What does the ACA mean for doctors?

“To sum it up…”

• There are now more covered services
• More patients have coverage than before the Affordable Care Act was put into effect
• Many doctors are not excited by exchange plans to the point of refusing to join them. They already have more than enough patients are not interested in taking on any more
• Higher out-of-pocket costs under ACA for patients means that many specialists have more difficulty collecting the fees due to them
• Primary care physicians have become more prestigious and appealing to physicians
• Doctors are more likely to work for large entities under ACA, as opposed to going into private practice
• New payment methods are replacing fee for service schemes
• Increased penalties under ACA is effectively reducing reimbursements to physicians

These are just some of the many ways that the Affordable Care Act has had a direct and almost immediate impact on doctors. Let us explore some of these more in depth below.

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More Services are Now Covered Under ACA

Under new insurance guidelines, more services are now covered under the Affordable Care Act. This means that doctors can experience a higher than normal patient flow because individuals are more likely to seek out care that they might not otherwise have gone to the doctor for.

Doctors have largely been in support of this provision of the ACA because it leads to better overall health and well-being early on via maintenance and wellness programs, leading to fewer complications down the road.

As of 2014, the ACA requires that insurers cover a total of 63 different services. Each of these services must be administered with no out-of-pocket of pocket cost to the patient. This includes the following services:

• Blood pressure checks
• Mammography Screenings
• Many types of immunizations
• Behavioral screenings for children
• Autism screenings for children
• Access to contraception

The good news for doctors is that they can expect to be reimbursed for any of the above-mentioned services without having to ever collect one dime for their patients. It is also important to note that, beginning in 2014, all individual and small group health insurance plans are mandated to provide coverage for certain essential health benefits.

Insurers are not obligated to pay doctors for the following services when they are provided:

• Maternity care
• Mental health related services
• Medications
• Rehabilitation services
• Management for chronic diseases

Finally, insurers are no longer able to deny coverage to patients on the basis of a pre-existing condition, meaning that doctors are seeing more patients than they normally otherwise would. This is because more people with insurance are now able to get the treatment they otherwise would not have been able to afford on an out of pocket basis.

Coverage is now Extended to More Patients

Because of enhanced options for purchased health insurance under the AA, more individuals than ever before now have insurance coverage. This means that doctors have seen a surge in inquiries from potential new patients, many of whom are lower income and potentially on Medicare.

The fees provided to the doctors for treating these patients varies depending on the services provided, but family practitioners appear to be the primary beneficiary of this.

The ACA has been particularly helpful to doctors with a young practice or in an area where they have traditionally struggle to attract new patients.

It is important to note that the health insurance exchange program is designed to provide coverage to the masses by keeping the premium down by offering subsidies to low-income individuals.

As such, the fees provided to physicians are often less than they would have been under the old system and from the patients that would traditionally pay out of pocket or are on private insurance. Because of this, many high priced clinics and hospitals have been excluded from this scheme.

Higher Out-of-Pocket Costs

Many patients today are facing with health insurance policies that contain high deductibles. For doctors, this has meant having to restructure payment policies in order to make sure that they are paid for the valuable services that they provide. In fact, it is estimated that the number of individuals having a deductible prior to the ACA was 52 percent, but that has since risen to more than 72 percent of policy holders. This amounts an average annual deductible of just under $1,100, or an 88 percent increase over the course of the last decade.

Many of the plans sold on the health insurance exchange today contain higher than normal out-of-pocket payments when compared to policies issued prior to the ACA.

This has a big impact on specialists who offer expensive services. An example would be an orthopedic surgeon.

Primary care physicians are also impacted because service fees can add up over time as well. In order to make sure that out of pocket expenses are collected, doctors have had to resort to charging for their services prior to treatment actually being rendered. This has altered the payment mechanisms that many doctors have had in place for years.

Primary Care Doctors Benefit from ACA

In the years following the passing of the ACA, it appears that primary care physicians have become the biggest beneficiaries. This is due to the perception that may of the key provisions in the new healthcare reforms tend to favor primary care services. This is seen in the form of enhanced reimbursements that take place under Medicare and Medicaid.

Primary care physicians have also benefited from new models of health care that include the patient-centered medical home and various preventative and wellness-based services that are now covered under the essential health benefits provision of the ACA.

Here is a summary of just some of the many ways that primary care physicians are benefitting under the Affordable Care Act:

• The Medicare program now pays primary care physicians a bonus of 10 percent for services that they perform for recipients
• The Medicaid reimbursements that primary care physicians receive for certain evaluation and immunization-related services have been raised.
• There were some initial problems in getting these payment mechanisms started, but the reimbursements are finally starting to come through.

Because of these programs initiated under ACA, new doctors are increasingly joining the ranks of primary care physicians willing to work with patients on Medicare.

Doctors are Flocking to Larger Facilities

Private practices are now being bought up by larger hospitals and clinics after the onset of the ACA. This appears to be a drawback that many doctors are not happy with, but the reality is that solo practices need to be aligned with a much bigger entity in order to be financially fixable under the new healthcare landscape.

This is not working to the advantage of either party because physicians are having to work for less money as paid employees of clinics and hospitals. As a result of the lower pay, however, doctors must have a light workload to comply with labor regulations. This is leaving hospitals to struggle to match the decrease in productivity.

In Conclusion…

There is no doubt that the ACA has impacted doctors in many ways, some positive and some negative. Here are a few points to remember as we conclude this section:

• As the ACA continues to evolve, it is obvious that penalties will continue to increase, and this is reducing reimbursements that come to physicians
• Under the ACA, doctors must meet a certain e-prescribing level. Those who do not face a penalty.
• Patients have more options today, meaning that new physicians have a more difficult time building their practice. At the same time, there are increasing numbers of insured today and that is opening up more options by the year.

As recent healthcare reforms continue to take shape, they will inevitably continue to impact doctors in various ways. The hope is that patients will ultimately benefit over time and that doctors will continue to feel free to practice in the best way they know how.

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1. http://www.nejmcareercenter.org/minisites/rpt/8-ways-that-the-aca-is-affecting-doctors-incomes/
2. https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/index.html
3. http://kff.org/health-costs/issue-brief/snapshots-the-prevalence-and-cost-of-deductibles-in-employer-sponsored-insurance/
4. https://www.ama-assn.org/resources/doc/washington/physician-compare-redesign-17july2013.pdf
5. http://ir.antheminc.com/phoenix.zhtml?c=130104&p=irol-irhome