The Paradox: PPACA vs. Value-Based Healthcare

Health-Care-Reform, ppca, acaby Jim Jones, Featured Contributor

You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.”

          –Thomas Sowell

PPACA IS 2,600 PAGES OF REGULATIONS and procedures that, good intentions or not, have caused the opposite of many of its stated objectives, with unfortunate consequences to both the physician and patient. And therein lies the paradox. PPACA’s oppressive regulations have placed unaccountable bureaucrats virtually in charge of physician offices with unprecedented control over the practice of medicine, ostensibly to provide “better” healthcare. And these bureaucrats have no concept of what it’s like to run a business or live in the world of their own procedural making.

Over the past two years, physicians have spent enormous amounts of time and money just to be able to continue in the practice of medicine due to regulatory mandates associated with PPACA. Here are just a few examples:

1) On-going training and software expense of Electronic Medical Records (EMR)

2) Implementation of the ICD-10 coding system

3) Updated compliance rules and software integration for Health Insurance Portability, HIPAA and the Physician Quality Reporting System (PQRS)

4) Additional staff to implement and communicate new regulations

5) Reduced reimbursement rates from private insurance and Medicare

These expenses and lower reimbursements have shifted to patients in the form of shorter office visits, less time with chronic disease patients and limited communication for complex treatment plans. Physicians have to see more patients and spend less time with each just to cover the extra expense of staying in business. Consumers are waiting longer to see their doctor and spend less time with them when they do.

In a 2015 survey of 400 practicing physicians1:

  • 84% believe quality patient time may be gone forever.
  • 78% say they frequently feel rushed when seeing patients.
  • 87% say the “business and regulation of healthcare” has changed the practice of medicine for the worse.

As a condition of PPACA, government regulators are pressing physicians to practice value-based healthcare. Value-based healthcare by definition is healthcare delivery with quantifiably improved clinical outcomes coupled with a reduction in the overall cost of care. Treating people with chronic disease accounts for 86% of our nation’s healthcare costs.2 Clearly, the treatment of chronic disease is where the most focus and intensity needs to lie – focus and intensity that requires more time with patients, not less. And so the paradox continues. PPACA, through its regulations and requirements, prohibits the very issues that it ostensibly requires in order to achieve value-based healthcare. Mr. Sowell’s comment above couldn’t be more right.

Three significant issues will manifest in the fall of 2015 that will exacerbate the paradox and create more hardship:

1) Individuals and employers will see double-digit increases on their 2016 health insurance plans in almost all cases.

2) Provider networks will become more limited as physicians either drop out of accepting private insurance or insurance companies form more narrow networks to lower their cost.

3) Out-of-pocket costs to consumers will rise as deductibles increase and prescription drug formularies change to higher co-pays.

So What’s the Solution? For physicians, it’s a matter of leveraging their time in order to achieve better clinical outcomes. For employers having to spend more on employee benefit plans, it’s a matter of reducing utilization on their health insurance. The train has left the station. PPACA is here to stay. The question now is “how do we live with it?” The good news is, there are solutions that are available to physicians and employers alike. Solutions that are quantifiable, proven and ready to deploy.

We look forward to facing the challenge and helping physicians and employers alike.

1 Geneia Survey

2 Chronic Disease Prevention


Jim Jones
Jim Jones
JIM Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Through Jim’s 30 years in the insurance and healthcare industry, he has developed a business model that integrates healthcare services that lowers insurance utilization, improves clinical outcomes and lowers overall healthcare spend. Wellspring is a dynamic company that focuses on helping middle-class Americans manage their out-of-pocket healthcare costs. As the cost of health insurance goes up and the amount of healthcare we get for our money goes down, Wellspring provides Americans with traditional options, alternative solutions and creative thinking to help solve the emerging crisis of affordable healthcare.

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