The U.S. Supreme Court is currently deliberating over arguments it heard last month for and against the constitutionality of the Patient Protection and Affordable Care Act, its individual mandate and the Medicaid expansion. The healthcare industry has been preparing for the proposed healthcare reform law for quite some time, and with the official ruling on the PPACA expected later this month, the predictions and forecasts will end.
For some healthcare organizations, payors, physicians, specialties and even specific hospital departments, the outcome of the Supreme Court ruling has significant implications. For instance, hospital emergency departments could be greatly affected, regardless of whether the Supreme Court finds the PPACA to be constitutional.
Here Lynn Massingale, MD, founder and chairman of TeamHealth, a leading provider of emergency room staffing, discusses two major implications for EDs depending on the Supreme Court decision.
If the law stands…
According to Dr. Massingale, emergency departments will experience an increase — albeit modest — in net reimbursements if the Supreme Court upholds the PPACA. In the ED arena, 20 percent of the patients are uninsured, Dr. Massingale estimates. If the PPACA stands, uninsured individuals, who have been paying for healthcare services independently — the lowest form of reimbursement for hospitals and EDs — will have access to insurance through Medicaid and state exchanges. "At the very least, EDs could expect Medicaid-level reimbursement from much of the previously uninsured population," says Dr. Massingale.
However, EDs may also see some downward pressure in reimbursement due to changes in commercial rates. If previously covered individuals move to state exchanges because of the PPACA, reimbursement amounts could change for some EDs. "Commercial rates are generally the best for providers, followed by Medicare and then Medicaid. If individuals move from employer-based, commercial insurance to commercial state exchanges, there may be a difference in reimbursements for the ED," says Dr. Massingale. However, the increase in insured patients would most likely outweigh the downward pressure of losing traditionally high commercial reimbursements.
If the law does not stand…
If the PPACA is found to be unconstitutional, the impact on EDs will not be as significant because the reimbursement situation will remain similar to what it is today. "EDs will continue to provide services to the uninsured and struggle with reimbursement. Although, EDs will experience greater and greater financial pressure in this situation," says Dr. Massingale. "Hospitals and ER physicians have shouldered a great deal of reimbursement problems for a long time, and EDs will have to figure out how to continue," he says.
If the law stands…
If the Supreme Court upholds the PPACA, hospital EDs will most likely see volumes increase for two reasons, says Dr. Massingale. "The mere fact that more individuals will be covered by insurance will bring more patients to the ED, especially since the uninsured population has healthcare needs on reserve. In addition, there is not a primary care practice excess in the country. The odds are that newly insured individuals will not be able to see primary care practitioners and instead will visit an emergency room," says Dr. Massingale.
If the law does not stand…
If the PPACA is struck down, EDs will still face increasing volume due to already existent factors. "ED patient volumes are historically increasing, particularly as hospitals close and patients are consolidated into fewer ERs. The law and any additional coverage for individuals will only add to the factors of aging population, lack of primary care capacity and the closing of hospitals. These factors all work together to increase patient volume," says Dr. Massingale.
Regardless of the PPACA's future, EDs face challenges in reimbursement and patient volume. "There are some who are very negative about these implications. However, it is important to stay focused on what is the best way to treat patients — the ER, urgent care centers or other locations — rather than complaining that there are too many patients," says Dr. Massingale.
Healthcare providers cannot control the outcome of the Supreme Court case or the presidential election, which may also have an impact on the future of the PPACA. However, they can position themselves to be responsive of the outcome. "Regardless of what the Supreme Court decides, who wins the presidency or which political party wins majority in Congress and the Senate, the emphasis over the next few years — in EDs and healthcare in general — should be on how to reduce cost, improve quality and improve access," says Dr. Massingale.
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For some healthcare organizations, payors, physicians, specialties and even specific hospital departments, the outcome of the Supreme Court ruling has significant implications. For instance, hospital emergency departments could be greatly affected, regardless of whether the Supreme Court finds the PPACA to be constitutional.
Here Lynn Massingale, MD, founder and chairman of TeamHealth, a leading provider of emergency room staffing, discusses two major implications for EDs depending on the Supreme Court decision.
Reimbursement
If the law stands…
According to Dr. Massingale, emergency departments will experience an increase — albeit modest — in net reimbursements if the Supreme Court upholds the PPACA. In the ED arena, 20 percent of the patients are uninsured, Dr. Massingale estimates. If the PPACA stands, uninsured individuals, who have been paying for healthcare services independently — the lowest form of reimbursement for hospitals and EDs — will have access to insurance through Medicaid and state exchanges. "At the very least, EDs could expect Medicaid-level reimbursement from much of the previously uninsured population," says Dr. Massingale.
However, EDs may also see some downward pressure in reimbursement due to changes in commercial rates. If previously covered individuals move to state exchanges because of the PPACA, reimbursement amounts could change for some EDs. "Commercial rates are generally the best for providers, followed by Medicare and then Medicaid. If individuals move from employer-based, commercial insurance to commercial state exchanges, there may be a difference in reimbursements for the ED," says Dr. Massingale. However, the increase in insured patients would most likely outweigh the downward pressure of losing traditionally high commercial reimbursements.
If the law does not stand…
If the PPACA is found to be unconstitutional, the impact on EDs will not be as significant because the reimbursement situation will remain similar to what it is today. "EDs will continue to provide services to the uninsured and struggle with reimbursement. Although, EDs will experience greater and greater financial pressure in this situation," says Dr. Massingale. "Hospitals and ER physicians have shouldered a great deal of reimbursement problems for a long time, and EDs will have to figure out how to continue," he says.
Volume
If the law stands…
If the Supreme Court upholds the PPACA, hospital EDs will most likely see volumes increase for two reasons, says Dr. Massingale. "The mere fact that more individuals will be covered by insurance will bring more patients to the ED, especially since the uninsured population has healthcare needs on reserve. In addition, there is not a primary care practice excess in the country. The odds are that newly insured individuals will not be able to see primary care practitioners and instead will visit an emergency room," says Dr. Massingale.
If the law does not stand…
If the PPACA is struck down, EDs will still face increasing volume due to already existent factors. "ED patient volumes are historically increasing, particularly as hospitals close and patients are consolidated into fewer ERs. The law and any additional coverage for individuals will only add to the factors of aging population, lack of primary care capacity and the closing of hospitals. These factors all work together to increase patient volume," says Dr. Massingale.
Regardless of the PPACA's future, EDs face challenges in reimbursement and patient volume. "There are some who are very negative about these implications. However, it is important to stay focused on what is the best way to treat patients — the ER, urgent care centers or other locations — rather than complaining that there are too many patients," says Dr. Massingale.
Healthcare providers cannot control the outcome of the Supreme Court case or the presidential election, which may also have an impact on the future of the PPACA. However, they can position themselves to be responsive of the outcome. "Regardless of what the Supreme Court decides, who wins the presidency or which political party wins majority in Congress and the Senate, the emphasis over the next few years — in EDs and healthcare in general — should be on how to reduce cost, improve quality and improve access," says Dr. Massingale.
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