Science is honing in on better ways to treat chronic pain. Read about it in this AARP series.
by Mary A. Fischer, AARP The Magazine, July/August 2010 issue
In late March, Ruth Kevess-Cohen, M.D., noticed a change in her patients. Usually they came to her Silver Spring, Maryland, office asking about their blood sugar levels or blood pressure. Now they had a new concern: Should they be worried about the new health care reform law? Would they still be able to get in to see her? Would they still get the same treatment for their diabetes or high blood pressure? “It’s on everyone’s mind,” says Cohen, an internist who specializes in geriatric medicine.
Much has been written about how health care reform will affect patients. But very little has been written about its impact on providers—and how that will affect you. Fortunately, for people over 50, the news is mostly good. “I’m telling my patients not to worry,” says Cohen. “The changes at this point do not affect the personal relationships between patients and their doctors. Patients can see their same doctors as before, doctors will continue to refer them for tests and to specialists as before, and patients can still get their prescriptions at their local pharmacy or through mail order.”
Here are the provisions of the bill most likely to affect you and your physicians—and advice on how to ensure you get the best care possible.
1. Seeing your doctor—when you want to
One of health care reform’s greatest achievements is its guarantee of health coverage for 32 million uninsured Americans. The benefit for those 50 and older who don’t have health coverage now because of preexisting conditions or economic hardship is that you will be able to see a doctor when you need to, without fear of paying exorbitant costs for routine medical care. The new law bans private insurers from dropping people who get sick, from turning away those who have preexisting conditions, and from setting lifetime caps on benefits. It also provides subsidies for low-income Americans so they can purchase private health insurance, it expands Medicaid (state-run health insurance programs for the poor), and it allows adult children to remain on their parents’ health insurance plans until age 26.
All of these guarantees do come with a challenge, though. Whereas those who currently have a primary care physician will be able to see him or her as before, those who do not presently have access to a doctor may find themselves on a waiting list. That’s because there are parts of the country where primary care physicians are already in short supply, and the new law will bring millions of additional patients into the system. The American Academy of Family Physicians predicts a shortfall of roughly 40,000 primary care doctors over the next decade as medical students are increasingly drawn to the higher pay and better hours of specialties such as surgery or radiology.
What’s more: “The issue of access is not just about the number of patients; it’s about making our delivery system more efficient and productive,” says Michael Newman, M.D., who has an internal medicine practice in Washington, D.C. “We want to make sure everyone gets the care he or she needs, but that doesn’t mean a physician has to be the one who provides all the care. We can take the burden off physicians by using more nurse practitioners and physician assistants, and other caregivers who can better deal with the management of chronic diseases, education, compliance, prevention, etc.”
Recognizing the growing need for access, legislators included in the new law bonus payments for primary care physicians as well as expanded community-health centers and forgiveness of tuition loans as incentives to medical students to pursue primary care careers.
Massachusetts’s experience also provides some reassurance. When the state approved universal health care in 2006, there was a backlog of new patients, plus long wait times to see a primary care physician. “Yes, we have a shortage of doctors, but now everything has settled down and everyone is getting better care,” says Mario Motta, M.D., president of the Massachusetts Medical Society, the statewide professional organization of physicians. In 2008 the state approved unprecedented financial incentives that made primary care careers more attractive to new physicians and nurses. Class sizes were expanded at the University of Massachusetts Medical School, and tuition was waived for students who agreed to work as primary care doctors in the state for four years after they finished training. Today about 96 percent of the state’s population is insured—the highest rate in the nation.
Patients themselves can play an important role in ensuring access. “They should be proactive and establish a relationship with a doctor before they get sick,” says David Reuben, M.D., chief of Geriatric Medicine at UCLA. “Planning your health care is no different than any other investment you make for the future. You want a primary care physician who knows you and your health issues, and can guide your care, including referrals to specialists when appropriate.”
2. Seeing a specialist—when you need to
Specialists currently dominate the medical field—roughly 70 percent of medical residents become orthopedists, gastroenterologists, or some other specialists—so patient access to them has been less of a problem than access to a primary care physician. That’s not likely to change anytime soon. “Getting into a hospital to have surgery is not going to be a problem, because our medical profession is overwhelmingly made up of interventionists like surgeons,” says Paul Torrens, M.D., professor of Health Services at the UCLA School of Public Health.
