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February 1, 2013 Volume 77, Number 2
Residents' Review: America’s Changing Demographic, the Affordable Care Act, and Provision of Culturally Competent Perioperative Care Jorge A. Caballero, M.D.


On March 23, 2010, the Affordable Care Act (ACA) was signed into law, making it the most significant – if not most controversial – piece of health care reform in the United States since the introduction of Medicare and Medicaid in 1965. The survival of the ACA, commonly referred to as “Obamacare,” is all but guaranteed following the recent presidential election. A number of provisions of the law have already been realized, including an expansion of the Medicaid program, an extension of health insurance coverage for young adults and the introduction of free preventive care for those individuals who are already insured. Implementation of the most divisive provisions is yet to come. The establishment of health insurance exchanges, enforcement of the individual mandate and adoption of a physician care quality payment model will go into effect within the next few years.1

In the 45 years between the introduction of Medicare and Medicaid and the passage of the ACA, the U.S. population has become increasingly diverse. According to the most recent U.S. census data, 50.5 million people living in the U.S. are of Hispanic or Latino origin.2 Between 2000 and 2010, the Hispanic population grew by 43 percent, accounting for more than half the total population growth in the U.S.2 Likewise, Black and Asian populations grew faster than the total U.S. population.3,4 A combination of factors resulting from the implementation of the ACA and an increasingly diverse patient population is certain to effect change in the practice of anesthesia and perioperative medicine.

Changes to Access and Health Care Utilization
One of the primary goals of the ACA is to address the problem of the uninsured. Comprising an estimated 47 million individuals, or 18 percent of the non-elderly population, the uninsured account for an estimated $35 billion in uncompensated care.5,6 According to the RAND Corporation, the ACA will expand health insurance coverage to an additional 25 million Americans by 2019.7 The growth in the pool of insured individuals is expected to result primarily from an expansion of employer-sponsored insurance in addition to greater numbers of Medicaid and non-group insurance enrollees.7

As Hispanic, Asian and Black individuals are disproportionately uninsured, the expansion of health insurance coverage will be most noticeable among individuals from minority groups. According to one estimate, almost 20 percent of Black and Asian patients are uninsured. Similarly, as many as three in 10 Hispanic individuals lack health insurance.8 It follows that physicians will soon witness increasing diversity in the cultural and ethnic makeup of their patient population.

There is evidence to suggest that newly insured individuals will seek more medical care. A significant increase in non-obstetrical inpatient procedures was observed after the implementation of health care reform in Massachusetts, most notably among Hispanic patients.9 Some estimates point to an increase in health care spending of up to 3.3 percent, primarily due to increased utilization among the newly insured. In addition, the newly insured are expected to spend more on health care than they did prior to gaining coverage.7

Pent-up demand for surgical services may translate to a significant rise in surgical volume. A study of 4,774 Hispanic individuals living in Arizona found that 2.2 percent had clinically significant cataracts and no previous cataract surgery.10 It was also found that Hispanic patients with medical insurance were almost three times as likely to have undergone cataract surgery than those without insurance. As more Hispanic patients become insured, the proportion of patients fulfilling their surgical needs is likely to rise.

Health Care Expenditures and Payment
As there is remarkable similarity between the Massachusetts health care reform law and the ACA,11 implementation of the Massachusetts statute is often invoked as a case study for upcoming ACA-driven reform in health care utilization and spending. Under the Massachusetts state plan, near-universal coverage was achieved but cost-containment has proven elusive. Total health care spending increased by 30 percent, or $418 million, between 2006 (pre-reform) and 2009.12,13

As the potential increase in health care expenditures runs counter to the goal of containing rising costs, the ACA seeks to ameliorate this through broad payment reform. The new law includes a number of provisions that enable the Centers for Medicare & Medicaid Cervices (CMS) to shift away from the fee-for-service paradigm toward a quality-driven payment model. As of October 1, 2012, all hospitals submitting claims to CMS are required to collect and report data related to 45 hospital quality measures as part of the Hospital Inpatient Quality Reporting (IQR) program – a new condition for payment. Under the new CMS payment system physician and hospital payments will depend, in part, on metrics that include a patient’s perception of the quality of care received.14 Thus, while it remains to be seen whether the ACA’s cost containment provisions will succeed, the new law places greater emphasis on improving customer service and the patient experience.

The convergence of an increasingly diverse population and a shift to a payment model that is based on subjective measures of the patient experience poses an important question: is the anesthesiology community prepared to address the challenge of providing care that is perceived to be of high quality to patients from a culturally diverse background? This seems unlikely based on the relative paucity of research studies that aim to identify and address health disparities in anesthesia and perioperative medicine.

Conclusions
As the provisions of the ACA are implemented, anesthesiologists are likely to experience an increase in surgical volume. The increased demand for anesthesia services will be a result of increased utilization by patients who are newly insured, many of whom will be minority patients as they comprise a greater proportion of the uninsured. The new quality-based payment system places a premium on physicians’ ability to communicate clinical decisions in a manner that reflects the provision of high-quality perioperative care to a culturally diverse patient population. Research efforts should aim to improve our understanding of our patients’ service expectations, particularly among Hispanic and other minority populations.



Jorge A. Caballero, MD is a CA-2 Resident, Stanford Hospital & Clinics, Stanford, California.


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