Obamacare's most vexing questions for physicians

September 10, 2013

As October 1 marks the start of open enrollment under the Affordable Care Act (ACA), primary care physicians will need to prepare for the possibility of increasing call volume, patient questions, and greater administrative complexities.

As October 1 marks the start of open enrollment under the Affordable Care Act (ACA), primary care physicians will need to prepare for the possibility of increasing call volume, patient questions, and greater administrative complexities.

Just as the public struggles to understand the new health insurance marketplaces that are a central feature of the law, so too do physicians.

A recent survey conducted by Deloitte Center for Health Solutions found that most primary care physicians are either pessimistic about the law or don’t know enough to make a determination. Nearly 32% believe it is a step in the wrong direction. And more than half of the physician respondents don’t believe the insurance exchanges will even be ready. The physician-staffing firm LocumTenens.com found that 57% say they are not at all familiar with the impact health plans purchased through the marketplaces will have on their business. About 35% of physicians say they don’t plan to make any changes to their practices in response to the law.

But taking the time to understand the health plans newly available to consumers and how patients can tap into benefits under the law is well worth physicians’ time, experts say. Among other reasons, it has much to offer those practicing primary care.

“For doctors like myself, internists who practice primary care, there have been a lot of benefits to the plan,” says David Cutler, MD, chair of the Board of Regents of the American College of Physicians. “Screening, for instance, is much more prominent, much more accepted now, not only by Medicare, but by the commercial payers. So it’s much easier for me now to screen patients, and to provide vaccinations, which historically were never covered, or weakly covered,” Cutler says.


And then there’s the potential to gain income on previously uncompensated care. Reid Blackwelder, MD, president-elect of the American Academy of Family Physicians  (AAFP), says that among the nearly 110,000 AAFP members, on average, physicians provide eight visits a week for people without insurance. “So ideally, that number should drop pretty dramatically. I may have patients who are getting care that haven’t before. I’m going to see patients now that have insurance coverage, which means it should help my payment structure.”

Public’s knowledge of the law is weak

The LocumTenens.com survey also found that 90% of doctors believe that the public has not been adequately educated about how marketplace health plans will function under the ACA.  And no doubt, Americans are still very much in the dark. According to a Kaiser Family Foundation poll taken earlier this summer, fewer than one in four Americans knew that the marketplaces existed; nearly one in five were unaware that the ACA was even the law of the land.

In addition, Kaiser found that 43% of those surveyed had an unfavorable view of the law, compared with just 35% who viewed the law in a positive light. This is despite the fact that many consumers have much to gain from many provisions of the ACA. For example, nearly half of those under the age of 65 surveyed believe that they or someone they live with has what would be considered a pre-existing condition, and one in four have either been denied insurance or had their premium increased as a result of an illness-two practices the law prohibits starting in 2014.

Often, however, details of what’s actually contained in the law have been lost in the political battle. “Peopleget ideas in their head that are influenced bysomething other than logic or reason, and I think it’s the nature of 24/7 news, and a lot of people who legitimately don’t like the Affordable Care Act,” Cutler says.

Once they understand what’s actually in the law and how they and their families can benefit, he says, perceptions often change.

“My patients very much appreciate, and have for several years now, the fact that their children can be on their plan up to the age of 26. They can’t be dropped because (their care) costs too much. Pre-existing conditions are starting to go away as a reason to be turned down for insurance,” Cutler says.

Estimates are that anywhere from 7 million to 8.5 million Americans will access the marketplaces in 2014 to obtain a health plan. Most people will have very little or no experience with insurance and will need guidance, experts say, and many will turnto doctors for information. A recent nationwide survey conducted byHealthpocket.com, a nonpartisan Web site that compares and ranks health plans, found that 14% of respondents who intended to seek advice on health plans preferred to get it from their doctor or pharmacist.

Family practitioners and internists are, therefore, in a unique position to educate patients about the law. What’s more, Blackwelder says, they have a responsibility to do so.

According to Blackwelder, when a physician sees a sick patient not currently covered by insurance it is his or her role-or that of someone on the team-to direct the patient toward state resources. “I think we must do that. And we have to be ableto do that regardless of our personal opinion, because it is law, and it is designed to increase the healthcare coverage of Americans,” he says. “How people move forward after October 1 really depends a lot on making sure they understand their responsibilities,” he says.

 Still, physicians often report being overwhelmed by the growing demands of running a practice. Taking the time to understand the health reform law and helppatients navigate the new marketplaces and select the right health plan is for many another burdensome task they simply don’t have time for. But there are fairly simple systems that medical practices can put in place to reduce the burden, say both Cutler and Blackwelder.

Use a team-based approach

Implementing a team-based approach to patient care can go a long way toward reducing the burden primary care doctors are likely to continue facing because of new pressures brought on by the law.

