Lack of detail on ACA replacement could spook patients, practices

The lack of specifics on an Affordable Care Act (ACA) replacement could have deleterious effects on cancer screening rates and other preventative care, according to Geraldine McGinty, MD, assistant professor of radiology at Weil Cornell Medicine in New York.

The repeal of the ACA appears imminent, but Republican leadership has been tight-lipped about the specifics of a replacement plan. President Donald Trump has promised to pull back the individual mandate while preserving the protections for people with pre-existing conditions, but leaked recordings of a closed-door meeting of Congressional Republicans showed intra-party concerns about their ability to follow through on all of their promises.

Adding to the uncertainty is the disconnect between Trump’s timeframe and the one proposed by mainstream Republicans. Trump has consistently called for simultaneous repeal and replace, while Paul Ryan put the ACA replacement in a list of objectives to accomplish by the end of 2017—getting no more specific than that. This uncertainty could discourage patients from utilizing preventative care measures, especially for patients with pre-existing conditions, said McGinty.

“In the days where we had the specter of pre-existing conditions, we saw people staying away from tests—such as genetic testing—that might prejudice their ability to get insurance in the future,” she said. “I would be concerned if it looked like that [protection] wouldn’t be coming back.”

Another important facet of the ACA was the requirement that insurers pay for patients’ out-of-pocket costs for U.S. Preventative Services Task Force (USPSTF)-approved screening. This provision increased cancer screening rates by removing a major financial barrier, and removing it could cause a return to pre-ACA screening levels. The American College of Radiology submitted a question in writing during the nomination hearings for Secretary of Health and Human Services nominee Tom Price, asking about low-cost coverage of cancer screening, but never received a response.

“We’ve also been struggling with misinformation for patients, conflicting guidelines we want our patients to understand,” she said. “They’ve been hearing from USPSTF—which does not include any imaging experts, and seems to be biased against mammography.”

However, the ACA isn’t perfect. High out-of-pocket costs can deter screening just as strongly as an uncertain future, McGinty cautions.

“When you haven’t met your high deductible and you’re responsible for the entire cost of your imaging study, people think twice about getting the care they need,” she said.

In addition, imaging practices could feel the squeeze from reduced usage of preventative services and zero-sum reimbursement of MACRA—which won’t be repealed along with the ACA. McGinty recommends signing up for the ACR’s Qualified Clinical Data Registry, a tool that greatly simplifies reporting to Medicare.

“It’s a powerful way to demonstrate the quality you deliver because it benchmarks you against peers,” she said. “MACRA has a financial impact, but one of the other things radiologists should be mindful of is that there’s going to be increased transparency. Scores that they receive under the MIPS program are going to be published, so there’s a reputational risk for not gearing up for this.”

In any case, McGinty is confident in the imaging industry’s ability to weather the storm.

“We’ve been dealing with change so long it’s a constant for us,” she said. “We’ve had any number of challenges that practices are dealing with while we try to give the best imaging care for patients.”