The ACA A PhysiciAn’s PersPective By Peter A. DeGolia

A Physician’s Perspective
By Peter A. DeGolia
am a geriatrician, a doctor who specializes in the care of older adults. I
am board certified in family medicine,
geriatric medicine, and hospice/palliative medicine. For 18 years, I have been
caring for older adults and people with
chronic diseases. I have an active house
calls practice in which I see homebound
seniors who cannot access primary care
because leaving their homes is a burden to them or their families. I know
first-hand the problems associated with
a fragmented, acute-care-focused health
insurance system that costs too much,
covers too little, and excludes too many.
It also does not match the needs of older
adults or people with chronic medical problems who require more than just
15 minutes with their primary care provider. Sometimes I can’t get through my
patient’s medication lists in 15 minutes!
Individuals with complicated needs
often require team-based care, as many of
their problems are not just biomedical in
nature but are, rather, intertwined with
social and psychological issues.
In February 2012, together with a
group of colleagues, I decided that too
few in our community really knew anything about the new healthcare law, the
Affordable Care Act (ACA). There was
already a lot of noise and misinformation
about the new law in the news and on the
Internet. I was surprised by how little my
medical colleagues actually knew about
the law. Our group decided that we had
an obligation to help educate our community about this new law. We believe
that doctors and nurses are still highly
respected within our community and that
we have important information to share.
Together with the Universal Health Care
Action Network (UHCAN), we organized
training sessions and created a speakers
Image: Corbis
Published in Experience, Volume 22, Number 3, 2013. © 2013 by the American Bar Association. Reproduced with permission. All
rights reserved. This information or any portion thereof may not be copied or disseminated in any form or by any means or stored in
an electronic database or retrieval system without the express written consent of the American Bar Association.
Peter A. DeGolia
(peter.degolia@, MD,
is a geriatrician and
family physician.
He is a professor of
family medicine and
community health and
the Jack H. Medalie
Endowed Professor in
Home-Centered Health
Care at Case Western
Reserve University
School of Medicine.
He is also director of
the Center for Geriatric
Medicine and Palliative
Care at University
Hospitals of Cleveland,
as well as medical
director of McGregor
PACE (Program of
All-Inclusive Care for
the Elderly), which
enables low-income
seniors in the Greater
Cleveland area to age
at home rather than in
costlier residential care
bureau called “Ask a Doc.” Since March
2012, we have presented to more than 50
groups totaling over 3,000 people. These
presentations have ranged from medical
groups to community forums to senior
I always start my presentations off
with a story.
Coverage for Prescription Medications
“Hey doc, guess what?” was the first
thing that Mrs. P asked me when I walked
into her house to see her one afternoon
in early September. Usually, she lets me
know right from the get-go what I’m not
doing or how I could provide better care
to seniors. For this 92-year-old, spunky,
Polish-American woman who lives in
Slavic Village on Cleveland’s South
Side, I learned to listen carefully and
express myself slowly. Mrs. P has severe
end-stage emphysema and requires continuous oxygen. I have seen her through
good times and bad. I have her on some
very expensive brand-name medications because the generic brand caused
her heart to race whenever she used her
inhalation treatments. Since I made this
change, she has felt much better, but her
pocketbook took a big hit and she let me
know it. I was certain she was going to
give me an earful at this visit as well.
Instead, Mrs. P explained to me that she
had just received her bill from Medicare and she wanted me to know that
she would be paying $600 less this year
when she hits the “donut hole.” She was
ecstatic, beaming from ear to ear!
The “donut hole” is the nickname for
the period of time during which Medicare beneficiaries must pay out of pocket
for all their medications. This period
begins after they reach Part D’s initial
coverage limit ($2,930 in 2012) and ends
when “catastrophic” coverage kicks in (at
$4,700 in 2012). At that latter point, coverage for prescription drugs begins again.
In 2020, the donut hole will be eliminated altogether.
In fact, the new healthcare law has
already cut the cost of out-of-pocket
payments on covered brand-name medications by 50 percent this year for
Medicare Part D beneficiaries in the
donut hole. That reduction saved Mrs. P
a whole lot of money. Since she is on a
fixed income, every dollar saved is a big
deal to her. She wanted me to know about
her good fortune right away.
Coverage for Preventive Care
I have a patient named Willard who has
a strong family history of colon cancer.
