Affordable Care Comes at High Price for O&P

The total number of amputees in the United States could reach 2.4 million by 2020; the total number of orthosis users could nearly triple that the same year, the American Orthotic & Prosthetic Association has found.

Although the Patient Protection and Affordable Care Act (ACA) was designed to make care more accessible and cost-effective, local and national providers are seeing the opposite effect.

Defining the law

The ACA was drafted to reform the American health care system by providing low-cost health insurance, new rights, benefits and protections for consumers.

Although it requires Americans to have health coverage, it is not a government-mandated health plan, Peter W. Thomas, JD, counsel to the O&P Alliance and general counsel to the National Association for the Advancement of Orthotics & Prosthetics (NAAOP), told O&P News.

“It is more like a mandate to have health insurance,” he said. “Whether that is from a public program like Medicare or Medicaid, or coverage through a separate, private insurer.”

“It was put in place to help those who are uninsured have options for care,” Dennis Clark, LCPO, president of the Orthotic and Prosthetic Group of America (OPGA) in Iowa, added. “Not just in O&P, but in the health care system overall.”

It seems as if the law is doing that. As of 2015, 11.9 million Americans are newly insured, according to the Henry J. Kaiser Family Foundation. The Association of American Medical Colleges predicts that number could rise to 30 million in the coming year.

The way it works is through health insurance exchanges. An exchange is a federal- or state-based marketplace where consumers can compare coverage options, Thomas said.

“They can go onto websites or even into brick and mortar buildings to review different insurance plans,” he said. “Different plans have different levels of cost sharing, but as long as they meet certain requirements, they can be sold on these exchanges.”

One of those requirements is “essential health benefits.” The ACA mandates the Department of Health and Human Services delineate 10 categories of benefits in every insurance plan, which include “rehabilitative and habilitative services and devices.”

Although orthoses and prostheses are not specifically defined in the regulation, it is generally assumed that they fall under that category, Thomas said.

‘Racing to the bottom’

With more individuals having access to care, it stands to reason that O&P providers would gain more patients and dollars, Thomas said.

“But, that is not necessarily the sense I get from people in the field,” he added.

People like Bruce “Mac” McClellan, CPO, LPO, FISPO, FAAOP, private practice owner in Texas and representative to the O&P Alliance. McClellan said the expansion of Medicaid to cover millions of additional Americans “could be detrimental in the long term.”

Clark agreed.

“It causes funding concerns. Some of us [independently owned practices] do not have the cash flow to take on those numbers,” he said, adding that more patients mean tighter reimbursement levels and more restrictive coverage policies.

“When it comes to documentation and demonstrating medical necessity, payers, who have always had rules in place, are now following them more strictly,” Rebecca Hast, president of Linkia, a Hanger company, told O&P News. “Insurers who may not have paid much attention to ancillary services such as O&P [before] are now looking at every provider relationship for how they can get value.”

“It adds layers of administrative costs on top of providing the prosthesis or orthosis,” Clark said. “So you find people racing to the bottom to find cheaper ways to care for their patients.”

It also increases insurance churn, Scott Williamson, MBA, CAE (Ret.), president of Quality Outcomes in Virginia, told O&P News.

“In the past, a person would have a policy and stick with it,” he said. “Now that the ACA eliminated preexisting conditions as barrier to receiving insurance, it frees people up to shop plans annually.”

That means insurers will have a 1-year planning horizon as they look at beneficiary coverage. According to a Dobson-DaVanzo report commissioned by the American Orthotic & Prosthetic Association (AOPA), the minimum payback period is 12 months or longer for orthoses, and approaching 2 years for prostheses.

“If the planning horizon is shorter than the payback period, the long-term impact could be negative because there is zero incentive for insurers to cover care,” Williamson said.

But that is not the only impact of the ACA, Hast added. Although the law has reduced the amount of uninsured Americans, many are required to pay higher out-of-pocket expenses, copays and deductibles depending on the level of plan they purchase.

“We are talking about patients having some skin in the game,” she said. “I think we all know that when you have to write the check, when the first several thousand dollars are going to come out of your pocket, you get serious about decision making.”

Many insurers only cover up to a certain dollar amount, and if a procedure or device is not included in-network, some patients may not have the capacity to pay for it.

It is almost as if the law is having the opposite effect of its intention, Glenn Crumpton, LPO, CPed, owner of Alabama Artificial Limb & Orthopedic Service, told O&P News.

“When the ACA came about, there were several people it seemed tailor-made for,” he said. “But some patients who signed up for it are now finding it is not what they expected.

“We had to help one woman navigate the system to even apply for it. When we finally got through, she found out that – on her $900 a month income – they were going to give her a higher bill and she would only have 60/40 coverage.”

Options for care

Health coverage under the ACA is not the only option, however. According to the Henry J. Kaiser Family Foundation, 48% of Americans are insured through an employer and 5% are self-insured.

Additionally, only 29 states have opted into the expanded Medicaid program, the foundation noted. There are federal guidelines under the ACA, but the U.S. Supreme Court ruled that each state could set up its own exchange.

“In those cases, the decisions are pushed down to the state level, where they choose what is covered and what is not,” Thomas said. “The state selects a benchmark plan, kind of a template of a benefit package to compare to, and makes sure it complies with the federal statue.”

“In Alabama, we do not participate in the federal health care exchange,” Crumpton said. “We are developing our own system.”

Many states are following suit. That system, or Accountable Care Organization (ACO), is a group of integrated health care networks designed to treat a large geographical area of patients through payment bundling. The ACO provides care using a capitation or fee-for-service payment model and is accountable to patients and third-party payers for the quality of that care.

