The Affordable Health Care Act, known as Obamacare, is intended to reduce healthcare costs through multiple methods. One way is through a pilot program known as “Independence at Home” that utilizes technology to monitor a variety of health conditions. Known as “e-care”, the program was specifically designed for Medicare patients that traditionally cost the most to treat.
The program was implemented in Jan. 2012. It’s supposed to provide a better level of care, prevent hospital readmissions, achieve a greater level of patient satisfaction, and ultimately, save money.
Medical teams deliver care to Medicare patients in their homes or through a community-based center.
If the team achieves the goals of the Independence at Home program, they’ll receive substantial financial rewards.
E-care can be used to monitor an array of vital signs, providing seniors with convenient, primary care services at home. For the disabled, seniors who find it difficult to leave their homes, and those with chronic illnesses, Independence at Home offers an alternative to expensive long-term care facilities.
Care management teams include practitioners in multiple specialties, from social workers and medical professionals to mental health providers.
Convenience Over Care?
The program opens up new and convenient possibilities for seniors, but all services are no so easily delivered. Those who require extensive physical therapy may not benefit from the pilot program.
The Independence at Home program may have the best of intentions, but it’s confusing for many Medicare recipients who believe they can receive virtually any healthcare service while remaining in their home.
The program could easily encourage seniors to remain in their homes and limit themselves to the available care rather than leave their home to seek services that include physical therapy.
At the other end of the spectrum, patients have expressed concern that the in-home program will promote the use of only basic services and that other options may not be explored in an effort to restrain the cost of care.
Rehabilitation and therapy services will be terminated if the medical team members determine the patient has attained the minimal skills and range of motion needed to conduct daily living activities, or if family members are available to perform those daily activities for them.
The Independence at Home program under Obamacare has the potential to underutilize or limit some treatments in favor of cost savings to a segment of the population that typically has more need and higher healthcare costs.
For physical therapists, it has the potential of providing them with a means of expanding their services into new venues for increased revenues.
It wasn’t that many years ago that few people had healthcare insurance and they only went to the doctor when faced with life-threatening injuries and illnesses. For virtually everything else, they utilized a variety of home remedies and over-the-counter treatments.
Over the years, that changed. The Affordable Health Care Act, known as Obamacare, is on track to curb over-utilization as a means of reducing healthcare costs.
Comfort Over Care
When designing the Act, the views of Dr. Ezekiel Emanuel weighed heavily in developing Obamacare.
A key advisor to the president, he advocated reducing costs through a combination of methods that includes scaling back on “luxury” services, tests and technology.
The Act assumes that patients are self-indulgent and demand amenities that aren’t necessary for their treatment or recovery.
Those demands include expensive hospital rooms, attractively appointed waiting rooms, convenient parking and facilities designed for comfort rather than utility.
Practitioner Protection, Medication And Patient Ignorance
Obamacare works on the theory that clinicians prescribe tests, utilize high-dollar technology and schedule office visits that aren’t needed as a way to earn more money and protect themselves against potential litigation.
Obamacare further cites drug prices that are 10 to 30 percent higher in the U.S. than other countries, marketing costs, and the fee-for-service payment model for rising prices.
Malpractice insurance and consumers’ ignorance of the true cost of their healthcare were also named as factors for skyrocketing prices.
Back To Basics
Obamacare offers a multi-pronged attack that focuses on the cost element of the healthcare equation. Medical professionals and facilities that produce desired patient outcomes are rewarded financially.
The goal is for practitioners to use fewer “unnecessary” tests and technology to determine exact causes and rely more on exams and a patient’s health history to prescribe medications, devise treatments and expedite recoveries.
The cost for using the technology remains the same, but it’s utilized less as a means of lowering costs.
Individuals are tasked with paying more of their healthcare costs and utilizing preventative measures to keep themselves healthy, as defined by their healthcare policy.
Employers and insurers are using financial incentives to promote healthy lifestyles, and encourage people to stop activities or practices that are deemed detrimental, from not getting enough exercise and giving up tobacco to eliminating soft drinks.
Taxes are imposed on people with “Cadillac” policies that Obamacare says encourages over-utilization of services, an outlook that could be an incentive for limited benefit packages in the future.
