Editor's note: The Catalyst's Cindy Abole sat down with Bill Moran, M.D., to talk about the June 28 Supreme Court ruling on President Barack Obama's health care law and how it affects consumers, the state of South Carolina and MUSC. Visit http://bit.ly/DrBillMoran.

Division of General Internal Medicine director Dr. Bill Moran talks about the June 28 ruling on the health care law. Moran discussed how it affects consumers, South Carolina and MUSC as a health care provider and employer.

What was your own reaction to the June 28 Supreme Court ruling on President Barack Obama’s Healthcare Law?
It surprised many of us. I’ve been working with the Society of General Internal Medicine Health Policy Committee and most of us really thought things would go a different way. The history of health care policy in the U.S. has starts and stops. Historically, we’ve been pushing for more than a century to get universal access for all Americans for basic health care services. This outcome pushes us a long way towards that goal. It’s a triumph for uninsured people. In South Carolina, there are almost a million uninsured people and we hope a large number will benefit from reform.

What will be the changes?
We’ll have to consider changing the delivery system and we will need more primary care. The insurance industry has to respond. But the people who win are the people who don’t otherwise have insurance. According to the Henry J. Kaiser Family Foundation, more than 50,000 Americans die every year because they are without health insurance coverage. That’s equates to about 2,000 uninsured people in South Carolina who receive fewer services and are more likely to die than insured patients.

What does the June 28 Supreme Court ruling mean?
There were three aspects to President Obama’s Health Care plan that the Supreme Court was evaluating

1) Did the court have any judicial oversight to the bill? The answer is yes.

2) Was the individual mandate, as it was called, constitutional? Or can the federal government require individuals to purchase a health insurance product because the government requires it? This was the most controversial part of the bill. As an analogy, let’s look at auto insurance, which protects not just the driver of a vehicle, but the other driver who is hit. The law requires people to purchase a product (in this case, car insurance) that they may use or may not need. And most people won’t need it. Many individuals who have no health insurance are relatively young and are employed,  but cannot afford health insurance because it is so expensive so they choose not to purchase it.

3) Is the bill, as it was written, constitutional? If the mandate was constitutional then the bill is constitutional.

The bill includes a large expansion of Medicaid, to insure adults who are at or below 137 percent of the poverty level.  In SC, Medicaid enrollment is 42 percent of the federal poverty level. By 2017, the part of the Medicaid costs will revert back to the state.

The bill provides leverage for states that participate in Medicaid funding, they have to participate in expansion, but the court said the federal government cannot force the states to expand Medicaid. 

It will be an interesting debate within the coming year whether billions of federal dollars that could come into South Carolina by expanding Medicaid is worth the costs to the state by 2017. There are many years to plan figure out effective ways to do it.

Other ramifications: Because the mandate was found constitutional, pre-existing condition exclusions are not allowed and lifetime $1 million cap for patients with chronic diseases is removed. There is an increased emphasis in medical practice on prevention. In the Medicare program, preventative and screening services now have no co-payments or deductibles. There’s no disincentive to get preventive services. This is one of the biggest parts of the bill: moving health care from the back end (disease and illness management) to the front end (building a primary care system that supports prevention and early control of the disease).

How is MUSC incorporating technology and other tools to support the health care law and improve patient care?
MUSC has adopted Epic, the hospital’s new electronic medical records system that was launched hospitalwide May 17. Using EPIC, I can tell if the patient I see today has a mammogram and colonoscopy. Epic gives us the ability to manage an entire population and allows the health care industry to focus resources in bringing in patients who need our preventive care.  Another issue is open access. We want patients telling us of what’s going on with their health. We don’t want them to call in and leave a message. The medical staff needs to be more available on the front end of care. We want to prevent patients going to the Emergency Department for a health problem we could’ve managed within our primary care system. Technology helps us practice better using reminder prompts for health care team reviews and work together as a communicative, coordinated team. Our subspecialists, hospitalists and everyone can communicate together using the same medical record and that’s important to providing a higher level of quality patient care. The Patient Protection and Affordable care act or Obama Health Care plan was established to protect consumers from insurance abuses and incentivize us to provide higher level of quality health care. One important aspect of the bill is measuring a hospital’s effectiveness with high readmission rates. That could imply that the quality of our care, discharge planning and patient follow up is not as good as it can be. One of the stipulations states that if there is a hospital attains a low re-admission rate, then they receive an incentive payment. If a hospital receives a high readmission rate, then they get penalized. MUSC, as a hospital system, must ensure that a patient gets the highest quality of care when they’re hospitalized and that their discharge and transition home is safe.  They should be quickly reconnected with their primary care physician or specialist so they won’t end up being readmitted to the hospital. There are incentives in the bill that change the way practitioners can link hospitals, specialists, primary care doctors together. We, as an organization, are perfectly positioned to improve on this.

