The real story of the Affordable Care Act (ACA) today is implementation—a quiet, less dramatic process, when compared to the fractious public debate of the last year. As 44 of the law’s 47 provisions, slated for 2010 to the end of 2011, are being put into operation, health care professionals at the policy level are struggling to build the complex infrastructure needed to support the law. In year one of implementation, the ACA has already begun to reshape the health care system, creating new prospects and unforeseen challenges for health care workers.
“It’s fascinating to see how the states are grappling with the changes that have to be completed now,” says Michael Gusmano, Ph.D., a Robert Wood Johnson Foundation (RWJF) Scholar in Health Policy Research (1995 - 1997) and a research scholar at the Hastings Center.
“We should take great pride in the amount of effort put in by people in civil service to make this law work in a very difficult environment,” says Frank Thompson, Ph.D., a 2007 winner of a RWJF Investigator Award in Health Policy Research.
That said, daily working life in most clinics, hospitals and physician’s offices has remained the same, but that will change in coming months. As the early provisions of the law take effect and we move toward 2012, “we will be seeing a shift in how doctors and hospitals do business,” says Lawrence Casalino, M.D., Ph.D., chief of the Division of Outcomes and Effectiveness Research in the Department of Public Health at Weill Cornell Medical College. “It may be hard for some, but many leaders in health care organizations see the challenges posed by the ACA as an opportunity to do good things for their patients.”
“I would say in the near term, things are going pretty well,” says David Cutler, Ph.D., a professor at Harvard University and expert on the economics of health care who has advised RWJF Scholars in Health Policy Research. “Young people are covered. The medical loss-ratio rules for insurance companies have gone into effect. None of this without hiccups, of course, but things are going fairly well.”
ACA At-a-Glance: The Workforce
The ACA is advancing, but as it rolls out, it is still difficult to sort through the many provisions affecting patients, insurance companies, hospitals and providers to determine what will have the most impact on health care workers.
Much of the current ACA activity focuses on the Centers for Medicare and Medicaid Services (CMS). “People at CMS have sustained the momentum to try to move things forward,” says Thompson, who is also a professor at Rutgers University. A 10 percent bonus payment plan for physicians serving Medicare patients with certain conditions and general surgeons has gone into effect, along with a rule reimbursing certified nurse-midwives at the same level as physicians. The new Center for Medicare and Medicaid Innovation has initiated stakeholder meetings and other activities as first steps toward its stated goal: to reform CMS’s payment structure in ways that will improve quality, while cutting costs.
At the same time, there are growing concerns about “current state efforts to cut Medicaid budgets and the viability of relying so heavily on Medicaid as the basis for insurance expansion,” Gusmano adds. “Even with generous federal matching rates, state willingness to sustain these expansions is uncertain and the implications for other state spending priorities are unclear.”
Because states can no longer cut Medicaid enrollment, “some have cut service packages, affecting dental care and even organ transplants,” says Thompson. “In addition, more than 30 states have cut some form of provider payment.”
The other highly active sector is community health. More than $900 million has been given to selected community health centers nationwide to expand the services they provide (part of $11 billion to be allocated over five years). And as of January, the Department of Health and Human Services (HHS) has created 11 new teaching health centers to support five-year graduate education programs to train a larger number of primary care physicians and dentists working in community settings. This, along with the $250 million from the Prevention and Public Health Fund slated to improve the supply of primary care providers, has begun and will continue to generate new job opportunities for community-focused physicians, nurses and frontline health care workers.
“To date, approximately 19 million people receive care at community health centers. It is predicted that by 2019, 50 million people—many of them with low incomes—will be served by these centers,” Thompson notes.
The ACA provision of greatest interest and concern to many medical professionals has yet to take effect: Accountable Care Organizations (ACOs). Under the ACA, consortiums of physicians and hospitals will have the option of contracting with Medicare to create ACOs. These organizations would provide care for Medicare beneficiaries in a new model that would link payment to quality measurements and reductions in the cost of care. Though it will not be implemented until 2012, “discussions are already going on among many public health experts about how to form ACOs,” Gusmano says.
“I think you will see implementation of many aspects of ACOs before the law takes full effect,” says Alan Garber, M.D., Ph.D., winner of a 2003 RWJF Investigator Award in Health Policy Research and professor of Medicine at Stanford University. “Some organizations are out in front. Many academic medical centers are looking to become ACOs or ACO-like entities. Organizations like the Cleveland Clinic, Intermountain Health Care, the Geisinger Clinic and of course Kaiser Permanente, which was way ahead of the curve, are models of how this might work.”
No one is sure how these shifts, along with new financial, tax and reimbursement rules for nonprofit hospitals, will alter the employment landscape for safety-net hospital workers. “The fear, for safety net hospitals, is what will happen if states become reluctant to support charity care for the estimated 23 million individuals who will likely remain uninsured after ACA is enacted,” says Gloria Bazzoli, Ph.D., a professor at Virginia Commonwealth University and 1999 winner of an RWJF Investigator Award in Health Policy Research.
The Road Ahead
Yet, for all of the uncertainty surrounding the ACA, certain themes are emerging for health care providers—collaboration, flexibility and patience. “There’s going to be a much greater emphasis on teamwork going forward with the ACA,” Garber says. “Accountable Care Organizations, for instance, are structured so that there are incentives for doctors and nurses to work together in a more integrated way.”
“For physicians, nurses and other health care workers, learning to work in a more integrated environment, across institutions, will take time,” Cutler says. “But there’s no doubt the demand for primary care providers will skyrocket.”
“The first, and most important piece of this is to get costs down without compromising quality,” Garber explains. “So I think there are going to be very strong pressures for nurses and other health care workers to take over some of the work physicians have been doing to help achieve this. Then there are the issues related to bundling payments.”
“ACOs will place hospitals, specialists and primary care organizations in one boat and reimbursements will have to be divided,” explains Casalino, who is also a 1999 winner of a RWJF Investigator Award in Health Policy Research. “Someone may have to give up some revenue. High-performing ACOs would be rewarded, ideally, but it remains to be seen whether the rewards will be sufficient to engage physicians and hospitals.”
“Some physicians are excited about these new opportunities, but there are others who do not trust the system—most still understand very little about the ACO concept,” Casalino says. “For nurses and other non-physician health care workers, there will be more demand for their services and more interesting work for them to do. They will have new opportunities to become more involved in patient care and the coordination of care.”
“Of course, the hardest issues are still to come,” Cutler says. “There are serious questions: Can we get providers to practice in a more cost-effective manner? What limitations will we see in insurance exchanges? Some folks will be happy, others less so. But I think the changes will be beneficial.”
“Even if the mandate is lost,” Thompson adds, “I think the Medicaid provisions and funding for community health centers will remain.”