Those without insurance are penalized for their irresponsibility in not carrying coverage.
Physician Strategies And Struggles
Under Obamacare, practitioners are urged to return patients to a functioning condition as quickly as possible by less expensive means than currently employed. The Act reduces Medicare reimbursements and bundles payments for in-patient hospital stays and post-discharge treatments that were previously billed individually.
Obamacare advocates e-care monitoring at home to avoid hospital admissions, readmissions, and stays in skilled nursing and long-term healthcare facilities.
Independent Payment Advisor Board (IPAB)
Obamacare operates under the theory that access to technology automatically equates with overuse.
IPAB has been charged with finding ways to cut Medicare costs and making recommendations for treatments that automatically go into effect unless Congress moves to block them.
The organization is responsible for determining which treatments and procedures, in the collective opinion of its members, provide the best results/value for the money spent.
The rising costs associated with healthcare are due to a variety of factors associated with a capitalistic society. Obamacare attempts to address those issues with multiple methods that changes the way healthcare is purchased and delivered, combined with an array of taxes on policies and penalties for non-compliance.
Many patients fear that Obamacare signals a return to health coverage that’s only used in the direst situations and losing access to life-saving technology if a governmental panel deems it as too expensive.
The Affordable Health Care Act, colloquially known as Obamacare, was signed into law on March 23, 2010, legislation that encompassed more than 2,500 pages and destined to be the biggest change in healthcare in more than 150 years.
Many of the Act’s finer points haven’t been finalized or even written.
For instance, the office of Health and Human Services has not created a full set of rules and regulations to ensure the workings of the initiative.
Obamacare marks a milestone in the evolution of healthcare, but to fully appreciate the changes generated by the Act, it’s important to understand the history of healthcare insurance in the U.S.
Other countries typically utilize some form of socialized medicine, while the U.S. combines several methods that includes government subsidized programs, employer-based coverage, and direct sales.
Insurance During World War II
Prior to World War II, health insurance was a commodity that individuals purchased for themselves and was viewed much like the traditional rainy day fund – it was something to be used in an emergency.
As millions of men went to war from 1939-1945, the federal government placed a freeze on wages to prevent inflation. To acquire and retain workers, employers began offering healthcare to workers.
The practice gained widespread popularity with employees as manufacturing processes of the time became more dangerous and the potential for injuries increased. It was a non-taxed benefit that made it doubly attractive.
Policies were much less inclusive than those enjoyed by today’s workers and were primarily used for hospitalization needs.
Inequities For The Self-Insured
Those who had to purchase their own insurance received none of the tax breaks or discounts on premiums available to those who obtained insurance through large employer pools. Obamacare helps narrow that gap with insurance offered through the Marketplace for the approximately 9 percent of the population that purchase their own healthcare.
The self-insured can obtain coverage at rates estimated to be comparable to employer-based policies.
Medicaid And Medicare
To address the needs of the disabled, elderly and poor, the federal government instituted Medicare and Medicaid. Obamacare increases Medicaid income eligibility requirements.
The change allows more people to enter the system, but those living in states that already have generous income requirements may no longer be eligible and will have to purchase coverage through the Marketplace.
Obamacare provides government subsidies to help individuals pay for Marketplace insurance.
Healthcare Through The Years
Healthcare has been an issue in the U.S. since 1854, when it was first proposed for the benefit of the indigent and insane.
The effort to overhaul healthcare in the U.S. gained prominence again in 1933 under President Franklin D. Roosevelt, who managed to enact healthcare as part of Social Security, but not for all citizens.
President Lyndon B. Johnson oversaw the passage of Medicare and Medicaid in 1964, but it took almost 17 years for all states to participate.
President Jimmy Carter and President Bill Clinton proposed sweeping changes in 1977 and 1994, respectively, but both plans failed and were met with significant resistance by the medical community and pharmaceutical companies.
President Obama vowed to fix what he perceived to be a broken healthcare system and in 2010, the Affordable Health Care Act became the law of the land.
It expanded Medicaid coverage, established the Marketplace where the uninsured can buy policies, and established a core of benefits that every policy must offer.
