New Physician — Jan/Feb 2014
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The ACA, Underway
Avery Hurt

Implementation of the Affordable Care Act goes into high gear, and future physicians should take note of the fine print

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act. The ACA is the most complex and far-reaching legislation since the Civil Rights Act of 1964. Though it can be hard to learn this from the press coverage, there is far more to this legislation than the bug-ridden health insurance marketplace. The ACA is set to completely change how and to whom health care is delivered in the United States. There's a lot to love in there. And for future physicians a few things to be concerned about.

TIME IS NOT ON OUR SIDE

By far the single biggest impact of the ACA will be to bring a flood of new patients into the health care system–an estimated 32 million additional people. We need more doctors. Stat. While this may sound like great news to aspiring doctors, the story is a little more complex.

For the past decade, medical schools, having anticipated this development and, already facing a physician shortage, have been increasing enrollment and turning out more graduates. However, in 1997, the Balanced Budget Act froze funding for graduate medical education, capping the number of residency slots at 1997 levels, a cap that remains in place today. Medical schools can crank out graduates by the truckload, but without a matching increase in GME slots to train them, there will not be a significant increase in the number of practicing physicians.

"We have a very inefficient system for training physicians," says Dr. Marc Kahn, senior associate dean at Tulane University School of Medicine. With four years of undergraduate study, four years of medical school, and at least three years of graduate medical education, it is, at minimum, 11 years before a beginning premed can start practicing, he explains. It doesn't have to be this way, and some of the fixes on the table could work rather quickly. Several medical schools, including Tulane, have already dispensed with the requirement that applicants have a college degree, requiring a demonstration of competency rather than specific courses and degrees, saving time on the premed end.

Time can be saved in medical school as well. The Liaison Committee on Medical Education requires medical school to be 130 weeks long, but not necessarily spread out over four years. Several schools in Canada and the U.S. offer some type of three-year track, and other schools are considering the idea.

These changes can be made relatively quickly at the institutional level. Shortening residencies is a rather more complicated matter. Several of the specialty boards are at least toying with the idea of shorter programs, but there are hurdles. "Getting all the training needed to be competent out in practice is especially hard given the work hours reduction act," explains Mark Richardson, dean of medicine at Oregon Health Sciences University.

Other than creating a few more primary care slots by moving some to primary care from less popular specialties, the ACA does little to address the problem directly. However, by bringing the physician shortage to a crisis point, it may provide the necessary motivation. The idea of shortening medical training by moving from a competency-based rather than a time-based evaluation has been knocked around for years, but to really make significant changes would take a lot of pressure, says Kahn. The ACA may be finally providing that pressure.

MORE PLACES TO TRAIN

Several other provisions in the ACA could affect medical education, and most of these having the biggest impact on primary care. In addition to increasing primary care GME slots, the ACA provides additional funding for scholarships and loan repayment for doctors in underserved areas. It permanently funds Federally Qualified Health Centers and the National Health Service Corps, while increasing funding for both, thus creating more training options for both graduate and undergraduate medical education. The ACA also establishes "teaching health centers" to provide community-based residency training programs for primary care physicians.

While none of these provisions will make a huge difference in medical education generally, it is important to keep in mind that the ACA is a work in progress, and it is clearly putting pressure on the health care system to educate and train more physicians–and do it quickly. Stay tuned.

CRYSTAL BALL

The big question on everyone's mind–especially future doctors– is "how will the ACA affect the outlook for the practice of medicine in the years to come?" To truly answer this question would probably require a crystal ball, but there are a few clues in the legislation as it now stands.

Primary care providers will finally get more respect and a bigger share of the profits. They will receive a 10 percent Medicare bonus and Medicaid rates for primary care will be increased to match Medicare rates. General surgeons who practice in rural areas will also qualify for the 10 percent Medicare bonus. By ensuring that people can get preventive care free or with no co-pay or deductible, primary care doctors will be able to catch more illnesses before they get serious, and when necessary refer patients to specialists sooner and in better shape, making everyone's job easier.