As health care reform takes hold, however, specialty care itself may change. “We’re going to see changes in how specialty care is provided, by online or telephone consultations, or by the primary care doctor consulting with a specialist without the specialist actually seeing the patient,” Reuben says. “In some managed care organizations this is happening now.”
Telemedicine, as this type of consultation is called, is often used to determine whether a patient in a remote or underserved region of the country needs to see a specialist. In urban centers where specialists are plentiful, though, seeing a specialist will be part of routine medical care, much as it is now.
To further reduce the demands on the system, specialists and patients alike will need to become more responsible about evaluation and treatment. “We have this notion that we should have unlimited access to medical care and all manner of tests,” says Newman. “But are they always really necessary? We need to provide appropriate tests. It’s not a matter of rationing; rather it is doing what’s appropriate and necessary for the care of the patient.”
3. More time with your pharmacist
Another big plus that health care reform delivers: to better monitor medications and their interactions (which sicken thousands every year), pharmacists will receive funding to help patients manage their medications. “Patients will be able to sit down with their pharmacist to see if there should be changes or reductions in their medication regimen,” explains Dennee Frey, Pharm.D., a pharmacist and medication-management consultant for Partners in Care Foundation in San Fernando, California.
Last December, Frey’s own mother experienced the miscommunication common in medication prescribing. After suffering a ministroke, her mother was released from the hospital with a list of medicines to take. “Two of the medications were wrong and had been discontinued by her other doctors,” explains Frey. “Luckily, my mother had me to ask the right questions. As pharmacists, we’ve been waiting and hoping for these changes.”
4. Closing the doughnut hole
One of the law’s biggest accomplishments for those on Medicare is its eventual closure of a huge loophole in prescription-drug coverage, known colloquially as the doughnut hole. In 2010, Medicare pays 75 percent of covered prescription-drug costs until the total drug costs (including the deductible and copays) reach $2,830. After that, patients fall into the doughnut hole—or coverage gap—and must pay the full cost of prescription drugs until their total out-of-pocket costs reach $4,550, when coverage kicks in again.
In the past, when internist Cohen’s Medicare patients fell into the doughnut hole, many stopped taking their medications because they couldn’t afford them anymore. To help them, she would prescribe a different medication or scrounge the shelves in her office for free samples. “But that was very disruptive to my patients,” she says. “The changes in the law are a big improvement.”
Under the law more than 3 million older adults who fall into the coverage gap will get a $250 rebate this year. The law provides for a 50 percent discount on brand-name drugs in 2011, and a smaller break on generics, until the doughnut hole is closed by 2020.
5. Better coordination of your health care
To improve efficiency and care coordination, the new law offers funding for such pilot programs as “accountable care” and “medical homes.” Under the medical-home model pioneered in Vermont, for instance, physicians are paid extra for coordinating care for their patients. They also receive bonuses if a patient’s health improves based on quality-of-care guidelines. The goal of the program is to help patients—especially those with chronic illnesses—stay healthy enough to avoid hospital stays and expensive treatments, saving money in the long run.
Similarly, Medicare-funded accountable-care organizations will be established over the next 18 months to ease transitions between hospital and home, and will influence how medical teams, as well as hospitals, operate. “Medicare will be making hospitals responsible for the costs of patient readmission,” says Albert Siu, M.D., chair of Geriatrics at New York City’s Mount Sinai School of Medicine, “so we’re making a variety of efforts to improve and coordinate patients’ care as they leave the hospital.” These include coaching patients and family members through the transition process and having a health professional act as a link between hospital and home.
6. Changes to Medicare and Medicare Advantage
Under the new law the roughly 34 million adults who receive traditional Medicare benefits will see their coverage enhanced, as they’ll be eligible for annual checkups and cancer screenings free of charge beginning in January 2011.
An additional 11.4 million Americans over 65 receive their Medicare-covered health care through private health insurance plans known as Medicare Advantage. Today the federal government pays private insurers to manage these programs—14 percent more per person than they pay for the traditional Medicare fee-for-service plans—and, in turn, insurers offer additional coverage such as prescription drugs and dental and vision care. The new health reform law will reduce—but not eliminate—the additional payments to Medicare Advantage plans. Consumers may see some benefits—such as free gym memberships and eyeglasses—adjusted, as the law cuts $136 billion from Advantage programs. Medicare Advantage plans cannot, however, by law, cut guaranteed Medicare benefits.
In sort, the new law should improve and ensure continuity of patient care. Reuben has studied the provisions of the bill and says, “There is nothing I’ve read in the law that will adversely affect my patients. Nothing.”
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