The evolution of U.S. healthcare took a major leap from the accepted norm with Obamacare, legislation that’s inarguably the biggest change in the nation’s healthcare practices in more than 150 years.
If you are not using an EMR system already, then the time to consider it is now. That’s not all. You want to ask the important question “Is my EMR system recognized and tested by the Office of the National Co-ordinator (ONC) and how can I verify this?”.
Healthcare is changing and practitioners must transform their practices to remain in business.
Government Sanctioned EMR Technology
We’re living in a new world, and I call it the “Obamacare Economy”. As a clinician, it’s your responsibility to document, code and bill effectively, and make sure everything is reported to CMS and other payers. You can achieve this the hard way with pen and paper, or the easy way with EMR technology.
Even through physical therapists are not ‘eligible professionals’ and therefore not eligible for Meaningful Use incentives like physicians, physical therapists should consider using (at minimum), a base EHR certified technology from January 1, 2014 to be eligible for PQRS incentives, according to a CMS Rule published 11/16/2012 that can be found here:
“Therefore, based on the comments received, we are also finalizing to the requirement that a direct EHR product be certified by ONC as Certified EHR Technology (CEHRT), and therefore meet the definition of CEHRT in ONC’s regulations (see 45 CFR 170.102), to submit PQRS measures. (For the 2014 Edition EHR certification criteria, please refer to 77 FR 54163)”
“We are discontinuing the qualification process and requiring that a direct EHR product be CEHRT beginning in 2014. A certified quality reporting module may be part of CEHRT, but CEHRT as a whole is more comprehensive. Please refer to ONC’s standards and certification criteria final rule for additional information on requirements for CEHRT (77 FR 54163).”
A CEHRT is defined as “EHR technology certified to the 2014 Edition EHR certification criteria that meets the Base EHR definition and would support the objectives, measures, and their ability to successfully report the CQMs, for the MU stage that they seek to achieve.”
These are the minimum modules that an EMR must be certified in to meet the requirements of being a CEHRT and being able to directly submit PQRS in 2014.
Includes patient demographic and clinical health information, such as medical history and problem lists
Demographics § 170.314(a)(3)
Problem List § 170.314(a)(5)
Medication List § 170.314(a)(6)
Medication Allergy List § 170.314(a)(7)
Has the capacity to provide clinical decision support
Clinical Decision Support § 170.314(a)(8)
Has the capacity to support physician order entry
Computerized Provider Order Entry § 170.314(a)(1)
Has the capacity to capture and query information relevant to health care quality
Clinical Quality Measures § 170.314(c)(1) through (3)
Has the capacity to exchange electronic health information with, and integrate such information from other sources
Transitions of Care § 170.314(b)(1) and (2)
Data Portability § 170.314(b)(7)
Has the capacity to protect the confidentiality, integrity, and availability of health information stored and exchanged
Privacy and Security § 170.314(d)(1) through (8)
The EMR software you use must satisfy these criteria, and must be tested and accredited by one of the four bodies approved by the ONC.
ONC Certified Base EHR Technology – Is Your Vendor Certified by one of the ‘Big Four’?
The Office of the National Coordinator for Health Information Technology is responsible for certifying electronic medical records software, and it does so through FOUR ‘Certification Bodies and Testing Laboratories’, which play a key role in the ONC HIT Certification Program.
Certifying and testing Electronic Health Record (EHR) technology provides assurance to providers and other purchasers that an EHR system offers the necessary technological capability, functionality, and security to help them meet the Meaningful Use criteria, and helps maintain quality and consistency across the certified products. Once again, physical therapists are not eligible for Meaningful Use funds, but a minimum ‘base EHR’ technology is required for reporting PQRS measures.
In the ONC HIT Certification Program, ONC-Authorized Certification Bodies (ONC-ACBs) conduct certification and Accredited Testing Laboratories (ATLs) conduct testing.
A single organization can be both an ONC-ACB and an ATL. ONC has authorized the following certification bodies to serve as ONC-ACBs in the ONC HIT Certification Program:
Certification Commission for Health Information Technology (CCHIT)
InfoGard Laboratories, Inc
Only test tools and test procedures that have been approved by the National Coordinator can be used to test Complete EHRs and/or EHR Modules in order for them to be eligible for certification by an ONC-Authorized Certification Body (ONC-ACB). ATLs are authorized to test Complete EHRs and/or EHR Modules according to the 2011 and/or the 2014 Edition EHR Certification Criteria.
