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Josh Adler: ACA's Impact on Hospitals and Medical Practice

Josh Adler, MD, is chief medical officer of UCSF Medical Center and UCSF Benioff Children's Hospital. He directs the doctors who provide patient care at UCSF and oversees the quality of medical services and the integration of patient care, education and research.

Adler also oversees care coordination, clinical resource management, compliance, medical staff affairs, quality assurance and risk management. Here, he discusses the Affordable Care Act's (ACA) impact on hospitals and medical practice.   

Q. How will the increase of newly insured consumers impact UCSF Medical Center and UCSF Benioff Children’s Hospital?       

We anticipate two important impacts. 

First, there likely will be increased demand for care – for emergency and urgent care services, followed by primary and specialty care. Emergency and urgent care services may be the first to be accessed by newly insured people because these will be available immediately upon obtaining insurance, without the need to choose a particular physician or health system and schedule an appointment.   

Second, there may be a larger-than-normal percentage of existing UCSF patients who will be changing insurance. The short-term impact will be more complexity for patients and for UCSF staff as patients register for care, and perhaps the need for patients to change medication regimens as drug formularies differ among health plans.

These impacts will be similar in nature for UCSF Benioff Children’s Hospital, although perhaps somewhat smaller in scale because a smaller percentage of California’s children are uninsured and thus fewer will be new to care.

Q. Do you think the exchanges ultimately will improve health outcomes while reducing costs?

This is one of the most important questions to answer regarding the ACA and the public exchanges.

The answer largely depends on the ultimate percentage of patients who obtain insurance through the exchange. If the percentage is substantial, the exchange likely will be able to impact costs by applying downward pressure on premiums for any entity offering a plan on the exchange. Impacting quality may also be possible if the exchange is able to require sufficiently transparent measurement and reporting of health outcome metrics, and require minimum levels on health outcomes performance as prerequisites for health care providers to participate in the exchange.

If the exchange does not ultimately represent a large proportion of those insured, its impact on quality and cost will be minimal.

Q. How is UCSF participating in Covered California?

UCSF Medical Center, UCSF Benioff Children’s Hospital and UCSF physicians are part of the network offered by the Anthem Blue Cross health plan offering on the Covered California exchange. This means that patients and families who wish to access UCSF for care via Covered California should choose the Anthem Blue Cross plan.

Of note, all UC Medical Centers and physicians are participating in Covered California in their respective geographic regions via the Anthem Blue Cross plan.

Q. Undocumented immigrants are not eligible for insurance under the exchanges. How will the exchanges impact their access to care?

This is uncertain. Undocumented immigrants will not be able to obtain coverage via the exchanges and thus will largely remain uninsured.  

The initial effect may, in fact, be reduced access for the remaining uninsured (including undocumented immigrants) as health systems struggle to meet the demand of the increased insured population. This will be particularly true for scheduled care in physicians’ offices, particularly primary care. If this is correct, then we may see further increases in the use of emergency department utilization for care of late-stage disease. 

Q. Do you think there are enough clinicians to handle the influx of newly insured?

Based on the current state and predicted increases in the number of insured Californians, there likely will not be sufficient capacity in the delivery system to meet the demand.

Rural areas will be more impacted than urban, because there already are relative shortages of physicians and, in some cases, hospitals. In all areas, there are likely to be shortages of primary care providers, mental health providers, and general surgeons. Other specialty areas that may have insufficient capacity include: endocrinology, neurology, and rheumatology. Many emergency departments will experience further overcrowding.

Solutions to remedy these shortages include expanding the primary care workforce. This would include expanding the number of physicians and nurse practitioners available to provide primary care. A complementary approach involves expanding the scopes of practice of nurse practitioners and other health professionals (nurses, pharmacist, psychologists, etc.) who can then assume portions of care now provided only by physicians. 

Emergency department overcrowding can be improved through primary care expansion and greater adoption of the primary care medical home model of care in which patients have much easier access to care from their own provider. In addition, expansion of urgent care centers – already occurring in the Bay Area – may provide lower cost alternatives to emergency department care for low acuity health needs