Recent surveys about physicians leaving practice or going out of business in droves were done in the heat of the moment of the Supreme Court ruling. Nonetheless, they signify a long-term concern, uncertainty, and fear, and there is good reason for all three.
Everyone in the practice and allied health world should take the title of the legislation seriously — The Patient Protection and Affordable Care Act (ACA). It does not say physician protection nor does it say it will be affordable for you. Most practices will suffer serious consequences, or fail without proper planning.
The safest course of action is to presume the ACA will continue either in whole or in part. Any replacement is a blank page, and either way, physicians will be negatively affected. The reality is that spending $2.9 trillion annually and compounding the cost each year for the present system is unsustainable. The argument is not if, but how, so, the battle is far from over. Further, there are major variables aside from the presidential election. While the Supreme Court upheld the federal government’s case, it also upheld, and shored up, states' rights, setting the stage for another round in the courts for both.
The crux of the problem is money. While the federal government will pay 100 percent of increased costs for Medicaid to states for two years and 90 percent thereafter, the states have to bear the entire cost of administering the expanded program. New York state is the first to estimate what it will cost — about a trillion dollars over the next 10 years. Florida has about the same population; Texas and California are larger. Only Texas is in good fiscal condition, and intends to stay that way. Florida and most other states are struggling or on the brink financially, and are either saying they will not implement Medicaid changes or insurance exchanges. That does not mean that they and their citizens will be exempt from complying with the rest of ACA, it means that the issues are far from settled and most of us will continue to live and work in uncertainty.
Here are five things you must do to protect your practice:
1. Get involved. If it seems that the ACA was conceived, drafted, and passed into law without the input of those who actually practice medicine, you would be correct. The Supreme Court has given physicians a second chance to be heard for the first time. States have a choice to take federal money and conditions, or to institute their own Medicaid reforms without being penalized or coerced. Governors of both parties in 11 states are giving opting out serious consideration, eight have announced they will not participate, and the rest are waiting until after the election. All will need the support of their legislative bodies. Join your local or county medical association chapter and insist they convene a committee to be heard in both the federal and state executive and legislative branches. Better yet, step up and speak up.
2. If you are a primary-care physician, take care in becoming dependent on Medicaid even though they will be paying Medicare rates. Your state may not participate or discontinue it in the likely event that it is unaffordable. Further, the program is for two years, or as long as the money lasts, which may not be long. If you fill your practice with Medicaid patients, you own them regardless of what happens to reimbursement. This is a harsh choice, but, if your practice fails, everyone loses. The ACA dumps this on your lap, and they need to fix it.
3. If you are not a primary-care physician, act now to develop and implement strategies to manage your payer mix. You have to see two privately insured patients to make up for the loss and just one surgery or procedure can increase the privately insured proportion substantially. PCP reasons apply.
4. Improve your quality of service. Less than half of people with health insurance are privately insured and competition for them will become increasingly intense.
5. Cut every ounce of fat in your operation and invest the savings in quality, image and marketing to keep and add as many privately insured patients as possible. Most are paying office visits out of pocket, and they expect much better service.
Next time, I'll address the physician shortage and how you can come out a winner.
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