The test tools and test procedures that align with the 2014 Edition are available here
On this site, providers can access all certified software and select individual products or combinations of products to use to attest for Meaningful Use funds through the CMS. Providers can also look for EHR vendors that have been tested and certified for certain specific criteria (these will appear as ‘Modular EHR’ technologies).
Try it out by selecting a 2011 or 2014 Edition software, placing it in the shopping cart, and see the resulting message that is generated.
What this Means for Physical Therapy Private Practice Owners
Physical therapists who bill Medicare must report PQRS measures (and Functional Limitation G codes) to avoid penalties and the best way to do this is with the use of an EMR system. Your EMR should be a registry, or provide claims based reporting options to CMS, or better yet, be recognized by the ONC as a ‘Modular EHR’ that fulfills the requirements of a ‘base EHR’.
Technology like this offers the ability to collect reimbursements quicker, maintain security compliance, and increase the profitability of practices.
EMR systems contain functionality to track multiple variables that affect the practice and market services successfully. The software can be deployed on tablet technology for portability, allowing therapists to save time during the patient encounter and complete paperwork electronically for quicker billing turnaround.
The EMR technology of the future must help grow your practice. It’s not enough for an EMR vendor to be ‘just another vendor’ that sells you software for scheduling, documentation, compliance and billing. It’s not enough for the software to have perks like appointment reminders and home exercise programs.
Your practice needs way more than that to be able to help you grow in the Obamacare economy, and that’s why we built In Touch EMR.
Your EMR software has to go above and beyond what it’s doing now.
It has to help you increase profits by integrating all the following within the interphase of the EMR software:
Increase referrals from physicians with automated marketing systems
Increase referrals from patients with automated newsletters, greeting card, phone, text and email communication systems
Increase referrals from other business in the community by creating and automating cross promotion marketing campaigns
Converting prospects to patients with done-for-you educational resources automatically distributed to patients
Diversification – The Way to Thrive in this New Economy
In this new economy, you don’t want to ‘keep all your eggs in the Medicare basket’. As patients see a decline in the quality of physical therapy, they will be looking for (and willing to pay for) options that make them healthier.
This is an unprecedented new opportunity, unlike anything we’ve ever seen before in physical therapy private practice.
That’s exactly where you come in.
Today’s patient is eager to partake of services and products perceived as “luxury” items. Known as cash paying services, they’re paid for at the time they’re delivered. Options include selling supplements, durable medical supplies and medical products to better serve patients and create multiple income streams.
Hiring the right staff to provide the services, and the right systems to be able to track these services is the first step towards diversification. Speaking of systems, nothing is more important than a simple, yet powerful electronic medical records (EMR) system for your private practice.
With the portability of EMRs, practitioners can expand their repertoire of offerings at the clinic and in other venues. Clinicians can feature a variety of different massage therapies, weight loss clinics and nutritional information, along with personal training,acupressure and wellness programs. Aquatic therapy, women’s programs, athletic training services and fall prevention offerings are also popular.
Your Action Plan with Obamacare
Strategies to maximize Medicare payments include:
Be more efficient with time spent with all patients, especially Medicare
Be more knowledgeable about the types of CPT codes and number of units billed
Here is how you can maintain (and even increase income) in the Obamacare economy:
Diversify your payer mix by having payers other than Medicare, preferably those who pay more than Medicare. Look at your payor contracts to determine how much you are getting paid and identify the ones where you are paid more. Reduce your dependence on Medicare patients. We can help you analyze this, as part of our coaching service in the Referral Ignition Elite program.
Setup different cash paying programs to increase income and increase lifetime value of each patient. Mobilize your staff, patients and referral sources to help you increase referrals and grow the practice. Diversify sources of income and services to serve patients better to make your business multi-faceted and diverse. You can get several free tips and tricks on how to market your private practice at our blog.
Clinicians must be more efficient in the time they spend with patients, from ascertaining the source of their ailments and creating documentation to preparing claims for billers.
