TBD Meeting (5123)

While critics charge that the Affordable Care Act makes health care more complex, at least one provision has the opposite aim: Section 1104 of the ACA directs the Health and Human Services department to standardize many elements of electronic interactions between doctors and health plans.

In July 2011, HHS issued the first in a series of regulations aimed at administrative simplification, adopting operating rules to make it easier for physicians to determine a patient’s eligibility for coverage and to obtain the status of a submitted claim. HHS also has issued rules for electronic funds transfers and remittance advance between health plans and physicians, and established a standard for a national unique health plan identifier. Regulations to outline standards and operating rules for electronic claims attachments are planned.

Robert M. Tennant, senior policy adviser at the MGMA-ACMPE, formerly known as the Medical Group Management Association, offered his thoughts on whether these regulations will reduce practices’ administrative burden.

Question: Section 1104 of the ACA contains many provisions that physician groups have been advocating for years. Does the law offer a good chance for relieving the paperwork burden on physician practices?

Mr. Tennant: Yes, it does. It has a number of provisions that we long called for. After the passage of HIPAA, we found that the implementation of the electronic transaction standards required under the law did not achieve the level of simplification that we had hoped for.

So back in 2005, an industry group came together to create what are called operating rules. One of the first transactions they tackled was eligibility. The operating rules were set up so that if a health plan agreed to participate, it would have to provide information to practices on patient financials, copays, and deductibles, and they would have to get back to the practice within 20 seconds. But since the operating rules were voluntary, not all the health plans adopted them and not all the vendors saw the value in supporting them.

The ACA has made those operating rules mandatory. That is a huge change. To have the kind of real-world capabilities that the operating rules bring, such as identifying immediately the patient financial responsibility, will be extremely beneficial.

Question: Will practices see efficiency as a result?

Mr. Tennant: There’s no question. Just that one simple operating rule for eligibility means that, in 20 seconds, you can get an answer from the health plan. That alone is going to really improve patient intake and speed up the claim adjudication process.

Question: When will these changes begin to affect physicians?

Mr. Tennant: Jan. 1, 2013. Health plans must be compliant with operating rules for eligibility verification and checking the status of previously submitted claims on that date. But the linchpin here is the vendor. There’s a lot going on in health care. There’s meaningful use EHR [electronic health records] and e-prescribing incentive programs, not to mention the huge challenge that adoption of ICD-10 will bring, and all of these require practices to upgrade or replace vendor software. With all of these mandates and opportunities, this is probably a good opportunity for the practice to take a step back and look at what they have currently in the way of technology. What transactions are you conducting in-house? What are you outsourcing? What are the costs for that? What are your manual processes? Take stock of how you are managing the claims-revenue cycle. Then ask yourself, is this a good time for the practice to move ahead with a more automated approach?

Question: Many of the Section 1104 requirements apply to health plans. Will the plans do most of the work or do physicians need to make changes, too?

Mr. Tennant: Health plans and clearinghouses have to be able to accept and generate these transactions and support the new operating rules. And providers must use the standards if they conduct those transactions. But the government is not requiring practices to accept an EFT [electronic funds transfer] payment, for example. On the other hand, there is no prohibition against a health plan, such as what Medicare does now, saying that they will only issue EFTs. That’s a business decision that the health plan may make. It’s something that practices should be asking their health plans about.

Question: Do physicians need to buy new systems to take advantage of the operating rule requirements?

Mr. Tennant: In the past, providers may have asked themselves, ‘Do I want to spend a lot of money and buy a practice management system that has all the bells and whistles only to find out that not all the health plans are supporting these automated transactions?’ The answer was probably no. But, with the ACA, it solves that problem to a certain extent. Now health plans are required by law to offer, in a more standardized format, all of these electronic transactions and operating rules. It’s not voluntary anymore. That should be a signal to the vendor community that they now can start to build these supporting software products, with practices now able to take better advantage of these standards and operating rules. But if the practice doesn’t have the capability in the office to handle these transactions electronically, then they’re not going to see an advantage from the regulations. The challenge is going to be to determine if your current vendor, or the vendor that you’re exploring, has the capability of accepting an EFT transaction, for example.

Mr. Tennant works on federal legislative and regulatory health information technology issues at the MGMA-ACMPE. He is also a member of the Board of Directors of the Workgroup for Electronic Data Interchange.

While critics charge that the Affordable Care Act makes health care more complex, at least one provision has the opposite aim: Section 1104 of the ACA directs the Health and Human Services department to standardize many elements of electronic interactions between doctors and health plans.

In July 2011, HHS issued the first in a series of regulations aimed at administrative simplification, adopting operating rules to make it easier for physicians to determine a patient’s eligibility for coverage and to obtain the status of a submitted claim. HHS also has issued rules for electronic funds transfers and remittance advance between health plans and physicians, and established a standard for a national unique health plan identifier. Regulations to outline standards and operating rules for electronic claims attachments are planned.

Robert M. Tennant, senior policy adviser at the MGMA-ACMPE, formerly known as the Medical Group Management Association, offered his thoughts on whether these regulations will reduce practices’ administrative burden.

Question: Section 1104 of the ACA contains many provisions that physician groups have been advocating for years. Does the law offer a good chance for relieving the paperwork burden on physician practices?

Mr. Tennant: Yes, it does. It has a number of provisions that we long called for. After the passage of HIPAA, we found that the implementation of the electronic transaction standards required under the law did not achieve the level of simplification that we had hoped for.

So back in 2005, an industry group came together to create what are called operating rules. One of the first transactions they tackled was eligibility. The operating rules were set up so that if a health plan agreed to participate, it would have to provide information to practices on patient financials, copays, and deductibles, and they would have to get back to the practice within 20 seconds. But since the operating rules were voluntary, not all the health plans adopted them and not all the vendors saw the value in supporting them.

The ACA has made those operating rules mandatory. That is a huge change. To have the kind of real-world capabilities that the operating rules bring, such as identifying immediately the patient financial responsibility, will be extremely beneficial.

Question: Will practices see efficiency as a result?

Mr. Tennant: There’s no question. Just that one simple operating rule for eligibility means that, in 20 seconds, you can get an answer from the health plan. That alone is going to really improve patient intake and speed up the claim adjudication process.

Question: When will these changes begin to affect physicians?

Mr. Tennant: Jan. 1, 2013. Health plans must be compliant with operating rules for eligibility verification and checking the status of previously submitted claims on that date. But the linchpin here is the vendor. There’s a lot going on in health care. There’s meaningful use EHR [electronic health records] and e-prescribing incentive programs, not to mention the huge challenge that adoption of ICD-10 will bring, and all of these require practices to upgrade or replace vendor software. With all of these mandates and opportunities, this is probably a good opportunity for the practice to take a step back and look at what they have currently in the way of technology. What transactions are you conducting in-house? What are you outsourcing? What are the costs for that? What are your manual processes? Take stock of how you are managing the claims-revenue cycle. Then ask yourself, is this a good time for the practice to move ahead with a more automated approach?

Question: Many of the Section 1104 requirements apply to health plans. Will the plans do most of the work or do physicians need to make changes, too?

Mr. Tennant: Health plans and clearinghouses have to be able to accept and generate these transactions and support the new operating rules. And providers must use the standards if they conduct those transactions. But the government is not requiring practices to accept an EFT [electronic funds transfer] payment, for example. On the other hand, there is no prohibition against a health plan, such as what Medicare does now, saying that they will only issue EFTs. That’s a business decision that the health plan may make. It’s something that practices should be asking their health plans about.

Question: Do physicians need to buy new systems to take advantage of the operating rule requirements?

Mr. Tennant: In the past, providers may have asked themselves, ‘Do I want to spend a lot of money and buy a practice management system that has all the bells and whistles only to find out that not all the health plans are supporting these automated transactions?’ The answer was probably no. But, with the ACA, it solves that problem to a certain extent. Now health plans are required by law to offer, in a more standardized format, all of these electronic transactions and operating rules. It’s not voluntary anymore. That should be a signal to the vendor community that they now can start to build these supporting software products, with practices now able to take better advantage of these standards and operating rules. But if the practice doesn’t have the capability in the office to handle these transactions electronically, then they’re not going to see an advantage from the regulations. The challenge is going to be to determine if your current vendor, or the vendor that you’re exploring, has the capability of accepting an EFT transaction, for example.

Mr. Tennant works on federal legislative and regulatory health information technology issues at the MGMA-ACMPE. He is also a member of the Board of Directors of the Workgroup for Electronic Data Interchange.

While critics charge that the Affordable Care Act makes health care more complex, at least one provision has the opposite aim: Section 1104 of the ACA directs the Health and Human Services department to standardize many elements of electronic interactions between doctors and health plans.

In July 2011, HHS issued the first in a series of regulations aimed at administrative simplification, adopting operating rules to make it easier for physicians to determine a patient’s eligibility for coverage and to obtain the status of a submitted claim. HHS also has issued rules for electronic funds transfers and remittance advance between health plans and physicians, and established a standard for a national unique health plan identifier. Regulations to outline standards and operating rules for electronic claims attachments are planned.

Robert M. Tennant, senior policy adviser at the MGMA-ACMPE, formerly known as the Medical Group Management Association, offered his thoughts on whether these regulations will reduce practices’ administrative burden.

Question: Section 1104 of the ACA contains many provisions that physician groups have been advocating for years. Does the law offer a good chance for relieving the paperwork burden on physician practices?

Mr. Tennant: Yes, it does. It has a number of provisions that we long called for. After the passage of HIPAA, we found that the implementation of the electronic transaction standards required under the law did not achieve the level of simplification that we had hoped for.

So back in 2005, an industry group came together to create what are called operating rules. One of the first transactions they tackled was eligibility. The operating rules were set up so that if a health plan agreed to participate, it would have to provide information to practices on patient financials, copays, and deductibles, and they would have to get back to the practice within 20 seconds. But since the operating rules were voluntary, not all the health plans adopted them and not all the vendors saw the value in supporting them.

The ACA has made those operating rules mandatory. That is a huge change. To have the kind of real-world capabilities that the operating rules bring, such as identifying immediately the patient financial responsibility, will be extremely beneficial.

Question: Will practices see efficiency as a result?

Mr. Tennant: There’s no question. Just that one simple operating rule for eligibility means that, in 20 seconds, you can get an answer from the health plan. That alone is going to really improve patient intake and speed up the claim adjudication process.

Question: When will these changes begin to affect physicians?

Mr. Tennant: Jan. 1, 2013. Health plans must be compliant with operating rules for eligibility verification and checking the status of previously submitted claims on that date. But the linchpin here is the vendor. There’s a lot going on in health care. There’s meaningful use EHR [electronic health records] and e-prescribing incentive programs, not to mention the huge challenge that adoption of ICD-10 will bring, and all of these require practices to upgrade or replace vendor software. With all of these mandates and opportunities, this is probably a good opportunity for the practice to take a step back and look at what they have currently in the way of technology. What transactions are you conducting in-house? What are you outsourcing? What are the costs for that? What are your manual processes? Take stock of how you are managing the claims-revenue cycle. Then ask yourself, is this a good time for the practice to move ahead with a more automated approach?

Question: Many of the Section 1104 requirements apply to health plans. Will the plans do most of the work or do physicians need to make changes, too?

Mr. Tennant: Health plans and clearinghouses have to be able to accept and generate these transactions and support the new operating rules. And providers must use the standards if they conduct those transactions. But the government is not requiring practices to accept an EFT [electronic funds transfer] payment, for example. On the other hand, there is no prohibition against a health plan, such as what Medicare does now, saying that they will only issue EFTs. That’s a business decision that the health plan may make. It’s something that practices should be asking their health plans about.

Question: Do physicians need to buy new systems to take advantage of the operating rule requirements?

Mr. Tennant: In the past, providers may have asked themselves, ‘Do I want to spend a lot of money and buy a practice management system that has all the bells and whistles only to find out that not all the health plans are supporting these automated transactions?’ The answer was probably no. But, with the ACA, it solves that problem to a certain extent. Now health plans are required by law to offer, in a more standardized format, all of these electronic transactions and operating rules. It’s not voluntary anymore. That should be a signal to the vendor community that they now can start to build these supporting software products, with practices now able to take better advantage of these standards and operating rules. But if the practice doesn’t have the capability in the office to handle these transactions electronically, then they’re not going to see an advantage from the regulations. The challenge is going to be to determine if your current vendor, or the vendor that you’re exploring, has the capability of accepting an EFT transaction, for example.

Mr. Tennant works on federal legislative and regulatory health information technology issues at the MGMA-ACMPE. He is also a member of the Board of Directors of the Workgroup for Electronic Data Interchange.

President Barack Obama’s health care law was, and remains, one of the more unpopular pieces of legislation in recent history. It was rammed through Congress along partisan lines, will spend trillions of dollars taking choices away from the American people, raises taxes, and raids Medicare.

The 2 years of bait and switch from President Obama about what his law would do has not convinced the American people, because they understand that at its core the law represents a fundamental change in the relationship between the people and their government. Continued public opposition is a direct response to this massive government intrusion into Americans’ personal lives.

(For a counterpoint on the 2012 election, click here.)

As I read the selling of the president’s health care law, it has consisted of one ruse after another:

• If you have insurance that you like, then you will be able to keep that insurance. In fact, the nonpartisan Congressional Budget Office (CBO) estimates that up to 20 million people could lose their employer coverage under the law.

• If you’ve got health insurance, we’re going to work with you to lower your premiums by $2,500 per family per year. Since making this promise, the average premium for a family plan has increased by more than $3,000. And according to the CBO, the law will drive up costs by nearly $2,400 when fully phased in.

• Under my plan, no family making less than $250,000 a year will see any form of tax increase. According the CBO, 3 million Americans who live in families that earn less than $120,000 per year will be hit by the individual mandate tax in 2016.

• We’re not going to mess with Medicare. Rather than save Medicare for today's retirees and future generations, the law raids Medicare by $716 billion to pay for its new spending. The majority of these cuts, more than $400 billion, fall on hospitals, skilled nursing facilities, and home health agencies. And according to Medicare’s own chief actuary, 15% of these providers will go into the red by 2019, jeopardizing seniors’ access to care.

