RSNA: Healthcare reform spurs shifts & sacrifices

The passage of the Patient Protection and Affordable Care Act  (PPACA) "is only the beginning" of the healthcare reform process, with dramatic but uncertain changes to the structure of healthcare delivery impending, according to a presentation Dec. 1 at the annual scientific meeting of the Radiological Society of North America (RSNA).

The healthcare legislation aimed at expanding coverage to 25 to 30 million Americans without health insurance will attempt to do so at an important price, according to William A. Sarraille, JD, a partner at Sidley Austin in Washington, D.C. Coverage is to be expanded, in part, by means of health benefit exchanges, essentially insurance markets in which individuals can purchase health coverage at low prices with guaranteed protections. According to the PPACA, states have until 2014 to establish these changes.

Sarraille offered that unsuccessful trial runs of health benefits exchanges came with the Medicare Part D Prescription Drug Plan. These exchanges have been tailored to provide discounted medications to high-risk populations, but some states opted out due in part to inadequate enrollment.

Sarraille sees little hope of major fixes to the PPACA given the soon-to-be-divided Congress. Moreover, he acknowledges what he considers to be a likelihood of about one-third that the Supreme Court ends up hearing, and overruling, states' challenges to the legislation. The two principal contentions, that government-mandated insurance oversteps the Commerce Clause and that the law violates states' rights under the 10th Amendment, have been considered adjudicable by courts.

If overturned, Sarraille argued that some form of the reform would likely persist, perhaps with Congress delegating modifications to the Independent Payment Advisory Board (IPAB), whose recommendations are law unless vetoed by Congress. Thus far, Congress has ordered IPAB to "reduce the per capita rate of growth in Medicare spending."

With radiology already taking a "disproportionate" share of cuts from Congress, Sarraille predicted a move to more provider-based medicine, with radiology on board by way of under arrangements. Under this system, radiology practices would increasingly be subcontracted by larger medical centers, though with these hospitals retaining primary responsibilities like billing, administrative decision making, establishing and maintaining contracts and appointing staff. Sarraille sees this move as a potential antidote, though by no means a panacea, to providers' growing needs to cut costs, increase revenue and reduce risks, which Sarraille argued hospitals may be able to accomplish because they maintain stronger bargaining positions.