Besides the clinician, the biller is the most important person in the practice. Here are some of the most time consuming aspects of billing:
Creating claims by copy pasting ICD, CPT, modifiers, supporting diagnosis data into the billing software
Editing and scrubbing this data before it is submitted to the payer
Manually batching claims and uploading them to the clearing house
Manually reviewing and posting ERAs to the patient record
Submitting secondary claims
Generating and mailing patient statements
Here’s the good news – EMR systems such as the In Touch EMR and the fully integrated In Touch Biller Pro automate all of these tasks for the biller. This allows the biller to focus on the things that drive revenue for the private practice such as:
Make sure all claims are submitted as quickly as possible
Identify reasons for denials and eliminate them
Provide simple guidelines to clinicians to maximize reimbursement and minimize denials
Call the insurance companies to follow up on claims
Make sure all EOBs are entered promptly
Write and mail appeal letters
Follow up with patients to make sure statements are paid
This makes things easier for the private practice owner, allowing him or her to plan and implement diversification endeavors.
Concierge Services – A Bold New Alternative
Concierge practices, also known as direct pay practices, are typically the bastion of primary care physicians, but the concept can work for physical therapists. In a concierge practice, patients pay a monthly or annual fee for enhanced services that can include same day appointments, email consultations, extended patient encounters and 24/7 access to their therapist, along with other perks.
Practitioners generally maintain a smaller roster of clients, but are paid better and work fewer hours. It’s a healthcare option that enables clinicians to practice in their own way, reduces staffing, compliance and administrative costs, and treats patients as individuals rather than part of an assembly line. Therapists can also continue to accept insurance payments if they choose.
Therapists don’t want to turn away any patient, especially those with Medicare who may need them most, even though they’re underpaid through Obamacare.
To combat the negative impact of Obamacare on patients and practitioners, clinicians must increase the efficiency level during the patient encounter.
Identifying cash paying services and products appropriate for the practice allows clinicians to attract a larger and more diverse clientele. Those services and products will establish multiple streams of revenue that ensures profitability through any economy and helps practices survive Obamacare.
The Affordable Health Care Act, known as Obamacare, impacts private practices in multiple ways, but nowhere is that more evident than a pilot program of Accountable Care Organizations (ACOs).
An ACO is a group of healthcare providers that work as a team to deliver and manage patient care. Primarily aimed at Medicare patients, the goal is to prevent hospital admissions and readmissions.
It’s one of many initiatives that Obamacare is utilizing as a means of lowering healthcare costs. The outcome of the program could affect the entire way that care is delivered to seniors.
If the new method becomes the standard, it will affect any private practice that isn’t part of an ACO.
Composition And Rewards Of An ACO
The ACO is multi-disciplinary team composed of hospitals, clinicians and home care providers that are charged with providing primary and ongoing care. Services are bundled and a flat fee is paid to the team.
Bonuses will be paid when teams provide quality care that falls below a to-be-determined dollar amount.
ACOs attempt to limit costs through the reduction of “unnecessary” tests and procedures, and less usage of expensive technologies. ACOs that reach target wellness goals can keep any savings for themselves.
Home monitoring and the services of nurse practitioners, physician assistants, dietitians and care coordinators are encouraged.
At the end of three years, the information will be used to evaluate the program and discover areas where the greatest savings were found. The data will be examined by the Patient Outcomes Research Institute created by Obamacare.
The Independent Payment Advisory Board will be free to enact laws based on the Institute’s final results.
Private Practice Concerns
The financial rewards can be great for ACO participants, but if the pilot program becomes the standard, it will significantly reduce revenues for clinicians in private practice. Medicare patients will be initiated into an ACO that will handle their care from the beginning of a medical episode and for up to 30 days following discharge.
Practices that rely heavily on technology will be most affected.
It’s conceivable that private practitioners will be required to participate in an ACO or lose a significant number of patients and corresponding revenues. Some clinicians are facing pressure to sell their practices to local hospitals to become cogs in an ACO.
Practitioners will need to find alternative revenue streams that could include the sale of supplements, medical products or becoming a concierge practice.