“Essentially, they are taking risks for their service … with the overall goal being to cap total health care costs,” Williamson said. “If you look at utilization data, expenditures have risen year-over-year pretty much every year. What Alabama is trying to do is cap those expenditures and free up more dollars for patients.”

Crumpton said it is not yet clear how that system will manifest itself. There will be continued discussions surrounding it in the future, he said, “but for now, the jury is still out.”

Challenges on the horizon

Hast is taking an optimistic view. Although she foresees growing pains as the front-end changes of the ACA take effect, she thinks it has the potential to advance the profession.

“I am not saying that there is suddenly going to be this wonderful situation where everybody has unlimited access to prosthetic care, but I do think there is an opportunity for more patient lives in the system who have not received care in the past … and ultimately, that will be a good thing.”

That is, if the law is not repealed. Various O&P organizations believe the Republican-led Congress will make repealing all or part of the ACA a major goal in the coming year. But without a 60-vote margin in the Senate, McClellan believes that is unlikely to succeed.

“As long as President Obama is in office, he will likely veto any proposed changes to the ACA. [The Republicans] certainly do not have the needed majority to override the president’s veto, so I do not see anything of consequence happening until after the 2016 election,” he said.

“Even so, many aspects of the ACA have either gone into effect, or taken hold already,” Thomas added. “It would be awfully difficult to turn back the clock and reverse the mechanisms and developments that have occurred over the last 5 years.”

But there are challenges on the horizon, he said; one in the form of King v. Burwell.

The U.S. Supreme Court is currently hearing arguments challenging federal subsidies in states that use the federal exchange to provide health insurance to their residents. There is a small passage in the bill that refers to subsidies flowing through “state” exchanges, which plaintiffs interpret to mean such subsidies cannot flow through the federal exchange.

“But that is a five- or six-word phrase in a 1,000-page law,” Thomas said. “The question is [whether] the whole framework of the ACA, which clearly anticipates federal subsidies flowing through both federal and state exchanges, [is] eclipsed by the omission of one sentence.”

If the case is decided in favor of the plaintiffs, it could put a “huge stake through the heart of the ACA,” he said, causing more than 7 million Americans to lose their health insurance.

As of press time, the final decision was scheduled for late June.

Taking a stand

Despite the obstacles, O&P will need to adapt in order to survive under the ACA, Thomas said, and advocate groups will have to fight to break its limitations. NAAOP is doing the latter.

“We have been actively engaged, for the past 4 or 5 years, in New York and some key states, monitoring regulations and pushing for O&P coverage nationally,” Thomas said.

Specifically, they have been orchestrating strategies at both the federal and regional levels to have New York State’s “one prosthesis, per limb, per lifetime,” restriction removed from its essential health benefits package.

Effective Jan. 1, 2016, that clause will be eliminated, NAAOP recently announced.

Other organizations are also getting involved. OPGA recently testified at a regulatory fairness hearing to high-level CMS officials about the impact the ACA is having on private practices.

Independently owned practices are being treated as an afterthought to national providers when it comes to federal funding, according to Clark.

“When a patient has an issue with their care, they cannot get it taken care of locally because the local businesses are out of business,” he said. “Then you wait longer and the problem exacerbates, and that dramatically increases the cost of caring.

“None of us want to do anything but provide great care for patients out there, but we have to be able to survive in order to do it.”

OPGA held a conference in June to discuss this issue with representatives from the Small Business Administration.

The American Board for Certification in Orthotics, Prosthetics & Pedorthics; the Board of Certification/Accreditation; the American Academy of Orthotists & Prosthetists; NAAOP and AOPA have been working as members of the O&P Alliance to improve legislation and regulatory language, McClellan said.

“Whatever is unfair or restricts O&P patients from equitable treatment, we are determined to correct it,” he said. “Recently, the Alliance submitted written testimony to the Senate Finance Committee following an April 28 hearing on the Medicare audits and appeals process, in which we supported certain proposals and opposed others.’”

Education will be a key factor in overcoming barriers, sources agreed. Not only educating those within the profession, but educating legislators about the importance of O&P, Hast said.

“It is something that we are going to have to think about and get creative about. We need some tools, some fresh ideas about how we are going to manage this,” she said. “Because the bottom line is, the more our voices are heard, the better chance we stand.”

Clark echoed her concern.

“Frankly, we have got to have more folks be their own advocates to help make some of these changes come through. Elected officials will have the final say, but when we get more constituents out there saying, ‘We have had enough. These are our lives you are messing with. This is the health of my father, my brother, my wife.’ That is when change will happen.” – by Shawn M. Carter

References:

American Orthotic & Prosthetic Association. CMS Proposed Rule Establishing Medicaid Eligibility Changes Under the Affordable Care Act. Available at www.aopanet.org/wp-content/uploads/2013/12/2011_CMS_MedicaidEligibilityRule.pdf. Accessed April 27, 2015.

Hanger Clinic Financial Consultation Guide. Available at www.hangerclinic.com/new-patient/Documents/Financial_Consultation_Guide_Web.pdf. Accessed April 28, 2015.

National Association for the Advancement of Orthotics & Prosthetics. Available at www.naaop.org. Accessed April 29, 2015.

Obamacare Facts. Available at http://obamacarefacts.com. Accessed April 30, 2015.

The Orthotic and Prosthetic Alliance. Inclusion of Prosthetic and Orthotic Coverage in the Essential Health Benefits Package under the Affordable Care Act. Available at www.oandp.org/assets/pdf/WhitePaper-OPandEHB.pdf. Accessed May 1, 2015.

Disclosures: Clark, Crumpton, Hast, McClellan, Thomas and Williamson report no relevant financial disclosures.