Health Reforms Effects on Medical Students and Their Patients

Photo Credit: David Pierre, Jr.

Cedric Dark, M.D., M.P.H.
Founder and Executive Editor
Policy Prescriptions

The Patient Protection and Affordable Care Act (or Affordable Care Act), which became law March 23, 2010, will continue to make dramatic changes to the American health care landscape over the coming decade. Members of the Student National Medical Association should begin to familiarize themselves with the many important provisions of the Affordable Care Act because several of these provisions will become implemented as current medical students begin and complete their residency training.

Of the more than 90 key provisions tracked by the Kaiser Family Foundation, 21 will become implemented in the new year (1) . The Affordable Care Act makes significant strides to regulate the health insurance industry and is termed by many policy wonks as “health insurance reform.” However, there remain many important aspects of the Affordable Care Act that affect programs such as Medicare (the public program benefiting the elderly) and Medicaid (the public program that benefits the poor). Other aspects of the law make changes more directly relevant to the the health care workforce – including practicing physicians, nurse practitioners, physician assistants, and physicians-in-training.

In this briefing, those provisions which will take effect in 2011 will be discussed. Sections of the law with the closest relevance to members of the Student National Medical Association and the patients they serve will be highlighted.

Medicare Provisions
Medicare patients, typically elderly but also including patients with end-stage renal disease and some disabled individuals, will see several changes of benefit to them in the new year. Many Medicare patients take multiple medications every day. Paying for prescriptions drugs tends to be a challenge for many patients.

Medicare beneficiaries who purchase prescriptions drugs after reaching the Part D coverage gap (known as the “doughnut hole”) will receive 50 percent rebates from manufacturers (2). Subsidies for generic drugs purchased after reaching the doughnut hole will also begin to be phased in this year.

Cost sharing (deductibles, copays, et cetera) for preventative screening tests approved by the United State Preventative Service Task Force and given a grade “A” or “B” rating will be eliminated this year (3). Other wellness checks such as annual physicals are also going to be free for Medicare patients beginning in 2011.

Physicians who accept Medicare patients will also start to see financial benefits. Medicare will provide bonus payments of 10 percent for primary care services beginning in 2011 and lasting through 2014 (4). Additionally, general surgeons practicing in health professional shortage areas (a federal classification for specific under-served areas) will also see 10 percent bonus payments for their work with Medicare patients.

The Affordable Care Act also creates a Medicare Independent Payment Advisory Committee (5). This group, comprised of 15 members, would be required to create legislative proposals that Congress might be able to act on in order to reduce the costs of care by altering provider payment rates – most likely reductions in specific payments. Funding for the Committee begins in 2011 but the first recommendations are not due until 2014. In the meantime, the issue of Medicare provider payments will likely continue to be a highly dramatized affair until Congress comes up with a new physician payment system. Current medical students should inquire about the business of medicine – an poorly covered subject in medical schools – in order to gain insight to this rapidly changing aspect of medical practice.

Medicaid Provisions
Medicaid is the joint federal-state program of health insurance for the poor. While sharing many common features, each program differs slightly in each state. Several programmatic changes will affect state Medicaid programs as a result of the Affordable Care Act. By far, the most significant change will be increasing the eligibility to all Americans under 133 percent of the federal poverty level, currently about $29,000 for a family of four.

Beginning January 1, 2011 states will be permitted to allow Medicaid enrollees with chronic conditions to select a particular health care provider (or team of providers) as a health home (6). States electing to choose this option will receive the benefit of higher federal matching funds (90 percent federal match) for health home services. The hope for this program is to improve care for individuals with chronic medical conditions such as asthma, diabetes, heart disease, mental health problems, substance abuse, and obesity.

Federal grants are also available for states that wish to open chronic disease prevention programs for their Medicaid populations (7). These programs will be designed to empower patients to undergo lifestyle changes of benefit to their health. Targeted lifestyle changes include quitting tobacco, weight loss, lowering cholesterol and blood pressure, and preventing type 2 diabetes.

