AFFORDABLE CARE ACT
What is affordable health care?
Davin Laurino, assistant vice president of commercial sales and broker service at Healthfirst, a New York City insurance company, said that question is a double-edged sword “because we know health care is not affordable.”
“We started about 25 years ago and we were more on the Medicare/Medicaid side,” he said, “but we have since moved into what we call ‘commercial,’ so, small employers, individuals [who] aren’t subsidized. We are working toward that common goal of trying to keep our members healthy and really, that goal is to try and control the spiraling cost of health care.”
The idea behind “affordable health care,” he said, is to serve as a mechanism for individual insurance subsidies.
“I think the whole premise there is that the government came in and allowed for subsidies for individuals buying insurance on the Exchange, which, depending on their income level can be a few dollars or many dollars,” he said. “We have a long way to go before care is truly affordable.”
Mr. Laurino said Healthfirst is expanding its networks on the East End and that unlike some private insurance companies, Healthfirst reinvests a portion of its profits into hospitals because they own a percentage of the company.
Joe Corso of Cutchogue, an audience member, asked what the consequences could be on the panelists’ businesses if the ACA were to be repealed without a replacement plan.
“I’m not a huge fan of the Affordable Care Act,” Paul Connor III, CEO of Stony Brook Eastern Long Island Hospital said, “but I am a fan of coverage and I have to say, this has covered 20 million more Americans — not so much on the Exchange — but on Medicaid expansion.”
As a hospital administrator, he said, the ACA is successful at getting people on insurance. But, he added, “there’s insurance and then there’s sort of the illusion of insurance.”
That is, until people hit their deductible, their insurance benefits don’t always kick in.
Mr. Connor said that if the rug is pulled out from under the ACA, “we will have a very, very significant crisis.”
New York has, as of July 2019, enrolled 6.5 million individuals in Medicaid and the Children’s Health Insurance Program — which falls, in part, under Medicaid. This figure represents a 14.51% net increase since the first Marketplace Open Enrollment Period and related Medicaid program changes in October 2013, according to Medicaid’s website. The fiscal year 2019 state executive budget recommends $142 billion for Medicaid, in a two-year appropriation authority, according to the New York State Department of Health.
“We all know New York State is a heavy, heavy Medicaid state,” Mr. Connor said. “Almost half the babies in this country are financed through Medicare; it’s a stunning number. If you take that … if that safety net is gone, we’re going to have a crisis. You can’t take away a service or a feature that we already have without having something equal or better and I’m afraid there will be nothing equal or better.”
PBMC CEO and president Andy Mitchell brought up the concept of “governmental amnesia,” saying that “the Affordable Care Act was enacted with significant reductions to the providers in the payment of Medicare. We gave up, as an industry, billions of dollars in our Medicare reimbursement to ensure that a population that didn’t have coverage would, in fact, have coverage and the grand theory was that if the people who have no coverage now have coverage, it would all come out in a wash.”
It probably has, he said, adding that if the ACA is repealed, Medicare reimbursement will not be restored to all of the hospitals.
“Without that, then we go into a crisis because Medicare reimbursement as it is today is barely adequate to cover the cost of care … 80% of patients in the hospital are covered by government reimbursement, largely Medicare, because of the age of the North Fork and central Suffolk region, and then the remainder is Medicaid,” he said. “We don’t negotiate those rates; we’re told what they are, we live with them, we adopt a certain level of budget to be able to continue to operate under those conditions. Now, take a whole portion of population who is insured out, don’t do anything to make it up and the industry goes into a spiral.”
Mr. Cardona acknowledged the ACA for streamlining benefits in some plans and better aligning other plans to heighten consumer understanding, but said the biggest problem with health care and health insurance is the lack of transparency in costs.
“What would happen is you’d see a lot of people who might be 55 years old, who might be a sole entrepreneur … scrambling to try to find coverage and there’s really no other avenue at this point for them to get individual coverage if the ACA does go away,” he said.
Dr. Jarid Pachter, vice chair of ELI Leadership Coordinating Council and SBUH Medical Board & MEC member at large, who is also the director of Quannacut Outpatient, said he doesn’t see the ACA ever going away.
“Everyday, you turn on the news … and there are hundreds of people dying of heroin overdoses,” he said. “The only reason these people get treatment is because of the Affordable Care Act so, while it may sound sexy at a rally to say ‘We’re going to repeal this, we’re going to repeal that … The people who are cheering this may not even realize that dozens of people they know may lose their treatment without what they’re asking to be repealed. Once I think that’s pointed out to people, they may start backing off because I don’t think any politicians will be elected when they’re letting their constituents continue to die of an opiate epidemic.”
Dr. Jarid Pachter, right, and Erica Gerrity.
CHALLENGES IN MEDICINE TODAY
When asked to discuss the most prominent challenges in medicine today, PBMC Medical Group Director of Management Services Erica Gerrity, who handles billing, said most of PBMC’s patients are satisfied until they get their bill.
“The biggest concern that patients have is that they don’t really understand their policies,” she said. “These patients say, ‘no, I work for a good company and they’re paying for my healthcare; this should be covered’ or, ‘I pay out of pocket, almost $800 a month for my own premium; this should be covered.’ It’s not up to the provider of service, whether it be a hospital or a physician to determine, based on a patient’s insurance, what will be covered and what will not be covered, so there’s always two aspects to that contract.”
She recommended reading contracts thoroughly before making any decisions and shopping around as a savvy consumer would. Most patients, she said, don’t understand how their health care is billed. As an example, she mentioned a doctor’s visit.
“In my head, that’s a visit, but you could have had an injection or blood work, gone to the [emergency room] where you saw multiple providers of service, had some radiology services and a lot of patients don’t know the questions to ask or who to ask them to … Where do you go? Do I ask my doctors these questions when I’m in the ER? The last thing on my mind is who’s paying for this.”
Dr. Pachter, who has been in practice for just under 10 years, said the main complaint he hears from patients is the switch to electronic medical records. He also took personal issue with the consumerism of medicine.
“You want to spend as much time with the patient, looking them in the eyes,” he said, adding that this becomes especially difficult when there is an overabundance of patients, files aren’t uploaded or prescriptions are denied by insurance companies.
“For so many years, people have ordered medications and ordered tests and ordered surgeries that aren’t needed that the costs of these things has gotten so high that it leads to all these battles between CEOs and insurance companies and doctors and insurance companies,” he said. “The biggest frustration throughout a day is medicine is so disjointed. Even within your own system, your electronic medical record doesn’t communicate with your parent hospital or your associate physicians.”