Wednesday, June 22, 2011

PPACA: A thumps up democratic vote for the health insurance mandate from the American Medical Association?

Keywords or Terms: American Medical Association (AMA); Patients Protection and Affordable Care Act (PPACA); Health Insurance; Health Care System; Guaranteed Reimbursement; Questions and Answers on PPACA; ERISA; Republicans; Comparative Effectiveness; Democrats; President Barack Obama

With all the shaky criticisms and innuendos from the right leaning public, the American Medical Association (AMA), debated and took a vote on the mandate provision of the Patients Protection and Affordable Care Act (PPACA), defaulting on the side of momentous history. Not being one to splurge in his own conviction, I took a look at the democratic voting results of the membership of the AMA, and came out with the result or conclusion: two-thirds of our doctors believe that the mandatory provisions of the Patients Protection and Affordable Care Law of 2010 was good, not only for the practice of medicine but also, for the opportunity it affords health care consumers. Doctors and patients for the first time are going into an accord, particularly for those under Medicare, to ensure that their rights as professionals, patients and consumers of health care as a product, are sacrosanct. The idea that patients’ rights and benefits are protected under a health insurance scheme, including the opportunity to receive care from physicians in a network of providers as well one, out of a network, and both guaranteed cost reimbursements for services received or tendered, are rather revolutionary.

This is why the Patients Protection and Affordable Care Act has translated to an opportunity for Americans as patients to receive truthful answers to questions about their health insurance coverage and be assured that the risks involved in their care are ameliorated to an extent permissible by patients, physicians and or representatives with utmost faith. Many scoffers of the mandatory provisions of the law, mostly republicans who chose to wait the law out, who complain that the law is either unconstitutional or shows an overstepping of the federal power, will end up punning up support, once they realize that members of a reputable organization like the AMA, must have mulled over this same provision in the law, debated actively its pros and cons; and voted, to support the law in spite of. Others, who believe in many of the provisions of the law, who are not necessarily on board at this time, would eventually subscribe to the mandatory provisions of the law, once they understand the reason for the provision. What is the difference between these two groups?

The group(s)of people still antagonistic of the mandatory provision of the law are failing to see how this provision came about; or, are oblivious to the reality of the debate over two summers ago, when republican lawmakers became too recalcitrant to work with, as they sought so many changes in the provisions, before they could throw their support behind the bill. Alas, they still retracted and held back their votes when the bill came to the floor vote in congress. You do not have to be a genius to understand that insurance is a game of number; underwriters need enough critical mass to be able to find underwriting of a policy profitable. To ignore the complexity of health insurance underwriting and essential components of actuaries is to fail to appreciate the reality of underwriting policy for millions of people, who have in the past been considered freeloaders of the American Health Care System.

Critics as well as supporters ought to now start to face the inevitable or reality: the Patient Protection and Affordable Care Act (PPACA) is not going anywhere. There may be need to improve on some of the provisions of the law; however, taking out the mandatory participation component is not part of this equation, no matter how appealing it looks. Underwriting health insurance policy is a business; and, successful management of the provision of the service to additional millions of American depends on peoples’ understanding and insurance companies’ insight. Insurance companies as well as health care consumers must see beyond the obvious for the impending reform components of the law to be borne out; and, for people to appreciate the challenges of what America’s Health Care System had become prior to PPACA; and, why it was absolutely necessary to do all it takes to ensure that health delivery, physicians and hospital providers’ performance and the health care insurance market, will move to a better future. For the law to be considered responsive to the needs of the average American there is need for a critical mass of healthy health care consumers who are buying the health insurance policies that will help build individual responsibility toward the law. This last comment is coming from someone, who was absolutely suspicious of insurance of any kind in the past, as I found the math always in the favor of the provider; and, not the consumer! However, there were too many Americans before the PPACA, who were without health insurance in a temperate climate and activities ladden society as ours, that I started considering that the issues of health care and insurance are life and death issues.

I have heard past criticisms of the PPACA and haven’t so much cared for them; because most of such criticisms come out of the misunderstanding of the whole essence of the law; and, why in the first place, we needed to reform the health care system as we once knew it. The American Health Care System was broken and needed fixes, for health care delivery to function better than it was, delivering all the types of expanded services that consumers of health care, so much longed for. The establishment of state insurance exchanges along side the mandatory provisions of PPACA, make the expectation of health care consumers and providers possible and the shaky criticisms against the law, especially the mandatory provisions of the law, rather moot. Dr. Cecil Wilson, the outgoing president of the AMA was quoted as saying: "The AMA has strong policy in support of covering the uninsured, and we have renewed our commitment to achieving this through individual responsibility for health insurance with assistance for those who need it." Through this statement AMA has appreciated the need for individual responsibility in their health care demand; and, the importance of giving health care consumers a base from where to get a bang for each of the dollar spend on health care services.