President Obama’s $2 trillion health care law will drive up costs, drive down quality, and drive the best and brightest out of medicine. It raises taxes on middle-income families, forces millions of Americans off the coverage they already have, and does nothing to prevent the collapse of a Medicare program teetering on the edge of insolvency.

Gov. Mitt Romney (R-Mass.) has committed to repealing this disastrous law beginning on his first day in office. And he has put forward a plan to replace the president’s health care law with reforms that focus on greater patient choice and control, lower costs, and better access for every American. Under Gov. Romney’s approach, Americans will be able to purchase health coverage on the same tax-preferred basis as employers do. And he would pursue robust reforms so that control over health care decisions resides with patients, families, and doctors, instead of Washington politicians and bureaucrats.

What’s more, Gov. Romney has put forward a proposal that actually protects Medicare for current seniors and strengthens the program for future generations. Unlike President Obama, he will make no changes for those seniors on Medicare today or for those who will enroll in the next 10 years.

Future generations will have a Medicare system that works like the health care program members of Congress already have. Seniors will have the option of choosing from a set of Medicare-approved, guaranteed-coverage plans. And among these choices will be the traditional Medicare plan that exists today. The government will provide financial support to help cover the cost of whatever health plan the senior chooses, with more support for the sick and the poor and less for the wealthy. Simply put, Gov. Romney’s plan empowers 50 million seniors across the country, along with their families and doctors, to make the health care choices that are right for them, not 15 bureaucrats in Washington.

Our health care system is the best in the world, but it faces serious challenges. President Obama’s solution was to spend trillions of dollars we don’t have and empower federal regulators we don’t need, all the while raising taxes on families and job creators. The president’s health care law takes what’s broken in health care and makes it worse. Gov. Romney will repeal this law. And he will replace it with reforms that address the challenges in health care without putting Washington in charge.

Rep. Tom Price (R) represents Georgia’s 6th congressional district in the U.S. House of Representatives. He is an orthopedic surgeon and a supporter of Romney/Ryan 2012.

President Barack Obama’s health care law was, and remains, one of the more unpopular pieces of legislation in recent history. It was rammed through Congress along partisan lines, will spend trillions of dollars taking choices away from the American people, raises taxes, and raids Medicare.

The 2 years of bait and switch from President Obama about what his law would do has not convinced the American people, because they understand that at its core the law represents a fundamental change in the relationship between the people and their government. Continued public opposition is a direct response to this massive government intrusion into Americans’ personal lives.

(For a counterpoint on the 2012 election, click here.)

As I read the selling of the president’s health care law, it has consisted of one ruse after another:

• If you have insurance that you like, then you will be able to keep that insurance. In fact, the nonpartisan Congressional Budget Office (CBO) estimates that up to 20 million people could lose their employer coverage under the law.

• If you’ve got health insurance, we’re going to work with you to lower your premiums by $2,500 per family per year. Since making this promise, the average premium for a family plan has increased by more than $3,000. And according to the CBO, the law will drive up costs by nearly $2,400 when fully phased in.

• Under my plan, no family making less than $250,000 a year will see any form of tax increase. According the CBO, 3 million Americans who live in families that earn less than $120,000 per year will be hit by the individual mandate tax in 2016.

• We’re not going to mess with Medicare. Rather than save Medicare for today's retirees and future generations, the law raids Medicare by $716 billion to pay for its new spending. The majority of these cuts, more than $400 billion, fall on hospitals, skilled nursing facilities, and home health agencies. And according to Medicare’s own chief actuary, 15% of these providers will go into the red by 2019, jeopardizing seniors’ access to care.

President Obama’s $2 trillion health care law will drive up costs, drive down quality, and drive the best and brightest out of medicine. It raises taxes on middle-income families, forces millions of Americans off the coverage they already have, and does nothing to prevent the collapse of a Medicare program teetering on the edge of insolvency.

Gov. Mitt Romney (R-Mass.) has committed to repealing this disastrous law beginning on his first day in office. And he has put forward a plan to replace the president’s health care law with reforms that focus on greater patient choice and control, lower costs, and better access for every American. Under Gov. Romney’s approach, Americans will be able to purchase health coverage on the same tax-preferred basis as employers do. And he would pursue robust reforms so that control over health care decisions resides with patients, families, and doctors, instead of Washington politicians and bureaucrats.

What’s more, Gov. Romney has put forward a proposal that actually protects Medicare for current seniors and strengthens the program for future generations. Unlike President Obama, he will make no changes for those seniors on Medicare today or for those who will enroll in the next 10 years.

Future generations will have a Medicare system that works like the health care program members of Congress already have. Seniors will have the option of choosing from a set of Medicare-approved, guaranteed-coverage plans. And among these choices will be the traditional Medicare plan that exists today. The government will provide financial support to help cover the cost of whatever health plan the senior chooses, with more support for the sick and the poor and less for the wealthy. Simply put, Gov. Romney’s plan empowers 50 million seniors across the country, along with their families and doctors, to make the health care choices that are right for them, not 15 bureaucrats in Washington.

Our health care system is the best in the world, but it faces serious challenges. President Obama’s solution was to spend trillions of dollars we don’t have and empower federal regulators we don’t need, all the while raising taxes on families and job creators. The president’s health care law takes what’s broken in health care and makes it worse. Gov. Romney will repeal this law. And he will replace it with reforms that address the challenges in health care without putting Washington in charge.

Rep. Tom Price (R) represents Georgia’s 6th congressional district in the U.S. House of Representatives. He is an orthopedic surgeon and a supporter of Romney/Ryan 2012.

President Barack Obama’s health care law was, and remains, one of the more unpopular pieces of legislation in recent history. It was rammed through Congress along partisan lines, will spend trillions of dollars taking choices away from the American people, raises taxes, and raids Medicare.

The 2 years of bait and switch from President Obama about what his law would do has not convinced the American people, because they understand that at its core the law represents a fundamental change in the relationship between the people and their government. Continued public opposition is a direct response to this massive government intrusion into Americans’ personal lives.

(For a counterpoint on the 2012 election, click here.)

As I read the selling of the president’s health care law, it has consisted of one ruse after another:

• If you have insurance that you like, then you will be able to keep that insurance. In fact, the nonpartisan Congressional Budget Office (CBO) estimates that up to 20 million people could lose their employer coverage under the law.

• If you’ve got health insurance, we’re going to work with you to lower your premiums by $2,500 per family per year. Since making this promise, the average premium for a family plan has increased by more than $3,000. And according to the CBO, the law will drive up costs by nearly $2,400 when fully phased in.

• Under my plan, no family making less than $250,000 a year will see any form of tax increase. According the CBO, 3 million Americans who live in families that earn less than $120,000 per year will be hit by the individual mandate tax in 2016.

• We’re not going to mess with Medicare. Rather than save Medicare for today's retirees and future generations, the law raids Medicare by $716 billion to pay for its new spending. The majority of these cuts, more than $400 billion, fall on hospitals, skilled nursing facilities, and home health agencies. And according to Medicare’s own chief actuary, 15% of these providers will go into the red by 2019, jeopardizing seniors’ access to care.

President Obama’s $2 trillion health care law will drive up costs, drive down quality, and drive the best and brightest out of medicine. It raises taxes on middle-income families, forces millions of Americans off the coverage they already have, and does nothing to prevent the collapse of a Medicare program teetering on the edge of insolvency.

Gov. Mitt Romney (R-Mass.) has committed to repealing this disastrous law beginning on his first day in office. And he has put forward a plan to replace the president’s health care law with reforms that focus on greater patient choice and control, lower costs, and better access for every American. Under Gov. Romney’s approach, Americans will be able to purchase health coverage on the same tax-preferred basis as employers do. And he would pursue robust reforms so that control over health care decisions resides with patients, families, and doctors, instead of Washington politicians and bureaucrats.

What’s more, Gov. Romney has put forward a proposal that actually protects Medicare for current seniors and strengthens the program for future generations. Unlike President Obama, he will make no changes for those seniors on Medicare today or for those who will enroll in the next 10 years.

Future generations will have a Medicare system that works like the health care program members of Congress already have. Seniors will have the option of choosing from a set of Medicare-approved, guaranteed-coverage plans. And among these choices will be the traditional Medicare plan that exists today. The government will provide financial support to help cover the cost of whatever health plan the senior chooses, with more support for the sick and the poor and less for the wealthy. Simply put, Gov. Romney’s plan empowers 50 million seniors across the country, along with their families and doctors, to make the health care choices that are right for them, not 15 bureaucrats in Washington.

Our health care system is the best in the world, but it faces serious challenges. President Obama’s solution was to spend trillions of dollars we don’t have and empower federal regulators we don’t need, all the while raising taxes on families and job creators. The president’s health care law takes what’s broken in health care and makes it worse. Gov. Romney will repeal this law. And he will replace it with reforms that address the challenges in health care without putting Washington in charge.

Rep. Tom Price (R) represents Georgia’s 6th congressional district in the U.S. House of Representatives. He is an orthopedic surgeon and a supporter of Romney/Ryan 2012.

Physicians have a front-row seat to the health care system, and we have seen for years that it needs reform. We’ve seen patients who we know how to help, but who can’t get treatment because they are uninsured. We’ve seen our colleagues burn out as they cope with a system that doesn’t reward quality of care and that at times gives too much power to insurance companies.

These changes are what drove President Barack Obama to work with a broad coalition of health care providers, insurance companies, employers, and patients to do what presidents have been trying to do for nearly a century – sign comprehensive health reform into law. Many people told him that the time wasn’t right. But he knew that healthy economies require healthy people and that access to affordable health care was a foundation for a strong middle class.

(Click here for a counterpoint on the 2012 election.)

While it is not a perfect solution to all that ails our health care system – no law could be – the Affordable Care Act represents a giant step toward a system that works for patients and physicians, which is why it was endorsed by many physician organizations, including the American Academy of Pediatrics, American College of Physicians, American Academy of Family Physicians, and the American Medical Association. Two and a half years after its passage, the law is making a difference for millions of Americans:

• 105 million people no longer have a lifetime cap on their coverage.

• Preventive care is covered without cost sharing.

• 13 million Americans got more than $1 billion in rebates from their insurance companies.

• 3 million more young adults have coverage because they can stay on their parents’ plan until they are 26 years old.

• Up to 17 million children with preexisting conditions can’t be denied coverage.

• Medicare patients are getting free preventive care and discounts on medication as the doughnut hole is closed.

• Medicare overpayments to insurance companies are being eliminated and we are extending the life of the Medicare Trust Fund by 8 years.

• Small businesses are getting tax credits to make health insurance coverage more affordable.

This is also a time of tremendous excitement across the health care system as we move toward new models of delivering and rewarding good care. For decades, we have been saddled with a system that rewarded quantity over quality, a system that didn’t recognize the value of time we spend with patients.

This is precisely why it has been so exciting to see the response to the delivery system reforms in the ACA. All over the country, health care providers are working together to form accountable care organizations, implement bundled payments, and reduce health care–associated infections and preventable readmissions. We have started to see increases in Medicare and Medicaid reimbursements for primary care providers, general surgeons, and mental health providers. And thanks to the Recovery Act, we have made unprecedented investments in electronic health records to make our systems more efficient and safe.

The initial results are promising: We are reducing central line infections and saving lives; we are witnessing superior care coordination across our health care system; and we have seen 3 years of record-low growth in our national health expenditures. While these changes have required hard work, they represent critical steps to move our health care system forward.

President Obama knows that the health care law is a beginning and not an end. He believes we need a permanent fix to the cuts in reimbursement called for by the sustainable growth rate formula. He supports medical malpractice reform. He wants to take the lessons we learn from implementing the health care law and build on them to improve our system further.

The president also recognizes that building a better health care system requires the leadership and partnership of physicians. His administration has worked hard to collaborate with physicians, and this partnership will remain central to his efforts in a second term.

Gov. Mitt Romney (R-Mass.) offers a radically different vision for the future of our health care system. He has pledged to repeal the ACA, which would give insurance companies more control, eliminate efforts to cover 30 million Americans, and weaken the physician work force. He and his running mate, Rep. Paul Ryan (R-Wisc.), stand behind a plan to block grant Medicaid and slash its funding by a third – leaving an additional 14 to 27 million of the most vulnerable Americans uninsured. Their budget could mean drastic cuts for everything from the National Institutes of Health to the National Health Service Corps. They have also pledged to transform Medicare into a voucher program in which guaranteed benefits would be replaced by a voucher people could use to buy private insurance or traditional Medicare. However, with no guarantee that the voucher keeps up with health care costs, their plan would leave people paying thousands of dollars more every year.

President Obama fought for the ACA not because it was good politics – but because it was good for patients and the country. The law isn’t perfect, but it represents a powerful step forward that will help millions of patients.

President Obama knows we can’t afford to go back to a broken health care system and to fight the political battles of the past again. At a time when we’ve started to see progress and when we have so much more to do, we need a president who will work with us and move the country forward. That is precisely what President Obama will do.

Dr. Murthy is an internist at Brigham and Women’s Hospital in Boston. Dr. Wisdom is the senior vice president of Community Health and Equity at Henry Ford Health System in Detroit and the former Surgeon General of Michigan. Dr. Kocher is the former Special Assistant to the President for Healthcare and Economic Policy and is a guest scholar at Brookings Institution in Washington. They are volunteer advisers to Obama/Biden 2012.

Physicians have a front-row seat to the health care system, and we have seen for years that it needs reform. We’ve seen patients who we know how to help, but who can’t get treatment because they are uninsured. We’ve seen our colleagues burn out as they cope with a system that doesn’t reward quality of care and that at times gives too much power to insurance companies.

These changes are what drove President Barack Obama to work with a broad coalition of health care providers, insurance companies, employers, and patients to do what presidents have been trying to do for nearly a century – sign comprehensive health reform into law. Many people told him that the time wasn’t right. But he knew that healthy economies require healthy people and that access to affordable health care was a foundation for a strong middle class.

(Click here for a counterpoint on the 2012 election.)

