Just a few minutes after the Supreme Court announced its decision on the Affordable Care Act, I saw a longtime patient of mine, a 71 year-old retired businessman with hypertension. His numbers were not good, but he had an unusual explanation.
“I think my blood pressure is up because I have been so worried about what the Court was going to do,” he said. “It would have been terrible if they had rolled the law back.” He was serious. He also needed an increase in his medications, but I was delighted to see so many people around me during my primary care session this morning who understood the importance of the day. The nurse’s aide who works with me looked over my shoulder as I read the news on my computer while that patient changed into his examination gown. She was overjoyed. “We have to take care of these people,” she said, meaning the millions of uninsured. “How could we do that without this law?” I can’t tell you off the top of my head what kind of insurance my 71 year-old with high blood pressure has. I just know he has insurance, as do all the patients in my practice. We don’t turn anyone away at my hospital, but, since health care reform passed in Massachusetts in 2006, the number of uninsured patients has dwindled.
That’s the good news. The tougher news is that it takes hard work to make coverage for everyone viable. And now that the ACA has survived, that hard work can get underway. A taste of what is coming can be gleaned from my experiences as I took care of patients today. I received emails about three patients who have been identified as “high risk” because of multiple medical conditions. My organization wanted me to verify that they are my patients, and that they are at sufficiently high risk that they should also be followed by a nurse case manager. Working with those case managers is going to mean more emails and more phone calls, and there will be moments when those interactions seem like a burden. I also received a computer reminder that a test I wanted to order on one of my patients might be a duplicate of one performed two months ago. Yes, it was the same test, but I needed to run it again. The reminder slowed me down but it could have prevented a mistake. These interruptions complicate my work — but they also improve the quality of care.
Why is my organization doing all these things that make my already difficult day harder? The reason is that, ahead of the Affordable Care Act, we had changed our main model from fee-for-service to population-based contracts, where we have an incentive to manage overall costs and outcomes of groups of people, rather than getting paid procedure by procedure, patient by patient. That is the logical consequence from the imperative to take care of everyone with limited resources — and we can expect similar consequences to flow throughout the country from the Court’s decision.
The Affordable Care Act will add complexity to some aspects of health care as organizations re-tool, and it may increase some costs in the short term. But ultimately it will improve the quality of patient care and reduce costs as providers and their organizations focus as much on keeping people healthy as they do on healing them when they’re sick. That’s something patients, providers, and employers who subsidize care — and want healthy employees — should be happy about.