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New health reforms impact doctors as well as patients


Many of the reforms in the Affordable Care Act affect not only patients, but doctors as well. Insurance industry reforms make it illegal for insurance companies to deny coverage to individuals based on pre-existing conditions, place a dollar limit on the amount of coverage a patient can receive and cancel a patient’s coverage because of an expensive health condition.

These reforms impact private practices differently than physicians in large medical groups.

Prior to passage of the Affordable Care Act, whenever insurance companies canceled a patient’s coverage, doctors would not get paid for their services, says Dr. Paul Phinney, president-elect of the California Medical Association and a primary-care physician with Kaiser Permanente. He explains that these insurance industry reforms have a stronger impact on solo practitioners because such practitioners do not have the financial cushion or support in numbers from a large medical group or company.

Unlike private practices, Kaiser has a three-part system of health insurance, hospitals, and medical groups. Because Kaiser’s patients are on the Kaiser Foundation Health Plan, which offers prepaid health plans and insurance, their doctors do not worry about not getting paid for services rendered.

On the other hand, private practices, which often accept many types of insurance, do not have such benefits and security. If a patient’s insurance company chooses to drop or cancel coverage prior to their treatment, the doctor does not get paid for services given. Dr. Theodore Mazer, an otolaryngologist and officer of the California Medical Association, explains that often doctors will render a service, such as surgery, unaware that their patient’s coverage was dropped because they were not notified in time. When this happens, they are not paid for their services.

The Affordable Care Act also provides more coverage to more people. According to the California Health Benefit Exchange, approximately 5 million people in California will have access to affordable health insurance by 2019. This new coverage will provide more business for doctors, as long as payment rates are adequate, explains Phinney.

However, Medi-Cal, the California Medicaid program that provides funding to low-income families, has one of the lowest Medicaid payment rates in the nation. The Affordable Care Act is trying to encourage primary-care doctors to take on more Medi-Cal payments by increasing the Medi-Cal payment rates. According to the California Department of Health Care Services, the reform will provide California with approximately $10 billion in federal funds to invest in the states’ healthcare system.

A portion of the funds will upgrade physician payment of Medi-Cal to the levels paid by Medicare nationally for primary-care physicians until 2014. This upgrade allows more primary-care physicians to take on more patients who have the new coverage.

Despite this payment increase for primary-care physicians, the California Medical Association argues that the newly insured patients are still not guaranteed access to doctors they need, because coverage for Medi-Cal and Medicaid under the new reform remains underfunded. Mazer said that simply giving patients a Medicare card does not mean they will have access to physicians, because it is already difficult for Medicare patients to find doctors that will take them because of the low payment rate of Medicare.

The Affordable Care Act also promotes the use of health information technology, which allows doctors to exchange a patient’s information by providing funding for technology to more efficiently access patient’s health information and records. Such technology makes information more accessible so that if a patient sees another doctor other than his/her normal physician, that doctor is not without access to their health records. The purpose is to make providing care more efficient and cost-effective so that doctors do not have to repeat the same tests and procedures that have already been done.

“Healthcare is in the dark ages” explained Phinney, when discussing how up-to-date doctors are with computers.

Primary-care physician Sherril Rieux, an advocate for health information technology, says: “It changes the way we practice medicine . . .  because computers are not our first language.”

However, she agrees that such technology provides better quality and efficient care.

Mazer, however, explains that the practice of health information exchange is more of an idea rather than what actually occurs. The problem with health information exchange is that there are many systems or brands that doctors can purchase, but those systems are not always compatible with one another. If a patient visits a hospital that does not have the same system as the patient’s usual physician, then it is unlikely those two systems would be able to exchange information.

Health information technology systems can be very costly, especially for those in private practice. The Affordable Care Act offers physicians an incentive of up to $44,000 over the next four years to underwrite the cost of purchasing the technology. However, Mazer explains that even with such an incentive, the equipment needed could cost around $84,000, which is still a high price for physicians to pay.

Although the new healthcare acts offers many positive incentives, there are several looming concerns. The California Medical Association argues that the Independent Medicare Payment Advisory Board created under the Affordable Care Act poses a threat to physicians. This 15-member board has the task of reducing the growth of Medicare spending. The California Medical Association is concerned that the members of the board are non-elected officials with little accountability, who can mandate physician payment cuts if Medicare spending exceeds a certain amount. According to medical association, if the board cuts spending for Medicare it will force physicians out of the program.