While it is not a perfect solution to all that ails our health care system – no law could be – the Affordable Care Act represents a giant step toward a system that works for patients and physicians, which is why it was endorsed by many physician organizations, including the American Academy of Pediatrics, American College of Physicians, American Academy of Family Physicians, and the American Medical Association. Two and a half years after its passage, the law is making a difference for millions of Americans:

• 105 million people no longer have a lifetime cap on their coverage.

• Preventive care is covered without cost sharing.

• 13 million Americans got more than $1 billion in rebates from their insurance companies.

• 3 million more young adults have coverage because they can stay on their parents’ plan until they are 26 years old.

• Up to 17 million children with preexisting conditions can’t be denied coverage.

• Medicare patients are getting free preventive care and discounts on medication as the doughnut hole is closed.

• Medicare overpayments to insurance companies are being eliminated and we are extending the life of the Medicare Trust Fund by 8 years.

• Small businesses are getting tax credits to make health insurance coverage more affordable.

This is also a time of tremendous excitement across the health care system as we move toward new models of delivering and rewarding good care. For decades, we have been saddled with a system that rewarded quantity over quality, a system that didn’t recognize the value of time we spend with patients.

This is precisely why it has been so exciting to see the response to the delivery system reforms in the ACA. All over the country, health care providers are working together to form accountable care organizations, implement bundled payments, and reduce health care–associated infections and preventable readmissions. We have started to see increases in Medicare and Medicaid reimbursements for primary care providers, general surgeons, and mental health providers. And thanks to the Recovery Act, we have made unprecedented investments in electronic health records to make our systems more efficient and safe.

The initial results are promising: We are reducing central line infections and saving lives; we are witnessing superior care coordination across our health care system; and we have seen 3 years of record-low growth in our national health expenditures. While these changes have required hard work, they represent critical steps to move our health care system forward.

President Obama knows that the health care law is a beginning and not an end. He believes we need a permanent fix to the cuts in reimbursement called for by the sustainable growth rate formula. He supports medical malpractice reform. He wants to take the lessons we learn from implementing the health care law and build on them to improve our system further.

The president also recognizes that building a better health care system requires the leadership and partnership of physicians. His administration has worked hard to collaborate with physicians, and this partnership will remain central to his efforts in a second term.

Gov. Mitt Romney (R-Mass.) offers a radically different vision for the future of our health care system. He has pledged to repeal the ACA, which would give insurance companies more control, eliminate efforts to cover 30 million Americans, and weaken the physician work force. He and his running mate, Rep. Paul Ryan (R-Wisc.), stand behind a plan to block grant Medicaid and slash its funding by a third – leaving an additional 14 to 27 million of the most vulnerable Americans uninsured. Their budget could mean drastic cuts for everything from the National Institutes of Health to the National Health Service Corps. They have also pledged to transform Medicare into a voucher program in which guaranteed benefits would be replaced by a voucher people could use to buy private insurance or traditional Medicare. However, with no guarantee that the voucher keeps up with health care costs, their plan would leave people paying thousands of dollars more every year.

President Obama fought for the ACA not because it was good politics – but because it was good for patients and the country. The law isn’t perfect, but it represents a powerful step forward that will help millions of patients.

President Obama knows we can’t afford to go back to a broken health care system and to fight the political battles of the past again. At a time when we’ve started to see progress and when we have so much more to do, we need a president who will work with us and move the country forward. That is precisely what President Obama will do.

Dr. Murthy is an internist at Brigham and Women’s Hospital in Boston. Dr. Wisdom is the senior vice president of Community Health and Equity at Henry Ford Health System in Detroit and the former Surgeon General of Michigan. Dr. Kocher is the former Special Assistant to the President for Healthcare and Economic Policy and is a guest scholar at Brookings Institution in Washington. They are volunteer advisers to Obama/Biden 2012.

Physicians have a front-row seat to the health care system, and we have seen for years that it needs reform. We’ve seen patients who we know how to help, but who can’t get treatment because they are uninsured. We’ve seen our colleagues burn out as they cope with a system that doesn’t reward quality of care and that at times gives too much power to insurance companies.

These changes are what drove President Barack Obama to work with a broad coalition of health care providers, insurance companies, employers, and patients to do what presidents have been trying to do for nearly a century – sign comprehensive health reform into law. Many people told him that the time wasn’t right. But he knew that healthy economies require healthy people and that access to affordable health care was a foundation for a strong middle class.

(Click here for a counterpoint on the 2012 election.)

While it is not a perfect solution to all that ails our health care system – no law could be – the Affordable Care Act represents a giant step toward a system that works for patients and physicians, which is why it was endorsed by many physician organizations, including the American Academy of Pediatrics, American College of Physicians, American Academy of Family Physicians, and the American Medical Association. Two and a half years after its passage, the law is making a difference for millions of Americans:

• 105 million people no longer have a lifetime cap on their coverage.

• Preventive care is covered without cost sharing.

• 13 million Americans got more than $1 billion in rebates from their insurance companies.

• 3 million more young adults have coverage because they can stay on their parents’ plan until they are 26 years old.

• Up to 17 million children with preexisting conditions can’t be denied coverage.

• Medicare patients are getting free preventive care and discounts on medication as the doughnut hole is closed.

• Medicare overpayments to insurance companies are being eliminated and we are extending the life of the Medicare Trust Fund by 8 years.

• Small businesses are getting tax credits to make health insurance coverage more affordable.

This is also a time of tremendous excitement across the health care system as we move toward new models of delivering and rewarding good care. For decades, we have been saddled with a system that rewarded quantity over quality, a system that didn’t recognize the value of time we spend with patients.

This is precisely why it has been so exciting to see the response to the delivery system reforms in the ACA. All over the country, health care providers are working together to form accountable care organizations, implement bundled payments, and reduce health care–associated infections and preventable readmissions. We have started to see increases in Medicare and Medicaid reimbursements for primary care providers, general surgeons, and mental health providers. And thanks to the Recovery Act, we have made unprecedented investments in electronic health records to make our systems more efficient and safe.

The initial results are promising: We are reducing central line infections and saving lives; we are witnessing superior care coordination across our health care system; and we have seen 3 years of record-low growth in our national health expenditures. While these changes have required hard work, they represent critical steps to move our health care system forward.

President Obama knows that the health care law is a beginning and not an end. He believes we need a permanent fix to the cuts in reimbursement called for by the sustainable growth rate formula. He supports medical malpractice reform. He wants to take the lessons we learn from implementing the health care law and build on them to improve our system further.

The president also recognizes that building a better health care system requires the leadership and partnership of physicians. His administration has worked hard to collaborate with physicians, and this partnership will remain central to his efforts in a second term.

Gov. Mitt Romney (R-Mass.) offers a radically different vision for the future of our health care system. He has pledged to repeal the ACA, which would give insurance companies more control, eliminate efforts to cover 30 million Americans, and weaken the physician work force. He and his running mate, Rep. Paul Ryan (R-Wisc.), stand behind a plan to block grant Medicaid and slash its funding by a third – leaving an additional 14 to 27 million of the most vulnerable Americans uninsured. Their budget could mean drastic cuts for everything from the National Institutes of Health to the National Health Service Corps. They have also pledged to transform Medicare into a voucher program in which guaranteed benefits would be replaced by a voucher people could use to buy private insurance or traditional Medicare. However, with no guarantee that the voucher keeps up with health care costs, their plan would leave people paying thousands of dollars more every year.

President Obama fought for the ACA not because it was good politics – but because it was good for patients and the country. The law isn’t perfect, but it represents a powerful step forward that will help millions of patients.

President Obama knows we can’t afford to go back to a broken health care system and to fight the political battles of the past again. At a time when we’ve started to see progress and when we have so much more to do, we need a president who will work with us and move the country forward. That is precisely what President Obama will do.

Dr. Murthy is an internist at Brigham and Women’s Hospital in Boston. Dr. Wisdom is the senior vice president of Community Health and Equity at Henry Ford Health System in Detroit and the former Surgeon General of Michigan. Dr. Kocher is the former Special Assistant to the President for Healthcare and Economic Policy and is a guest scholar at Brookings Institution in Washington. They are volunteer advisers to Obama/Biden 2012.

Starting in 2014, the Affordable Care Act requires states to offer Medicaid coverage to individuals under age 65 who earn less than 133% of the poverty level (about $29,000 for a family of four). While a few states already cover these people, for most states this would be the first time that Medicaid coverage was available to nondisabled adults without children.

But it is unclear how many states will expand their Medicaid programs. In June, the Supreme Court found that Congress had overstepped its powers when it mandated the expansion. However, the high court said the expansion could move forward if states were given the opportunity to opt out and simply forfeit the associated federal matching funds.

The Congressional Budget Office estimates that 11 million people will gain Medicaid coverage; that’s compared with a projected 17 million before the Supreme Court decision.

Dr. David L. Bronson, president of the American College of Physicians, explained the possible impact of the Supreme Court’s ruling and the ACP’s views on the Medicaid expansion.

Question: Now that the Supreme Court has made the Medicaid expansion optional for states, what is the implementation likely to look like around the country?

Dr. Bronson: We feel the implementation will be challenging in some states. Many states will jump in right away and take advantage of the opportunity. Other states have indicated they don’t intend to participate. By comparison, Medicaid was originally passed in 1965, and it took until 1982 before Arizona actually joined the program. Hopefully it won’t take 17 years to get all the states participating. We’re hopeful that within a few years, all of the states will participate.

Question: If Medicaid expansion ends up being a patchwork, what will that mean for patient access?

Dr. Bronson: Access will depend on where you live. That will really be a very dysfunctional system.

Question: The ACA calls for covering low-income childless adults for the first time in many places. Is this a population that is currently falling through the cracks?

Dr. Bronson: Absolutely. This is a major gap in the current coverage system. This is a vitally important group to get covered. The practical difference is that if these people can be covered, they hopefully would be able to have their chronic medical problems managed, reducing the burden on the entire health care system. They would be a lot healthier because they would avoid complications of their chronic conditions. It would also help prevent both premature death and disability and all the health care expenses associated with sickness and disability. It’s really a big deal.

Question: Will the expansion of Medicaid guarantee access to care, or will low reimbursement for physicians cancel that out in some cases?

Dr. Bronson: It’s going to be a challenge. Some of those challenges are being addressed on the primary care side by increasing the Medicaid payment level to the Medicare level for at least 2 years. We are hopeful that will be extended beyond the initial period. If you don’t have primary care access, you can’t make the system work. Traditionally, many specialties have done reasonably well under Medicaid on the procedural side, though not on the evaluation and management side. So with specialists, access should be less of a problem. If primary care physicians and those that provide cognitive services are reimbursed at Medicare levels, I think that will help maintain access.

Question: What’s the impact of the ACA’s provision to temporarily boost Medicaid payments to Medicare levels through 2014? What happens if that provision is not extended?

Dr. Bronson: It makes a very large difference to the primary care practices. If you’re extremely efficient in your practice and you have a low cost structure, you might break even with Medicare, but you’ll never break even with Medicaid in primary care. Having that provision really helps primary care practices survive and serve that population. We are hopeful that over that 2-year period we will see improved access to patients and that will lead to an extension of the increased payments on a more permanent basis.

Question: What do physicians need to know about the Medicaid expansion in their states?

Dr. Bronson: Having health care coverage available to every American is a long-term policy goal of a lot of organizations, including the American College of Physicians. It’s simply the right thing to do. Physicians should know that the ACA is the only active, passed legislation that accomplishes it. Although it may not be ideal, waiting another 10 years to find a new solution only leaves us with 10 years of people with inadequate health care. We would encourage physicians to get behind the Medicaid expansion because it’s the right thing to do.

Dr. Bronson is the president of the American College of Physicians. He is also president of the Cleveland Clinic Regional Hospitals and a professor of medicine at the Cleveland Clinic’s Lerner College of Medicine of Case Western Reserve University.

Starting in 2014, the Affordable Care Act requires states to offer Medicaid coverage to individuals under age 65 who earn less than 133% of the poverty level (about $29,000 for a family of four). While a few states already cover these people, for most states this would be the first time that Medicaid coverage was available to nondisabled adults without children.

But it is unclear how many states will expand their Medicaid programs. In June, the Supreme Court found that Congress had overstepped its powers when it mandated the expansion. However, the high court said the expansion could move forward if states were given the opportunity to opt out and simply forfeit the associated federal matching funds.

The Congressional Budget Office estimates that 11 million people will gain Medicaid coverage; that’s compared with a projected 17 million before the Supreme Court decision.

Dr. David L. Bronson, president of the American College of Physicians, explained the possible impact of the Supreme Court’s ruling and the ACP’s views on the Medicaid expansion.

Question: Now that the Supreme Court has made the Medicaid expansion optional for states, what is the implementation likely to look like around the country?

Dr. Bronson: We feel the implementation will be challenging in some states. Many states will jump in right away and take advantage of the opportunity. Other states have indicated they don’t intend to participate. By comparison, Medicaid was originally passed in 1965, and it took until 1982 before Arizona actually joined the program. Hopefully it won’t take 17 years to get all the states participating. We’re hopeful that within a few years, all of the states will participate.

Question: If Medicaid expansion ends up being a patchwork, what will that mean for patient access?

Dr. Bronson: Access will depend on where you live. That will really be a very dysfunctional system.

Question: The ACA calls for covering low-income childless adults for the first time in many places. Is this a population that is currently falling through the cracks?

Dr. Bronson: Absolutely. This is a major gap in the current coverage system. This is a vitally important group to get covered. The practical difference is that if these people can be covered, they hopefully would be able to have their chronic medical problems managed, reducing the burden on the entire health care system. They would be a lot healthier because they would avoid complications of their chronic conditions. It would also help prevent both premature death and disability and all the health care expenses associated with sickness and disability. It’s really a big deal.

Question: Will the expansion of Medicaid guarantee access to care, or will low reimbursement for physicians cancel that out in some cases?