He is a truck driver for a small company
and did not have very good health insurance before he turned 65 years of age and
got onto Medicare. Even then he refused
to pay the extra cost for a screening colonoscopy to look for colon cancer. I tried
to explain to Willard how it could be
cheaper in the long run to screen for this
disease since he had two first-degree relatives who developed colon cancer. He
would not budge. He could not afford it.
He was without symptoms.
With the passage of the new healthcare
law and his going onto Medicare, I immediately contacted him and explained to
him that he could now have a screening
colonoscopy performed without paying
extra. The ACA allows for payment for
24 prevention services, including specific tests, examinations, and counseling
to target potentially treatable life-threatening or chronic diseases. Colon cancer is
a readily treatable disease if found early.
Willard was at very high risk and needed
to be screened. With the passage of the
ACA, Willard could now have his screening colonoscopy without having to pay
additional out-of-pocket costs. He agreed
to have the test, and two precancerous
growths were found and removed! His
next colonoscopy won’t be a screening
test, but we eliminated a major problem
that could have caused death or misery,
as well as significantly greater healthcare
The new healthcare law provides free
annual wellness examinations. Primary
care providers are expected to focus on
developing a personal prevention plan
with each patient and to identify for the
patient which of the 24 preventive services are appropriate for him or her
given his or her age and health history.
Services such as influenza and pneumococcal pneumonia vaccinations, pap
smears, mammograms, colonoscopies,
mental health screenings, nutritional
Published in Experience, Volume 22, Number 3, 2013. © 2013 by the American Bar Association. Reproduced with permission. All
rights reserved. This information or any portion thereof may not be copied or disseminated in any form or by any means or stored in
an electronic database or retrieval system without the express written consent of the American Bar Association.
counseling, and smoking cessation/counseling are some of the free health services
now available to all Medicare and Medicaid beneficiaries. Beginning in August
2012, these requirements were extended
to all new private health insurance plans
as well.
Prevention of Fraud, Waste, and Abuse
I was contacted by the grandson of a bedbound patient to ask me to take over his
grandmother’s medical care. He reported
that a for-profit visiting physician’s organization had made a home visit recently
to establish care for his grandmother and
had ended up billing her insurance for
nearly $4,000. She was expected to pay
$800 out-of-pocket. When I asked what
had been done, he said, “Everything.”
This included many unnecessary but billable tests, including several radiologic
studies done in the home by the provider,
minor procedures, and extensive blood
work. The grandson did not understand
that some of these things were not medically necessary or that his grandmother
would have to pay 20 percent of the outof-pocket costs.
ranging from services billed for but not
provided, to services that do not meet
medical necessity, to overbilling for services. A large number of older adults
with multiple chronic health problems
report duplicate tests and procedures,
conflicting diagnoses for the same set
of symptoms, and contradictory medical information. See Gerard Anderson,
Chronic Care: Making the Case for Ongoing Care (2010), available at www.rwjf.
chronic-care; see also www.fightchronic
Drs. Agrawal and Budetti describe the
problem of physician medical identity
theft in their February 1, 2012, article
in the Journal of the American Medical Association (Vol. 307, No. 5). They
describe how a physician applied to and
interviewed at a medical practice but
chose not to work for the group. Nearly
two years later, Medicare asked this
physician to return $350,000 in overpayments made to the practice he had
interviewed with but never joined. The
Department of Treasury began to garnish his Social Security payments for
The new healthcare law is a small but significant step toward
meaningful change that has already benefited millions of Americans.
The Economist reported on June 17,
2011, that the estimated U.S. healthcare
spending waste for 2009 ranged from
$600 to $800 billion. The cost of unnecessary care ranged from $250 to $325
billion, and the cost of fraud and abuse
was put at $125 to $175 billion. Other
estimated waste categories included
administrative inefficiencies, hospital
inefficiencies, uncoordinated care, and
avoidable care.
Under our current health insurance
system, providers are paid for doing
things—for quantity, but not necessarily
for quality. Medicare expects all visits,
tests, and procedures to be performed
based on medical necessity. We practitioners must use our clinical judgment
to make decisions and record justification of the medical necessity for things
we do or order. However, Medicare fraud
and abuse has become a serious problem,
unpaid debts. The subsequent investigation revealed his medical identity had
been stolen by a fraudulent clinical practice that was part of a complex Medicare
fraud scheme that victimized numerous
physicians and resulted in the criminal conviction of six perpetrators. The
new healthcare law establishes strong
anti-fraud measures, including tougher
penalties for criminals. Hotlines now
exist for reporting of potential physician
medical identity theft: 1-800-MEDICARE
and 1-800-HHS-TIPS.