Provisions in the law encourage the implementation of electronic medical records, provide grants to states to be used to develop alternatives to court litigation, and require insurers to make changes that will standardize medical billing and simplify coding systems, all of which should, eventually, make the business side of medicine less of a headache.

These changes are small pieces in a very big, messy puzzle, but it just might be that when it comes to the ACA, the whole is greater than the sum of the parts. "Any time you have a major piece of legislation–it was this way with Medicare and civil rights–you can expect it to need tinkering," says Dr. Reid Blackwelder, current president of the American Academy of Family Physicians. The ACA will not in one great sweep fix the many problems of our health care system, but it is a giant step in that direction. "People go into the healing profession because they want to help people. We owe it to our students to allow them to make decisions based on something besides money," Blackwelder says. The ACA will make it less risky financially for students to choose primary care, but should also open more options in other fields. "As the ACA opens the doors of clinics and hospitals to almost everyone, many of whom have been putting off getting necessary health care– knee replacements, diabetes care, cardiac interventions–there will be more need for all kinds of doctors. I tell students not to let circumstances dictate what they do. Follow your passions; do what you love."

"It won't happen overnight," says Richardson, "but the ACA is a great opportunity to transform our system. In the long run, if we stick with it, we can make health care delivery and the practice of medicine much better."

Avery Hurt is a writer based in Birmingham, Alabama.

ACA Timeline

Though we've been hearing more about it since the exchanges opened in October, the changes mandated by this historic legislation have been implemented gradually since the legislation was first signed into law. Here is a timeline highlighting some of the provisions already in place and what is on the way.

2010

•Authorizes funding for scholarships and loan repayments for health care providers in underserved areas

•Increases payments for rural care practitioners

•Allows adults to stay on their parents' plans until they are 26 years old

•Requires all new plans to provide certain types of preventive care with no co-pay or deductible

•Permanently authorizes the federally qualified health centers (FQHCs) and National Health Service Corps (NHSC) programs and increases funding for FQHCs and the NHSC for fiscal years 2010-2015

2011

•Creates the Center for Medicare and Medicaid Innovation to test new payment and delivery system models

•Preventive care becomes free under Medicare

•Authorizes $50 million for five-year demonstration grants to states to help develop alternatives to current tort litigation

•Establishes teaching health centers and provides payments for primary care residency programs in community-based ambulatory patient care centers. On January 25, 2011, HHS announced the designation of 11 new teaching health centers

•Redistributes currently unused GME slots to provide more primary care slots. Promotes training in outpatient settings

•Provides a 10 percent Medicare bonus payment for primary care services, and a 10 percent Medicare bonus payment to general surgeons practicing in underserved communities, such as in rural areas

•Provides no-cost preventive care, such as annual wellness visits and personalized prevention plans for Medicare patients

2012

•Implements changes that will standardize medical billing

•Requires health plans to adopt and implement rules for the secure exchange of electronic information

•Imposes new annual fees on the pharmaceutical manufacturing Sector

2013

•Increases Medicaid reimbursement to Medicare rates for primary care services.

•Provides new funding to state Medicaid programs that choose to cover preventive services for patients at little or no cost

•Increases Medicaid payments for primary care services provided by primary care doctors to 100 percent of the Medicare payment rate for 2013 and 2014, financed with 100 percent federal funding

2014

•Doctors with small private practices will be able to join with other small businesses to purchase health insurance for their employees in the health insurance marketplaces

•Prohibits insurers from discriminating due to pre-existing conditions in adults

•Requires U.S. citizens and legal residents to have qualifying health coverage, including a phased-in tax penalty for those without coverage, with certain exemptions

•Creates an essential health benefits package that provides a comprehensive set of services. Creates four categories of plans to be offered through the exchanges, and in the individual and small group markets, varying based on the proportion of plan benefits they cover.

For more detailed timelines, check out these sites:

• www.healthcare.gov/timeline-of-the-health-care-law

• kff.org/interactive/implementation-timeline
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