Dr. Bronson: It’s going to be a challenge. Some of those challenges are being addressed on the primary care side by increasing the Medicaid payment level to the Medicare level for at least 2 years. We are hopeful that will be extended beyond the initial period. If you don’t have primary care access, you can’t make the system work. Traditionally, many specialties have done reasonably well under Medicaid on the procedural side, though not on the evaluation and management side. So with specialists, access should be less of a problem. If primary care physicians and those that provide cognitive services are reimbursed at Medicare levels, I think that will help maintain access.

Question: What’s the impact of the ACA’s provision to temporarily boost Medicaid payments to Medicare levels through 2014? What happens if that provision is not extended?

Dr. Bronson: It makes a very large difference to the primary care practices. If you’re extremely efficient in your practice and you have a low cost structure, you might break even with Medicare, but you’ll never break even with Medicaid in primary care. Having that provision really helps primary care practices survive and serve that population. We are hopeful that over that 2-year period we will see improved access to patients and that will lead to an extension of the increased payments on a more permanent basis.

Question: What do physicians need to know about the Medicaid expansion in their states?

Dr. Bronson: Having health care coverage available to every American is a long-term policy goal of a lot of organizations, including the American College of Physicians. It’s simply the right thing to do. Physicians should know that the ACA is the only active, passed legislation that accomplishes it. Although it may not be ideal, waiting another 10 years to find a new solution only leaves us with 10 years of people with inadequate health care. We would encourage physicians to get behind the Medicaid expansion because it’s the right thing to do.

Dr. Bronson is the president of the American College of Physicians. He is also president of the Cleveland Clinic Regional Hospitals and a professor of medicine at the Cleveland Clinic’s Lerner College of Medicine of Case Western Reserve University.

Starting in 2014, the Affordable Care Act requires states to offer Medicaid coverage to individuals under age 65 who earn less than 133% of the poverty level (about $29,000 for a family of four). While a few states already cover these people, for most states this would be the first time that Medicaid coverage was available to nondisabled adults without children.

But it is unclear how many states will expand their Medicaid programs. In June, the Supreme Court found that Congress had overstepped its powers when it mandated the expansion. However, the high court said the expansion could move forward if states were given the opportunity to opt out and simply forfeit the associated federal matching funds.

The Congressional Budget Office estimates that 11 million people will gain Medicaid coverage; that’s compared with a projected 17 million before the Supreme Court decision.

Dr. David L. Bronson, president of the American College of Physicians, explained the possible impact of the Supreme Court’s ruling and the ACP’s views on the Medicaid expansion.

Question: Now that the Supreme Court has made the Medicaid expansion optional for states, what is the implementation likely to look like around the country?

Dr. Bronson: We feel the implementation will be challenging in some states. Many states will jump in right away and take advantage of the opportunity. Other states have indicated they don’t intend to participate. By comparison, Medicaid was originally passed in 1965, and it took until 1982 before Arizona actually joined the program. Hopefully it won’t take 17 years to get all the states participating. We’re hopeful that within a few years, all of the states will participate.

Question: If Medicaid expansion ends up being a patchwork, what will that mean for patient access?

Dr. Bronson: Access will depend on where you live. That will really be a very dysfunctional system.

Question: The ACA calls for covering low-income childless adults for the first time in many places. Is this a population that is currently falling through the cracks?

Dr. Bronson: Absolutely. This is a major gap in the current coverage system. This is a vitally important group to get covered. The practical difference is that if these people can be covered, they hopefully would be able to have their chronic medical problems managed, reducing the burden on the entire health care system. They would be a lot healthier because they would avoid complications of their chronic conditions. It would also help prevent both premature death and disability and all the health care expenses associated with sickness and disability. It’s really a big deal.

Question: Will the expansion of Medicaid guarantee access to care, or will low reimbursement for physicians cancel that out in some cases?

Dr. Bronson: It’s going to be a challenge. Some of those challenges are being addressed on the primary care side by increasing the Medicaid payment level to the Medicare level for at least 2 years. We are hopeful that will be extended beyond the initial period. If you don’t have primary care access, you can’t make the system work. Traditionally, many specialties have done reasonably well under Medicaid on the procedural side, though not on the evaluation and management side. So with specialists, access should be less of a problem. If primary care physicians and those that provide cognitive services are reimbursed at Medicare levels, I think that will help maintain access.

Question: What’s the impact of the ACA’s provision to temporarily boost Medicaid payments to Medicare levels through 2014? What happens if that provision is not extended?

Dr. Bronson: It makes a very large difference to the primary care practices. If you’re extremely efficient in your practice and you have a low cost structure, you might break even with Medicare, but you’ll never break even with Medicaid in primary care. Having that provision really helps primary care practices survive and serve that population. We are hopeful that over that 2-year period we will see improved access to patients and that will lead to an extension of the increased payments on a more permanent basis.

Question: What do physicians need to know about the Medicaid expansion in their states?

Dr. Bronson: Having health care coverage available to every American is a long-term policy goal of a lot of organizations, including the American College of Physicians. It’s simply the right thing to do. Physicians should know that the ACA is the only active, passed legislation that accomplishes it. Although it may not be ideal, waiting another 10 years to find a new solution only leaves us with 10 years of people with inadequate health care. We would encourage physicians to get behind the Medicaid expansion because it’s the right thing to do.

Dr. Bronson is the president of the American College of Physicians. He is also president of the Cleveland Clinic Regional Hospitals and a professor of medicine at the Cleveland Clinic’s Lerner College of Medicine of Case Western Reserve University.

Starting in 2015, Medicare-participating physicians will be paid in part based on the quality and cost of the care they provide. That’s when the Centers for Medicare and Medicaid Services will begin to apply a value-based modifier to Medicare fee-for-service payments.

Some doctors will be rewarded for providing high-quality, low-cost care, but others will be penalized for low-quality, high-cost work. Those in the middle of the cost and quality spectrum will see no financial impact.

To come up with the value-based modifier, the CMS will begin measuring cost and quality for groups of 25 or more next year, based in part on data reported to the PQRS (Physician Quality Reporting System). Group practices of 25 or more that don’t participate in the PQRS in 2013 will see a 1% Medicare pay cut; those that successfully report will be able to choose between their standard fee-for-service payment or payments adjusted based on quality and cost.

Jonathan Blum and Dr. Patrick Conway of the CMS discussed how the program will work.

QUESTION: Does the timeline for the program mean that all physicians in groups of 25 or more should start participating in PQRS next year, if they haven’t already?

Mr. Blum: Yes, our goals are to encourage participation in [PQRS] and for physician groups to use the information and feedback to improve the care that their patients receive.

QUESTION: The program allows physician groups that successfully participate in PQRS to opt for a 0% modifier rather than take on risk based on quality and cost. Will that option continue?

Dr. Conway: We are seeking comment on whether to continue with this option in future years.

QUESTION: What can physicians do to prepare for this program?

Dr. Conway: Participate in the PQRS, because it makes sense to [do so]. We know the adage that "what gets measured gets done" is true, and PQRS gives physicians and other clinical professionals the opportunity to put administrative practices in place that allow for such performance measurement to take place. Also, participating in PQRS helps physicians avoid a PQRS- and value-based modifier downward adjustment. Lastly, I recommend that physicians review the group feedback report they will receive next year to help inform their decision about whether to elect the value-based modifier.

QUESTION: Is it necessary to have an EHR (electronic health record) to participate?

Mr. Blum: No. Physicians and physicians’ groups can submit data for the PQRS using registries and claims as well. Groups of physicians also can use the Group Practice Reporting Option web interface, which does not require an EHR but can accept data from electronic sources.

QUESTION: When will physicians in small groups be impacted by the value-based modifier?

Mr. Blum: The statute requires [that] the value-based payment modifier cover all physicians by 2017.

QUESTION: Do you think the incentives under the value-based modifier will be significant enough to change how care is delivered?

Mr. Blum: We have started the program cautiously, by providing for a possible 1% negative payment adjustment for low-quality, high-cost care or for failure to satisfactorily participate in PQRS. We’ve also proposed that the biggest payment adjustments go to groups of physicians with high-quality, low-cost care [delivered] to the highest risk patients.

Dr. Conway: As we move forward, we will assess whether and how to adjust the incentives to encourage better care. We believe physician groups will be able to participate in PQRS in 2013 successfully; receive a PQRS incentive payment; avoid the PQRS and value-based modifier downward adjustment; and have the opportunity to elect the value-based modifier for an upward payment adjustment for providing low-cost, high-quality care to their patients.

Mr. Blum is the acting principal deputy administrator and director of the Center for Medicare at the CMS. Dr. Conway is the agency’s chief medical officer and director of the Center for Clinical Standards and Quality.

Starting in 2015, Medicare-participating physicians will be paid in part based on the quality and cost of the care they provide. That’s when the Centers for Medicare and Medicaid Services will begin to apply a value-based modifier to Medicare fee-for-service payments.

Some doctors will be rewarded for providing high-quality, low-cost care, but others will be penalized for low-quality, high-cost work. Those in the middle of the cost and quality spectrum will see no financial impact.

To come up with the value-based modifier, the CMS will begin measuring cost and quality for groups of 25 or more next year, based in part on data reported to the PQRS (Physician Quality Reporting System). Group practices of 25 or more that don’t participate in the PQRS in 2013 will see a 1% Medicare pay cut; those that successfully report will be able to choose between their standard fee-for-service payment or payments adjusted based on quality and cost.

Jonathan Blum and Dr. Patrick Conway of the CMS discussed how the program will work.

QUESTION: Does the timeline for the program mean that all physicians in groups of 25 or more should start participating in PQRS next year, if they haven’t already?

Mr. Blum: Yes, our goals are to encourage participation in [PQRS] and for physician groups to use the information and feedback to improve the care that their patients receive.

QUESTION: The program allows physician groups that successfully participate in PQRS to opt for a 0% modifier rather than take on risk based on quality and cost. Will that option continue?

Dr. Conway: We are seeking comment on whether to continue with this option in future years.

QUESTION: What can physicians do to prepare for this program?

Dr. Conway: Participate in the PQRS, because it makes sense to [do so]. We know the adage that "what gets measured gets done" is true, and PQRS gives physicians and other clinical professionals the opportunity to put administrative practices in place that allow for such performance measurement to take place. Also, participating in PQRS helps physicians avoid a PQRS- and value-based modifier downward adjustment. Lastly, I recommend that physicians review the group feedback report they will receive next year to help inform their decision about whether to elect the value-based modifier.

QUESTION: Is it necessary to have an EHR (electronic health record) to participate?

Mr. Blum: No. Physicians and physicians’ groups can submit data for the PQRS using registries and claims as well. Groups of physicians also can use the Group Practice Reporting Option web interface, which does not require an EHR but can accept data from electronic sources.

QUESTION: When will physicians in small groups be impacted by the value-based modifier?

Mr. Blum: The statute requires [that] the value-based payment modifier cover all physicians by 2017.

QUESTION: Do you think the incentives under the value-based modifier will be significant enough to change how care is delivered?

Mr. Blum: We have started the program cautiously, by providing for a possible 1% negative payment adjustment for low-quality, high-cost care or for failure to satisfactorily participate in PQRS. We’ve also proposed that the biggest payment adjustments go to groups of physicians with high-quality, low-cost care [delivered] to the highest risk patients.

Dr. Conway: As we move forward, we will assess whether and how to adjust the incentives to encourage better care. We believe physician groups will be able to participate in PQRS in 2013 successfully; receive a PQRS incentive payment; avoid the PQRS and value-based modifier downward adjustment; and have the opportunity to elect the value-based modifier for an upward payment adjustment for providing low-cost, high-quality care to their patients.

Mr. Blum is the acting principal deputy administrator and director of the Center for Medicare at the CMS. Dr. Conway is the agency’s chief medical officer and director of the Center for Clinical Standards and Quality.

Starting in 2015, Medicare-participating physicians will be paid in part based on the quality and cost of the care they provide. That’s when the Centers for Medicare and Medicaid Services will begin to apply a value-based modifier to Medicare fee-for-service payments.

Some doctors will be rewarded for providing high-quality, low-cost care, but others will be penalized for low-quality, high-cost work. Those in the middle of the cost and quality spectrum will see no financial impact.

To come up with the value-based modifier, the CMS will begin measuring cost and quality for groups of 25 or more next year, based in part on data reported to the PQRS (Physician Quality Reporting System). Group practices of 25 or more that don’t participate in the PQRS in 2013 will see a 1% Medicare pay cut; those that successfully report will be able to choose between their standard fee-for-service payment or payments adjusted based on quality and cost.

Jonathan Blum and Dr. Patrick Conway of the CMS discussed how the program will work.

QUESTION: Does the timeline for the program mean that all physicians in groups of 25 or more should start participating in PQRS next year, if they haven’t already?

Mr. Blum: Yes, our goals are to encourage participation in [PQRS] and for physician groups to use the information and feedback to improve the care that their patients receive.

QUESTION: The program allows physician groups that successfully participate in PQRS to opt for a 0% modifier rather than take on risk based on quality and cost. Will that option continue?

Dr. Conway: We are seeking comment on whether to continue with this option in future years.

QUESTION: What can physicians do to prepare for this program?

Dr. Conway: Participate in the PQRS, because it makes sense to [do so]. We know the adage that "what gets measured gets done" is true, and PQRS gives physicians and other clinical professionals the opportunity to put administrative practices in place that allow for such performance measurement to take place. Also, participating in PQRS helps physicians avoid a PQRS- and value-based modifier downward adjustment. Lastly, I recommend that physicians review the group feedback report they will receive next year to help inform their decision about whether to elect the value-based modifier.

QUESTION: Is it necessary to have an EHR (electronic health record) to participate?

Mr. Blum: No. Physicians and physicians’ groups can submit data for the PQRS using registries and claims as well. Groups of physicians also can use the Group Practice Reporting Option web interface, which does not require an EHR but can accept data from electronic sources.

QUESTION: When will physicians in small groups be impacted by the value-based modifier?

Mr. Blum: The statute requires [that] the value-based payment modifier cover all physicians by 2017.

QUESTION: Do you think the incentives under the value-based modifier will be significant enough to change how care is delivered?