How will the new health care law affect MUSC or change our workforce?
One of the things about MUSC’s workforce, which is true of many academic health centers, is that we have a lot of specialists and not enough primary care physicians. Other industrialized countries have provider ratios of 40 to 50 percent primary care physicians compared to 50 percent specialists. In the U.S., primary care specialists are at about 25 to 30 percent and the number keeps dropping. The worry is that when new patients get insurance, we need to have more primary care providers.  We also need to train and prepare more primary care providers very quickly. When then Massachusetts Gov. Mitt Romney enacted health care reform in 2006, there were immediate primary care physician shortages. About 300,000 patients couldn’t find primary care physicians. We need to change the structure of primary care medicine in how it’s delivered and fix the payment mechanism. As it stands right now, primary care is at the bottom of physician payments. We have to fix that in order to build incentives and attract a new primary care physicians. We also need to change the way we train medical professionals and work within interprofessional teams. Today, medicine works in complicated team around a sophisticated, electronic infrastructure. We all need to be working together and recognizing people on these teams – pharmacists, nurses, therapists, medical assistants, registration staff and other specialists. Every component of delivery system has to work together to provide the best level of care for our patient population.

How was tort reform addressed in the bill?
Tort reform refers to litigation or damages for compensating wrongs and harm done to another person. It advocates and proposes procedural limits on the ability to file medical claims and caps awards of damages. Tort reform remains a huge issue and the administration avoided it by defining it as a state issue. In medicine, providers order more tests that are necessary because they’re leery of being sued by their patients. But studies have shown that a good relationship between provider and patient is equally important in preventing lawsuits.   

Although tort reform remains an important issue, we also must consider our role in causing lawsuits. There are a number of organizations that are evaluating physician and provider behavior and our role in  inciting lawsuits.

For employees, what can be done to reduce the cost of health insurance and other benefits?
If MUSC doesn’t advocate for getting insurance costs under control, then the benefits employees get will continue to shrink. We need to think differently and be stewards of resource. We need provide services that add value to patient care and not just provide services that increase our volume and revenue. That’s the fundamental challenge that delivery systems and insurers face. Employers are demanding a different kind of system of care.  They are tired of large annual insurance costs increases each year, while their employees workers get minimal raises.  Employees want a different model: one that maximizes value for them and their dependents but doesn’t take every extra dollar out of their paycheck. Reform works toward helping us purchase services that add value to care, instead of volume. MUSC, as a delivery system, has to think how to do this effectively. Our system is volume driven and we will have to rethink this strategy. Employers see escalating premiums and workers see higher co-payments and deductibles. We need to rethink how to deliver care. 

What are the benefits of insurance exchanges under the health care plan?
For health care reform in Massachusetts, the state needed a mechanism for marketing different health insurance products and making sure that people and business owners who bought these insurance products knew what they were purchasing. The exchanges established the insurance exchange model where a small business or individual can compare products and learn about different levels –evaluate coverage differences, regarding coverage and costs. Introducing competition and transparency about costs and covered benefits is the foundation of what defines the insurance exchange. Consumers will be looking for the best insurance deal for the services, value and costs. The bill also defines a cap on administrative costs for insurance companies at 20 percent, so 80 percent of every dollar goes to patient care/quality and 20 percent administrative. Medicare has 94 percent of every dollar going to patient care, and 6 percent is used administrative costs. The bill therefore challenges insurance companies to be more efficient and transparent regarding the services they provide and costs. This is a good thing because it supports competition within the insurance industry.

Globally, the health care bill pushes us to evolve.  It doesn’t fix everyone’s problems but instead continues the country on a road where we can address problems from different perspectives – value, prevention, perspective, improving competition, being more transparent, focusing on quality, efficiency and being more patient-centered. We’ll evolve from here to help more Americans with health insurance and provide an improved delivery system.

Is it possible that the health care bill be repealed?
Speaker of the House Rep. John Boehner has called to repeal the bill in the U.S. House of Representatives. A bill to repeal health care reform legislation was passed by the House earlier this year, but didn’t make it through the Senate. To repeal a bill, it must be passed by the House passed by the Senate with 60 votes, and signed by the president. So the House, Senate and president must be aligned to repeal the bill.  This is very unlikely in the current congress, but it’s definitely an issue for in the coming presidential election.

Is it a good time for health care in America?
Yes, it’s a good time now.  Many of the changes with health insurance reforms are already in place. The country will move forward with establishing health exchanges. This will progress now that there are no additional barriers to health care reform. We need smart people to put in place the needed changes to respond to the mandates of the bill.  At MUSC, we’re already re-aligning systems to do this, like the patient-centered medical home in Internal Medicine and Family Medicine, and soon in Pediatrics. Our leadership will focus on value-based services and realign our delivery systems slowly over time to meet the challenges that are part of health care reform. It’s a good time to work and start a career in health care and I am encouraged by health care reform efforts.