December 5, 2013
Under the Affordable Care Act (ACA), insurance companies must provide health coverage for all applicants despite preexisting conditions, and have only limited ability to adjust premiums based on age.
Under these constraints, companies must compete head-to-head based on premiums for standardized policies.
Thus, insurance companies are now tightly focused on reducing the costs of the services provided under the policies that they offer.
Two major strategies are to “narrow down” the sizes of provider networks (in order to maximize financial controls and to achieve reductions in required payments for care) and to increase out-of-pocket costs for those who are being insured, within the limits allowed by the ACA (to reduce the total care sought and to shift some of the costs of care).
Physician practices of all sizes are now being impacted by these shifts.
And the move to narrower networks is resulting in expressions of concern by all types of physician practices.
Physicians can choose to cooperate with insurance company requirements, or to “opt out” of some of the more-restrictive networks. Access to care by individuals may be affected by both responses.
Physicians who “opt in” may move to restrict access according to network rules, and individuals may hesitate to seek care because of out-of-pocket expenses.
And physicians who “opt out” of a network will no longer be available to those individuals who are signed up for this network.
These results are predictable outcomes of the cost-control efforts that are under way.
Many physicians will feel under more pressure no matter how they respond. “Opting in” can lead to new practice pressures, while “opting out” can result in reduced demand for services from the public.
At the same time, many individuals resent increased out-of-pocket costs and the loss of access to familiar and preferred providers.
Increased financial stresses are likely to grow on both sides of the patient-provider relationship. The result may be significant changes in this relationship.
After years of discussion, it is yet to be seen how the public will respond to cost control through reduced access to physicians.
There are inadequate funds to go back to more unrestricted access to care, but there may be growing resentment with respect to new restrictions on access.
Attorneys will inevitably be drawn into the resulting stresses and strains, by trying to help clients find the “best way forward” when “preferred options” have been taken off of the table, and by helping clients deal with the conflicts that appear to be inevitable.
It is often difficult for attorneys to advise clients when all available options appear to be unsatisfactory, and the “best of unsatisfactory choices” is all that can be offered.
More on these and related ACA topics, with an in-depth discussion of organizational reactions to implementation issues, may be found in a recent book by the authors that describes evolution of the ACA, and in a new Practice Guide by the authors that addresses funding and access issues in health care.