Mr. Blum: We have started the program cautiously, by providing for a possible 1% negative payment adjustment for low-quality, high-cost care or for failure to satisfactorily participate in PQRS. We’ve also proposed that the biggest payment adjustments go to groups of physicians with high-quality, low-cost care [delivered] to the highest risk patients.

Dr. Conway: As we move forward, we will assess whether and how to adjust the incentives to encourage better care. We believe physician groups will be able to participate in PQRS in 2013 successfully; receive a PQRS incentive payment; avoid the PQRS and value-based modifier downward adjustment; and have the opportunity to elect the value-based modifier for an upward payment adjustment for providing low-cost, high-quality care to their patients.

Mr. Blum is the acting principal deputy administrator and director of the Center for Medicare at the CMS. Dr. Conway is the agency’s chief medical officer and director of the Center for Clinical Standards and Quality.

The federal government is requiring health plans to make it easier for physicians to get paid electronically.

On Aug. 7, the Department of Health and Human Services released new rules for health care electronic funds transfers (EFT) and electronic remittance advice (ERA). Starting Jan. 1, 2014, health plans must offer a standardized, online form for physicians and hospitals to enroll to electronically receive payments, as well as notices about claims adjustments and denials. The new rules are required under the Affordable Care Act.

©Brian Jackson/iStockphoto.com

"These new rules will cut red tape, save money, and ensure doctors spend more time seeing patients and less time filling out forms," HHS Secretary Kathleen Sebelius said in a statement.

The requirements could help shift more physician practices away from paper billing. About 70% of health care claim payments are still made in paper check form, according to HHS.

The interim final rule from HHS does not require physicians and hospitals to accept electronic payments. However, if they do, the agency estimates that they will save time and money. For example, practices will save time in handling payment denials since health plans are required to simplify the codes used to explain whether a claim is paid and why.

The net savings to the health care industry from the new electronic standards will be between $300 million and $3.3 billion over 10 years, according to the final rule. HHS officials predicted that most of the implementation cost would be borne by health plans, but most of the benefits would go to providers.

The interim final rule with comment period will be published in the Federal Register on Aug. 10. The public comment period closes on Oct. 9.

The federal government is requiring health plans to make it easier for physicians to get paid electronically.

On Aug. 7, the Department of Health and Human Services released new rules for health care electronic funds transfers (EFT) and electronic remittance advice (ERA). Starting Jan. 1, 2014, health plans must offer a standardized, online form for physicians and hospitals to enroll to electronically receive payments, as well as notices about claims adjustments and denials. The new rules are required under the Affordable Care Act.

©Brian Jackson/iStockphoto.com

"These new rules will cut red tape, save money, and ensure doctors spend more time seeing patients and less time filling out forms," HHS Secretary Kathleen Sebelius said in a statement.

The requirements could help shift more physician practices away from paper billing. About 70% of health care claim payments are still made in paper check form, according to HHS.

The interim final rule from HHS does not require physicians and hospitals to accept electronic payments. However, if they do, the agency estimates that they will save time and money. For example, practices will save time in handling payment denials since health plans are required to simplify the codes used to explain whether a claim is paid and why.

The net savings to the health care industry from the new electronic standards will be between $300 million and $3.3 billion over 10 years, according to the final rule. HHS officials predicted that most of the implementation cost would be borne by health plans, but most of the benefits would go to providers.

The interim final rule with comment period will be published in the Federal Register on Aug. 10. The public comment period closes on Oct. 9.

The federal government is requiring health plans to make it easier for physicians to get paid electronically.

On Aug. 7, the Department of Health and Human Services released new rules for health care electronic funds transfers (EFT) and electronic remittance advice (ERA). Starting Jan. 1, 2014, health plans must offer a standardized, online form for physicians and hospitals to enroll to electronically receive payments, as well as notices about claims adjustments and denials. The new rules are required under the Affordable Care Act.

©Brian Jackson/iStockphoto.com

"These new rules will cut red tape, save money, and ensure doctors spend more time seeing patients and less time filling out forms," HHS Secretary Kathleen Sebelius said in a statement.

The requirements could help shift more physician practices away from paper billing. About 70% of health care claim payments are still made in paper check form, according to HHS.

The interim final rule from HHS does not require physicians and hospitals to accept electronic payments. However, if they do, the agency estimates that they will save time and money. For example, practices will save time in handling payment denials since health plans are required to simplify the codes used to explain whether a claim is paid and why.

The net savings to the health care industry from the new electronic standards will be between $300 million and $3.3 billion over 10 years, according to the final rule. HHS officials predicted that most of the implementation cost would be borne by health plans, but most of the benefits would go to providers.

The interim final rule with comment period will be published in the Federal Register on Aug. 10. The public comment period closes on Oct. 9.

From abortion restrictions to emergency department caps, state legislatures are having a big say in the practice of medicine.

Over the last year, states have considered major cuts to Medicaid funding, criminal penalties associated with performing abortions, new mandates for continuing medical education (CME), enlarging the scope of practice for certain mid-level providers, and the list goes on.

Not all the bills have made it into law, and doctors have worked overtime to stop or alter these proposals.

"State legislatures probably impact the daily practice of medicine more than [Congress does]," said Dr. Dan K. Morhaim, a practicing internist and delegate to the Maryland General Assembly.

Licensing, CME requirements, loan forgiveness, scope of practice, insurance and hospital regulation, physician payment, and malpractice – each affects day-to-day practice and states have a hand in all of them, said Dr. Morhaim, a Democrat who serves as the deputy majority leader in the Maryland House of Delegates.

Even some of key federal efforts – such as the Affordable Care Act and incentives for the adoption of electronic health records – are being implemented in part by the states, he said.

During the recent Maryland legislative session, physicians scored a big win with the passage of a bill to standardize and automate prior authorization requests. The issue had been on the table for a few years, Dr. Morhaim said, but physicians finally argued successfully that the volume of prior authorization paperwork was driving up costs and slowing down care.

The bill requires payers to establish an online prior authorization system by next summer.

Fighting ED Caps

Meanwhile, in Washington state, physicians worked with lawmakers to stop a policy that would have eliminated Medicaid payments for any emergency department visit deemed "not medically necessary."

Under a proposal put forward by the Washington Health Care Authority in January, Medicaid would have paid for ED visits only if the ED was the medically necessary setting for care.

The Washington State Medical Association, the Washington State Hospital Association, and the Washington Chapter of the American College of Emergency Physicians, joined forces to stop the proposal. The alternative proposal they championed was adopted by the legislature in April.

The alternative calls on hospitals to adopt best practices such as extensive case management for frequent ED users, timely follow-up by primary care physicians, controls on narcotic prescribing, and better emergency visit tracking. Hospitals must implement the best practices this summer and show a reduction in the number of preventable ED visits by January 2013.

Dr. Nathan Schlicher, an emergency physician in Tacoma and the legislative affairs chairman for the state ACEP chapter, said he’s hopeful that the Washington state agreement can be a model for other cash-strapped states looking to cut down on unnecessary ED care.

The key to their success was having an alternative plan to offer to the legislature, Dr. Schlicher said.

"You can’t just say no," he said. "Saying no is not a solution."

Controlling Costs

In an effort to curb their state’s growing budget deficit, Texas legislators in 2011 cut payments to doctors treating patients eligible for both Medicare and Medicaid by about 20%.

The cut means that fewer and fewer physicians are willing to take on new Medicaid patients, said Dr. Michael E. Speer, president of the Texas Medical Association (TMA) and a professor of pediatrics and ethics at Baylor College, Houston.

As a result, hospitals located in Medicaid-heavy environments are seeing more of these patients – and they are presenting when they are sicker, requiring more care and more expensive care, Dr. Speer said.

That’s the case the TMA will be make to lawmakers when they return to the statehouse in 2013.

"This is not saving money," he said. "This is actually spending more money."

Massachusetts is also looking at ways to control costs as it continues to implement its landmark health reform law.

Photos courtesy Flickr Creative Commons and Wikimedia Commons

This year, the Massachusetts legislature is considering bills to curb the growth in health care costs by gradually moving away from the current fee-for-service system. The bills would provide bonus Medicaid payments next summer for providers who choose alternative payment models, such as global payments through an accountable care organization.

The bills also require the use of electronic health records and outline greater public reporting of quality and cost data. One of the bills includes a "luxury tax" on physicians and other providers whose costs exceed certain benchmarks.

Separate similar bills have passed the Massachusetts House and Senate; a joint committee is now working out the differences.

The Massachusetts Medical Society hasn’t endorsed either of the plans, but urged lawmakers to take a "market-led" approach, avoid unnecessary bureaucracy in setting these new requirements and to provide additional support for the transition to EHRs.

One bright spot in the bills is the inclusion of a disclosure, apology, and offer provision that sets a 182-day cooling off period after the filing of malpractice claim. The disclosure, apology, and offer policy would allow for an open, transparent discussion and the ability to provide compensation to patients when appropriate, according to Dr. Richard V. Aghababian, president of the Massachusetts Medical Society.

Abortion Politics

In just the first 3 months of this year, lawmakers around the country introduced more than 900 provisions related to reproductive health; about half were restrictions on abortion, according to an analysis from the Guttmacher Institute.

Among the trends noted by the Guttmacher analysts is a move to require an ultrasound before abortion and restrictions on non-surgical abortions.

Kathryn Moore, director of state government affairs at the American College of Obstetricians and Gynecologists, said that in the last year or so, she’s seen a "more aggressive effort" to legislate reproductive health issues than she’s seen in several years.

The Virginia legislation that got a lot of attention requires women to have an ultrasound at least 24 hours before they can obtain an abortion. Women will be offered the chance to view the ultrasound image but can refuse. Physicians who fail to comply with the law could face a $2,500 fine.

Gov. Bob McDonnell (R) signed the law in March; it goes into effect this summer.

State lawmakers revised the law’s original language, which would have required a transvaginal ultrasound.

Earlier this year in Georgia, the legislature passed a bill criminalizing abortion after 20 weeks from fertilization. The new law is problematic because it limits the ability of ob.gyns. to identify pregnancies in which a fetus is going to be nonviable but could carry to term, said Dr. Sandra B. Reed, and ob.gyn. and president of the Medical Association of Georgia.

"I don’t like it," Dr. Reed said. "They are legislating medical care and they didn’t go to medical school. They don’t understand all of the ramifications of what they are doing in a day-to-day practice."

From abortion restrictions to emergency department caps, state legislatures are having a big say in the practice of medicine.

Over the last year, states have considered major cuts to Medicaid funding, criminal penalties associated with performing abortions, new mandates for continuing medical education (CME), enlarging the scope of practice for certain mid-level providers, and the list goes on.

Not all the bills have made it into law, and doctors have worked overtime to stop or alter these proposals.

"State legislatures probably impact the daily practice of medicine more than [Congress does]," said Dr. Dan K. Morhaim, a practicing internist and delegate to the Maryland General Assembly.

Licensing, CME requirements, loan forgiveness, scope of practice, insurance and hospital regulation, physician payment, and malpractice – each affects day-to-day practice and states have a hand in all of them, said Dr. Morhaim, a Democrat who serves as the deputy majority leader in the Maryland House of Delegates.

Even some of key federal efforts – such as the Affordable Care Act and incentives for the adoption of electronic health records – are being implemented in part by the states, he said.

During the recent Maryland legislative session, physicians scored a big win with the passage of a bill to standardize and automate prior authorization requests. The issue had been on the table for a few years, Dr. Morhaim said, but physicians finally argued successfully that the volume of prior authorization paperwork was driving up costs and slowing down care.

The bill requires payers to establish an online prior authorization system by next summer.

Fighting ED Caps

Meanwhile, in Washington state, physicians worked with lawmakers to stop a policy that would have eliminated Medicaid payments for any emergency department visit deemed "not medically necessary."

Under a proposal put forward by the Washington Health Care Authority in January, Medicaid would have paid for ED visits only if the ED was the medically necessary setting for care.

The Washington State Medical Association, the Washington State Hospital Association, and the Washington Chapter of the American College of Emergency Physicians, joined forces to stop the proposal. The alternative proposal they championed was adopted by the legislature in April.

The alternative calls on hospitals to adopt best practices such as extensive case management for frequent ED users, timely follow-up by primary care physicians, controls on narcotic prescribing, and better emergency visit tracking. Hospitals must implement the best practices this summer and show a reduction in the number of preventable ED visits by January 2013.

Dr. Nathan Schlicher, an emergency physician in Tacoma and the legislative affairs chairman for the state ACEP chapter, said he’s hopeful that the Washington state agreement can be a model for other cash-strapped states looking to cut down on unnecessary ED care.

The key to their success was having an alternative plan to offer to the legislature, Dr. Schlicher said.

"You can’t just say no," he said. "Saying no is not a solution."

Controlling Costs

In an effort to curb their state’s growing budget deficit, Texas legislators in 2011 cut payments to doctors treating patients eligible for both Medicare and Medicaid by about 20%.

The cut means that fewer and fewer physicians are willing to take on new Medicaid patients, said Dr. Michael E. Speer, president of the Texas Medical Association (TMA) and a professor of pediatrics and ethics at Baylor College, Houston.

As a result, hospitals located in Medicaid-heavy environments are seeing more of these patients – and they are presenting when they are sicker, requiring more care and more expensive care, Dr. Speer said.

That’s the case the TMA will be make to lawmakers when they return to the statehouse in 2013.

"This is not saving money," he said. "This is actually spending more money."

Massachusetts is also looking at ways to control costs as it continues to implement its landmark health reform law.

Photos courtesy Flickr Creative Commons and Wikimedia Commons

This year, the Massachusetts legislature is considering bills to curb the growth in health care costs by gradually moving away from the current fee-for-service system. The bills would provide bonus Medicaid payments next summer for providers who choose alternative payment models, such as global payments through an accountable care organization.

The bills also require the use of electronic health records and outline greater public reporting of quality and cost data. One of the bills includes a "luxury tax" on physicians and other providers whose costs exceed certain benchmarks.

Separate similar bills have passed the Massachusetts House and Senate; a joint committee is now working out the differences.

The Massachusetts Medical Society hasn’t endorsed either of the plans, but urged lawmakers to take a "market-led" approach, avoid unnecessary bureaucracy in setting these new requirements and to provide additional support for the transition to EHRs.

