Spine Surgeon Raj Rao, MD, is professor of orthopaedic surgery at the Medical College of Wisconsin in Milwaukee and is also a major player in U.S. regulatory and health policy. He's a voting member of the Advisory Panel on Orthopaedic and Rehabilitation Devices of the U.S. Food and Drug Administration and also a member of the board of directors of the North American Spine Society.
From 2008 to 2011 — during the drafting and passing of the Patient Protection and Affordable Care Act — Dr. Rao led the national advocacy efforts of the North American Spine Society.
He continues to keep a pulse on what's going on in healthcare policy, especially now, given the Supreme Court will soon issue a decision on the constitutionality of the 2010 healthcare reform law.
"While PPACA will certainly have multiple tangible effects on us as the law unfolds, currently it primarily affects physicians and surgeons through a sense of anxiety it provokes about the eventual state of affairs, watching all the preparations by the various stakeholders in healthcare," Dr. Rao says.
Here, Dr. Rao shares insight into what may come in the aftermath of the Supreme Court's decision.
If the Court upholds PPACA:
1. Reimbursement will go down. Dr. Rao notes that a number of regulations are already in play that affect spine surgeons and all physicians because of PPACA — EMRs, patient quality reporting initiatives, e-prescribing and meaningful use criteria to name a few. "We’ve moved from the bonus phase of many of these regulations where we were given additional money for meeting thresholds on these requirements, to the penalty phase for not meeting the requirements." Should the Supreme Court uphold PPACA, he foresees changes in the amount physicians are reimbursed, with specialists receiving less pay and primary care physicians receiving more.
"Reimbursements for specialty care have been steadily ratcheted down through various avenues over the last 10 years or so," Dr. Rao says. "Reimbursement for primary care has been steadily ratcheted up."
2. Primary care will continue to be incentivized to play a bigger role. State and federal government programs that provide incentives for primary care physicians, and for medical students to choose primary care practice because of shortages in that area are laudable in theory, Dr. Rao says.
In many instances, primary care physicians tend to act as a triage and refer to a specialist for appropriate care. "They simply don't have time to keep up with a rapidly expanding field of medicine, and generally tend to recommend patients receive complex care from physicians who specialize in it," Dr. Rao says.
He gives an example in his field of orthopaedic and spine care. Patients with strains in their lower back are okay to receive primary care. But the minute the strain worsens to the point where the pain is unbearable, the patient more often than not will demand to see an orthopedic spine surgeon or other spine specialist who understands back pain on a much more sophisticated level than the primary care.
3. Specialty shortages will create access to care issues. Additionally, specialty care is in jeopardy of hitting a shortage as worrisome as primary care in the next 10 to 15 years as physicians retire and baby boomers need more specialized care, according to Dr. Rao.
"What most people don't talk about is the shortage in specialty care," he says. "What has kept American healthcare glorious is specialty care." He fears that a de-emphasis on specialty care could fade that reputation.
4. Spine surgeons will limit their practices to private payors. Another potential outcome if PPACA is upheld is a lowering of Medicaid and Medicare reimbursements, to the point where some physicians may no longer be financially able to provide care for patients with government payors.
And if PPACA is upheld and some 30 to 40 million more Americans receive federally-subsidized insurance, Dr. Rao foresees some physicians being unable to continue to maintain an independent practice at all.
"The cost of providing quality of care will far exceed the reimbursement of government-sponsored insurance," Dr. Rao says.
If the Court strikes down the individual mandate or all of PPACA:
"If it isn't upheld, all bets are off," Dr. Rao says.
5. A new cost-reducing plan will arise. Politicians and healthcare leaders will need to ask each other what the next version of reform should look like if PPACA is stricken down.
"I don't believe anyone knows what will happen," says Dr. Rao. "There will probably be some reflection on various options, and renewed efforts will develop to somehow reduce costs associated with healthcare."
He continues to keep a pulse on what's going on in healthcare policy, especially now, given the Supreme Court will soon issue a decision on the constitutionality of the 2010 healthcare reform law.
"While PPACA will certainly have multiple tangible effects on us as the law unfolds, currently it primarily affects physicians and surgeons through a sense of anxiety it provokes about the eventual state of affairs, watching all the preparations by the various stakeholders in healthcare," Dr. Rao says.
Here, Dr. Rao shares insight into what may come in the aftermath of the Supreme Court's decision.
If the Court upholds PPACA:
1. Reimbursement will go down. Dr. Rao notes that a number of regulations are already in play that affect spine surgeons and all physicians because of PPACA — EMRs, patient quality reporting initiatives, e-prescribing and meaningful use criteria to name a few. "We’ve moved from the bonus phase of many of these regulations where we were given additional money for meeting thresholds on these requirements, to the penalty phase for not meeting the requirements." Should the Supreme Court uphold PPACA, he foresees changes in the amount physicians are reimbursed, with specialists receiving less pay and primary care physicians receiving more.
"Reimbursements for specialty care have been steadily ratcheted down through various avenues over the last 10 years or so," Dr. Rao says. "Reimbursement for primary care has been steadily ratcheted up."
2. Primary care will continue to be incentivized to play a bigger role. State and federal government programs that provide incentives for primary care physicians, and for medical students to choose primary care practice because of shortages in that area are laudable in theory, Dr. Rao says.
In many instances, primary care physicians tend to act as a triage and refer to a specialist for appropriate care. "They simply don't have time to keep up with a rapidly expanding field of medicine, and generally tend to recommend patients receive complex care from physicians who specialize in it," Dr. Rao says.
He gives an example in his field of orthopaedic and spine care. Patients with strains in their lower back are okay to receive primary care. But the minute the strain worsens to the point where the pain is unbearable, the patient more often than not will demand to see an orthopedic spine surgeon or other spine specialist who understands back pain on a much more sophisticated level than the primary care.
3. Specialty shortages will create access to care issues. Additionally, specialty care is in jeopardy of hitting a shortage as worrisome as primary care in the next 10 to 15 years as physicians retire and baby boomers need more specialized care, according to Dr. Rao.
"What most people don't talk about is the shortage in specialty care," he says. "What has kept American healthcare glorious is specialty care." He fears that a de-emphasis on specialty care could fade that reputation.
4. Spine surgeons will limit their practices to private payors. Another potential outcome if PPACA is upheld is a lowering of Medicaid and Medicare reimbursements, to the point where some physicians may no longer be financially able to provide care for patients with government payors.
And if PPACA is upheld and some 30 to 40 million more Americans receive federally-subsidized insurance, Dr. Rao foresees some physicians being unable to continue to maintain an independent practice at all.
"The cost of providing quality of care will far exceed the reimbursement of government-sponsored insurance," Dr. Rao says.
If the Court strikes down the individual mandate or all of PPACA:
"If it isn't upheld, all bets are off," Dr. Rao says.
5. A new cost-reducing plan will arise. Politicians and healthcare leaders will need to ask each other what the next version of reform should look like if PPACA is stricken down.
"I don't believe anyone knows what will happen," says Dr. Rao. "There will probably be some reflection on various options, and renewed efforts will develop to somehow reduce costs associated with healthcare."