By George W. Chapman
House Speaker Mike Johnson has more than once threatened to repeal the Affordable Care Act. President-elect Trump baselessly calls it “lousy healthcare,” which must make our hard working physicians, nurses and ancillary professionals feel really appreciated. After 10 years, 45 million people are covered by the ACA, giving them access to the same hospitals and providers as the rest of us. By significantly reducing (almost eliminating) the uninsured, it has provided sorely needed revenue to hospitals and physicians virtually saving providers serving inner cities and remote rural areas from closing. It is by no means “lousy healthcare.” The ACA was carefully crafted by the AHA, the AMA, commercial insurance carriers, CMS and various industry experts. It was bipartisan and non-political. It works effectively in both red and blue states alike. Congress has enough things to fix, including inflation, immigration, public safety, women’s reproductive rights and infrastructure. Like everything else, the ACA could be tweaked. But in no way is it “lousy healthcare” screaming for repeal.
The ACA impacts all of us. It ended pre-existing conditions. It capped commercial insurer profits at 15%. If a carrier spends less than 85% of premiums on claims, it must rebate the difference to members. It eliminated the confusion in comparing plans by establishing minimum benefits for three levels of coverage: bronze, silver and platinum. The ACA was not an issue in the election this year because it works. Trump inexplicitly attempted to repeal the ACA more than 60 times. He failed every time. I’m concerned he still doesn’t get the message.
Physician Pay Threatened
CMS (Medicare) has proposed to cut, yes cut, physician reimbursement by 2.5% next year, despite its own medical economic index showing 3.5% inflation. The cut is tantamount to an inflation-adjusted 6.3% reduction in reimbursement. Recognizing this absurdity, a bipartisan committee has hurriedly proposed a bill eliminating the possible cut and proffering a 4.7% update to the physician reimbursement schedule. The committee wants to push the bill before Congress goes on recess. The ridiculous and untenable cut would be further compounded and exacerbated by copy cat cuts from commercial insurers. The pandemic has created incomparable increases in staff and supply costs for physician practices.
Ghost Networks
No, not as in Halloween. It refers to provider directories that list non-participating or even non existent providers. Individual consumers and businesses typically base their purchasing decision primarily on premiums, benefits and the plan’s provider network. An inflated directory of providers has created legal problems for NYS plan Anthem BCBS. The case is centered around “ghost” mental health providers listed in the iAnthem directory. With increasing mental health problems, especially among younger adults, provider participation can be paramount to plan selection. Attorneys for the plaintiffs called the first 100 mental health providers listed in the Anthem directory. Only seven providers out of the 100 were actual participants. The other 93 providers did not accept Anthem insurance, were retired or never existed. Plaintiffs argue that this deception caused them undue anguish and financial hardship by having to seek out and use more expensive out -of-network care. (The Anthem directory lists a total of 4,300 providers.) The Departments of Labor and Health have promulgated rules to protect and expand equitable access to mental health services. Provider directories are updated annually as older physicians retire, newer physicians join the plan, office affiliations or addresses change, the provider is not accepting new patients or the provider has opted out altogether. Normally, this activity would account for maybe 5% of the listings from year to year. It becomes a ghost or false network when 93% of providers don’t participate or even exist. When changing plans, especially for mental health, it is recommended you call the particular provider office you are considering and verify they are accepting new patients AND accept the insurance.
AI in Medicine
There is no doubt in the technical power of artificial intelligence in medicine. Billions of dollars are being invested in AI development. (Even the ubiquitous Elon Musk is getting involved.) AI innovations have improved care and future AI applications are endless. However, while the technical aspects of AI are a given, AI must also engender patient trust, be transparent, offer choices and protect privacy and autonomy. Otherwise, success will be compromised. For example, patients want to know when they are talking to either a real human being or a chatbot. We don’t want to be “catfished.” Providers need to keep the patient’s experience personal, not cookie cutter, especially in times of crisis.
SimplePay Health
Aetna-CVS is offering self-insured businesses and organizations a product that will simplify the patient experience, reduce costs and improve quality. (Not exactly an innovative concept.) By directing members to “high-quality” providers (Just how is that determined? I am skeptical. Are high-quality providers the ones that will accept a lower fee from Aetna in exchange for higher volume and year end profit sharing? Just saying.) Aetna claims it will save the client money. So far, they claim a 60% increase in the use of high-quality providers saves the self-insured plan about 12%. Members can search for the high-quality providers via an app. Aetna-CVS seems to be a victim of over-diversification having to divest or shrink certain lines of business that are not profitable. Aetna might want to stick with selling insurance and CVS with selling drugs.
Racial Disparity in Health
Dating back to the end of the Civil War, Black Americans have lagged far behind whites when it comes to overall health and life expectancy. Study after study has concluded there has been little to no progress even in the last two decades. Lingering racism in government, intentional or not, bears a lot of the blame. South Carolina’s notorious “corridor of shame,” 17 predominately Black poverty-stricken rural counties along interstate 95, has some of the nation’s worse outcomes. According to the few providers serving the area, most of the residents cannot afford care, so they don’t seek care. South Carolina is one of the few states to refuse Medicaid expansion which would have given the residents at least some insurance. The Black residents living in the corridor suffer much higher rates of high blood pressure, diabetes and heart disease than whites. The National Academies of Sciences, Engineering and Medicine concluded our fragmented and uneven system of healthcare results in millions of preventable deaths and the loss of billions in economic benefit. Many states, Louisiana for example, allow residents to carry concealed and unregistered guns. Gun violence is the No. 1 killer of kids and young adults. Blacks are 18 times more likely to die by gun than whites. Adding to the disparity, 80% of all solid waste incinerators are located in low income communities. An AMA study in 2023 calculated that in the last 20 years there have been 1.63 million excess deaths among Blacks versus Whites, resulting in 80 million years of lives lost. America is still caught up, consciously or not, in our deep seeded racial history and government decisions regarding gun control, expanded medical insurance or even incinerators contribute to the continuing disparity in health among Blacks.
George W. Chapman is a healthcare business consultant who works exclusively with physicians, hospitals and healthcare organizations. He operates GW Chapman Consulting based in Syracuse.