Maneuvering around problems with PPACA

Columbia, MD-The Patient Protection and Affordable Care Act (PPACA) was designed to provide health insurance for millions of uninsured citizens with no exclusions for pre-existing conditions, expanded services like screening and preventive health coverage, and be less costly for patients and the government.

Considering the troublesome initial operation of the PPACA sign-up website, David Glasser, MD, who is in private practice in Columbia, MD, speculated about the future of the program.

“My first prediction is that some form of ‘Obamacare’ will be around long after President Obama leaves office,” he said.

However, a number of questions arise when he considers the future of the PPACA, such as whether there will be more government regulations, potential loss of patients, limited therapeutic options, and physician reimbursement.

“There are definitely more government ‘hoops,’” he noted.

For example, the PPACA and the Health Information Technology for Economic and Clinical Health Act brought meaningful use criteria, such as better care through evidence-based clinical guidelines and value-based purchasing. However, new insurance plans, he said, will present new restrictions in the form of new contracts, possibly more procedural preauthorizations, and more restrictive formularies and networks for physicians and facilities.

Physicians may also have fewer patients since healthy individuals may not sign up for health coverage because of cost, and with only sick individuals signing up, the insurance will be more expensive.

Dr. Glasser said a cost-cutting measure is to limit provider networks to those willing to discount the cost of coverage heavily.

“This cuts physician access to some patients other than those who are covered by Medicare,” he said. “The ability to see patients will depend on if the carrier accepts physicians into their network and if the carrier payments are acceptable to physicians.”

Therapeutic options may be subject to cost-cutting measures also, he proposed.

“Carriers will start contracting with limited hospitals and ambulatory surgical centers that provide a good deal, which may not be where a physician has privileges,” he said.

Dr. Glasser said he wonders if there will be problems with payments for corneal tissue and more adverse medical necessity determinations that may make it more difficult for certain procedures to be performed.

Regarding payments, he expects to deal with new and unknown carrier fee schedules and insurance plans with high deductibles. In addition, if patients pay the initial insurance premium and then default, medical visits that took place before the default may be paid by carriers but then require payment back to the carrier by the physician and billing patients for reimbursement.

Dr. Glasser advised that physicians simplify when possible.

He recommended using the American Academy of Ophthalmology’s IRIS Registry to remove the busy work from an electronic health records system, analyze the payer mix and fee schedules, read contracts, and tell the ambulatory surgical centers to analyze their contracts for potential tissue payment issues.

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