Patient Fears For The Future
Obamacare functions on the assumption that ACOs will replace the current treatment and reimbursement model.
Many patients are concerned that the quality of their healthcare will suffer and access to technology will be limited as ACO teams prescribe treatment with an eye to a financial bonus at the end of the encounter.
The Possible End Of Employer-Based Insurance
ACOs have the potential to replace employer-based insurance. Instead of contracting with insurance carriers, employers could choose to join an ACO network to provide care for employees.
Private practices derive a significant portion of their patient base through contracts with employer-provided insurance plans.
The ACO model is an inclusive group that disperses work throughout its members. Clinicians could find their access to patients limited if they’re not ACO participants.
ACOs will affect patients and practitioners in various ways.
The driving force behind Obamacare is finding ways to save money, particularly in the Medicare arena. ACOs are touted as a means to rein in costs while providing quality care. To accomplish that goal, clinicians may have to be prepared to become an ACO participant, and patients may have to be content with less access to technology if it’s deemed too expensive.
The Affordable Health Care Act, known as Obamacare, will affect people in different ways, Coverage is guaranteed either through the Healthcare depending upon their situation. Marketplace or expanded Medicaid programs.
Obamacare promises affordable healthcare, but the term affordable is based on a government formula and it doesn’t necessarily mean cheap.
The Department of Health and Human Services estimates the average cost of a Marketplace plan will be $328 per month for mid-level coverage.
Four plans are offered in the Marketplace – bronze, silver, gold and platinum – each with different levels of out-of-pocket expenses.
The lowest average catastrophic plan premium is estimated at $129 per month.
Essential Medical Coverage
Everyone covered with an insurance plan, whether it’s a purchased policy, Medicare or Medicaid, are entitled to a core group of services ranging from hospitalization and prescriptions to lab tests.
Many preventative tests, wellness screenings and counseling services can be obtained at no cost to the patient.
Employees with coverage through their employer don’t have to apply through the Marketplace. If the cost of an employer policy is more than 9.5 percent of the worker’s wages, then they can apply for insurance through the Marketplace.
Pre-existing Conditions And Breaks For Children
Patients with any type of pre-existing medical condition can’t be turned down for coverage or charged more than other policyholder.
Children can now remain on parental insurance policies until the age of 26.
Spouses May Not Qualify As Dependents
Spouses may not be eligible for family coverage under Marketplace policies. Obamacare provides the means for the primary policyholder to cover dependents (children) but spouses are not necessarily considered dependents any longer.
In plans that don’t count spouses as dependents, individuals will be responsible for obtaining coverage through their own employer or buying a plan through the Marketplace.
Medicare And Seniors
There will be no change in how Medicare recipients choose their physicians and Obamacare will completely close the gap in what they pay for prescriptions by 2020, once a deductible of $4,750 is met. After that, seniors pay 5 percent of the cost for the remainder of the year.
Seniors with high medical needs will be able to receive basic care in their home to reduce and prevent hospital stays.
Couples with yearly earnings of $200,000 or more will see a tax rate increase of .9 percent for Medicare Part A coverage and a new income-related premium will be established for Medicare Part D.
Many consumers will qualify for federal subsidies to help them purchase coverage on the Marketplace. Financial assistance is dependent upon household income.
The cost of the policy will depend on the coverage selected, the person’s income and the geographic area in which the policyholder lives.
The Individual Mandate Tax (IMT)
Anyone who chooses not to obtain insurance will be assessed a penalty on their income tax returns. Fines begin at $95 for adults and $47.50 for children in 2014, escalating to $695 for adults and $347.50 for children in 2016.
Interest accrues on unpaid amounts and fines can be deducted from any refund that’s due.
Exemptions from the IMT are available for certain religious groups, members of Native American tribes, and those who are incarcerated.
Also exempt are people with incomes of $9,500 or less who aren’t required to file a tax return, along with those whose premiums would exceed 8 percent of their income after employer contributions and federal subsidies.
Obamacare will affect everyone in different ways. For some, it will mean access to healthcare services for the first time. Others will see an increase or decrease in their coverage costs, depending on the type of policy they currently have.
Most consumers will have to wait to see exactly how Obamacare will impact them now and in the future.