The Affordable Care Act, Practically Speaking

The ACA is without question the most sweeping piece of social welfare legislation since the New Deal. It is complicated and, whether you like it or not, it must be implemented.
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Amidst all the posturing and second guessing about whether the Supreme Court's ruling on the Affordable Care Act (ACA) is constitutional, a tax or bad policy, some important issues are getting short changed.

The ACA is without question the most sweeping piece of social welfare legislation since the New Deal. It is complicated and, whether you like it or not, it must be implemented.

Hospitals have a moral obligation to provide care to all patients, regardless of their ability to pay. According to the American Hospital Association, 5.8 percent of median expenses nationwide are attributed to charity care. At Mount Sinai alone, we provided $77 million of uncompensated care in 2011. Charity care comes not only as a cost to hospitals but impacts the well-being of those without insurance.

Charity care is almost always provided when illnesses have already reached advanced stages. Without insurance, individuals often do not get the right care at the right time. As a result, they may not comply with recommended protocols, such as taking medications regularly and making routine visits to their primary care provider. Thus starts rescue medicine, where the entry point for care is through the hospital's emergency department when, more often than not, the condition is more expensive to treat, more disruptive to patients' lives, and less likely to have ideal outcomes. We would much rather be treating these patients sooner with preventive and maintenance medicine, at early stages of disease with multidisciplinary teams. The ACA addresses this issue directly by enabling more than 30 million people to get comprehensive health coverage. It also means a measure of relief for hospitals by reducing uncompensated care.

Preparing for the influx of millions of newly insured patients is not something any medical center can take lightly. We must continue to invest in primary care medicine by providing more clinics and training the next generation of doctors. We must also make electronic medical records available across networks and between hospitals. Most importantly, we must take advantage of accountable care organizations and patient-centered medical homes in which physicians and hospitals are rewarded for reducing hospital readmissions and improving patient outcomes. As an example, Mount Sinai has an outreach program for high-risk patients which has cut hospital readmissions by 46 percent in a targeted population.

However, implementing the ACA will not address all the needs we have in this country to reform health care and reduce costs. More needs to be done to prevent and manage chronic conditions like diabetes, hypertension and Alzheimer's disease. Diabetes impacts nearly 26 million Americans, and hypertension affects 30 percent of adults in the United States. Predicting, preventing or postponing onset of these conditions could bring tremendous savings to our health care spending. Consider too that one in eight adults 65 years of age and older has Alzheimer's and with our nation's aging population, that number is expected to soar over the next 50 years. It has been estimated that if, by 2015, we delayed the onset of Alzheimer's by five years in the entire population, it would lead to a cost savings of $111 billion over 10 years.

Rather than treat late-stage illness with high tech treatments, we must invest in the development of novel therapeutics that will delay the onset of disease. We are at a point in medical history and scientific evolution which represents the golden age of biomedical advances. We must focus our efforts on developing diagnostics and therapeutics that should be made available to all Americans. We must continue investing in the future of medicine because only real innovation can bring greater value from our health care investments.

On the whole, medicine's fee-for-service model must be reoriented to reflect our current and future population patterns: one that is older and has a high prevalence of chronic disease. We must manage population health better and be rewarded for keeping patients out of the hospital.

The ACA also includes multiple new taxes, cuts to reimbursement, and unfunded regulatory mandates -- the combined impact of which will increase costs while reducing funding for medical centers. It calls for a $18.1 billion cut to federal payments in uncompensated care, and if lawmakers fail to reduce the deficit by $1.2 trillion over 10 years, there will be $123 billion lost in payments to Medicare providers. These numbers are particularly sobering for teaching institutions such as Mount Sinai that serve disproportionately large populations of Medicare and Medicaid patients and rely on Graduate Medical Education funding by the federal government to train the next generation of doctors and physician scientists.

The ACA is a strong step forward but there is still so much more to do. We in health care will continue to work to implement the ACA, and build an even better health system for our community and for the future of medicine.

Kenneth Davis is president and Chief Executive Officer of The Mount Sinai Medical Center and Wayne E. Keathley is president and Chief Operating Officer of The Mount Sinai Hospital.

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