2014: The national landscape has changed health care


As 2013 draws to a close and we look forward to 2014, the national health care environment will see significant changes. In 2014, most of the provisions of the Affordable Care Act (often referred to as Obamacare) kick in nationwide. In Massachusetts, we have been the beneficiaries of most of these provisions since 2006, when then Governor Romney signed An Act Providing Access to Affordable, Quality, Accountable Health Care (Romneycare) into law.

This law forms the basis for Obamacare, and as such we will only see a few changes in 2014. These changes include the elimination of the state-run Commonwealth Care product, the expansion of access to Medicaid to those with incomes up to 138 percent of the poverty level, the expansion of tax credits to those making up to 400 percent of the poverty level, and fines on employers with more than 50 employees who do not offer health insurance will be increased substantially.

Patients are not the only ones affected by the Affordable Care Act. In fact, hospitals and hospital systems will have to change how care is delivered. Obamacare is expensive, and one way for the country to afford the cost of this program is to decrease the cost of care. The easiest way to decrease costs is for the government to pay less. In fact, the Medicare rates that the hospitals have been paid have been cut in each of the last three years. The goal is that with more people insured and less charity care being required, these cuts will balance out. Certainly in Massachusetts the rate of health care cost growth has been slower than in the country as a whole, since the implementation of Romneycare.

Given that health care costs in our nation account for 18 percent of our gross domestic product (GDP), even a small slowing in cost rise can have a tremendous effect on our country’s finances and international competitiveness. For comparison, no other country spends more than 12 percent of GDP on health care, and in many of those countries people live both longer and healthier than they do in the United States. The debate surrounding the cost of Obamacare will persist, but it will become more rational as we obtain real data when the program is rolled out.

Although the news surrounding the Affordable Care Act almost always concerns costs, the act is also focused on both enhancing the quality of care and the provision of preventative services. It is in this arena that physicians and hospitals are seeing significant changes. As a physician, these are perhaps the most important aspects of the new regulations. The government will actually withhold payments if the quality of our care does not measure up. These quality measures are far reaching, and some examples will give one an idea of what the Martha’s Vineyard Hospital (MVH) is doing to measure and improve the quality of care you receive.

Obamacare allows the government to withhold payments for patients who are re-admitted too soon after discharge for diagnoses such as heart failure or pneumonia. To help prevent such admissions we have improved our discharge instructions and education, and we make sure that all patients have a scheduled follow-up appointment with their primary care provider. For very high-risk patients, we have hired a nurse coordinator who is involved with all aspects of the patient’s care. By helping a patient navigate a complex health care system, such a coordinator helps the patient by getting them the right care the first time. Such support decreases costs, but more importantly, increases patient satisfaction.

Hospital-acquired infections are another area of quality focus. We are lucky to have an all private room facility which is a big help in avoiding infections. We have an infection control nurse who constantly monitors our infection control practices. Urinary catheters are often a source of infection. Patients with such catheters are reviewed daily and the catheters are removed promptly when no longer needed. Although the government will reduce payments to hospitals with excessive infection rates, the driving force here is the importance of avoiding infection, not the receipt of a reduced payment.

Monitoring and improving quality requires hard data, and Obamacare has provisions to encourage hospitals to use information technology under so-called Meaningful Use. These provisions begin as financial support for the implementation of this technology and eventually evolve into penalties on those hospitals that fail to comply. Meaningful Use is a set of guidelines and requirements for such systems to ensure that they end up as more than glorified word processors. It is with Meaningful Use that we can expect the most significant change in 2014 at MVH. We have begun implementing an in-hospital electronic medical record system (EMR), and this will be fully operational by early spring. This system will complement our Longitudinal Medical Record (LMR), the electronic health record that has been in use in our outpatient practices for the last three years. These record-keeping systems will be linked so as to provide important information across the continuum of care.

The LMR system used in our offices was implemented in partnership with the Massachusetts General Hospital (MGH) and has allowed us to enhance patient information flow with the MGH and other hospitals in the Partners Healthcare Network. We can use the information in the LMR to monitor health care outcomes across specific populations and for specific conditions. Thanks to the LMR, we know that our hypertensive patients have their blood pressures controlled and that our diabetic patients are appropriately monitored. When data was published regarding the value of a specific vaccine in preventing illness in patients who had their spleens removed, we were able to quickly track down the three patients among thousands who stood to benefit, and we were able to get them vaccinated.

The EMR will provide us with the same capabilities for inpatients. We will be able to track that the right medication was delivered to the right patient at the right time. We will be able to monitor infection rates in real time and intervene promptly. We will be able to avoid duplication of imaging and laboratory testing. Most importantly, we will be better able to communicate a patient’s in-hospital treatment with his or her outpatient providers. These changes are significant and will require a significant investment of money, as well as clinician time. As clinicians, we are willing to commit to these efforts because we know that ultimately it is our patients who will benefit.

The health of our citizens is our most important asset. Whether one favors Obacamare or not, it has succeeded in focusing the debate on this critical issue. Here at the Martha’s Vineyard Hospital we are working hard to stay abreast of the changes sweeping health care across the county. Rest assured that in this time our focus as always remains on keeping you healthy.

Dr. Pieter M. Pil, a surgeon, is chief of staff of Martha’s Vineyard Hospital.