One bright spot in the bills is the inclusion of a disclosure, apology, and offer provision that sets a 182-day cooling off period after the filing of malpractice claim. The disclosure, apology, and offer policy would allow for an open, transparent discussion and the ability to provide compensation to patients when appropriate, according to Dr. Richard V. Aghababian, president of the Massachusetts Medical Society.

Abortion Politics

In just the first 3 months of this year, lawmakers around the country introduced more than 900 provisions related to reproductive health; about half were restrictions on abortion, according to an analysis from the Guttmacher Institute.

Among the trends noted by the Guttmacher analysts is a move to require an ultrasound before abortion and restrictions on non-surgical abortions.

Kathryn Moore, director of state government affairs at the American College of Obstetricians and Gynecologists, said that in the last year or so, she’s seen a "more aggressive effort" to legislate reproductive health issues than she’s seen in several years.

The Virginia legislation that got a lot of attention requires women to have an ultrasound at least 24 hours before they can obtain an abortion. Women will be offered the chance to view the ultrasound image but can refuse. Physicians who fail to comply with the law could face a $2,500 fine.

Gov. Bob McDonnell (R) signed the law in March; it goes into effect this summer.

State lawmakers revised the law’s original language, which would have required a transvaginal ultrasound.

Earlier this year in Georgia, the legislature passed a bill criminalizing abortion after 20 weeks from fertilization. The new law is problematic because it limits the ability of ob.gyns. to identify pregnancies in which a fetus is going to be nonviable but could carry to term, said Dr. Sandra B. Reed, and ob.gyn. and president of the Medical Association of Georgia.

"I don’t like it," Dr. Reed said. "They are legislating medical care and they didn’t go to medical school. They don’t understand all of the ramifications of what they are doing in a day-to-day practice."

From abortion restrictions to emergency department caps, state legislatures are having a big say in the practice of medicine.

Over the last year, states have considered major cuts to Medicaid funding, criminal penalties associated with performing abortions, new mandates for continuing medical education (CME), enlarging the scope of practice for certain mid-level providers, and the list goes on.

Not all the bills have made it into law, and doctors have worked overtime to stop or alter these proposals.

"State legislatures probably impact the daily practice of medicine more than [Congress does]," said Dr. Dan K. Morhaim, a practicing internist and delegate to the Maryland General Assembly.

Licensing, CME requirements, loan forgiveness, scope of practice, insurance and hospital regulation, physician payment, and malpractice – each affects day-to-day practice and states have a hand in all of them, said Dr. Morhaim, a Democrat who serves as the deputy majority leader in the Maryland House of Delegates.

Even some of key federal efforts – such as the Affordable Care Act and incentives for the adoption of electronic health records – are being implemented in part by the states, he said.

During the recent Maryland legislative session, physicians scored a big win with the passage of a bill to standardize and automate prior authorization requests. The issue had been on the table for a few years, Dr. Morhaim said, but physicians finally argued successfully that the volume of prior authorization paperwork was driving up costs and slowing down care.

The bill requires payers to establish an online prior authorization system by next summer.

Fighting ED Caps

Meanwhile, in Washington state, physicians worked with lawmakers to stop a policy that would have eliminated Medicaid payments for any emergency department visit deemed "not medically necessary."

Under a proposal put forward by the Washington Health Care Authority in January, Medicaid would have paid for ED visits only if the ED was the medically necessary setting for care.

The Washington State Medical Association, the Washington State Hospital Association, and the Washington Chapter of the American College of Emergency Physicians, joined forces to stop the proposal. The alternative proposal they championed was adopted by the legislature in April.

The alternative calls on hospitals to adopt best practices such as extensive case management for frequent ED users, timely follow-up by primary care physicians, controls on narcotic prescribing, and better emergency visit tracking. Hospitals must implement the best practices this summer and show a reduction in the number of preventable ED visits by January 2013.

Dr. Nathan Schlicher, an emergency physician in Tacoma and the legislative affairs chairman for the state ACEP chapter, said he’s hopeful that the Washington state agreement can be a model for other cash-strapped states looking to cut down on unnecessary ED care.

The key to their success was having an alternative plan to offer to the legislature, Dr. Schlicher said.

"You can’t just say no," he said. "Saying no is not a solution."

Controlling Costs

In an effort to curb their state’s growing budget deficit, Texas legislators in 2011 cut payments to doctors treating patients eligible for both Medicare and Medicaid by about 20%.

The cut means that fewer and fewer physicians are willing to take on new Medicaid patients, said Dr. Michael E. Speer, president of the Texas Medical Association (TMA) and a professor of pediatrics and ethics at Baylor College, Houston.

As a result, hospitals located in Medicaid-heavy environments are seeing more of these patients – and they are presenting when they are sicker, requiring more care and more expensive care, Dr. Speer said.

That’s the case the TMA will be make to lawmakers when they return to the statehouse in 2013.

"This is not saving money," he said. "This is actually spending more money."

Massachusetts is also looking at ways to control costs as it continues to implement its landmark health reform law.

Photos courtesy Flickr Creative Commons and Wikimedia Commons

This year, the Massachusetts legislature is considering bills to curb the growth in health care costs by gradually moving away from the current fee-for-service system. The bills would provide bonus Medicaid payments next summer for providers who choose alternative payment models, such as global payments through an accountable care organization.

The bills also require the use of electronic health records and outline greater public reporting of quality and cost data. One of the bills includes a "luxury tax" on physicians and other providers whose costs exceed certain benchmarks.

Separate similar bills have passed the Massachusetts House and Senate; a joint committee is now working out the differences.

The Massachusetts Medical Society hasn’t endorsed either of the plans, but urged lawmakers to take a "market-led" approach, avoid unnecessary bureaucracy in setting these new requirements and to provide additional support for the transition to EHRs.

One bright spot in the bills is the inclusion of a disclosure, apology, and offer provision that sets a 182-day cooling off period after the filing of malpractice claim. The disclosure, apology, and offer policy would allow for an open, transparent discussion and the ability to provide compensation to patients when appropriate, according to Dr. Richard V. Aghababian, president of the Massachusetts Medical Society.

Abortion Politics

In just the first 3 months of this year, lawmakers around the country introduced more than 900 provisions related to reproductive health; about half were restrictions on abortion, according to an analysis from the Guttmacher Institute.

Among the trends noted by the Guttmacher analysts is a move to require an ultrasound before abortion and restrictions on non-surgical abortions.

Kathryn Moore, director of state government affairs at the American College of Obstetricians and Gynecologists, said that in the last year or so, she’s seen a "more aggressive effort" to legislate reproductive health issues than she’s seen in several years.

The Virginia legislation that got a lot of attention requires women to have an ultrasound at least 24 hours before they can obtain an abortion. Women will be offered the chance to view the ultrasound image but can refuse. Physicians who fail to comply with the law could face a $2,500 fine.

Gov. Bob McDonnell (R) signed the law in March; it goes into effect this summer.

State lawmakers revised the law’s original language, which would have required a transvaginal ultrasound.

Earlier this year in Georgia, the legislature passed a bill criminalizing abortion after 20 weeks from fertilization. The new law is problematic because it limits the ability of ob.gyns. to identify pregnancies in which a fetus is going to be nonviable but could carry to term, said Dr. Sandra B. Reed, and ob.gyn. and president of the Medical Association of Georgia.

"I don’t like it," Dr. Reed said. "They are legislating medical care and they didn’t go to medical school. They don’t understand all of the ramifications of what they are doing in a day-to-day practice."

With all of the political uncertainty facing American health care in the coming years, health systems are already moving quickly to get ahead of the curve on the quality improvements and cost reductions that are being demanded by health reform and the marketplace.

Hearken to the recently departed Dr. Stephen Covey, who taught millions about the "circle of concern" and the "circle of influence." The circle of concern includes the broader issues of the November election, the future of the Affordable Care Act (ACA), and the health of the global economy. Dr. Covey recommended we focus on the things we can do something about – and there’s plenty of that in health care – our circle of influence.

In this climate, some hospitals have accelerated their adoption of Lean improvement principles and the broader Lean management system. Some, like ThedaCare in Appleton, Wis., are leveraging their experience with using Lean to redesign care processes and build new facilities to design completely new ways of working – as a part of the Accountable Care Organizations that are part of the ACA.

The ACO’s fixed "per episode" payment model places a premium on process improvement and effective collaboration to prevent errors and shorten length of stay, while working to avoid admissions and readmissions. In keeping with the Lean model of starting with small-scale scientific improvements, ThedaCare CEO Dr. Dean Gruner told me earlier this year, they consider the early ACO work to be an experiment. In this light, they are starting with care that represents just 20% of their revenue to see if they can make the ACO model work.

ACOs fit well with the Lean model and its definition of customer value – where people want to pay for results, not activity. In the current fee-for-service model, Dr. Gruner says, "if we’re healthy and don’t get sick, nobody gets paid. We’re paying for illness, when what [patients] want is wellness – that sounds sort of wacky, doesn’t it?" With ACOs, hospitals that can best work together with primary care physicians to keep patients out of the hospital will have the most to gain financially. "The ACO model is better connected to keeping people healthy," says Dr. Gruner.

When patients do need to get admitted, hospitals (with or without an ACO structure) can use Lean methods to provide the safest, highest-quality care that gets the patient home as soon as medically ready. The Lean improvement model engages frontline staff to find ways, for example, of improving the inpatient discharge process, something that involves many disciplines and, often, many organizations. Hospitalists can play a key role in preventing communication problems that would cause a patient to stay in the hospital a day or two longer than necessary.

The shorter length of stay in a fixed reimbursement model means cost savings for the hospital for that case. Additionally, beds are freed up, which means higher volume (and, often, more revenue) for the hospital; and freed-up beds often mean that a hospital increases its capacity without the need for multimillion-dollar expansions. ThedaCare, for one, has published results that show 25%-30% reductions in the cost of inpatient care, 25%-30% reductions in length of stay, and dramatic reductions in errors and mortality – through their Lean-based "collaborative care" model.

Hospitalists are playing a major role in using Lean to drive improvements in organizations. If your organization is not yet "getting Lean" (meaning formally adopting this methodology), then you can play a role in getting things started – your patients, staff, and organizations will all benefit, even in these challenging and uncertain times. As Dr. Covey would remind us, these process improvements are right in our circle of influence.

Mr. Graban is the coauthor of the book "Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements," released in June 2012, and the author of "Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement."

He has employment with and ownership stakes in Constancy Inc., Lean Pathways Inc., and KaiNexus; and he is a former employee of the Lean Enterprise Institute, a formal partner with ThedaCare in the Healthcare Value Network initiative.

With all of the political uncertainty facing American health care in the coming years, health systems are already moving quickly to get ahead of the curve on the quality improvements and cost reductions that are being demanded by health reform and the marketplace.

Hearken to the recently departed Dr. Stephen Covey, who taught millions about the "circle of concern" and the "circle of influence." The circle of concern includes the broader issues of the November election, the future of the Affordable Care Act (ACA), and the health of the global economy. Dr. Covey recommended we focus on the things we can do something about – and there’s plenty of that in health care – our circle of influence.

In this climate, some hospitals have accelerated their adoption of Lean improvement principles and the broader Lean management system. Some, like ThedaCare in Appleton, Wis., are leveraging their experience with using Lean to redesign care processes and build new facilities to design completely new ways of working – as a part of the Accountable Care Organizations that are part of the ACA.

The ACO’s fixed "per episode" payment model places a premium on process improvement and effective collaboration to prevent errors and shorten length of stay, while working to avoid admissions and readmissions. In keeping with the Lean model of starting with small-scale scientific improvements, ThedaCare CEO Dr. Dean Gruner told me earlier this year, they consider the early ACO work to be an experiment. In this light, they are starting with care that represents just 20% of their revenue to see if they can make the ACO model work.

ACOs fit well with the Lean model and its definition of customer value – where people want to pay for results, not activity. In the current fee-for-service model, Dr. Gruner says, "if we’re healthy and don’t get sick, nobody gets paid. We’re paying for illness, when what [patients] want is wellness – that sounds sort of wacky, doesn’t it?" With ACOs, hospitals that can best work together with primary care physicians to keep patients out of the hospital will have the most to gain financially. "The ACO model is better connected to keeping people healthy," says Dr. Gruner.

When patients do need to get admitted, hospitals (with or without an ACO structure) can use Lean methods to provide the safest, highest-quality care that gets the patient home as soon as medically ready. The Lean improvement model engages frontline staff to find ways, for example, of improving the inpatient discharge process, something that involves many disciplines and, often, many organizations. Hospitalists can play a key role in preventing communication problems that would cause a patient to stay in the hospital a day or two longer than necessary.

The shorter length of stay in a fixed reimbursement model means cost savings for the hospital for that case. Additionally, beds are freed up, which means higher volume (and, often, more revenue) for the hospital; and freed-up beds often mean that a hospital increases its capacity without the need for multimillion-dollar expansions. ThedaCare, for one, has published results that show 25%-30% reductions in the cost of inpatient care, 25%-30% reductions in length of stay, and dramatic reductions in errors and mortality – through their Lean-based "collaborative care" model.

Hospitalists are playing a major role in using Lean to drive improvements in organizations. If your organization is not yet "getting Lean" (meaning formally adopting this methodology), then you can play a role in getting things started – your patients, staff, and organizations will all benefit, even in these challenging and uncertain times. As Dr. Covey would remind us, these process improvements are right in our circle of influence.

Mr. Graban is the coauthor of the book "Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements," released in June 2012, and the author of "Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement."

He has employment with and ownership stakes in Constancy Inc., Lean Pathways Inc., and KaiNexus; and he is a former employee of the Lean Enterprise Institute, a formal partner with ThedaCare in the Healthcare Value Network initiative.

With all of the political uncertainty facing American health care in the coming years, health systems are already moving quickly to get ahead of the curve on the quality improvements and cost reductions that are being demanded by health reform and the marketplace.

