⁹

Provisions Affecting Primary Care Physician Providers

Healthcare reform is also addressing the looming shortage of primary care providers. To encourage more medical students to concentrate on primary care, healthcare reform provides for expanded funding for scholarships and loan repayments for primary care providers working in underserved areas beginning in 2011. To supplement workforce shortages, reform initiatives will also expand primary care and nurse training programs, such as the Medicare Graduate Medical Education Program, beginning in July 2011.¹⁰ Primary care providers (pediatricians, family physicians, and internists) will also receive increased Medicaid payments starting in 2013, gradually increasing to Medicare payments levels by 2014.¹¹

Another focus of the ACA is ensuring patient access to preventive care services.  As such, several provisions require insurance providers to expand coverage to include these types of services. In addition, no payments or deductibles will be required under Medicare for annual wellness visits or for the development of personalized prevention plans. These incentives may influence primary care providers to change the focus of their practices and the scope of services offered.¹²

Provisions Affecting Specialty Physician Providers

Specialty physician providers may experience increased regulatory limitations on their practice under healthcare reform. In addition to increased Stark disclosures, physicians are required under the ACA to inform all patients at the time of referral, in writing, of any alternative imaging providers (to be listed for the patient), other than the one suggested by the referring physician.¹³

Conclusion

Overall, changes to the US healthcare delivery system under the reform initiatives are intended to improve the quality of care delivered to patients, as well as to reign in healthcare costs and increase patient access. Many physicians are critical of healthcare reform for failing to address issues regarding: the Medicare Sustainable Growth Rate (SGR); increases in the cost of pharmaceuticals production; and, changes to the Medicare benefit structure for patients.¹⁴  While time will tell who the ultimate winners and losers will be, amid the looming uncertainty of reform, one thing remains clear – healthcare reform must be viewed as a process rather than as a single event. This series will continue to explore this process in the next issue with a discussion regarding the impact of healthcare reform on employers.