Ask your average interventional radiologist (IR) how the Affordable Care Act (ACA) is likely to affect his or her pocketbook, and the near-universal response at this point is likely to be a look of befuddlement mixed with anxiety. The truth is, no one really knows what the end result of the sweeping changes to healthcare delivery will be.
We do know that total healthcare spending is not likely to keep pace with the number of insured patients seeking care. We also know that Medicare and third-party payers are intent on cutting costs. Finally, we know that interventionalists must become highly aware of the new healthcare changes, and they must take steps to help mitigate potential financial pitfalls in their practice. Consequently, every IR should be asking four specific questions:
Let’s look at each question and what you should know to answer them for yourself.
ACA enrollment is facilitated through the federal and state insurance marketplaces known as healthcare exchanges. The ranks of the insured are also growing through associated Medicaid expansion in participating states. An IR practice’s exposure to the ACA depends largely on five issues: whether contracting has rolled the practice into the exchanges through its current payers, whether the practice is open to new Medicaid patients, whether the state is participating in the Medicaid expansion, and whether patients in the state are taking advantage of new coverage that is available to them.
Many plans have created “narrow networks” to contain costs; a given practice may or may not be an “in-network provider” by the plans sold on the exchange. For example, you may be a Blue Cross provider in your state, but you may not be a Blue Cross provider through that state’s healthcare exchange because you haven’t been included in the narrow network for your region. As a result, IRs should first determine if payers in their region are offering them as a choice in the plan’s narrow network; you can find this out by searching the online directories for regional plans. If your practice is in the narrow network, request a sample fee schedule from the payer. Reimbursements vary by state and region, but payments generally are 70 percent to 100 percent of the HMO fee schedules for various levels in the plans. The next step is to determine if you can opt out of certain tranches within each plan; your practice will need to determine which tranches, if any, you are willing to accept.
ACA participation has other potential financial pros and cons. Obviously, exclusion from a narrow network could result in a drop in demand for a physician’s services. Demand will also likely be influenced by the types of patients entering the exchanges; patients buying into the ACA may be those who have been waiting for a chance to obtain much-needed care; they may have delayed treatments for chronic health problems because they could not previously afford health insurance. Patients with chronic and untreated health issues may require more treatment, which could increase demand for IR services.
Participating in the Medicaid expansion may also have ramifications. New Medicaid coverage is also extended to all individuals with incomes below 133 percent of the poverty level; this is expected to swell the ranks of the insured. Physician practices need to analyze the impact this may have on overall reimbursement and determine if this line of service will be accepted.1
Simply put, the ACA will affect these aspects of practice significantly. In general, patients with insurance through the exchanges may have high deductibles. Front office staff must be diligent about preauthorization, copayments and deductibles, especially for high-value procedures. Many of these patients may be new to health insurance; they may be very unfamiliar with deductibles, copays, and other aspects of the billing process. Generally speaking, many patients are under the impression that once they pay their premium, the care is free. Under the ACA, practices will need to plan strategies for managing patient expectations and collecting large amounts of money prior to treatment. The days when patients could walk into a practice and leave without paying are over; physicians must restructure their practices to deal with payment collection issues. Specifically, they should proactively implement credit card processing and other retail strategies to help facilitate payment. They should also consider pressing the reset button for staff education to ensure everyone knows the new billing practices. The importance of imbuing staff with the skills and knowledge to manage patients’ financial expectations in the brave new world of the ACA cannot be overemphasized.
