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“Procedure Bum Rush” Before ACA Overhaul

Jessica Mehta • Wed, March 15th, 2017

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According to the Wall Street Journal, patients are hustling to get procedures before the Affordable Care Act (ACA) is overhauled. Wells Fargo’s equity research department for medical supplies and devices has also commented on the rush, and while such reports are anecdotal, “We saw a similar phenomenon around the time the ACA was first implemented,” says Larry Biegelsen. “Although the benefit to device manufacturers could be one-time in nature, we believe it plausible that we could see a potential bump to results as early as Q1 or Q2.” Biegelsen specifically cites the spine as a potentially popular pre-ACA overhaul surgery due to diagnoses like lumbar spinal stenosis being more common in younger people who may rely on “the Marketplace” for their insurance needs.

The Overhaul Begins

On Thursday, March 9 during a pre-dawn vote, the GOP plan to overhaul the ACA was voted in via a House Ways and Means Committee vote. It was the culmination of 18 hours of arguments and debate, finally approved at 4 a.m. The first step is nixing the requirement to either buy insurance or pay a fine. According to the Committee’s chairman, Rep. Kevin Brady of Texas, “This is an historic step, and important step in the repeal of ObamaCare.” The vote passed 23 to 16.

Concerns regarding how a Trump presidency might impact access to healthcare began months ago. Women in particular kick started a movement rushing to get intrauterine devices (IUDs) before the ACA overhaul. Worried that they may no longer have the same access to Planned Parenthood and birth control in general, headlines included Cosmopolitan’s “Talk to Your Doctor About an IUD” with journalist Dr. Colleen Krajewski saying, “In the weeks since Donald Trump became our country’s president-elect, I have fielded dozens of worried calls and emails.” Her suggestion? “If you’ve been considering getting one (an IUD) but putting off making an appointment, do it now.”

She isn’t the only doctor stepping up with insight on the impending overhaul. The American Medical Association’s (AMA) CEO Dr. James Madara penned a letter to congressional leaders Tuesday, January 3, 2017 encouraging the preservation of the ACA. Speaking for the AMA, Dr. Madara wrote, “We believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies.”

Dr. Anita Gupta, medical director of the Division of Pain Medicine and Regional Anesthesiology at Hahnemann University Hospital and Drexel University College of Medicine in Philadelphia, Pennsylvania, says her patients are stressed about coverage and are hurrying to her office because they think they’re about to lose coverage. "Doctors are frustrated, too, they're not sure what they'll need to do for patients in addition to what they're doing already. There were new trainings and policies mandated by the ACA such as the Sunrise Act, MACRA [Medicare Access and CHIP Reauthorization Act], and many others and doctors want to know what is going to happen to them. There are more questions and frustrations than answers on the new proposal from doctors, which adds to the already frustrated healthcare environment for us." She says, "I often have to choose cheaper less effective drugs for treatment of pain because the other more innovative cutting edge technology is not covered or even on formulary. Less coverage means less innovation and less options to offer sicker patients. This adds to the frustration of my patients who are having surgery, increases their anxiety and fear and often causes them to delay critical care they may need to that their condition. Patients often don't even fill medications that are too expensive because their insurance won't pay or cover it."

Survey Says

The New England Journal of Medicine published survey results on Wednesday, January 24, 2017 in which 426 doctor respondents revealed that regardless of political party, the majority did not want the ACA repealed. Just 38% of self-proclaimed Trump voters were for the appeal, and 32% of Republicans overall. There wasn’t one Democrat respondent who supported the repeal. In total, 95% of respondents “supported the insurance-market regulations that prohibit insurance companies from denying coverage or charging higher prices on the basis of preexisting conditions.” Authored by Drs. Craig Evan Pollack (Johns Hopkins), Katrina Armstrong (Massachusetts General Hospital) and David Grande (University of Pennsylvania), the researchers say 50% of doctors support keeping tax penalties for those who don’t purchase insurance.

However, concerns about the ACA and its repeal also varies based on practice. Some spine surgeons including Dr. Eugene Carragee, vice chairman of Orthopedic Surgery at Stanford University’s School of Medicine, says the ACA was challenging for spine surgeons in particular. Pointing out that chronic back pain has long been targeted by some as a so-called “excessive and wasteful utilization of medical services,” spine care experts had to shift to a more “high-value care” approach with the initial introduction of the ACA. Dr. Carragee says that with 20+ million new patients via the ACA, some have “definitive spinal pathologies.” However, most have “co-morbid” complex conditions. He says that even though spinal surgery is safer than ever with the latest technology, a lot of spine care approaches (particularly with axial back pain) are still waiting for validation from reputable independent clinical trials. This posed a challenge under the ACA for patients with “gray problem areas.”

