Despite being upheld by the Supreme Court, the Affordable Care Act remains a subject of debate heading into next month’s presidential election. Meanwhile, government affairs experts are working to determine just how the ACA will affect lower extremity practitioners.
By Shalmali Pal
The US Supreme Court may have greenlighted the Affordable Care Act (ACA), but practitioners’ winding road trip through healthcare reform isn’t over yet: While implementation of the ACA ramps up, Republicans continue to threaten a fight for its repeal. And their party’s presidential hopeful, Mitt Romney, has selected a running mate with his own Medicare overhaul plan.
Politics notwithstanding, lower extremity specialists are not waiting for the polls to close on November 16 to make the ACA a reality. Lower Extremity Review checked in with representatives of different specialties to discuss how the some of the major ACA provisions will impact their members.
An essential service
The ACA mandates that the Department of Health and Human Services (HHS) delineate “essential health benefits.” In turn, HHS passed that task on to the states, which must have these lists together by January 2014. The essential benefits must fall under the 10 general categories laid out by the ACA, including ambulatory patient services, preventive and wellness services, and chronic disease management.
One of the main issues that all lower extremity specialty groups are still sorting out is whether the care they provide is considered an essential health benefit under the ACA.
Podiatric medicine, for example, was considered an essential benefit under the original version of the ACA that went to the House of Representatives, but was taken off the bill in the version signed by President Barack Obama, explained Scott Haag, JD, MSPH, director of the Center for Professional Advocacy & Health Policy & Practice at the American Podiatric Medical Association (APMA) in Bethesda, MD. This could be particularly problematic in states where officials elect to expand Medicaid to qualify for federal funding under the ACA.
“Under a Medicaid expansion, there’s some lowering of the criteria for people to receive insurance,” Haag explained. “That population could represent a large number of people who are at risk for obesity or diabetes…and have a very critical need for foot and ankle care provided by a podiatrist. There’s a great opportunity to treat these conditions and address them before the complications set in.
“It was a bit shortsighted not to include podiatrists under Title XIX to begin with,” he added, referring to the original provision of the Social Security Act that requires states to establish public health insurance programs.
While many states have opted to include podiatric foot and ankle care in their programs, the APMA is pushing for recognition on a federal level.
“It’s one of the APMA’s highest legislative priorities,” Haag said. “We’re currently developing materials for state representatives to present to the state leadership that educates them about the role of podiatric foot and ankle care.”
On the other hand, said Peter Rosenstein, executive director of the American Academy of Orthotists and Prosthetists (AAOP), orthotics and prosthetics specialists may be on slightly more solid ground.
One of the 10 ACA categories is rehabilitative and habilitative services, Rosenstein explained.
“It’s generally assumed that O&P will fall under that [category], but it has not been defined,” he said. “Currently, each state will define that on its own but that may change after the election.”
The AAOP isn’t waiting to take action: They are one of five organizations that have formed the O&P Alliance, designed to educate legislators about the importance of covering O&P services, with an emphasis on cost savings.
“One of the things that we really want to drive home to legislators is that if you give an individual appropriate O&P care, then it results in a better quality of life: They can continue to work, they continue to be tax-paying citizens, they can support themselves and their families. If you say, ‘That prosthetic is not covered,’ then that person potentially becomes a burden on the system,” Rosenstein said.
Physical therapists are in a similar situation; although they are not currently listed as an essential health benefit, they do come under the broader umbrella of rehabilitative and habilitative services. In a January 2012 letter to HHS Secretary Kathleen Sebelius, the American Physical Therapy Association (APTA) highlighted why physical therapy deserves consideration as an essential healthcare field.
A key point the APTA wants to make is that patient care doesn’t always stop once the acute condition has been treated.
“The option of continuing physical therapy in certain situations—such as an individual’s fragile health state becoming stabilized through rehabilitative services—becomes an essential health service so that an individual’s health does not continue to deteriorate,” the letter stated.
To that end, the physical therapy community is taking steps in the direction of being long-term health wellness providers, said Justin Moore, vice president of public policy, practice and professional affairs for the APTA.
“[PT is] seeing a trend nationally where once the medically oriented PT is over, how do you help an individual maintain optimal health? A lot of practices are collaborating with other allied health professionals, hospitals, gyms, yoga studios, and Pilates studios, to really embrace the continuum of care versus just a single episode of care,” he said.
Preventive care and patient access
The ACA places a premium on preventive care services that should theoretically give more patients a wider berth to seek a variety of healthcare services. But is every lower extremity specialist qualified to provide preventive care?
