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ALBUQUERQUE, N.M. — Readers have a lot of questions about how the Affordable Care Act is affecting their pocketbooks and their access to health providers, and more than a few of those concerns got an airing recently at a forum the Journal held to focus on the changing health-care landscape under Obamacare.
Rep. Michelle Lujan Grisham, a Democrat and former state secretary of health who now represents the Albuquerque area in Congress, spent two hours fielding questions raised by readers who responded to a Journal invitation to weigh in with their concerns.
• Confusing medical bills: Sponsoring bill to require patient be notified if he/she transitions to an out-of-network provider during care.
• Shortage of providers: Co-sponsor of Resident Physician Shortage Reduction Act to fund 15,000 additional residency positions over next five years; supported bills and programs that provide assistance to providers who practice in rural, low-income or minority communities.
• High prescription drug prices: Co-sponsor of Patients’ Access to Treatments Act, which would prohibit health plans from placing drugs in “specialty tiers” with high cost-sharing; supported legislation to allow Medicare to negotiate drug prices.
Around 15 of those who sent in questions attended, along with nearly 30 representatives from Presbyterian Healthcare Services, University of New Mexico Health Sciences Center, Blue Cross Blue Shield of New Mexico, Molina Healthcare of New Mexico, New Mexico Health Connections, ABQ Health Partners, as well as Insurance Superintendent John Franchini.
Journal Editor Kent Walz and UpFront columnist Winthrop Quigley moderated the event, which was held last week at the Journal’s office. KANW broadcast the forum live on 89.1, and Lujan Grisham said her office would provide written responses to those who had submitted questions.
Here are just a few of the areas that were covered:
By its very name, the Affordable Care Act was expected to address the rising expense of health care, in addition to making it accessible to more people. Lujan Grisham said the act has gone some way toward addressing that, such as removing lifetime caps on what an insurer will spend, allowing parents to keep children on their plan until age 26, providing premium subsidies and enabling states to expand Medicaid enrollment. Medicaid now covers about 40 percent of New Mexico’s population.
“But I’m clear we have a long way to go,” Lujan Grisham said.
Out-of-pocket costs for things such as deductibles and copays have soared, and the number of emergency room visits – the most expensive way of seeing a provider – remains high.
“While the overall costs of health care are down, they still aren’t sustainable over the long run, and if consumers can’t afford it, we can’t maintain that,” Lujan Grisham said.
The hope, she said, is that as more people get access to health care, the cost of caring for chronic diseases that incur so much expense can come down, along with some pharmaceutical and insurance costs.
She agreed that state and congressional policymakers need to tackle the issue of high copays and deductibles, although there doesn’t appear to be strong bipartisan support on specific action.
She warned that Congress must ensure that it can cover the cost of the Affordable Care Act – the most recent Congressional Budget Office estimate is $1.2 trillion over 10 years – without incurring more debt. The law provided for an array of taxes and caps on certain types of treatments that were supposed to cover that cost.
Under its budgeting rules, Congress is not supposed to take actions that would increase the deficit, Lujan Grisham said.
She noted that out-of-pocket expenses are becoming a barrier to care, in some cases. For example, colonoscopies, as a preventive measure, are supposed to be free under the ACA. But if a polyp is found and removed during a colonoscopy, the patient can be stuck paying a large bill, depending on their coverage. That financial risk discourages some people from getting the test, an important tool in detecting potential problems like colon cancer, Lujan Grisham said.
“It is the area we are going to have to fix, otherwise the sustainability of getting people healthier and more preventative care isn’t sustainable under the current affordable health-care design,” she said.
For those on Medicare, she said the federal government has programs to help lower out-of-pocket costs. In addition, she said she will be introducing legislation to require more transparency in health-care costs so people can better understand their bills.
A number of people at the forum expressed outrage at the skyrocketing cost of prescription drugs, questioning why identical or similar medication could be purchased overseas for a fraction of the price U.S. consumers are charged.
Colleen Aycock said she had needed Advair for breathing problems. The price of the medication at her local pharmacy recently jumped from $500 to $700 for one atomizer. She said she was able to buy the same medication in Canada for $249.
Dr. Paul B. Roth, chancellor for Health Sciences at the University of New Mexico, said that in the U.S., the major market for prescription drugs, costs are driven by market pressures. A 2013 MIT Technology Review article on drug prices said they are set and raised according to what the market will bear, “and the parties who actually pay the drug companies will meet whatever price is charged for an effective drug for which there is no alternative.”
Lujan Grisham said there is support in Congress for requiring the Centers for Medicare and Medicaid Services to negotiate on pharmaceutical prices to ensure drug prices are affordable.
“It’s the one area that seems to be a top priority for bipartisan effort to address, which gives me great hope because it’s exactly what we need in Congress,” she said.
She pointed out that Congress recently passed the 21st Century Cures Act, which streamlines the Federal Drug Administration’s drug-approval system. The new rules are intended make bringing a medication to market less expensive, less time-consuming and more predictable.
In response to a question, Presbyterian President and CEO Jim Hinton said the Affordable Care Act itself covered 1,990 pages, and 20,000 pages of regulations were issued pertaining to the act. On top of that, there are myriad rules related to Medicaid programs and various insurance groups.
“We have like floors of people that are working on various aspects of trying to comply with regulations,” Hinton said. He said regulations are needed to protect consumers from “bad actors” in the heath-care system but, he said, “I think it’s fair to say today that it’s quite a bit of an overreach.”
Lujan Grisham ventured that health care has become so complicated that consumers, insurance companies and even providers have difficulty keeping up with the constantly changing rules.
“We need to demystify,” she said, “Because if we don’t do that, there isn’t anyone who can really right-size this nation’s health-care system. It is far too complicated.”
Gilles Marshal, a therapist who attended the forum, expressed frustration about getting the care coordination promised by Medicaid managed-care organizations for mentally ill patients who need to see multiple providers.
Roth agreed that behavioral-health care is fragmented in New Mexico. He said UNM, Bernalillo County, the city of Albuquerque, Presbyterian and the state are looking at ways to improve communication so patients don’t fall through the gaps.
Greater Albuquerque Chamber of Commerce President and CEO Terri Cole said there is a need for a centralized authority that could look at the problems on a statewide basis. The chamber has a task force looking at the problem and earlier this year took local elected officials and behavioral-health providers to Tucson to study programs that have proved successful there.
Lujan Grisham said congressional members could help find funding for a pilot program to replicate what is being done in other states.
Pressures physicians face
Barbara Johnstad asked why doctors can’t look at multiple health problems during one visit instead of requiring separate appointments.
Lujan Grisham speculated that it was either because they could bill for each visit, there were too few providers or they couldn’t spend enough time with patients.
“Either of those is untenable,” she said, “The intent of all of the reforms at the state and federal level have been to create a holistic, patient-centered approach, and that is an example where we aren’t getting that done.”
Lance Wilson, an emergency medicine physician at the independent physician group ABQ Health Partners, talked of the challenges organizations that are not affiliated with a hospital or health plan face.
“The financial pressure to see more patients to generate enough revenue to support a medical group is challenging, so sometimes the time allotted to each patient is inadequate,” Wilson said, “So if you have only 15 minutes because you have to get 20 patients in that day to make your budget and to make money, you can only deal with a few problems.”
That’s the pressure physicians face even though they want to treat the whole patient. Under the ACA, Wilson said, medical contracts are moving toward rewarding providers for the value of care rather than the volume.
Medicare Advantage plans particularly give incentives for quality as measured by preventive care such as colonoscopies and mammograms.
“More care is not necessarily better care,” Wilson said.