A doctor will see you ... or someone will
At Baystate Mason Square Neighborhood Health Center, a clinic near downtown Springfield, the wait for appointments hit six months after Romneycare passed. So the clinic began offering shared appointments for chronic conditions such as diabetes and high blood pressure. Patients chat individually with a doctor for a few minutes, then hear about treatment plans and prevention tips from a nurse or social worker as a group.
"You don't have to repeat yourself 10 times," says Elizabeth Boyle, the center's medical director. Today new patients wait less than a month to be seen.
Introducing 400,000 newly insured patients to a health system was a bumpy proposition, even in a state with more doctors per resident than any other. But the initial spike in demand has leveled off. In 2012, 19% of residents said they waited to see a doctor, according to a Massachusetts Medical Society survey, down from 25% in 2008 and in line with waits on the eve of reform.
To relieve the pressure, medical practices are increasingly relying on so-called advanced practitioners.
"Physician assistants and nurse practitioners, we think, will be the future of filling out our primary-care infrastructure," says Dr. Mark Keroack, who oversees Baystate Health's 450 physicians and 150 advanced practitioners in western Massachusetts. With a commonplace condition like an earache or pinkeye, you'll see an advanced practitioner; doctors focus on diagnostic puzzles and complicated conditions. Keroack says his doctors have seen little pushback from patients.
One place that's nearly as crowded, though, is the emergency room, where patients, despite having insurance, still show up with nonemergencies. "That is one of the biggest disappointments," says Jonathan Gruber, an MIT economist who consulted on both Romneycare and Obamacare.
Kevin Epstein, an internist in Springfield, has hung posters illustrating when to go to the ER on the back of every exam-room door. He even offers same-day appointments. But many of his patients haven't kicked the ER habit.
Even if patients are slow to change, doctors and insurers aren't sitting still. For good reason: After essentially leaving cost controls out of the 2006 law, Massachusetts is cracking down. Anticipating those changes, many in the medical community are rushing headlong into payment reform -- rewarding doctors for providing high-quality care, not simply for performing costly tests.
Under one common new approach, insurers give doctors a budget for a group of patients. If certain measures of care are met and the treatment comes in under budget, doctors can earn a share of the savings. "It fundamentally changes how you think," says Keroack. Roughly 70% of Baystate physicians' patients are in an alternative payment system.
At Tufts Medical Center Physicians Organization in Boston, doctors are using electronic health records to track how well the practice is doing, says Dr. Michael Wagner, the group's CEO. Nurses call patients who are behind on care and check in after hospital stays. Nutritionists, social workers, and pharmacists educate patients on diet plans and medication regimens.
What's in store for you: In this case, Massachusetts is your future. In fact, you may already find yourself sitting with a nurse practitioner more often than with a doctor (keep in mind you can always insist on seeing an MD if you're worried, says Keroack). Private insurers nationwide are experimenting with alternative payment models, and Medicare is dipping a toe in the water.
To prepare for an onslaught of 14 million more insured Americans next year (27 million by 2017), lock in a doctor you're happy with now. Come 2014, you may have to make more calls to find one who'll take a new patient.
Reform has not bankrupted the state, but costs are a worry
So how is Massachusetts affording all this? The state shifted some direct payments to hospitals and community health centers into individual insurance subsidies. A $1 tax hike on cigarettes was approved in 2008. After the recession added more residents to the Medicaid rolls (under both Romneycare and Obamacare, the poorest Americans stay on Medicaid), Massachusetts cut Medicaid payments to providers. Plus, the federal government kicks in toward the subsidies.
Yet high health care costs could create bigger funding problems ahead. Total per capita health care spending is $9,278, the highest in the country and well above the $6,815 national average. While the 2006 law did little to tackle costs, a 2012 one does so aggressively. Health care providers must keep overall spending growth below certain goals -- 3.6% a year now. Failing that, the doctors and hospitals will have to devise cost savings plans and even possibly face fines. Insurers and medical providers have to post prices for medical services online, in the hope that more transparency will spur consumers to choose lower-cost care and providers to compete on prices.
What's in store for you: Obamacare attempts to control costs from the outset, encouraging the types of alternative payment models Massachusetts is experimenting with. Health reform also reduces Medicare spending by $425 billion over 10 years and establishes a board of 15 health experts that can recommend more limits on the program.
Come 2018, a tax kicks in on the most generous health plans, encouraging firms to pare back benefits and push more health costs onto you, which will, in theory, slow spending.
These measures all stop short of the aggressive steps that Massachusetts is taking. If those programs actually manage to rein in costs, some Romneycare veterans suspect -- or hope -- that the state may once again be a model. "We're confident if you come back five years from now," says consumer advocate Slemmer, "we'll be showing the country how to have better care at lower cost."
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