• The High Court Has Spoken on Health Care--What’s Next for Physicians?
  • August 21, 2012 | Author: Calvin B. Marshall
  • Law Firm: Chambliss, Bahner & Stophel, P.C. - Chattanooga Office
  • The health care community is still digesting the Supreme Court’s much anticipated and surprising decision on the Affordable Care Act (ACA).  Chief Justice John Roberts confounded experts on both sides by upholding the so-called individual mandate and ruling that although the mandate was not within Congress's power to regulate interstate commerce, it could be reasonably viewed as a tax.

    At the same time, the Court modified the ACA's Medicaid expansion, ruling that the federal government cannot take away states' pre-existing federal Medicaid grants if they refuse to participate in the expansion.

    The Court’s decision means the vast majority of the ACA will remain in effect, notwithstanding promises of repeals and waivers.  For physicians, the provisions of the law include the following:

    Primary Care:  The ACA contains a number of measures aimed at bolstering primary care.  These measures include, among others, a 10% Medicare bonus payment for physicians providing primary care from 2011-2015, increasing the Medicaid reimbursement rates for primary care physicians to 100% of Medicare rates for 2013 and 2014, and funding additional primary care residency slots.

    Medicare Shared Savings Program (MSSP):  The MSSP, which rewards coordination and cooperation among providers and suppliers for improving the quality of care and reducing unnecessary costs, also promotes integration among these entities through the formation of Accountable Care Organizations (ACOs).  Over 150 ACOs have begun participating in the MSSP to date, and participation is expected to accelerate in the wake of the Supreme Court's decision.

    Fraud and Abuse:  The ACA has produced significant changes to fraud and abuse law, including the Medicare Self-Referral Disclosure Protocol (SRDP), which allows health care providers and suppliers to disclose actual or potential violations of the Stark Law and, in turn, allows the U.S. Department of Health and Human Services (HHS) to compromise on penalties and enter into settlements.  Additionally, under the ACA, providers are now required to report and return overpayments within 60 days of their identification or the date that any corresponding cost report is due.

    Physician Payment Sunshine Act (PPSA):  The PSSA requires, among other things, that manufacturers of pharmaceuticals, medical devices and biologics annually report to HHS any payments or transfers to physicians and teaching hospitals, including gifts, payments for meals, travel, honoraria, research payments and investment interests.  Manufacturers must report a variety of information in order to avoid civil monetary penalties, including physicians' names and business addresses.  Significantly, this information will be publicly available.

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    These provisions are only a brief sampling of the many changes contained within the ACA that will impact physicians directly.  Moreover, what is more difficult to determine, at this juncture, is how the law's many other requirements, such as the individual mandate, employer "pay or play" rule, insurance rules and state exchanges, will impact physicians and their practices over the long term.  As we have already learned, analyzing and digesting a law of this magnitude is a long process, and there are bound to be surprises.