Hearken to the recently departed Dr. Stephen Covey, who taught millions about the "circle of concern" and the "circle of influence." The circle of concern includes the broader issues of the November election, the future of the Affordable Care Act (ACA), and the health of the global economy. Dr. Covey recommended we focus on the things we can do something about – and there’s plenty of that in health care – our circle of influence.

In this climate, some hospitals have accelerated their adoption of Lean improvement principles and the broader Lean management system. Some, like ThedaCare in Appleton, Wis., are leveraging their experience with using Lean to redesign care processes and build new facilities to design completely new ways of working – as a part of the Accountable Care Organizations that are part of the ACA.

The ACO’s fixed "per episode" payment model places a premium on process improvement and effective collaboration to prevent errors and shorten length of stay, while working to avoid admissions and readmissions. In keeping with the Lean model of starting with small-scale scientific improvements, ThedaCare CEO Dr. Dean Gruner told me earlier this year, they consider the early ACO work to be an experiment. In this light, they are starting with care that represents just 20% of their revenue to see if they can make the ACO model work.

ACOs fit well with the Lean model and its definition of customer value – where people want to pay for results, not activity. In the current fee-for-service model, Dr. Gruner says, "if we’re healthy and don’t get sick, nobody gets paid. We’re paying for illness, when what [patients] want is wellness – that sounds sort of wacky, doesn’t it?" With ACOs, hospitals that can best work together with primary care physicians to keep patients out of the hospital will have the most to gain financially. "The ACO model is better connected to keeping people healthy," says Dr. Gruner.

When patients do need to get admitted, hospitals (with or without an ACO structure) can use Lean methods to provide the safest, highest-quality care that gets the patient home as soon as medically ready. The Lean improvement model engages frontline staff to find ways, for example, of improving the inpatient discharge process, something that involves many disciplines and, often, many organizations. Hospitalists can play a key role in preventing communication problems that would cause a patient to stay in the hospital a day or two longer than necessary.

The shorter length of stay in a fixed reimbursement model means cost savings for the hospital for that case. Additionally, beds are freed up, which means higher volume (and, often, more revenue) for the hospital; and freed-up beds often mean that a hospital increases its capacity without the need for multimillion-dollar expansions. ThedaCare, for one, has published results that show 25%-30% reductions in the cost of inpatient care, 25%-30% reductions in length of stay, and dramatic reductions in errors and mortality – through their Lean-based "collaborative care" model.

Hospitalists are playing a major role in using Lean to drive improvements in organizations. If your organization is not yet "getting Lean" (meaning formally adopting this methodology), then you can play a role in getting things started – your patients, staff, and organizations will all benefit, even in these challenging and uncertain times. As Dr. Covey would remind us, these process improvements are right in our circle of influence.

Mr. Graban is the coauthor of the book "Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements," released in June 2012, and the author of "Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement."

He has employment with and ownership stakes in Constancy Inc., Lean Pathways Inc., and KaiNexus; and he is a former employee of the Lean Enterprise Institute, a formal partner with ThedaCare in the Healthcare Value Network initiative.

The Affordable Care Act provided $1.5 billion through September 2015 to the National Health Service Corps to train more primary care providers via scholarships and loan repayment assistance. In return, these physicians and other providers pledge to serve in Health Professional Shortage Areas.

Dr. Atul Grover, the chief public policy officer at the Association of American Medical Colleges (AAMC), discussed the impact the new funding is having on the primary care workforce.

Question: The ACA sets aside $1.5 billion over 5 years to expand the National Health Service Corps (NHSC). Is that money dedicated to the NHSC or could Congress divert it for other purposes?

Dr. Grover: The ACA created a mandatory fund for the NHSC that more than doubles previous funding levels, starting with $290 million for fiscal year 2011 and increasing by $5 million each year through fiscal year 2015. As it is currently structured, that money is dedicated to NHSC scholarships and loan repayment awards. But what Congress giveth, Congress can taketh away. Congress could rescind this funding directly through an annual appropriations bill or repeal the ACA in its entirety.

Question: What will happen in fiscal 2016 when the funding expires? Will enough progress have been made in bringing physicians to underserved areas?

Dr. Grover: Starting next year, the NHSC’s entire budget will be tied to the ACA fund and the program faces a severe funding cliff in fiscal 2016. Congress will be tasked with finding new money for the program – at least $310 million to prevent a cut in annual NHSC scholarship and loan repayment awards. If Congress returns NHSC funding to the annual appropriations process, it will face an already strained federal budget and be pitted against other programs of importance to medical students and academic medicine, such as Title VII health professions training and the National Institutes of Health.

Question: After the service obligation expires, do physicians typically continue to practice in these underserved areas?

Dr. Grover: A number of factors influence physicians to practice in underserved areas, including personal history, mentorship, and putting down social roots in these communities. The NHSC has been a very successful recruitment tool to give young physicians exposure to this type of practice setting and "pull" their foot in the door, so to speak. According to NHSC clinician retention surveys, over three-quarters of NHSC providers stay at their service site, another NHSC site, or in an underserved area after completing their service obligation.

Question: The ACA raised the amount of the annual loan repayment from $35,000 to $50,000. Is $50,000 per year enough to attract primary care physicians who have significant education debt?

Dr. Grover: The NHSC loan repayment award not only serves as a recruitment tool for physicians to practice primary care, but also to practice in underserved areas. Medical students graduating in 2011 had an average educational debt of $162,000, but will repay between $300,000 and $450,000 over the life of the loans depending on the repayment plan. NHSC loan repayment awardees can receive up to $170,000 over 5 years of service right out of residency, erasing their student loans, but could save even more on student loan interest that they won’t have to pay.

Question: The ACA also allows teaching to count toward the NHSC obligated service. How will that encourage more physicians to pursue this path?

Dr. Grover: The ACA reauthorized the NHSC with several changes designed to increase flexibility and allow for additional physicians to participate in the program. Counting teaching time as well as half-time service toward the service obligation will expand the program to physicians who are unable to practice full time at NHSC sites. The NHSC also recently announced that the program is expanding to include outpatient clinics at critical access hospitals. Hopefully, these changes will open doors to faculty, parent-physicians, split practices, as well as primary care subspecialists, and ultimately improve access to care for our nation’s underserved.

Question: The Health and Human Services Department estimates that by fiscal 2016, this investment will lead to an increase of 12,000 primary care providers, nurse practitioners, and physician assistants. How much of that will be for physicians versus other health care providers?

Dr. Grover: The NHSC makes award determinations based on the demonstrated need of the facilities in underserved areas that are seeking NHSC providers and does not preallocate awards by discipline or specialty. Historically, physicians have made up a quarter or more of the NHSC field strength. As a direct result of the ACA funding, physicians are exclusively eligible for the new NHSC Student to Service Loan Repayment Program (S2S LRP), which provides up to $120,000 during residency in exchange for a 3-year service commitment.

Dr. Grover, who trained as a general internist, manages the health, educational, and scientific policies of the AAMC.

The Affordable Care Act provided $1.5 billion through September 2015 to the National Health Service Corps to train more primary care providers via scholarships and loan repayment assistance. In return, these physicians and other providers pledge to serve in Health Professional Shortage Areas.

Dr. Atul Grover, the chief public policy officer at the Association of American Medical Colleges (AAMC), discussed the impact the new funding is having on the primary care workforce.

Question: The ACA sets aside $1.5 billion over 5 years to expand the National Health Service Corps (NHSC). Is that money dedicated to the NHSC or could Congress divert it for other purposes?

Dr. Grover: The ACA created a mandatory fund for the NHSC that more than doubles previous funding levels, starting with $290 million for fiscal year 2011 and increasing by $5 million each year through fiscal year 2015. As it is currently structured, that money is dedicated to NHSC scholarships and loan repayment awards. But what Congress giveth, Congress can taketh away. Congress could rescind this funding directly through an annual appropriations bill or repeal the ACA in its entirety.

Question: What will happen in fiscal 2016 when the funding expires? Will enough progress have been made in bringing physicians to underserved areas?

Dr. Grover: Starting next year, the NHSC’s entire budget will be tied to the ACA fund and the program faces a severe funding cliff in fiscal 2016. Congress will be tasked with finding new money for the program – at least $310 million to prevent a cut in annual NHSC scholarship and loan repayment awards. If Congress returns NHSC funding to the annual appropriations process, it will face an already strained federal budget and be pitted against other programs of importance to medical students and academic medicine, such as Title VII health professions training and the National Institutes of Health.

Question: After the service obligation expires, do physicians typically continue to practice in these underserved areas?

Dr. Grover: A number of factors influence physicians to practice in underserved areas, including personal history, mentorship, and putting down social roots in these communities. The NHSC has been a very successful recruitment tool to give young physicians exposure to this type of practice setting and "pull" their foot in the door, so to speak. According to NHSC clinician retention surveys, over three-quarters of NHSC providers stay at their service site, another NHSC site, or in an underserved area after completing their service obligation.

Question: The ACA raised the amount of the annual loan repayment from $35,000 to $50,000. Is $50,000 per year enough to attract primary care physicians who have significant education debt?

Dr. Grover: The NHSC loan repayment award not only serves as a recruitment tool for physicians to practice primary care, but also to practice in underserved areas. Medical students graduating in 2011 had an average educational debt of $162,000, but will repay between $300,000 and $450,000 over the life of the loans depending on the repayment plan. NHSC loan repayment awardees can receive up to $170,000 over 5 years of service right out of residency, erasing their student loans, but could save even more on student loan interest that they won’t have to pay.

Question: The ACA also allows teaching to count toward the NHSC obligated service. How will that encourage more physicians to pursue this path?

Dr. Grover: The ACA reauthorized the NHSC with several changes designed to increase flexibility and allow for additional physicians to participate in the program. Counting teaching time as well as half-time service toward the service obligation will expand the program to physicians who are unable to practice full time at NHSC sites. The NHSC also recently announced that the program is expanding to include outpatient clinics at critical access hospitals. Hopefully, these changes will open doors to faculty, parent-physicians, split practices, as well as primary care subspecialists, and ultimately improve access to care for our nation’s underserved.

Question: The Health and Human Services Department estimates that by fiscal 2016, this investment will lead to an increase of 12,000 primary care providers, nurse practitioners, and physician assistants. How much of that will be for physicians versus other health care providers?

Dr. Grover: The NHSC makes award determinations based on the demonstrated need of the facilities in underserved areas that are seeking NHSC providers and does not preallocate awards by discipline or specialty. Historically, physicians have made up a quarter or more of the NHSC field strength. As a direct result of the ACA funding, physicians are exclusively eligible for the new NHSC Student to Service Loan Repayment Program (S2S LRP), which provides up to $120,000 during residency in exchange for a 3-year service commitment.

Dr. Grover, who trained as a general internist, manages the health, educational, and scientific policies of the AAMC.

The Affordable Care Act provided $1.5 billion through September 2015 to the National Health Service Corps to train more primary care providers via scholarships and loan repayment assistance. In return, these physicians and other providers pledge to serve in Health Professional Shortage Areas.

Dr. Atul Grover, the chief public policy officer at the Association of American Medical Colleges (AAMC), discussed the impact the new funding is having on the primary care workforce.

Question: The ACA sets aside $1.5 billion over 5 years to expand the National Health Service Corps (NHSC). Is that money dedicated to the NHSC or could Congress divert it for other purposes?

Dr. Grover: The ACA created a mandatory fund for the NHSC that more than doubles previous funding levels, starting with $290 million for fiscal year 2011 and increasing by $5 million each year through fiscal year 2015. As it is currently structured, that money is dedicated to NHSC scholarships and loan repayment awards. But what Congress giveth, Congress can taketh away. Congress could rescind this funding directly through an annual appropriations bill or repeal the ACA in its entirety.

Question: What will happen in fiscal 2016 when the funding expires? Will enough progress have been made in bringing physicians to underserved areas?

Dr. Grover: Starting next year, the NHSC’s entire budget will be tied to the ACA fund and the program faces a severe funding cliff in fiscal 2016. Congress will be tasked with finding new money for the program – at least $310 million to prevent a cut in annual NHSC scholarship and loan repayment awards. If Congress returns NHSC funding to the annual appropriations process, it will face an already strained federal budget and be pitted against other programs of importance to medical students and academic medicine, such as Title VII health professions training and the National Institutes of Health.

Question: After the service obligation expires, do physicians typically continue to practice in these underserved areas?

Dr. Grover: A number of factors influence physicians to practice in underserved areas, including personal history, mentorship, and putting down social roots in these communities. The NHSC has been a very successful recruitment tool to give young physicians exposure to this type of practice setting and "pull" their foot in the door, so to speak. According to NHSC clinician retention surveys, over three-quarters of NHSC providers stay at their service site, another NHSC site, or in an underserved area after completing their service obligation.

Question: The ACA raised the amount of the annual loan repayment from $35,000 to $50,000. Is $50,000 per year enough to attract primary care physicians who have significant education debt?

Dr. Grover: The NHSC loan repayment award not only serves as a recruitment tool for physicians to practice primary care, but also to practice in underserved areas. Medical students graduating in 2011 had an average educational debt of $162,000, but will repay between $300,000 and $450,000 over the life of the loans depending on the repayment plan. NHSC loan repayment awardees can receive up to $170,000 over 5 years of service right out of residency, erasing their student loans, but could save even more on student loan interest that they won’t have to pay.

Question: The ACA also allows teaching to count toward the NHSC obligated service. How will that encourage more physicians to pursue this path?

Dr. Grover: The ACA reauthorized the NHSC with several changes designed to increase flexibility and allow for additional physicians to participate in the program. Counting teaching time as well as half-time service toward the service obligation will expand the program to physicians who are unable to practice full time at NHSC sites. The NHSC also recently announced that the program is expanding to include outpatient clinics at critical access hospitals. Hopefully, these changes will open doors to faculty, parent-physicians, split practices, as well as primary care subspecialists, and ultimately improve access to care for our nation’s underserved.

Question: The Health and Human Services Department estimates that by fiscal 2016, this investment will lead to an increase of 12,000 primary care providers, nurse practitioners, and physician assistants. How much of that will be for physicians versus other health care providers?