Starting October 1, 2011, Medicaid programs will begin receiving enhanced matching payments from the federal government for long term care services provided in the noninstitutional setting (8). This so-called “Community First Choice Option” would likely result in lower cost services by providing community-based home support services and thereby keep disabled patients out of long term care facilities such as nursing homes.

Beginning in July 2011, the federal government will eliminate payments for Medicaid services deemed secondary to hospital-acquired conditions (9). Whether or not States will still pay hospitals for these conditions (examples include ventilator-associated pneumonia and pressure ulcers acquire in the hospital) would be up to the individual state Medicaid programs. However, it should be expected that health providers simply would not be compensated for care of patients when their hospitalization is complicated by these types of hospital-acquired conditions.

Workforce Provisions
The Affordable Care Act attempts to provide incentives that will promote training of more primary care providers. In that vein, funding is available to establish Teaching Health Centers which will help benefit primary care residency programs in internal medicine, pediatrics, obstetrics and gynecology, geriatrics, and dentistry (10). Teaching Health Centers are designed to place their trainees outside of hospitals and hospital clinics into community-based ambulatory care practices. Hopefully, this will give young doctors a more realistic viewpoint of ambulatory care and will encourage residents to engage in primary care careers as opposed to sub-specialization.

Beginning July 1, 2011, currently unused residency (graduate medical education) positions will be redistributed (11). This redistribution will focus on primary care and general surgery. Three-fourths of a hospitalʼs new residents must be from those specialties in order to receive the redistribution.

Another interesting development will be noticed by patients, doctors, and non-patients alike this spring. All chain restaurants with 20 or more stores will be required to list nutritional information on their menu boards beginning March 23, 2011 (12). Some restaurants across the country have already begun this transformation. This simple change will allow consumers to better judge their caloric and nutritional intake when
eating out.

A similar law, recently implemented in New York City, demonstrated a dramatic increase in consumer knowledge about calorie content (25 percent before implementation versus 64 percent after implementation, p<0.001) (13). Additionally, the fraction of consumers using nutritional information to make food choices increased significantly albeit mildly (32 percent before implementation versus 38 percent after implementation).

Conclusion
The Affordable Care Act does many good things for Medicare patients, encourages healthy behavior and better management of chronic conditions in Medicaid, and will try to push medical students into careers focused on primary care (including general surgery). Although many of the changes the health reform law promises to deliver will not arrive for several years, several important provisions go into effect in 2011.

After reading this policy brief, medical students will have the necessary information to educate their Medicare and Medicaid patients of benefits which can be expected this year. Medical students can empower their patients with critical knowledge about the benefits of the Affordable Care Act while a Republican-controlled House of Representatives attempts to repeal the entire law (14).

1 Kaiser Family Foundation – Implementation Timeline. Retrieved from http://healthreform.kff.org/timeline.aspx (Accessed Jan 1, 2011).
2 Patient Protection and Affordable Care Act, Section 3301.
3 Patient Protection and Affordable Care Act, Section 4104.
4 Patient Protection and Affordable Care Act, Section 5501.
5 Patient Protection and Affordable Care Act, Sections 3403 & 10320.
6 Patient Protection and Affordable Care Act, Section 2703.
7 Patient Protection and Affordable Care Act, Section 4108.
8 Patient Protection and Affordable Care Act, Section 10202.
9 Patient Protection and Affordable Care Act, Section 2702.
10 Patient Protection and Affordable Care Act, Section 5508.
11 Patient Protection and Affordable Care Act, Section 5503.
12 Patient Protection and Affordable Care Act, Section 4205.
13 Dumanovskym T, et al. (2010) Consumer awareness of fast-food calorie information in New York City after implementation of a menu labeling regulation. Am J Public Health, 100 (12), 2520-5.
14 Repealing the Job-Killing Health Care Law Act. Retrieved from: http://rules-republicans.house.gov/Media/PDF/HR__-Repeal.pdf (Accessed: Jan 4, 2011).

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