Innovations in Healthcare Delivery
Mrs. J is an elderly African-American
woman who lives alone in an independent senior living apartment building
on Cleveland’s Southeast Side. She has
Medicare and Medicaid health insurance. Her health problems consist of
early Alzheimer’s disease, hypertension,
Published in Experience, Volume 22, Number 3, 2013. © 2013 by the American Bar Association. Reproduced with permission. All
rights reserved. This information or any portion thereof may not be copied or disseminated in any form or by any means or stored in
an electronic database or retrieval system without the express written consent of the American Bar Association.
and diabetes mellitus with complications
including skin and vascular disease, kidney insufficiency, and nerve damage. She
has a wheelchair, two walkers, a cane, a
tub chair, and plenty of diabetic supplies.
She has a skilled nursing service coming
to her home weekly, as well as nonskilled
home care provided by an aide two hours
a day, five days a week. She has a wound
care doctor, a renal doctor, and a diabetologist, in addition to me! What she does
not have is good coordinated care.
Despite all these services, she has
been hospitalized three times in the past
six months. To prevent her health from
deteriorating further, it is essential to control her blood pressure and maintain her
blood sugar in a safe range. However,
because of her memory problems, she frequently forgets to take her medication.
There are signs everywhere in her apartment instructing her about what to do or
not to do. Despite all this, she continues
to not take her medications properly or do
the other things she needs to do to remain
safe in her home. The home health aide
does not communicate with the home
care nurse (two different agencies), and
the nurse does not communicate with
her primary doctor (two different agencies). She needs the coordinated services
of a physician, nurse, and social worker
who communicate effectively together
and who work together to improve the
care of their patient. She needs one physician directing these services so that Mrs.
J can receive the right care at the right
time in the right place. Without this, she
will not be able to remain living in the
Managing the care of dual eligible individuals (insured by both Medicare and
Medicaid) is expensive and very challenging. This is a small but expensive
segment of our society. It truly takes a
team to effectively coordinate the care
of these individuals. People with complicated health conditions need care
coordination. We also need to control
unnecessary and excessive spending on
wasteful care. These factors are behind
changes built into the ACA. The new law
provides for the development of “accountable care organizations,” entities that
will be accountable for the quality of care
provided to their members through the
promotion of good communication and
coordinated and comprehensive care.
The new law established the MedicareMedicaid Coordination Office to bring
these two health insurance systems
together to provide better care and services for the dual eligible population. It
created the Center for Medicare and Medicaid Innovation to fund efforts, such as
“Transition Coach Initiatives,” to find new
ways of providing “better care at lower
costs.” Transition coaches are nurses or
social workers who work with hospitalized patients and families to help them
understand how they can take control of
their healthcare needs. They act as patient
advocates to educate patients about their
principle diseases, factors that cause these
diseases to get out of control, medications
they are taking, and questions they should
ask their doctor. This simple intervention
has been shown to significantly reduce the
readmission rates of patients to hospitals.
Health care is rapidly changing. The
way things were done in the past cannot
be the way we do things in the future. The
new healthcare law is a small but significant step toward promoting meaningful
change. It has already benefited millions
of Americans, be they children who can
no longer be denied health insurance
because of preexisting conditions, young
adults who have access to their parents’
health insurance plans, or older Americans who now receive preventive services
without paying out-of-pocket costs.
Key to controlling healthcare costs in
the future and improving health services
for all Americans will be our ability to
build a meaningful healthcare system that
emphasizes preventive care and continuity of care; quality, rather than quantity, of
services provided; and insuring the uninsured. Right now we have a healthcare
industry. We need a healthcare system
that places the patient and the patientprovider relationship at the center of
care. The new healthcare law begins to
acknowledge this and is an effort to redirect our health service ship. We have a
long way to go. Achieving meaningful and
sustained reform will require the engagement of all our citizenry. n
Published in Experience, Volume 22, Number 3, 2013. © 2013 by the American Bar Association. Reproduced with permission. All
rights reserved. This information or any portion thereof may not be copied or disseminated in any form or by any means or stored in
an electronic database or retrieval system without the express written consent of the American Bar Association.