Tuesday, December 17, 2013

What Should Physicians Expect When the ACA goes live on January 1?

Starting on January 1, the ACA will begin to transform how millions of Americans get health insurance coverage, although most of us will find that the plans offered by our employers are largely 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 FPL.  (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 ACA'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 www.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 last month, 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. 

Today's question: what do you think will be the biggest "nuts and bolts" challenges for physicians and patients when the ACA's coverage expansions start to go live on January 1?


Robert J. Sobel, M.D. said...

I cant help but want to comment on point 3, the formulary issue. As you finish with this being an issue of social justice, after describing our system as very complicated and complex, I must laser in on the biggest hassle of the modern physician, the third-party obstacles to basic prescribing. Our job is easier when we comply with a stable generic prescribing routine, but this unduly disrupts the primacy of clinical considerations. It has engendered a huge bureaucracy and failed to rein in costs. I believe that the huge price discrepancies between the old and new fails the test of just resource utilization and should be fixed.

We reward the new exuberantly, as the patent means no cost discussions (an empiric reality even if not dictated). The inevitable response has been the generic takeover, as facilitated by the pharmacy-benefit industry. This is real and current. It is not being addressed. You should support a fix for this that eliminates this unnecessary, duplicative regime.

The fall-out from Hatch-Waxman creates problems for all payers. Medicare Part D suffers. Even the for-profit insurance giants struggle. States employ various strategies in Medicaid, but I know of few who claim huge savings on drugs.

You are right. Greater patient out of pocket payment is a trend that predates Obamacare. A stable insurance environment with fair treatment of providers is hardly the status quo, so the current chaos is not particularly unique. With the for-profit basis of much of health care left untouched by reform, however, we have some irreconcilable issues if consolidation progresses further.

We are inundated with bureaucracies (HIPPA, ACO, PFP, PQRS) that are advocated as saviors from fee for service. This is a farce. I'm sorry to be so critical, but independent physicians can only absorb so much. Your support of these bureaucracies represents a deaf ear to the real costs of all these distractions, especially punitive on the independent private physician. With current trends, that is understandable, but it cannot be denied.

Only an urgent reform of basic insurance company structure and an equalization of brand-generic prices (or essentially, the harmonization by a single set of rules) will have any impact on costs without the badgering of modern physicians into a quality nexus. When some common drugs have annual costs equal to many years of my service, it is clear we can construct a more fair system.

I am hopeful some stability will follow the initial chaos. I attempt to ignore the conspiracy theorists who believe this is a designed implosion that will lead to national health care. My main argument against single payer reflects the strong focus of our forefathers: a desire to avoid unchecked power. A single payer can't help but become sclerotic and oppressive.

A series of state-based, private, non-publically traded insurance companies that cover the bulk of the population, even moving into the Medicare market, would be the most straightforward way to regulate our growth. Hospital infrastructure can be carefully assessed, as billions of dollars are provided to the academic centers annually, and for-profit entities can probably be reined in. Outpatient physicians could become more cost effective, as resources wasted on administrative hassles and over-priced aspects of care could be channeled to paying for the bread and butter. Expanding the existing system without this basic restructuring may accelerate our excesses, not resolve them.

ryanjo said...

My daughter, who lives in London and experiences the glories of the National Health Service, found out the limits of physician autonomy in such a system. Her family physician informed her that she would have to try what is basically an extract of cranberry for her UTI, before he could prescribe an antibiotic. When she called me reporting flank pain and fever, I was able to implore a British colleague who I had met at a meeting to provide her some ciprofloxacin (which resolved her symptoms by the second tablet).

Undoubtedly Don Berwick et al will protest that there is no such imperative for UK physicians, but my daughter's doctor implied practitioner monitoring of antibiotic use was a quality indicator of the NHS. Dr. Sobel's says it well: "sclerotic & oppressive".

Is there really any difference between this insensitivity to patient needs and the harassment of US doctors by Pharmacy Benefit Managers mentioned by Dr. Sobel above? A healthcare system guided by 3rd party sanctions against doctors who ask for best care for patients is not patient centered or ethical.

And what is ACP doing? Oh, I think there's a policy statement or white paper on the website somewhere. But don't forget that we now have medical care for all! Token or not.

Unknown said...

At what point does the personal political beliefs of the leadership of ACP, color the objective assessment of how 'well' the Affordable Care Act is actually working? I have not seen any ACA review or progress articles, in any publication of the American College of Physicians to date, that doesn't spin the roll out of the ACA in the best light possible. This leaves some of your membership wondering if now we are just being fed 'talking points' . I have families that have lost their insurance, and rate climbs disproportionate from what we would have expected. Why ACP is so silent is the most disturbing of all.

BDoherty said...

Dr. Silverman, ACP's views on the ACA are not based on the personal political beliefs of ACP's current leaders (which vary greatly, by the way) but on policies adopted by the Board of Regents, with input from committees, councils and board of governors, over many decades. The law is imperfect but it is very consistent with ACP's long-standing policies. In this blog, I have strived to accurately present what is working well with the ACA, as well as elements that are not going so well--as you can see from this current post, which identifies concerns that I raised directly with White House officials. I have commented in this blog that some persons, about 5% of the population, have received cancellation notices, but most of them(71 percent) are eligible for premium subsidies to buy a new plan that must cover 10 categories of essential benefits, no pre-existing condition exclusions, no cost preventive services, and no lifetime or annual limits on coverage--benefits that are better than most plans now available on the individual insurance market. As far as premiums are concerned, the typical premiums offered through the ACA exchanges vary greatly by state, but when premium subsidies,most are affordable to the vast majority of persons. There are some people, though--mainly those who earn more than 400% of the FPL (about $94,000 for a family of four)--who will pay more because they earn too much to qualify for the ACA premium subsidies. As far as employer-based premiums are concerned (large employers), this year's increase has been very modest, with no evidence that the ACA has caused a premium spike. Overall health care spending increases for the past three years have been at 50 year lows. These aren't talking points--but well documented facts. It is unfortunate that some people, including some of your patients, may have to pay more (and I can understand why they would be upset) but it is a relatively small percent of the population. At least 14 percent of the population, the currently uninsured,will have access to affordable coverage, an historic step forward toward ACP's decades'long advocacy for universal coverage. The 80% of us who get insurance from large employers are mostly unaffected by the changes.