Yes, though in some cases it will require a change in the way these specialists approach their practice.
In physical therapy, there needs to be an emphasis on population health, looking at fitness, wellness, and disease prevention.
“That’s going to challenge the profession,” Moore said. “[PT] tends to be based in more one-on-one, clinically directed care.”
An example of this type of care would be a fall prevention program for people who haven’t sustained an acute injury, but who experience problems with range of motion and balance.
“PT-based intervention with fall prevention programs could be a cost-effective solution to stop the secondary injuries related to those falls,” Moore said.
For podiatry, preventive care means continuing the services they already provide.
Haag pointed to a 2010 study by Thomson Reuters showing that even a single visit to a podiatrist for a diabetic patient being treated for foot ulcers could reduce the risk of amputation by about one third. In addition, if an at-risk diabetes patient saw a podiatrist, it could save the healthcare system close to $4 billion annually, according to the study, which was presented at the 2012 APMA annual meeting held in Washington DC.
For orthopedic surgeons, the emphasis on preventive care won’t necessarily change the current referral structure, but it will give patients a broader range of treatment options rather than having them constrained by their insurance payer’s policies or their own financial resources.
“We’re looking at patients who may not have been able to get insurance before because of preexisting conditions who will now be covered,” said Peter Mandell, MD, chair of the council on advocacy for the American Academy of Orthopedic Surgeons (AAOS).
The ability to keep patients active and healthy is one of the great rewards of the specialty, Mandell added.
“We can help restore motion to patients and get people back to doing what they love to do, whether it be playing with their grandchildren, being able to run their next marathon, or even return to active duty,” he said.
In addition to getting the right patients to the right care provider, the ACA is also designed to reduce ballooning healthcare costs. But implementing the reform act will cost money upfront, though exact dollar amounts have varied wildly, up to as much as $3 trillion dollars over a decade. A report from the Congressional Budget Office puts the cost at $930 billion over 10 years, leading to an ultimate reduction in the federal deficit of $210 billion.
The ACA also calls for “administrative simplification standards” to reduce paperwork and administrative costs for providers. The experts who spoke to LER agreed that simply covering more people will come with a price tag, but how much that will be, no one knows at this point.
Rosenstein said he is taking an optimistic view.
“The most efficient insurer in the country right now is Medicare,” he said. “The government’s administrative costs for the amount of people insured are much less than private industry costs.”
Haag is more cautious, however, citing the Therapeutic Shoe Bill as example of how a plan to achieve efficiency can backfire.
“The Therapeutic Shoe Bill was implemented with good intentions, but it’s one of the biggest obstacles that our members are dealing with right now in terms of the certification and documentation requirements,” he said. “That program was designed to get Medicare beneficiaries with diabetes the care that they need so that they don’t develop ulcers and possibly face amputation down the line. But the number of denied claims, prepayment claims, and audits out there has prompted a number of podiatrists to say they just can’t participate in the program, as much as they want to help their patients. That was in place long before the ACA but it’s an example of how these programs, which are well intentioned, sometimes play out.”
Moore predicted “growing pains” while front-end changes of the ACA are put in place, but he anticipates that providers will see improvements, especially once electronic healthcare records (EHR) become the norm.
“Right now, they still have a lot of documentation requirements and a lot of regulatory hoops to jump through. EHRs could really help providers be more compliant and reduce those burdens,” he said.
The payment process
When it comes to the proposed payment and reimbursement plans under the ACA, the experts were mostly critical.
First, there is the Independent Payment Advisory Board (IPAB), which has a laudable goal: The 15-member executive branch agency is charged with achieving Medicare savings without adversely affecting coverage or quality.
Currently, the Medicare Payment Advisory Commission (MedPAC), an independent agency established by the Balanced Budget Act of 1997, advises Congress on issues affecting the Medicare program. But MedPAC recommendations require an act of Congress to take effect; IPAB will be granted more authority to make changes to Medicare without congressional approval, though Congress will have the option to overrule an IPAB decision through a supermajority vote.
A major potential problem with this board is that it will be composed of appointees who are not required to have any medical background, nor is the board required to seek input from practitioners.
“Right now, we have the Relative Value Update Committee and it isn’t perfect, but…at least [the podiatric community] has some say in the process,” said Haag, referring to the American Medical Association (AMA) expert panel that makes reimbursement recommendations to the Centers for Medicare and Medicaid Services (CMS). In addition to AMA members, the committee consists of representatives from other specialty groups.