Particularly concerning to practices is the insured status of patients. Patients of the state insurance exchanges who sign up on healthcare.gov have three months to pay their premiums, and are considered “fully insured” during that period whether or not they pay their premiums. During the second and third months of this grace period, payers are not obligated to pay for any services the patient receives if the premiums haven’t yet been paid. The insurers are indemnified by law for 80 percent of any losses, but providers are not. Insurers are supposed to notify providers if premiums have not been paid; however, practices should strongly consider whether to rely on this provision — they could be left with the collection burden for any services rendered in the second and third months. Ideally, practices will require patients to prove they have paid their premiums as part of the preauthorization process. Alternatively, practices may request proof of premium payment directly from the payers during preauthorization. As a last resort, practices may consider treating these patients as self-pay and require payment either at time of service or under a payment plan.2
Interventional radiology practices participating in ACA exchange plans may also be impacted by ACA rules governing preventive versus diagnostic services. The exchange plans cover preventive care without patient cost sharing (ie, no co-pays, co-insurance, or deductibles), but services not considered as preventative care are subject to cost sharing. Given the exchange plans’ high deductibles, financial responsibility for non-preventive care could easily fall on patients. Staff and patient education will be very important in regard to this provision of the law. Coding and billing will need to be adept at navigating the difference between the two lines of service and coding appropriately. Office staff should be prepared to educate patients who have little or no comprehension of the intricacies of medical coding. Your practice does not want to be faced with patients who are billed for what they assumed were preventive services which were in fact diagnostic. Practices should consider presenting patients with a a brief explanation of the different types of care and what their potential out-of-pocket costs might be. A simple statement on the financial intake forms to the effect of, “I do (or do not) want to receive diagnostic services not covered under my preventive benefits,” along with relevant education would go a long way toward mitigating surprises for patients.3
Yes, he certainly is, and in several ways that may impact the finances of you and your practice. The Physician Quality Reporting System (PQRS) is one example. Until now, this provision of the ACA has been used as an incentive to reward reporting of specific quality measures related to patient care. Beginning in 2015, however, professionals who do not report appropriate quality data measures will be penalized. Unfortunately, the penalties imposed in 2015 are based on historic data. IR practices hoping to mitigate financial losses should act immediately to ensure they are enrolled in the PQRS and are collecting and reporting the appropriate care measures.
The ACA also includes a misvalued-code provision under which all current procedure terminology (CPT) codes are being evaluated for potential misvaluation. Essentially all IR CPT codes have been identified as targets for this provision. As a result, many procedural codes have been subject to change, bundling and revaluation. With near uniformity this has led to reduced valuations. The current trajectory of this provision is unlikely to change in the future.
The ACA also established the Independent Payment Advisory Board, which is composed of 15 presidential appointees with a mandate to maintain Medicare spending below a specific cap by restricting payments to physicians and hospitals. The board will have minority physician membership. It will require confirmation by the U.S. Senate. It is not required to be bipartisan. It is required to propose a plan to Congress and the President for achieving Medicare savings targets each year.
The ACA also includes the Open Payment Program, which is part of the Physician Payments Sunshine Act. This program was created to establish a usable public file that discloses the financial interest or arrangements between physicians and their suppliers. Essentially, any interventional radiologist who accepts an honorarium, teaching grant, or other financial benefit from industry should expect to have that benefit on display for the public to interpret in whatever fashion they choose. The Sunshine Act also allows for background checks on certain “high-risk” providers. While this may seem remotely applicable to most interventionalists, the broader interpretation of the “suspect” categories opens the door to scrutiny of IRs with pertinent ownership interest in OBELs, imaging centers, home health care agencies, DME agencies, and other entities.4
Last, but not least — taxes. Interventional radiologists along with anyone else making more than $200,000 ($250,000 family income) must now pay an additional 0.9 percent Medicare payroll tax to help pay for the benefits provided by the ACA. Taxes on investment income were also increased by 3.8 percent for the same reason. Consult your accountant or tax advisor for a better explanation of the nature of the pain.
Accountable care will, first and foremost, require an attitude adjustment. The do more/make more mentality may soon join the ranks of the double wall arterial puncture. Future revenues will be tied to outcomes, patient satisfaction, and cost reductions. Interventional radiologists should immediately and aggressively adopt best practices and outcomes monitoring. All IR practices should also take a hard look at reducing costs and identifying ways to redesign the care process to improve operations and efficiency while making sure that care is delivered in an appropriate setting. Hospital-based IRs must take a leadership role in redesigning care delivery. Motivated physicians will need to translate this leadership into an equity position in pay-for-performance negotiations. Payers will not dictate who gets what from episodes of care, so the difficult negotiations to establish a financial benefit for IRs involved in the process should be entered into early and with a clear vision of the value they bring to the negotiating table.4
The goal of the ACA is to reduce spending while providing more and higher-quality care. Hospital care represents the largest opportunity for the government to save money. This may present opportunities for interventionalists on multiple levels. Commercial carriers are already directing patient care away from hospital-based services and toward freestanding facilities. Interventional radiologists providing outpatient alternatives to expensive inpatient or hospital care may provide a value proposition that is attractive to payers.5
The Accountable Care Organization (ACO) model is one of many models that may or may not be present in the future of health care. The Centers for Medicare and Medicaid Services has and will continue to introduce new care models in an effort to see what does and does not work. In light of this, IRs shouldn’t focus on any particular medical delivery mechanism, but rather on the goal of any new system of care delivery -- value. Satisfaction and quality of care metrics will soon be readily available for payers as well as for patients. Practitioners with better scores will have the most likelihood of attracting patients, securing payers, and surviving in the age of the ACA, no matter which medical delivery system ultimately wins in the end.