Sideline Consult
A Pragmatic Approach to Healthcare Changes in 2017
Bert R. Mandelbaum, MD, DHL (Hon)
Healthcare in 2017: A Perspective
In the wake of the presidential election, a lot of people are fretting about changes to our healthcare system.
The president-elect promised to repeal the Affordable Care Act (ACA), and many patients are wondering how this might affect their own healthcare plans. Sports medicine practitioners want to know how their practices will change.
When I talk about these questions with patients, I start by offering reassurances. The vast majority of people who are covered by employers' plans should not expect any big changes. But even for those without insurance or coverage through the ACA, I believe it's important to take a pragmatic approach.
To any patients without adequate healthcare coverage, I point out that we are in the midst of open enrollment for the ACA. People can sign up for insurance under the ACA until January 31, 2017.
Congress may repeal the ACA soon after the new president's inauguration. But it's unlikely that Congress will simply cut off health insurance for the 20 million-plus people who are covered through the program without offering anything its place.
Encourage Patients to Get Insurance
In the meantime, most states offer good options for patients trying to get coverage on their own through the healthcare exchanges set up by the ACA. The policies offered there may be expensive, but they are more complete than many policies offered before the ACA, and the law provides subsidies for people who have difficulty paying. I tell my patients, "You can't afford not to have health insurance."
Also, the ACA prevents insurers from denying coverage based on preexisting conditions. That's huge, because there are 15 million survivors of cancer in this country. The ACA also allows adults to stay on their parents' plans until age 26. I'm optimistic that whatever changes the new administration makes will retain these popular provisions.
It's exciting that the president-elect has named an orthopedic surgeon as head of the Department of Health and Human Services. Although I don't know Dr Price personally, I've been following his career in Congress. I see him as a practical person who will do what's best for our patients.
The biggest problem we have with the ACA is that the risk pools in the exchanges are small and don't have enough healthy people in them, so many of the insurers are getting out of them. Too much money in the system is flowing out of the pockets of patients, physicians, and hospitals and into the pockets of insurers. What could be better for our patients than a president-elect and secretary of Health and Human Services making this problem a top priority?
Motivate Patients to Empower Themselves
But health insurance alone will not protect our patients. As our patients contemplate changes to our healthcare system, we should remind them that they can do more to improve their health than we can.
My years as a sports physician have taught me to think in terms of the tripod: prevention, optimizing performance, and injury or illness care. For each of these aspects of healthcare, our ability to motivate our patients matters more than our skill in reading radiographs or reattaching ligaments.
First, we must motivate our patients to exercise; eat well; get plenty of sleep; and regularly undergo appropriate screening, such as colonoscopy, mammography, prostate-specific antigen measurement, and blood chemistry panels. These steps will prevent many of the most common illnesses.
Second, we must help our patients optimize their performance through fitness. That means adopting an aerobic, resistance, and flexibility routine appropriate to their current fitness and to the activities in which they engage.
I encourage even those people who don't like sports to think of themselves as athletes. Not all our patients are playing soccer or running marathons. For some people, walking across a room or reaching a high shelf is challenge enough. But they still need to optimize their performance for these tasks of daily living. We must empower our patients to improve their physical, emotional, and spiritual lives.
In illness and injury, our role as physicians comes to the fore. Yet patients still play an essential role. They must become informed about their condition, consult with us about their treatment plan, and carefully follow the steps agreed upon for their rehabilitation. Here again, motivation is essential, and we can only truly succeed when we can inspire patients to act in their own best interests.
Embrace the New Medicare Payment Models
Even while working to empower our patients, sports physicians are facing changes in our practices brought about by healthcare reform.
On January 1, we will enter a new system: Under the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA), physicians reimbursed through Medicare will get increases or decreases in payment that are based on quality measures.
The new program takes a step away from the conventional fee-for-service model of healthcare, which rewards physicians for treating patients, to a system that rewards physicians for maintaining patients' health.
This approach empowers the physician as a leader, not only in one-to-one relationships with individual patients, but also of whole populations. And private insurers are following in the path blazed by Medicare. Accountable care organizations, global-fee relationships with hospitals, bundled payments—these are upon us.
The Kerlan-Jobe Institute in California, at which I serve as co-chair of medical affairs, is an example of a practice well-positioned for these changes. We're an institute of 40 physicians within Cedars-Sinai Medical Center in Los Angeles. We have fully implemented an electronic medical record. We're using this technology to monitor our successes and challenges in pre-, peri- and postoperative situations.
Long before MACRA, we started tracking such outcomes as the Knee injury and Osteoarthritis Outcome Score; Short Form (SF)-36 and SF-12 quality-of-life indices; the Marx Activity Scale; and the International Knee Documentation Committee Subjective Knee Form.
We have participated in the Arthrex Surgical Outcomes System for 5 years. This gives you an optimal dashboard to look at your cases, see how your outcomes have changed over time, and see how you compare with the general population of physicians.
Now we anticipate rewards for this work through MACRA's Merit-Based Incentive Payment System, which pays bonuses or subtracts penalties of up to 4% on the basis of quality standards.
Your practice should be adopting these measures sooner rather than later. They will be necessary to succeed in the new healthcare landscape as it is shaping up.
Use Technology to Improve Patient Adherence
We are also using new technology to educate not only present but also potential patients. For example, we encourage patients to use a mobile software application called HealthLoop. If you've had an anterior cruciate ligament reconstruction, for instance, you enter your postsurgical data into the program, and at the appropriate time, a prompt comes up saying, "Your range of motion should be 0-90°. Your wound should be closed. It's time to do these exercises. If you have problems, please let us know." Such reminders should improve adherence.
I'm optimistic that with a CEO and a physician in charge of healthcare reform, physicians will be empowered on behalf of their patients. But regardless of how the system changes, what really matters is what's best for our patients.
When I'm confronted with policy decisions and decisions about patients, I always put my hands close to my eyes and ask myself what's best for the patient. What do the kids with sprained ankles in Peoria, Illinois, truly need? What does a young fullback with a concussion truly need? If you can answer such questions as these, then you'll have the best plan.
If you take care of your patients, your patients will take care of you.
Medscape Orthopedics © 2016 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this article: A Pragmatic Approach to Healthcare Changes in 2017. Medscape. Dec 22, 2016.