Healthcare Reform and the Delivery of Cardiovascular Care: Update 2016

The Affordable Care Act (ACA) remains a hot topic for both patients and physicians. As discussed in my new book, Losing Our Way In Healthcare, many Americans are beginning to realize some of the negative fallout now that the legislation has been fully implemented. In the second year of Obamacare, we have seen premiums increase and, in many cases, patient choices have become more limited. In many states, premiums have risen by nearly 45%, with a national average of just under 10%. Thousands of healthcare consumers have been forced to switch insurers since their current insurer has either folded or dropped out of the ACA exchanges due to the rising costs of the expanded insurance pool. In the last month, one of the nation’s largest insurers, UnitedHealthcare, announced they will likely be leaving the ACA exchanges. There is concern that this move will likely result in even higher individual costs and even less choice for patients.

For physicians, large hospital groups and healthcare systems have continued to form through the acquisition of smaller practices.

In some cities, healthcare “monopolies” are becoming commonplace and competition among healthcare systems has been eliminated. Physicians are losing their autonomy, and bureaucrats are finding their way into clinics, EP labs, and exam rooms. While the number of physicians entering the marketplace every year has either remained constant or risen at only a modest rate, the number of hospital administrators has risen nearly 300% in the last few years. 

Most significantly, however, beyond the obvious financial concerns that surround the ACA legislation, is an even more pressing issue for healthcare consumers and physicians alike: the impact that reform is beginning to have on the doctor-patient relationship. The interactions that patients have with their doctor and other medical staff members are one of the most privileged and protected relationships in the world. There have been numerous studies in the medical literature that have demonstrated that when doctors and patients bond and connect, outcomes improve. 

It is essential that there is a bond of trust between doctor and patient, and that this relationship remain sacred. The exam room is designed to be a safe place where patients can share their health history and the intimate details of their lives, and develop a bond with their healthcare providers. Any actions that serve to erode the sanctity of this very unique relationship may ultimately impact health outcomes in a negative way. 

Healthcare reform has affected every aspect of our society. There are many stakeholders — patients, doctors, insurers, politicians and pharmaceutical companies — each with their own priorities. However, in order to be successful in providing healthcare for all Americans, reform must be patient centric, focusing on how we can best deliver quality care and produce outstanding outcomes. 

HOW HAS REFORM AFFECTED THE PRACTICE OF CARDIOVASCULAR MEDICINE?

Increasing Costs

In the initial year of the ACA, it appeared that healthcare costs in the U.S. were beginning to level off for the first time in decades. However, as the healthcare law moves beyond year one, the costs have begun to rise again. Most insurers in the exchanges underestimated the expenses associated with the large pool of millions of newly insured Americans. The expected enrollment of the “young and healthy” persons did not meet predictions, and the majority of enrollees tended to be older, sicker, and have more chronic medical problems. All of this has resulted in increasing premiums for patients. In almost every state, premiums have increased anywhere from 5-45%. Many patients have resorted to “middle tier” plans that have very high deductibles. Ultimately, while patients have insurance on paper, many cannot afford to utilize their policies due to high out-of-pocket costs. Physicians are unable to focus on prevention, and instead, are seeing more patients in the acute phase of disease, since these patients with high deductibles often only use their insurance for emergencies. These acute hospitalizations and urgent care place a significant financial burden on the healthcare system. 

Limited Choice/Access

One of the basic tenets of universal healthcare is that patients should have easy access to healthcare and be able to choose the healthcare provider they prefer. Unfortunately, in many states, there are a limited number of insurers participating in the exchanges. In fact, many notable, well-respected academic institutions are not able to care for patients through the ACA due to the inability to agree on terms of reimbursement. Ultimately, these changes in networks and affiliations may result in the separation of doctor and patient. If a particular physician is no longer “in network,” a patient may be forced to either pay out of pocket to maintain a relationship with his or her physician, or change to an entirely different provider. As discussed, cooperative efforts between doctor and patient improve outcomes; however, when patients have to start with a new provider, it can take a while to develop that same bond of trust. In addition, well-respected institutions are finding that participating in exchanges comes at a great cost — the limited reimbursement schedules often cut into the operating budgets of many hospitals. Reduction in budgets can result in more limited resources — less support staff, fewer dollars for capital purchases (such as new EP lab equipment, etc.), as well as less monies available for outreach and other market development opportunities. Cardiovascular disease and in particular, electrophysiology, are areas of intense research and innovation. The tools that allow us to treat heart rhythm disorders are constantly changing and evolving — if we are limited by increasing budgetary concerns, we may not be able to provide our patients with the latest and most effective technologies.

WHAT ARE THE MOST PRESSING ISSUES FOR PHYSICIANS AND OTHER HEALTHCARE PROVIDERS?

