The Affordable Care Act (ACA)
What health reform means for Emergency
Physicians
Main Provisions of ACA
1.
2.
3.
4.
5.
Expanding Insurance Coverage
Health Insurance Reform
Improve Quality
Contain Costs
Consumer Protections
Expanding Coverage
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Individual Mandate
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Employer Mandate
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50 employees: Penalty/shared responsibility
requirement for not offering adequate insurance
Some premium subsidies for businesses with 25
employees who choose to offer insurance
Expansion of Medicaid
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Own qualifying health insurance or pay fine
Multiple exemptions (financial, religious, etc)
133% of FPL
Simplified CHIP enrollment
Other Expanded Coverage
Dependent coverage up to 26y
 Federal funding to preserve employer
insurance for early retirees
 Prescription drug discounts and tax
rebate for seniors who hit Medicare
donut hole

Access to Primary Care
Increased loan repayment and funding
for primary care physicians and midlevel providers practicing in shortage
areas
 Increased payments to rural health
providers
 Increased payments to primary care
physicians under Medicaid
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Health Insurance Reform

State-based/Regional Health Insurance
Exchanges
Income-based premium and cost sharing (up
to 400% FPL)
 Separate exchanges for small businesses
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Medical Loss Ratios
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80-85% of premiums must be spent on patient
care
Improving Quality
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Comparative Effectiveness Research
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Patient-Centered Outcomes Research Institute
(PCORI)
Demonstration Projects
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Center for Medicare and Medicaid Innovation
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Bundled payment pilot program
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ACO development
Medical Home
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Cost Containment

Medicare payment reform and restructuring
(selected provisions)

Shared cost-savings for ACOs
Cost of care of single patient shared between all parties
within ACO (clinic & hospital based physicians, ancillary
staff)
 Also shared losses
 Value-based purchasing program
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Payments linked to quality outcomes
Reduced payments for readmissions & hospital-acquired
infections
 Potential for bonus payments

Independent Payment Advisory Board (IPAB)

Recommendations on cost-reduction (primarily of physician
services)
Cost Containment
Reduce Medicare and Medicaid
Disproportionate Share Hospital
payments
 Prohibit federal Medicaid payment to
states for health-care acquired
conditions
 Increased anti-fraud activities

Consumer Protections
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Removal of pre-existing condition exclusions
Prohibit arbitrary rescissions of health care
No lifetime limits on coverage
Regulation of annual limits on coverage
Patient choice of provider within network
Removal of barriers to emergency care
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No higher co-payments for out-of-network
emergency care
Health plans must reimburse out-of-network
providers rendering emergency care
Emergency Medicine & ACA

Essential Health Benefits Package
 Primary,

preventative, emergency services
Prudent Layperson
 Reimbursement
provided for person with
average medical knowledge who presents
to ED with presumed emergency
Pilot projects for trauma regionalization
 Increased funding for emergency
medicine and systems research

The ACA does a lot more…
For Further Information:
http://www.healthcare.gov/law/about/order
/byyear.html
http://www.kff.org/healthreform/8061.cfm
Impact of ACA on EM
Insurance ≠ Access

ACA does little to improve immediate physician
supply or access to care

Demonstration projects (eg. medical home) only
promise to improve efficiency
 influx of newly-insured patients will increase demand
for health resources before increases in efficiency
realized

Exacerbation of projected physician shortages

Shortage of 91,500 physicians by 2020 and 130,600 by
2025 (AAMC 2008)
 Crosses all specialities: -46K primary care

Fewer practices taking Medicaid (and Medicare)
due to poor reimbursements, though ACA expands
the number covered
Strain on Emergency Systems

Closure of ~27% of EDs over last 20 years,
while ED visits continue to increase (Hsai
2011)
 Insured patients utilize emergency services
more than uninsured (NCHS 2010; Tang
2010)
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Medicaid patients have highest annual rate of ED
visits
Reflects difficulty in obtaining access in to primary
care services in the community
Increasing number of insured under the ACA
will increase demand for emergency services
ACOs

Current payment system focuses on individual
services and providers
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More services/tests, more pay
Does not amount to better quality

Attempt to incentivize higher quality, more
efficient care (lower costs, higher pt
satisfaction)
 Rewards coordinated care based on outcomes
 Income incentives apply to primary physicians
only
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Hospitals/specialists still reimbursed by volume
Bundled payments currently only demonstration project
Provider responsibility to improve outcomes, no
patient responsibility
ACOs, Where is the ED?

Will emergency services be bundled with
hospitals or outpatient services?
ED plays a transient role in care > outcomes
depend on subsequent hospital or outpatient
care
 Income redistribution without control
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Often difficult to coordinate care between
ED and primary care practices
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PCP’s not always able to be contacted
Patients often don’t f/u
Out-of-network patients
Medicare/Medicaid Payment

EDs often provide care at or below
actual costs

low reimbursement rates
 ACA increases patients covered without
increase in tax revenue > likely increase in
non-reimbursed care
 new penalty programs (eg. hospital acquired
infections, poor outcomes)

No solution for SGR
ACEP’s position
You can find ACEP’s position statements
at:
http://www.acep.org/advocacy/federalissu
es/
(under the Health Reform heading)
References
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Hsia, R., Kellerman, A., Shen, Y. Factors Associated With
Closures of Emergency Departments in the United States
Renee JAMA. 2011; 305(19): 1978-1985.
The Complexities of Physician Supply and Demand: Projections
Through 2025 (PDF). 2008. AAMC
Garcia, TC., Bernstein, AB., Bush, MA. Emergency Department
Visitors and Visits: Who Used the Emergency Room in 2007?
NCHS Data Brief. May 2010; (38)
Tang, N. etal. Trends and Characteristics of US Emergency
Department Visits, 1997-2007. JAMA. 2010 August 11; 304(6):
664–670.
Kaiser Family Foundation. Summary of New Health Reform.
2010. http://www.kff.org/healthreform/8061.cfm
Gerardi, M. The ACA-Driven ACO Movement: Implications for
Emergency Medicine - EM Practice Management & Health
Policy Section Newsletter, March 2011.
http://www.acep.org/Content.aspx?id=77674