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What will insurance exchanges, Medicaid expansion mean to your primary care practice?


The impact of the health exchanges and Medicaid expansion will depend on geography, but every practice will be affected to some extent.


The saying, “all politics is local” also applies to the impact of the new healthcare insurance exchanges and expanded Medicaid eligibility that are part of the Affordable Care Act (ACA). Depending on where you are and the choices your practice makes, the effects of these developments will range from negligible to profound, although most providers will be affected at least indirectly.

The exchanges and Medicaid expansion are intended to provide healthcare insurance to a large portion of the approximately 50 million Americans who currently lack it. The exchanges, which started in October, let customers shop for and compare health insurance plans in four broad price ranges. The ACA also includes subsidies, in the form of tax credits, to help make the plans more affordable. Insurance companies are not required to participate in the exchanges, and practices are not required to accept patients who obtain insurance under the exchanges.

The ACA originally broadened Medicaid eligibility nationwide to people with income up to 138% of the federal poverty level-about $32,500 for a family of four.  The U.S. Supreme Court later ruled, however, that states could decide for themselves whether to expand Medicaid eligibility. As of early December, 26 states and the District of Columbia had chosen to do so, according to the Kaiser Family Foundation.

Given all the uncertainties surrounding the ACA, including the startup problems of, the federal health exchange website, it’s not surprising that medical practices are approaching the exchanges very cautiously. Fewer than half of the 1,000 practices responding to an October survey by the Medical Group Management Association said they were not planning any business changes as a result of the ACA, and fewer than 5% anticipated adding new providers or extending business hours.

What does it mean for you?

So what will Medicaid expansion and the insurance exchanges mean for your practice? If you are in one of the 20 states that have not expanded Medicaid-or if your state has expanded Medicaid eligibility but your practice does not accept Medicaid patients-obviously that part of the legislation will not affect you. The same holds true for practices that choose not to contract with exchange plans or accept patients who enroll through the exchanges, or who already have a large percentage of patients covered by Medicare, Medicaid, or some other public payer.

On the other hand, if you are in a state that has expanded Medicaid eligibility, and/or your practice will accept patients from the insurance exchanges, then you could be in for some significant changes-starting with the makeup of your patient population. Almost by definition, many of these new patients will not have had access to regular healthcare previously. Consequently, they are more likely to have chronic conditions, such as diabetes, hypertension, and hyperlipidemia, for which they have received little or no treatment. (EDs).

“I see patients who come in all the time with no insurance, and they’re pretty sick. And of course we spend a lot of money on their care because they’re in the critical care phase of their disease, whereas if they’d had some prior care we may have been able to decrease the level of care they have to get now,” says Robert Hunter, DO, FACOFP, an emergency department and family physician in Dayton, Ohio.

Adds Thomas Zimmerman, DO, a family physician in Oceanside, New York: “I was hopeful about the ACA and the whole idea of getting more people on insurance, people who would otherwise go untreated or, just as bad, clog up the EDs with non-acute issues. As things stand now, you have people there from both ends of the spectrum, either with bellyaches or full-blown myocardial infarctions because their hypertension has gone untreated for so long.”

Compliance challenges

In addition, because they have not been accustomed to regular care, many of the new patients are likely to present compliance challenges. “The combination means you’re putting a lot of work into patients who will probably have a poor follow-through,” says Hunter. “I believe that’s why you have primary care doctors and specialists who don’t want to treat this population, because they’re very labor-intensive and that causes providers to become frustrated.”

Rather than refusing to treat these new patients, however, Hunter advocates taking the time to explain to patients the reasons for a course of treatment and why it’s important for the patient to stick to it. “I think the best thing we can do as primary care doctors is to engage patients in their care, talk to them about hemoglobin A1C and why it’s important to bring that number down and how they can’t get better if we don’t see them,” he says.

“The most important thing for most of us is taking care of our patients,” adds Reid Blackwelder, MD, FAAFP, president of the American Academy of Family Physicians. “And the challenge of caring for more of them (as a result of the ACA) will require us as physicians to make sure we do good education, because one of the most important aspects of adherence to treatment plans is making sure you’re clear about what you’re doing, and why, so you can explain it to the patient.”

Preparing for more patients

The multi-specialty group to which Hunter belongs is gearing up for an influx of new patients by looking at ways of maximizing its existing space. “The group is asking, ‘how can we make every office, and every room in every office, more profitable?” he says. “Whereas before the attitude was ‘see your patients and don’t worry if some rooms are empty’ now it’s ‘could we put a lab station in a room that’s not being used? Could we have a surgeon use it a few days a week?’ We’re trying to make use of every inch.” The group has also hired additional nurse practitioners to handle the anticipated patient volume.

Of course, even practices not directly affected by the insurance exchanges or Medicaid expansion may feel some indirect impact Probably the most common are patients whose insurance policies are not being renewed because they don’t meet the ACA’s minimum standards of coverage, or insurance companies dropping  physicians from their panels. Insurance giant United Healthcare, for example, announced in November that it planned to cut physicians from its Medicare Advantage plans in 11 states, including 2,200 in Connecticut alone.

In addition, many of the policies on the exchanges are likely to include fairly narrow networks of providers, leading to “churn” in the marketplace. (See “Top 10 issues facing physicians in 2014,” page 20.)

For all the challenges new patients may pose, Blackwelder sees them as an opportunity as well. He notes that the average family practitioner now treats nine uninsured patients each week, most of whom are receiving free or greatly discounted care. If even a portion of those patients were to obtain insurance coverage, it would represent a boost to the practice’s income.

Blackwelder says a simple step practices can take to accommodate the changes brought on by the ACA is to start asking patients if they’ve changed their insurance status when they call for appointments. “The more you can identify if there are any insurance-related issues, if they might have to dot some i’s or cross some t’s before they come in, the better off they will be,” he says.

In addition, practices need to find ways to use the physician’s time more efficiently. One way to do that is to add a patient portal, so that patients can take care of needs that formerly required a face-to-face visit, such as obtaining lab results or getting prescriptions refilled.

Along the same lines, using a team-based approach to patient care allows non-physician providers to take on some of the tasks traditionally provided by physicians, such as patient education or coordinating care with family members or other providers. “A big part of the challenge of taking care of more patients is seeing what you can do in your own practice to create that team-based care,” he says. 

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Jennifer N. Lee, MD, FAAFP
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© National Institute for Occupational Safety and Health