Increasing Paperwork Demands

Healthcare professionals are beginning to feel the pressure of increasing amounts of federally mandated electronic paperwork and documentation. Rather than spending more meaningful time with patients in exam room consultations, doctors are forced to enter data into a computer while talking to patients and their families. A computer screen, rather than a patient, becomes the central focus of the visit. It becomes more difficult to bond with patients and their families — often resulting in a lack of connection and the erosion of the doctor-patient relationship. In the EP lab and throughout the hospital, electronic medical record (EMR) use has been a dominant theme. Many hospital systems have become far less efficient due to arduous and complicated peri-procedural electronic documentation requirements. While not strictly a part of the ACA legislation, most of these EMR requirements have been federally mandated as part of CMS reimbursement rules. These EMR systems many times create poor morale among staff and can result in a lack of patient-centered focus during interactions. 

Decreased Time With Patients

Declining reimbursement and increasing non-clinical duties have caused many physicians to see more patients in less time. In addition, many physicians are utilizing physician extenders to see patients in the office. While physician extenders such as nurse practitioners (NPs) and physician assistants (PAs) play a vital role in patient care, they do not replace the physician and his or her relationship with each patient and family. Patients may not have the same access to their physician, and regular follow-up may be more inconsistent if they see a different provider every time they have an office visit. In the hospital setting, routine daily follow-up may become fragmented as hospitalists take care of admitted patients — without an existing relationship with either patient or family. 

SO WHAT CAN WE DO?

Affordable, accessible, high-quality healthcare for everyone is a noble goal — everyone in the United States should have the opportunity to obtain the healthcare that they need. Patients must take control of their own healthcare, and partner with their physician and healthcare team. Most importantly, healthcare workers must advocate for their patients. For example:

Help Patients Understand Their Individual Healthcare Needs

In order to navigate the complexities of today’s healthcare market, patients must have a sound understanding of their healthcare problems. When patients are informed about their chronic conditions, they are better equipped to make better decisions when selecting a healthcare plan that offers access to a provider that they prefer. In addition, patients need to consider whether or not in the future they will need access to specialized care at a particular institution — it is essential to sign up for a plan that will provide for that type of access. When interacting with patients in the office or hospital, all members of the healthcare team must look for opportunities to educate. These opportunities may present themselves in the EP lab, recovery area, clinic, or on the post-operative floor. 

Help Patients Understand Their Healthcare Options

Signing up for a healthcare plan can be very confusing. The signup period often takes healthcare consumers by surprise, and patients sometimes make quick decisions when they elect a particular plan for coverage. Patients should contact enrollment call centers and ask questions. It is essential to make an informed decision. Patients must carefully read the benefits of each type of plan. Everyone must consider the cost of the plan, the deductible amount, and cost of prescriptions, as well as the costs of emergency and specialty care. The challenge for most is to match the plan with individual budgets and coverage needs. As healthcare providers, we often do not have the time or the tools to counsel patients about health insurance specifics. While many organizations do have specially trained personnel who can help patients navigate the confusing issues surrounding health insurance coverage, I believe that hospital systems can do more to support its customers. 

Be the Squeaky Wheel

As healthcare professionals, we must advocate for our patients. Each of us must work together to use our collective voice to reach out to lawmakers at the local, state, and federal levels in order to affect change. Organizations such as the Heart Rhythm Society and the American College of Cardiology have an active lobby in Washington. Membership in these organizations can help promote better healthcare coverage for all of our patients. In addition, these organizations can help improve our experiences on the “front lines” of healthcare through advocacy efforts on Capitol Hill.

We are fortunate to have in the United States some of the most innovative medical care in the world. Unfortunately, our costs have outpaced those of any other industrialized country. The current system under the ACA is no longer sustainable. As major insurers such as UnitedHealthcare are pulling out of the exchanges, I fear that the problems with the ACA will continue to expand. We must create a better system in which we have affordable, accessible, high-quality medical care for all. The future of healthcare in the U.S. is uncertain. In the coming years, I expect that our lawmakers will have to make a choice — further reform or allocate funds for a “bailout,” similar to those provided to the banking industry in 2009. As patient advocates, we must be sure to have a “place at the table” as healthcare reform is modified in the next decade.

For more information about Losing Our Way In Healthcare, please visit https://www.amazon.com/Losing-Our-Way-Healthcare-Impact/dp/9814725447

Kevin R. Campbell, MD, FACC is with North Carolina Heart and Vascular and UNC Healthcare. He is also Assistant Professor at UNC Department of Medicine, Division of Cardiology, and Director of Electrophysiology at Johnston Health. In addition, Dr. Campbell is President of K-Roc Consulting, LLC.

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