“It would help to have someone in your practice specifically for this role,” Blackwelder says. “It would really make sense to have somebody who…knows the resources. When a patient came in, if someone was identified as a new enrollee or potentially someone who could benefit from the exchange, then there would be an opportunity for someone in the front office to have that conversation.”


Starting a dialogue with patients, rather than jumping in with facts about the ACA, can make it easier to provide useful information. “You can’t just give facts toovercome fear,” Blackwelder says. He suggests asking open-ended questions, directly identifying patients’ emotional state and giving them a chance to express their position before explaining details of the law and how it might affect them.

Don’t re-create the wheel. So much of this, in general, is “how you work smarter and not harder,” Blackwelder says. There are a host of resources available to explain details of ACA provisions for both physicians and consumers.

The government-created health reform Web site Healthcare.gov explains the law and provides tools and information about each of the state marketplaces including Web sites and phone numbers. (See “ACA Resources” on page 18.)

FamilyDoctor.org offers a page addressing common consumer questions about the ACA.

The American College of Physicians offers “An Internist’s Practical Guide to Understanding Health System Reform” on its Web site (acponline.org), as well as a physician and practice timeline that outlines which provisions of the law are taking effect and when.

Creating a printed handout with state-based resources where consumers can go for personalized assistance to learn about their health insurance options provides an important service for patients that may ultimately serve the interests of a medical practice.

Important contracting considerations

Physicians also have numerous administrative issues to deal with under the law. One of the more immediate concerns is whether or not to participate in the networks of the new health plans being sold through the state-based marketplaces. And despite the late date, many of the networks have yet to be solidified.

“There is a lot of variability across the states in terms of where practices are with their contracting with payers and making decisions about how to or whether or not to participate with these exchange products,” says Allison Brennan, senior advocacy advisor with the Medical Group Management Association.

Among the questions she hears from physicians many concern payment rates, the size of the patient population insurers expect to serve, and which insurers are offering products through the marketplace.

In many markets around the country, newer payers with whom many physicians may not have experience have entered the market. “One of the things that we’ve been hearing is just the uncertainty and the variation across states in terms of where practices and payers are in that contract negotiating process,” Brennan says.

As practices consider the contracts before them, Brennan advises watching for several items when deciding whether to participate in marketplace plans:

1. Look at payer mix. “We recommend our members evaluate their practice’s payer mix and determine how much capacity they would have to accept new patients,” Brennan says.

2. Reach out to payers you want to work with. “If the payers have already been identified in your exchange, and you want to participate, you can reach out to them and try to initiate that discussion and start to have those contract negotiations,” Brennan says.

Watch for communication from insurers. According to Brennan, some insurers are requiring practices with whom they have already contracted to actively opt out of contracting for the exchange plans if they wish not to participate.

“So, rather than the plan calling them up and saying, ‘hey, do you want to contract for this exchange product,’ what they’re doing is sending them a letter that says unless you respond to this within seven days, we’ll assume that you’ll be participating in this new plan,” he says

3. Pay close attention to contract details. One major concern for physician practices is contract language that allows for a 90-day grace period for a patient who has an exchange plan and stops paying his or her premium. During the first 30 days of that period, the insurer is required to continue to pay claims. But in the last 60 days, payment can be withheld. If the patient fails to pay all of his or her premiums, they’ll lose the coverage at the end of the 90 days, and physicians will be required to collect any withheld payments directly from the patient.

“That puts an unfair burden on providers, especially if they don’t know that a patient is in this grace period,” Brennan says. “So we would like to see Congress or [the Center for Medicare and Medicid Services] change this grace period provision to protect providers, and at the very least, they should make some specific changes requiring insurers to provide up-to-date information when a patient enters the grace period,” Brennan says.

As a matter of protection, she says, practices need to conduct eligibility verification requests for every visit. And, it’s worth requesting that some of that liability shift back to the insurer or requiring contract language that says the insurer will notify the practice when the patient has entered the grace period.

4. Evaluate and revamp payment and collections policies and procedures. This is especially important if your practice treats many patients with high-deductible health plans, which will be common among those purchasing coverage through the exchanges.

An alarming study from Jackson Hewitt concludes that more than one in four uninsured Americans (approximately 8.5 million people) eligible for the new ACA premium assistance tax credits do not have a checking account, the vehicle through which insurance companies plan to require customers to pay healthcare premiums.

5. Know your state. While the health reform law seeks to create uniformity in health plan offerings, there are still wide variations among the states. Brennan suggests doctors stay abreast of what’s happening in their area. “They have to make sure they’re really tracking how this is evolving in their state, and in their local market,” she says.

A new world awaits

The true impact of the ACA and whether the marketplaces will operate as promised, whether enough consumers will buy insurance policies, and how heavily affected primary care practices will be all remain to be seen.

Will we end up with a healthcare system that works better for consumers and physicians alike in the long run? “I’m an optimist,” Blackwelder says. “I’m not going to say I’m sure it will work. Then again, the flip side of that is, it would be hard pressed to do worse than some of the systems we’ve already suffered through.”