Both school districts and universities are cutting the hours of some employees so they won't have to give them health insurance. But their efforts won't help them avoid fines under the Affordable Care Act, researchers say.
And as different parts of the health reform law come into play, universities are grappling with how to train medical students fast enough to keep up with the influx of patients who are getting insured because of the new law.
The problem is that medical school graduates need to work in a clinic as a resident under the supervision of licensed doctors, but there aren't enough residency slots available for them because of a federal cap, said Richard “Buz” Cooper, director of the Center for the Future of the Healthcare Workforce at the New York Institute of Technology (NYIT) and a senior fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania.
The Affordable Care Act addressed this issue in an earlier version. But the final version did not include any funding for residency positions and did not lift the cap, which are set by the government since it pays for most of the residency costs, Cooper said.
As a result, more patients will have health care, but there won't be enough doctors to treat them. And that decision means the government can keep its health care costs down.
"It was utterly irresponsible," Cooper said. "It's like planning a war and not training any soldiers."
Five years after graduating from medical school, some graduates could still be without a residency, with $200,000 in debt, but no means to pay it off.
This situation has left universities to figure out how they're going to get students trained and licensed to practice medicine at a time when the licensure process has become backlogged.
Some universities are turning to simulation labs to get students more clinical experience before they go into their residency. At NYIT, students in the School of Health Professions work on manikins and actors playing the role of the patient.
The manikins allow students to learn how to put an IV in someone's arm without actually hurting anyone, and they beep when students don't hit the vein. Fully programmable manikins can run anywhere from $100,000 to half a million dollars, but they're worth every penny and provide some of the best pre-training that's available, said Patricia Chute, dean of the NYIT School of Health Professions.
Sometimes, the actors will play family members of the manikin patient, and these patients have to go to a mock emergency room set up in the simulation lab and end up dying.
"Because the parents are real, when the patient dies, the kids are crying," Chute said. "And so, what that does is it really makes them ready for the real world."
Right now, accreditors don't allow these simulation lab experiences to count as hours spent in residency. If they allow, for example, 25 percent of these hours to be on a manikin, that might help reduce the backlog of med students waiting for residency and prepare the students faster for clinical work.
"We're teaching some very important aspects of medicine that help the student once they get into the actual clinical experience," Chute said. "But the question is, 'How much experience clinically are we going to be able to give them if there's more and more of a stranglehold on these clinical sites because of money issues and because of time and all of the other things that tend to get in the way?'"
While obtaining the necessary clinical experience remains in question, the law does provide for electronic health records and a medical team approach to medicine.
When medical professionals electronically tag patient conditions, medications and responses to medication, it opens the door for better research on patient outcomes and ultimately more effective treatment from medical teams, Chute said.
"You've got to look at some of this patient-centered research to find out what the big picture's going to look like to be able to make those generalizations," Chute said.
The next big challenge is to make these electronic health records more like credit cards that any provider can read, she said.
On the employer side of the equation, some community colleges and universities have decided to cut adjunct faculty hours because they are concerned about the costs of their insurance.
"If you start treating those people as if they were disposable and dropping things in terms of the benefits that they had before, I think there is going to be some backlash against that and it's going to be a decision that will hurt the corporate culture and will make it so that they will not be able to attract the employees that they wanted to attract before," said Shana Alex Lavarreda, director of health insurance studies and research scientist for the UCLA Center for Health Policy Research who teaches a class through UCLA Extension.
At the K-12 level, school districts are tracking the time their substitute teachers work and cutting hours as well.
In Jefferson County School System in Alabama, the school district moved from a paper-based timesheet to a digital one with software from Kronos over the last year. The district wanted to know how many hours substitute teachers worked each week so it could keep them under 30 hours and avoid up to $9 million in penalties under the law, said Sheila Jones, chief financial officer of the system.
Many schools in the district use the same substitute teachers, and they often have one substitute take over if someone is on an extended leave of absence.
"Unfortunately, the Affordable Care Act will have a direct impact on the classroom in that it limits our options as far as getting replacement teachers for teachers who either are maybe on a long-term leave or may just be out a day or two during a week," Jones said.
In Alabama, the state government provides health insurance and previously decided not to provide benefits to substitute teachers. But with the new law, the school district wants to make sure that it will not be penalized for the state government's position.
"We have these federal mandates put on us, but we have no way of increasing revenue to cover the cost of meeting those mandates because our revenue comes from taxes that are already legislatively determined," Jones said.
However, no education institution or business will avoid penalties by cutting employee hours to under 30, Alex Lavarreda said. The law does not draw a magic line at 30 hours or any other time period. Instead, it triggers fines if employers do not offer affordable coverage to full-time employee equivalents.
"It doesn't surprise me much that they are being this short-sighted because I really think that people are trying to game the system and feel like they found some kind of loophole," Alex Lavarreda said, "and they're just going to be very surprised when they find out that that loophole doesn't actually exist."