Robert W. Yelverton, MD, FACOG
The Women’s Health Medical Home—This Slipper May Fit in Florida
Well, it’s here, or most of it. The Affordable Care Act (ACA) has now entered its most challenging phase with the critical provisions going live this January 2014.The answers to the big questions will be apparent soon enough. Is health care administered by both government and private insurance under the provisions of the ACA going to result in a spiraling collapse of our health care system as the doomsayers predict, or will it salvage our severely broken system in a miraculous way? Since nearly all health care consultants, administrators, columnists and bloggers have given their “expert” opinions on the issue, I thought I would weigh in as well. Be aware that my credentials are suspect. I have only a medical degree (MD) behind my name, no MBA, PHD or MPH degrees to cloud my thinking. But I do have bootleg qualifications: 33 years in private practice in a tough central Florida market and 10 years of experience in consolidating and then managing a large group of general OB/GYNs. I have experienced the economic advantages and disadvantages of small group practice. The disadvantages became the dominant theme with the advent of managed care in the 80s with its capitation, gatekeepers and the like. My response 15 years ago was to consolidate into a more efficient large group practice. At the time, consolidation into a highly integrated single specialty group proved to be a successful model. While many of the ugly features of managed care were rejected by the medical profession and their patients, physician reimbursement never recovered as private insurance mimicked the lower rates featured for our services in Medicare and especially Medicaid. Now, with the ACA, OB/GYNs need to be particularly careful about how they position themselves and their practices in order to survive in the medical market place.
I believe the ACA, with relatively minor fixes overtime, is here to stay as have all other federal entitlements when launched. There are advantages to medical practices who position themselves well, given the wide coverage options featured in the ACA. Forty-seven million women will gain excess to women’s health services, including maternity, reproductive and wellness services. Technically, the vast majority of United States citizens will be covered by insurance gained through employer sponsored plans, privately through healthcare exchanges, Medicaid or Medicare. Florida, to date, is one of the states that has rejected federal funds to allow for Medicaid expansion but I feel that Florida’s hold out will be short lived, given the billions of dollars to be forfeited and the need to expand. Florida’s population is predicted to exceed 20 million in the next few years with a likely shortage in women’s health providers, particularly in rural counties. The health care industry is reacting to health care reform in a predictable manner. The ACA purposely encourages health care provided by large integrated health care entities, hence the creation of the Accountable Care Organization (ACO), a large, highly intergraded organization that includes hospitals, physician groups, home health services, and others. Centers for Medicare and Medicaid Services (CMS) are encouraging the formation of ACOs in hopes that these organizations will improve quality and reduce costs for Medicare. Over 30 such organizations exist currently in Florida, most in urban counties. Some ACOs have been incorporated by primary care physicians, but most have been created by hospital systems partnering with Medicare or private insurance companies, and one created by a drugstore chain. To date, there is relatively little data to support the claims that ACOs will accomplish their goals of improved quality at reduced cost. Physicians should join these organizations only after careful study. While most ACOs are wading in on the reimbursement methods slowly with shared savings fee for service contracts, many medical management experts state that the ultimate goal of CMS and private payers is to reimburse such organizations by bundled payments per episode of care or even capitation, leaving it up to the ACO as how the organization will reimburse the physician component. Beware of an ACO that does not have a governance process designed to give the participating physicians a strong voice in how reimbursements are distributed within the organization.
If you are currently working as an employed physician in a health plan, hospital system or a government supported clinic you will not experience an immediate economic strain as a result of the ACA, but do expect a significant increase in demand for your services as the numbers of insured, particularly low income insured, crowd your waiting room. If you have sold your practice to a hospital system you must become a proactive partner and be certain that reimbursement is managed properly. Be aware that if you are a hospital-owned practice, the hospital is currently billing for your ambulatory services under Part A Medicare, a significantly higher reimbursement than that received by independent practices under part B. This may change soon in that CMS is considering a rule change that will eliminate this discrepancy. Most experts predict that independent OB/GYNs face a challenge of frozen or even lower reimbursement and increased overhead with the full implementation of the ACA. While primary care physicians have seen Medicaid rates for office based services increase dramatically in 2013, OB/GYNs are considered by Medicaid as surgical specialists and received no increase. At the time of this column, the insurance exchanges had not released their reimbursement rates but several insurance companies have announced that they will be utilizing their “efficiency provider networks” for the exchange plans, which traditionally are made up of physicians who accept lower reimbursement.
So what is a Florida OB/GYN in a private independent practice to do? There are a number of options, but my recommendation is to consider designing your practice in a fashion that allows you to increase volume without sacrificing quality. A practice that emphasizes primary care and wellness to whatever level you desire, but continues to direct the core practice to gyn surgery, obstetrics or both. My ideal model is a collaborative practice using ARNPs and midwives to create a true Patient Centered Women’s Health Medical Home that can be marketed as such, an approach designed to emphasize primary care and improve care coordination. Many of your practices are half there already. An ideal medical home features good access, evidenced based practice, and internal capabilities to manage most of the patient’s health needs and excellent connectivity with a “neighborhood” of health care facilities featuring specialty care, hospital and home health care. The medical model will serve our patients well, particularly in their reproductive years. There are hurdles to becoming a women’s health medical home. Currently the practice of general OB/GYN is not considered primary care by the federal government, a problem that may affect the needed reimbursement increase to cover medical home services. ACOG needs to continue efforts to correctly educate the government of the fact that the majority of women in their reproductive years consider their OB/GYN to be their primary care physician. However, this is recognized by many and several avenues are opening to allow OB/GYN practices to become certified as medical homes. On the ACOG websitewww.acog.org you can view the Women’s Health Medical Home Toolkit. In the next issue of the newsletter, I will explore the women’s health medical home in more detail. You can reach me at firstname.lastname@example.org if you have any questions.