“[APMA] is afraid that with a body like IPAB, we’ll lose that voice,” Haag added.
Mandell echoed the concern, pointing out that physicians who do serve on IPAB are not allowed to be practicing actively, calling into question the committee’s ability to make the right choices for real-world orthopedic surgeons.
“[IPAB] represents a fast-track method for doing short-term cuts without addressing any real, long-term approach for increasing value in the healthcare system,” he added.
For now, the new IPAB will operate alongside Medicare’s old system of the sustainable growth rate (SGR) formula, which has resulted in a constant concern for healthcare: Medicare reimbursement cuts. And where the government goes, private payers generally follow.
“In the absence of a permanent solution to the SGR, we think we are looking at a minimum of 40% cuts over the next decade to the physician fee schedule,” Mandell explained. “IPAB cuts don’t take those [SGR] cuts into account and would be added on top of the [SGR-based] cuts. All of that would pretty much spell the end of small group and solo practices.”
Another potential problem is the concept of bundling. Instead of paying healthcare providers for each service provided, a bundled payment would be a single fixed compensation for a patient’s stay and any follow-up care. This flat payment would cover all treatments and expenses.
Bundling is intended to motivate providers to reduce cost and volume of services, but is not a guaranteed cost saving mechanism, Rosenstein pointed out.
“Let’s say someone undergoes an amputation. There’s a certain amount that the hospital charges for the amputation and that money is going to be split between the hospital or surgical center, the prosthetist, PT, the rehabilitation center, everyone involved in that patient’s care,” he said. “But there’s no cap on that fee in the ACA so there’s no guarantee that money will be saved.”
However, it’s not all dire news on the payment front. While he did call IPAB a “potentially negative centralization of power on payment policy,” Moore added that the proposed plan of pay-for-performance to replace the current fee-for-service structure is not a bad one. In fact, the APTA has already proposed a new payment system for physical therapy services that would focus on physical therapy rather than the sum of the interventions.
“This [payment] system would classify patients based on the severity of their condition and the intensity of PT needed to address that condition. [PT] would aggregate that at the per-session level,” Moore explained.
Moore said the proposed payment scheme has been sent to APTA members for feedback and that the association hopes to make a formal proposal in the next year.
“Then it will probably take two to three years to implement it with commercial payers and Medicare,” he said.
More patients, more providers
It’s estimated that by 2015, 30 million more Americans will join the ranks of those with some kind of health insurance, according to the Association of American Medical Colleges (AAMC). By that same year, however, AAMC predicts a shortfall of nearly 63,000 physicians. A focus of the ACA has been boosting the ever-dwindling numbers of primary care physicians, but a potential manpower shortage was mentioned as a key concern by almost all the experts with whom LER spoke.
“Orthopedic surgery is going to need to be included in that mix if we are going to meet the demands of a growing burden of disease,” Mandell pointed out.
The AAOS estimates that about 90 million individuals report musculoskeletal disease as a primary health concern and that over the next two decades the demand for total knee replacements will increase by more than 650%.
“By the year 2035, the number of people over age 65 is going to double and the number of people over 85 will be the most rapidly expanding segment of society. All of that suggests that there will be a greater demand for musculoskeletal treatment. To do that, we are going to have to ramp up our orthopedic surgery residency programs,” Mandell said.
Physical therapists have similar concerns, Moore said.
“If payment for our services is issue number one, maintaining an adequate workforce is issue number one A,” he said. “It’s really going to tax physical therapists who already have a workforce issue.”
The physical therapy community must grapple with some weighty questions: As they take on new roles in preventive care and wellness, will they give up old roles? How can they become more efficient with limited resources?
One answer to that question is that physical therapists will have to change how they practice along with who they practice with, Moore said.
“I think there is going to be more pressure to see patients less and develop more patient empowerment between PT visits,” he said.
In O&P, the 2010 requirement of a master’s degree for entry into the profession has led to greater interest in the field and more applicants to O&P programs, according to Rosenstein. People who once considered O&P a trade are now looking at it as a profession, especially if they are interested in working with computer-aided design and sophisticated fabrication technology, he added.
But the growing number of patients with obesity and diabetes who may require O&P services will prove challenging.
“We are now seeing 12-year-olds getting new-onset diabetes,” Rosenstein said. “If a child has to live with diabetes his whole life, chances are that we are going to see more complications from diabetes.”
Shalmali Pal is a freelance writer based in Tucson, AZ.