Dr. Grover: The NHSC makes award determinations based on the demonstrated need of the facilities in underserved areas that are seeking NHSC providers and does not preallocate awards by discipline or specialty. Historically, physicians have made up a quarter or more of the NHSC field strength. As a direct result of the ACA funding, physicians are exclusively eligible for the new NHSC Student to Service Loan Repayment Program (S2S LRP), which provides up to $120,000 during residency in exchange for a 3-year service commitment.

Dr. Grover, who trained as a general internist, manages the health, educational, and scientific policies of the AAMC.

Questions and uncertainty abound as state governments begin deciding whether they will participate in the expansion of Medicaid that was called for by the Affordable Care Act.

In light of the Supreme Court’s decision that the federal government cannot penalize states that don’t participate, the governors of Texas, South Carolina, Nebraska, Iowa, Louisiana, Mississippi, and Florida have said that their states will opt out.

Leaders in other states say they need more information.

"The original act was very punitive for states that didn’t expand Medicaid. [The Supreme Court decision] now gives some options which, honestly, I don’t think a lot of us expected," Gov. Bob McDonnell (R-Va.) said at a press conference held at the National Governors Association annual meeting. "I don’t think it’s responsible fully for my state to make a decision now, because there’s still more information I need."

"I think this is a really historic opportunity to align the health care system for health."

Gov. Jack Markell (D-Del.) said he sees the expansion as a "good deal for Delaware taxpayers," but agreed that most states will need more guidance from the federal government before making a decision.

As the ruling allows states to opt out of Medicaid expansion without losing existing federal monies, health care reform likely will look very different from state to state, said Sheila Burke of the John F. Kennedy School of Government at Harvard University, Cambridge, Massachusetts.

"These states are going to respond to this very differently, and they are very different in terms of their preparation and their capacity to take on these changes. Governors, state legislators, exchange directors, and insurance commissioners all may have a different view," Ms. Burke said at a briefing held by the Alliance for Health Reform. She pointed out that many states legislatures won’t meet again until next year, so meaningful decision making may be on hold until then.

Prior to passage of the ACA, Medicaid provided health care coverage for the indigent, especially those who were dependent children, pregnant women, disabled, or elderly. Under the expansion, Medicaid would also cover anyone younger than age 65 years with an annual income less than 133% of the federal poverty level. The law also provides tax credits for people with incomes between 100% and 400% of the federal poverty level to purchase insurance.

If a state decides to opt out of Medicaid expansion, people whose income is above the federal poverty level, those who are single, childless, or don’t live with their children would not be covered. In addition, those who qualify for premium subsidies under the law but can’t find affordable coverage (that is, mostly low-wage workers) would not be covered.

States that opt out of the expansion also could have a harder time balancing impending cuts to providers and hospitals, according to Chris Jennings, president of Jennings Policy Strategies and former top health aide to President Clinton.

Physicians face a 27% Medicare pay cut in January according to the Sustainable Growth Rate (SGR) formula; hospitals, too, face cuts to their Disproportionate Share Hospital (DSH) payments.

Although there may be other ways to balance the cuts, the easiest is expanding Medicaid to get the extra funding, said Mr. Jennings. "It’s a harder road to go than just taking the money."

While an influx of federal funding would help states offset other cuts, it’s unlikely that it would be enough for physicians to rebound from a huge SGR cut, according to Dr. Glen R. Stream, president of the American Academy of Family Physicians.

"If the SGR-indicated payment cut was to go into place, there’s no way that the expansion of Medicaid is going to offset the devastating financial impact that that’s going to have for practices," he said in an interview. But he added that expanding Medicaid is currently the best option for providing much-needed care for low-income Americans.

"I don’t think anyone necessarily envisions expansion of Medicaid as the ideal means to expand coverage, but it is the one that’s on the table. My hope would be that if states chose to opt out of the Medicaid expansion, they would do so with some other plan to meet the needs of their citizens. The challenge would be that the plan wouldn’t be coming with any federal dollars," Dr. Stream said.

Officials with the American College of Physicians said that states should move forward with expansion as soon as possible.

The "ACP also strongly urges states to move forward on expanding Medicaid to all persons with incomes up to 133% of the federal poverty level, notwithstanding the court’s ruling that states may not be denied existing Medicaid dollars for failing to do so," ACP president David L. Bronson said in a statement following the court’s ruling.

Even as states weigh their options, Mr. Jennings speculated that more will participate in the Medicaid expansion than most people currently think.

Dr. Stream agreed. "I suspect, at the end of the day, that we’ll have a lot more states coming in than we currently are hearing, primarily because I have some confidence in stakeholders’ abilities to encourage legislatures and governors to move ahead," he said.

Maryland is one of those states. Dr. Joshua Sharfstein, the state Secretary of Health and Mental Hygiene, said that implementing the law will give states an edge over those that opt out.

"I’ve heard [Gov. Martin O’Malley (D-Md.)] say that he ultimately sees successful implementation of the law as a competitive advantage for Maryland [and] for businesses to locate in the state if there’s real investment in the workforce," Dr. Sharfstein said at the briefing. "I think this is a really historic opportunity to align the health care system for health and I think it’s those types of things that are going to get the job done."

Questions and uncertainty abound as state governments begin deciding whether they will participate in the expansion of Medicaid that was called for by the Affordable Care Act.

In light of the Supreme Court’s decision that the federal government cannot penalize states that don’t participate, the governors of Texas, South Carolina, Nebraska, Iowa, Louisiana, Mississippi, and Florida have said that their states will opt out.

Leaders in other states say they need more information.

"The original act was very punitive for states that didn’t expand Medicaid. [The Supreme Court decision] now gives some options which, honestly, I don’t think a lot of us expected," Gov. Bob McDonnell (R-Va.) said at a press conference held at the National Governors Association annual meeting. "I don’t think it’s responsible fully for my state to make a decision now, because there’s still more information I need."

"I think this is a really historic opportunity to align the health care system for health."

Gov. Jack Markell (D-Del.) said he sees the expansion as a "good deal for Delaware taxpayers," but agreed that most states will need more guidance from the federal government before making a decision.

As the ruling allows states to opt out of Medicaid expansion without losing existing federal monies, health care reform likely will look very different from state to state, said Sheila Burke of the John F. Kennedy School of Government at Harvard University, Cambridge, Massachusetts.

"These states are going to respond to this very differently, and they are very different in terms of their preparation and their capacity to take on these changes. Governors, state legislators, exchange directors, and insurance commissioners all may have a different view," Ms. Burke said at a briefing held by the Alliance for Health Reform. She pointed out that many states legislatures won’t meet again until next year, so meaningful decision making may be on hold until then.

Prior to passage of the ACA, Medicaid provided health care coverage for the indigent, especially those who were dependent children, pregnant women, disabled, or elderly. Under the expansion, Medicaid would also cover anyone younger than age 65 years with an annual income less than 133% of the federal poverty level. The law also provides tax credits for people with incomes between 100% and 400% of the federal poverty level to purchase insurance.

If a state decides to opt out of Medicaid expansion, people whose income is above the federal poverty level, those who are single, childless, or don’t live with their children would not be covered. In addition, those who qualify for premium subsidies under the law but can’t find affordable coverage (that is, mostly low-wage workers) would not be covered.

States that opt out of the expansion also could have a harder time balancing impending cuts to providers and hospitals, according to Chris Jennings, president of Jennings Policy Strategies and former top health aide to President Clinton.

Physicians face a 27% Medicare pay cut in January according to the Sustainable Growth Rate (SGR) formula; hospitals, too, face cuts to their Disproportionate Share Hospital (DSH) payments.

Although there may be other ways to balance the cuts, the easiest is expanding Medicaid to get the extra funding, said Mr. Jennings. "It’s a harder road to go than just taking the money."

While an influx of federal funding would help states offset other cuts, it’s unlikely that it would be enough for physicians to rebound from a huge SGR cut, according to Dr. Glen R. Stream, president of the American Academy of Family Physicians.

"If the SGR-indicated payment cut was to go into place, there’s no way that the expansion of Medicaid is going to offset the devastating financial impact that that’s going to have for practices," he said in an interview. But he added that expanding Medicaid is currently the best option for providing much-needed care for low-income Americans.

"I don’t think anyone necessarily envisions expansion of Medicaid as the ideal means to expand coverage, but it is the one that’s on the table. My hope would be that if states chose to opt out of the Medicaid expansion, they would do so with some other plan to meet the needs of their citizens. The challenge would be that the plan wouldn’t be coming with any federal dollars," Dr. Stream said.

Officials with the American College of Physicians said that states should move forward with expansion as soon as possible.

The "ACP also strongly urges states to move forward on expanding Medicaid to all persons with incomes up to 133% of the federal poverty level, notwithstanding the court’s ruling that states may not be denied existing Medicaid dollars for failing to do so," ACP president David L. Bronson said in a statement following the court’s ruling.

Even as states weigh their options, Mr. Jennings speculated that more will participate in the Medicaid expansion than most people currently think.

Dr. Stream agreed. "I suspect, at the end of the day, that we’ll have a lot more states coming in than we currently are hearing, primarily because I have some confidence in stakeholders’ abilities to encourage legislatures and governors to move ahead," he said.

Maryland is one of those states. Dr. Joshua Sharfstein, the state Secretary of Health and Mental Hygiene, said that implementing the law will give states an edge over those that opt out.

"I’ve heard [Gov. Martin O’Malley (D-Md.)] say that he ultimately sees successful implementation of the law as a competitive advantage for Maryland [and] for businesses to locate in the state if there’s real investment in the workforce," Dr. Sharfstein said at the briefing. "I think this is a really historic opportunity to align the health care system for health and I think it’s those types of things that are going to get the job done."

Questions and uncertainty abound as state governments begin deciding whether they will participate in the expansion of Medicaid that was called for by the Affordable Care Act.

In light of the Supreme Court’s decision that the federal government cannot penalize states that don’t participate, the governors of Texas, South Carolina, Nebraska, Iowa, Louisiana, Mississippi, and Florida have said that their states will opt out.

Leaders in other states say they need more information.

"The original act was very punitive for states that didn’t expand Medicaid. [The Supreme Court decision] now gives some options which, honestly, I don’t think a lot of us expected," Gov. Bob McDonnell (R-Va.) said at a press conference held at the National Governors Association annual meeting. "I don’t think it’s responsible fully for my state to make a decision now, because there’s still more information I need."

"I think this is a really historic opportunity to align the health care system for health."

Gov. Jack Markell (D-Del.) said he sees the expansion as a "good deal for Delaware taxpayers," but agreed that most states will need more guidance from the federal government before making a decision.

As the ruling allows states to opt out of Medicaid expansion without losing existing federal monies, health care reform likely will look very different from state to state, said Sheila Burke of the John F. Kennedy School of Government at Harvard University, Cambridge, Massachusetts.

"These states are going to respond to this very differently, and they are very different in terms of their preparation and their capacity to take on these changes. Governors, state legislators, exchange directors, and insurance commissioners all may have a different view," Ms. Burke said at a briefing held by the Alliance for Health Reform. She pointed out that many states legislatures won’t meet again until next year, so meaningful decision making may be on hold until then.

Prior to passage of the ACA, Medicaid provided health care coverage for the indigent, especially those who were dependent children, pregnant women, disabled, or elderly. Under the expansion, Medicaid would also cover anyone younger than age 65 years with an annual income less than 133% of the federal poverty level. The law also provides tax credits for people with incomes between 100% and 400% of the federal poverty level to purchase insurance.

If a state decides to opt out of Medicaid expansion, people whose income is above the federal poverty level, those who are single, childless, or don’t live with their children would not be covered. In addition, those who qualify for premium subsidies under the law but can’t find affordable coverage (that is, mostly low-wage workers) would not be covered.

States that opt out of the expansion also could have a harder time balancing impending cuts to providers and hospitals, according to Chris Jennings, president of Jennings Policy Strategies and former top health aide to President Clinton.

Physicians face a 27% Medicare pay cut in January according to the Sustainable Growth Rate (SGR) formula; hospitals, too, face cuts to their Disproportionate Share Hospital (DSH) payments.

Although there may be other ways to balance the cuts, the easiest is expanding Medicaid to get the extra funding, said Mr. Jennings. "It’s a harder road to go than just taking the money."

While an influx of federal funding would help states offset other cuts, it’s unlikely that it would be enough for physicians to rebound from a huge SGR cut, according to Dr. Glen R. Stream, president of the American Academy of Family Physicians.

"If the SGR-indicated payment cut was to go into place, there’s no way that the expansion of Medicaid is going to offset the devastating financial impact that that’s going to have for practices," he said in an interview. But he added that expanding Medicaid is currently the best option for providing much-needed care for low-income Americans.

"I don’t think anyone necessarily envisions expansion of Medicaid as the ideal means to expand coverage, but it is the one that’s on the table. My hope would be that if states chose to opt out of the Medicaid expansion, they would do so with some other plan to meet the needs of their citizens. The challenge would be that the plan wouldn’t be coming with any federal dollars," Dr. Stream said.

Officials with the American College of Physicians said that states should move forward with expansion as soon as possible.

The "ACP also strongly urges states to move forward on expanding Medicaid to all persons with incomes up to 133% of the federal poverty level, notwithstanding the court’s ruling that states may not be denied existing Medicaid dollars for failing to do so," ACP president David L. Bronson said in a statement following the court’s ruling.

Even as states weigh their options, Mr. Jennings speculated that more will participate in the Medicaid expansion than most people currently think.

Dr. Stream agreed. "I suspect, at the end of the day, that we’ll have a lot more states coming in than we currently are hearing, primarily because I have some confidence in stakeholders’ abilities to encourage legislatures and governors to move ahead," he said.

Maryland is one of those states. Dr. Joshua Sharfstein, the state Secretary of Health and Mental Hygiene, said that implementing the law will give states an edge over those that opt out.

"I’ve heard [Gov. Martin O’Malley (D-Md.)] say that he ultimately sees successful implementation of the law as a competitive advantage for Maryland [and] for businesses to locate in the state if there’s real investment in the workforce," Dr. Sharfstein said at the briefing. "I think this is a really historic opportunity to align the health care system for health and I think it’s those types of things that are going to get the job done."