The uniqueness of the PPACA is the preservation of the rights of out-of-network physicians and hospitals as well as in-network physicians and hospitals in terms of reimbursement for services; and, this may have been one of the reasons why more physicians are in support of the law. Yes, there is a message that encourages broader participation of Americans in the health insurance coverage as well; but more importantly for out-of-network physicians and hospitals, is the message that no matter where services are provided or received, payment or reimbursements must seize to be based on whether the provider is out-of-network or in-network. In one sentence, the Patients Protection and Affordable Care Act protects not only the rights of the patients, but also, the rights of the physicians or provider. The old discriminatory anti-assignment practices that discriminated against all out-of-network providers in receiving direct reimbursements and appeal rights, are a thing of the past, with the onset of PPACA. On September 23, 2010, the age-old discriminatory practices, which many out-of-network physicians and hospital have repeatedly complained about, became a thing of the past in the American health care delivery system.

No one is ruling out that physicians and hospitals have their own interest to preserve regarding the provisions of the health care reform law. Many of the benefits that are about to phase in come 2014, including 50% discounts for name brand drugs for seniors in the Medicare “donut hole”, tax credits for small businesses that provide insurance for their employees, and increased access of patients to preventive health care services, directly or indirectly, impacts many physicians and small hospitals, far flung in the land. Doctors are no longer bound to recommend name brands and when they do and patients are compelled to buy that prescription because of their location or any obscure reasons, there is an opportunity for discount for Medicare patients. Did this catch the attention of physicians or is it the fact that increased accesses to preventive cares create more volume for business for the physicians or providers? Not only does PPACA provide better benefits for patients, it is affording them better health as they get to see their physicians and provider more often, with the greater possibility of catching ailments before they become too big of a problem to treat. The dramatic changes that PPACA is going to afford or is already affording in preventive care services, is the care of Americans, wherever and from whomever they choose to receive care; and this, the American Medical Association is saying: that's Okay with us along as they mostly carry health care insurance.

Why is the AMA's support of the mandatory participation of Americans in the health insurance coverage laudable? Often, the mention of health care bills, as the number one cause of personal bankruptcy in America made physicians and providers complicit in the problem. Many providers never wanted to be labeled as the cause, or part of the reasons why their patients, especially their long-term patients, go bankrupt. Hardly will being part of a problem rather than the solution, stimulate one’s ego. Thus, finding physicians subscribing to an arrangement, that will make it possible for health insurance to cover the risks, which have in the past been borne by providers, affluent and not-so affluent patients, seem advisable and pleasing to physicians and providers. No one needs to persuade the physicians and hospital providers that having more patients carrying health insurance helps spread out the risks of underwriting, and helps ensure payments or re-imbursements for treatment of patients. This is probably another reason, why more physicians have fallen in love with the singular provision of mandatory participation.

Physicians as well as hospital providers were concerned by the critical element of the downward trending health care system, including the double-digit increases in health care costs in America, before the onset of the Patients Protection and Affordable Care Act. Many physicians and hospital providers, like the federal government, were interested in dealing with the problems of uninsured 51 million and 60 million underinsured Americans, if not overtly, but covertly, in a more than positive way. Part of the reasons for the double digit increases in health care cost was the problem of free-loaders, who benefited from emergency room visitation, but unable to pay. There were few things that sank the hearts of some physicians and hospital providers, when they learned that their treated patients are uninsured or underinsured. The negative feeling that the physicians or hospital providers would have to recoup cost of their services elsewhere, including turning to debt collection agencies for assistance, was getting to be a public relation disaster, especially for those physicians and or providers, who wanted to keep their patients as long-term customers. The PPACA was probably perceived as a life-saver for the health care industry; and, maybe that is why two-thirds of members of the American Medical Association have flocked toward it.

Additionally, part of what probably closed the deal for the AMA members was the fact that PPACA outlaws managed care anti-assignment practice for all group health plans outside Medicare and Medicaid programs, including individual policy markets in all the fifty states. This is an innovative provision that guarantees that care of patients will hardly be determined outside of the patient’s charts. The fact that a patient had to call a non-treatment insurance administrator, who will then determine whether a necessary procedure recommended by a physician is going to take place or not, is now a thing of the past; with the Patient Protection and Affordable Care Act, patients now have a bill of rights, which now auger well for their care and treatment. Not only has PPACA adopted the federal law ERISA claim regulations as a minimum standard for internal claims and reimbursements to providers, it defines a claimant to include the health care provider as an authorized representative. While very revolutionary, this is the first step to ensure that providers like claimants can receive reimbursement checks directly and can at the same time protect the interest of the patients, regardless of their participation in a network or non-networked service. This type of reform definitely endeared the physicians and providers to the Patients Protection and Affordable Care Act.

At the end of the day, the overwhelming support from members of the American Medical Association is a function of personal and professional interest; and, the need to facilitate better health care delivery. Doctors swore to an oath to do no harm; and, while the Patients Protection and Affordable Care Act, in the form that it is in, is not a panacea to all problems, it is still a better prescription for the health care system problems. Yes, there are the criticisms that Republicans had no hand in the law; that Democratic lawmakers resorted to reconciliation to get the bill through the possibility of a Republican's filibuster and that some money had to be shifted from Medicare program while making it more efficient; however, no one can say definitely that a law that builds on the 2003 Medicare Modernization Act, is completely absolved of Republicans contributions! The American Medical Association has democratically given the Patients Protection and Affordable Care Act’s provision of mandatory participation, a thumb up. Can we now rely on the Republicans to do the same?

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