Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Reimbursement News

Is the ACA Working as Intended to Improve Healthcare Access?

By Jacqueline DiChiara

- Is the Affordable Care Act (ACA) living up to its full potential or is it more a matter of all healthcare hands on deck? In past interviews with, healthcare experts and leaders from both athenahealth and the Robert Wood Johnson Foundation (RWJF) have addressed a variety of healthcare IT news topics, including an earlier report from athenahealth/RWJF that executed trifold monitoring of the ACA's specific influence, complexity, and its impact on care delivery.

affordable care act physician reimbursement

This week, Josh Gray, Vice President of Research at athenahealth, chatted with to offer deeper insight regarding a joint research initiative from athenahealth and RWJF about “modest” increases in provider reimbursement, and out-of-pocket costs across the healthcare system related to the ACA.

According to both the joint research initiative’s reported findings and my discussion with Gray, physician reimbursement from commercial insurance carriers increased between 2013 and 2014 by 2 percent on average for established patients; the reported increase for new patients was 1.4 percent.

The proportion of health care costs paid directly by patients slightly increased by 3.5 percent for established patients (roughly $1 per physician visit) and 2.7 percent for new patients (roughly $1.20 per visit),” as reported by ACAView in July by Health Affairs. “Primary care physicians are seeing slightly increased payment levels from insurance carriers, relative to most specialists included in the study,” ACAView adds.

Gray mentions within the aforementioned press release that understanding the financial impact of health reform is both “incredibly important” and “valuable” for healthcare providers, patients, and policymakers.

READ MORE: Physician Compensation for Specialists 45.6% More than for PCPs Can you pinpoint specific causes for the noted 2 percent and 1.4 percent increases in physician reimbursement? Is there particular significance to this moderate increase?

Josh Gray: That overall pattern played out differently for primary care physicians and specialists. We're seeing signs of a tilt towards primary care – reimbursement for primary care physicians increased 3.4 percent but actually decreased on a per visit basis for orthopedists, general surgeons, and other specialists.

I think that the tilt towards primary care is part of a broader cost control strategy on the part of payers.  Moving forward, it is likely that the insurance industry will continue to try to be comparatively generous towards primary care, and tougher on specialists. What role do high deductibles play in all of this, especially in terms of increased patient spending?

JG: More and more families are choosing high deductible health insurance plans. The ACA really hasn't changed the trend towards patients paying a greater share of the total share of care out of their pockets.

READ MORE: Is Radiation Overuse Contributing to Higher Healthcare Costs?

Patient obligations for primary care visits increased at a rate of 3.5 percent for established patients. Almost all of that growth was due to increases in patient deductibles, which increased by 9.5 percent during 2014, a huge change for one year.

I am concerned with how this trend will play out, especially for working class people with chronic diseases. We haven't seen a reversal or even a slow-down in the rate of increase in patients' out-of-pocket obligations as more patients are insured.

There's a real risk the patients that really need the care – those with lower incomes, those with chronic disease – will not see the doctor when they are suffering and vulnerable. You could have patients with diabetes skipping visits and not having their blood sugar controlled end up in the emergency department, which is terrible for the patient, but also ends up costing a great deal. Is there anything that stands out to you in particular regarding the findings?

JG: The ACA was really supposed to improve outcomes by dramatically improving access to healthcare. There's no question that the uninsurance rate has gone down and that previously uninsured people are getting care. It's a more dignified process than it has been in the past. So in that sense the ACA is working as intended.

READ MORE: Boost Healthcare Competition to Drive Down Prices, Up Quality

The rise in patient obligations is still a big challenge, however. We don’t have a precise idea about how to optimize out-of-pocket obligations. Ideally patients would pay more out-of-pocket for services where the evidence of benefit is weak and paying less or nothing at all for services that are helpful. The ACA has some unfinished work to do in terms of more carefully designing benefits structures so patients will not face financial pressures to skip beneficial care. 

It’s ironic that high-income, healthy individuals can receive care that might not have a proven benefit, but a person with lower income with serious diseases can only afford a high deductible plan and therefore have to pay more out of pocket when they receive care. Therefore, they have to make some dreadful decisions about when to skip care that they can't comfortably afford. That raises issues of fairness and is fiscally prudent in the long-term. Where is the financial realm of healthcare reform headed next? Where should healthcare providers be focused?

JG: One of the most important trends in healthcare is the movement towards provider groups assuming more responsibility for the cost and quality of care for attributed populations, through risk-based mechanisms, such as shared savings contracts or bundled payments.

These approaches transfer risk from the insurer or employer to physicians. That's where we're headed, and it’s happening fast. Over time it will be increasingly challenging for many physicians to prosper under fee-for-service. The most successful provider organizations will show they can achieve excellent clinical outcomes at a competitive cost.


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