Dr. Christian Zimmerman, a neurosurgeon at Idaho Neurological Institute in Boise, Idaho, has struggled with the ACA’s reimbursement structure. Particularly for doctors with Medicare patients, he says bundling procedures under a single category made the matter even worse. Older patients naturally have a higher rate of degenerative spinal disease, and the sociological impact is getting severe. For Dr. Zimmerman, he’s found that instead of disease type, “patient insurance profiling” has become the norm in many practices as politics inform economics.

The Patient’s Perspective

In late January 2017, Quinnipiac University published results of a national poll, revealing that only 16% of Americans wanted Congress to repeal the ACA. Additionally, 51% said parts should be repealed and 30% wanted no changes made at all. In an unexpected dig, respondents suggested that they’d punish Congress members and senators who voted for a repeal, with 43% saying they’d be less likely to vote for a candidate who voted for an appeal. A lot has changed in a few years. In March 2014, the same question was asked in an NBC News/Wall Street Journal survey and 47% of respondents said they’d prefer to vote for a candidate who votes for an appeal.

Cancer patients and survivors, including those with spinal cancer, have been particularly vocal about the impending ACA overhaul. Ashley Wanton, a cancer survivor, was unable to get insurance coverage until the ACA provided eligibility for her under the California Medicaid program. By then, the cancer had spread throughout her body. Without the ACA, she says, “I would likely be dead and my family would likely be bankrupt trying to save me.”

Dr. Sarah Squire, an oncologist in Winston-Salem, North Carolina, says, “I see fear in my cancer patients’ eyes over (the) Obamacare repeal.” While she agrees that the ACA isn’t perfect, it’s done a lot to offer security and options for patients with pre-existing conditions or who otherwise couldn’t afford healthcare coverage. “As I look into the eyes of patients asking me how these votes will affect them, I have little to offer,” she says. Like doctors and patients around the country, everyone is waiting to see how the overhaul and repeals play out.

However, for some, it’s a time of action. Getting procedures in under the wire has become a priority and mission founded on fear and uncertainty.

Gearing Up for Battle

The February 24, 2017 leaked ACA replacement includes a number of points, including the repeal of the ACA’s essential health benefits regulations. Under the ACA, insurers have to cover ten service categories. However, under the repeal states can select which services they want to cover beginning in 2020. Many are applicable to spinal surgeries including hospitalization, prescription drugs, rehabilitative and habilitative services/devices, laboratory services, preventive and wellness services along with chronic disease management, and pediatric services.

The 32 states which chose to expand coverage for Medicaid patients under the ACA will be phased out in the next three years, every state will have a Medicaid payment cap, and older patients can be charged more than what they’re paying now for coverage (to the tune of five times more than their younger counterparts).

Rita Tyner, a 70-year-old resident of Central Point, Oregon, relies on Medicaid for numerous health issues including a collapsed vertebrate from osteoporosis. With a vertebral compression fracture (VCF), she’s been considering vertebroplasty for a few years, but others issues got in the way—including numerous strokes, heart attacks, and kidney failure.

She’s depended on the ACA/Medicaid for health coverage to cover numerous hospitalizations and trips to the ER. When she heard about the ACA repeal, she booked an appointment with a local spine surgeon immediately and is currently undergoing tests to gauge her candidacy for vertebroplasty. Until then, she’s remaining dependent on chronic pain management to get by, although even the simplest of tasks and walking can be a challenge.

“I’m not sure what I’ll do if this repeal happens,” she says. “Not just for my back, but for everything. The doctors keep telling me I wait too long, to come in earlier, but I can’t. I just can’t. I can’t be going to the doctor every time every little thing goes wrong, I’d be there all the time. And I just can’t afford that.”

Her words echo the concerns of millions who are ACA-dependent. The silver lining? There’s likely to be a three-year window before any appeals and changes will go into effect, giving patients time to schedule surgeries and take care of any urgent medical procedures they may need. However, that’s a quick fix and a Band-Aid approach. There’s no telling what the final repeal product will look like, how it will go into effect and be enforced, and how many people will be impacted. Until then, doctors can expect a continuing influx of patients, all saddled with fears that this might be their last chance for an affordable and perhaps life-saving procedure.

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