What can physicians expect from Obamacare in 2014?

Tthe ACA will now begin to transform how millions of Americans get health insurance coverage.  Most of us will find that the plans offered by our employers are mostly unchanged because they measure up to federal standards.  To the extent that some employers are imposing “negative changes, which include higher premiums, co-pays and deductibles, they’ve all been happening for more than a decade” because of employers wanting to curtail their health benefit costs. “Nor are there any signs that the Affordable Care Act has accelerated the trend.”

Yet Obamacare will continue to be blamed for any changes in healthcare that the public dislikes.  Critics of the law will continue to stoke groundless fears in their relentless efforts to oppose and undermine it.  It will be important for supporters of the ACA to provide accurate information on what the law does including the better consumer protections it offers most of us that have insurance, like no lifetime limits on coverage, and access to affordable coverage for millions of uninsured persons — while acknowledging that not everything will be hunky-dory on January 1.

There will be problems and unintended consequences, especially in the early start up months.  Physicians especially, need to be prepared for concerns and problems that will occur in the new year as patients show up with insurance that differs from what they had before, if they even had insurance before the ACA.  Especially for the heretofore uninsured, learning what health insurance does, and doesn’t do, for them will be a steep learning curve.

Here are five things physicians need to be prepared for that can or will happen on or after January 1:

1. There will be more Medicaid patients, a lot of them, many of them won’t have a personal physician so will be looking for a physician who will agree to see them. They will be very low income people who were uninsured before, so this is good news overall, but it remains to be seen how many physicians will be available and willing to accept larger numbers of Medicaid patients.  How many there are will also be highly variable, depending on whether the physician and patients are in a state that is going along with the Medicaid expansion.  This is one reason that ACP is asking Congress to extend the Medicaid primary care pay parity program, set to expire at the end of 2014, for at least two more years. This program, created by the ACA, pays primary care physicians and some medical specialists no less than the Medicare rates for designated services provided to Medicaid enrollees.

2.  Patients who select silver and bronze plans will have substantial cost-sharing requirements (60-69% of the value of the covered benefits for bronze, 70-79% for silver).  For previously uninsured people, even a plan with high deductible/co-pays is better than having no coverage at all, and for their physicians, it is better than the care they provide to these patients being entirely uncompensated.

Also, the high deductibles are mitigated to some degree by first-dollar (no cost to the patient) coverage for USPSTF preventive and screening tests and procedures. Total out of pocket expenses are capped at approximately $12,600 for a family, and $6,300 for an individual, with reduced cost sharing for those with incomes up to 250% of the federal poverty line.  (And of course the uninsured who are now able to get Medicaid generally will pay little or nothing out of pocket).  Also, most of the people buying coverage through the exchanges will get tax credit subsidies that limit the amount they must pay for premiums, pegged at a silver plan level.

Still, for some patients, especially those who are new to health insurance or who had lower deductibles under their “cancelled” individual insurance plans, the high cost sharing could be problematic, and they may not realize that they have to pay their physician out of pocket until the deductibles or total out of pocket limits are reached.

3.  The prescriptions their physician has ordered for them may not be on the formulary exchange plan they chose.  This is particularly a concern for patients who must receive treatment for an ongoing chronic condition, like HIV, or an acute condition like a cancer patient getting chemotherapy.  Health plans offered through the exchanges should be transparent in what is included in the formularies and the criteria they use for making such determinations, and have an exceptions or appeals process for patients whose drugs are not covered, similar to what exists under Medicare Part D.

The administration’s request to insurers that they continue to cover such drugs for patients with acute conditions may help, but a regulatory fix may be needed.  At the same time, it is not realistic to demand that all prescriptions be covered if the evidence does not support their effectiveness compared to other available prescriptions. And since many insurance plans in the traditional individual insurance market did not include any medication coverage, patients overall will benefit from the ACAS’s requirement that all plans cover medically appropriate drugs in all categories.

4.  Physicians or their hospitals may not be in the network of the exchange plan the patient chooses.  We don’t know how often this will be the case, and narrow networks are becoming increasingly common under Medicare Advantage and private insurance unrelated to the ACA.  There should be an exception process to treat a physician as an in-network provider for patients who are undergoing treatment for an acute condition, especially if the physician is willing to accept the network payment rates.  There needs to be transparency in how insurers make these decisions.  The federal government and states should ensure that the ACA’s network adequacy standards are being met, not just the letter of the law but in spirit.  Physicians should be able to challenge being “de-selected.” And patients should have real time and accurate info on participating network providers when they choose a plan through the exchange.

5. Some patients may think they successfully signed up for insurance but their insurance company doesn’t know it.  This could be the case if the patient didn’t pay the premium by December 31, the new deadline set by the administration.  Or it could be the case if the federal government’s troubled Healthcare.gov didn’t provide accurate enrollment information to the insurance company, a problem the federal government insists is mostly solved but the insurance industry says continues to a problem.  In this case, physicians may not know for several weeks if their patient had insurance, and who to bill for services provided during the interim.

I brought many of these issues up at a White House meeting that ACP’s CEO Dr. Steve Weinberger and I attended recently, and we will continue to seek answers and solutions. The administration subsequently took steps to work with the insurance industry to mitigate some of these and other issues.  But more will likely need to be done as we learn what issues arise on or after January 1.

The fact that not everything will go exactly as was intended by the ACA when most of its biggest changes start to go live at the start of the new year should surprise no one.  Health care is complicated, our health insurance system is even more complicated, people — even the usually well-informed — don’t understand it, and the ACA is trying to put in place complicated changes in coverage to close gaps in this very complicated and complex system, even as many are doing everything they can to make it fail.

But the policies it is trying to implement are necessary and appropriate as a matter of social justice: no one in America should have to go without health insurance because of their age, their health status, their gender, where they live, where they work, and how much they make.  In a less polarized political environment, the mantra as problems arise with ACA implementation would be fix it, not nix it.  Until we get to that point, we’ll have to muddle through, documenting problems as they come up and seeking the most feasible solution available given the political constraints.

Bob Doherty is senior vice-president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog.

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