February 5, 2014
The new Health Benefit Exchange (wahealthplanfinder) has established a marketplace through which individuals may now obtain standardized coverage through Qualified Health Plans (QHPs), while they also are considered for premium subsidies.
At the same time, the Exchange acts as a referral resource for low-income individuals to obtain coverage through the Washington Medicaid program (now called Apple Health), which has been expanded to include eligibility for almost all adults.
Insurance companies are developing new approaches to provider networks, in order to more tightly control services and costs. Some providers have been excluded from new “narrow” networks, while others have chosen not to participate in selected networks. As a result, individuals are being forced to adapt to major restrictions placed on the availability of providers under many plans.
Further, significant changes in provider strategies are taking place. Under pressure to evolve from a “fee-for-service” orientation to a more “service value” approach to care, physicians and hospitals are reorganizing the ways in which they provide care.
Individuals with new ACA-based QHPs may find the services that they receive are much more driven by care protocols and reimbursement restrictions.
Similarly, changes in Medicaid are also being affected by the expanded use of insurance companies, to help manage the care received by individuals.
As a result of more patients with health coverage seeking care from the established Health Care System, there is the potential for access to be reduced due to an inadequate supply of physicians (and perhaps of hospital beds).
It is likely that reliance will increase on the use of Nurse Practitioners (NPs) and Physician Assistants (PAs), and on outpatient care strategies.
Against this backdrop, the State is increasing reimbursement for independent Advanced Registered Nurse Practitioners (ARNPs). The expansion of ARNP roles and payment may improve more flexibility and availability for care.
Also, the Medicaid program has introduced “Health Home (HH)” coordinating activity as a new approach to managing care for individuals with chronic conditions. HH services are treated as a new benefit under Medicaid.
Through a complex organizational structure, HH “care coordinators” are being introduced to manage services in such situations. These coordinators are new “social service” providers and may help reduce the demand on physicians and hospitals.
In this environment, it is not yet clear how community clinics and their resources will “fit into the picture”. Increases in the numbers of individuals seeking coverage under the ACA, combined with new provider strategies, will likely result in major operational strategies by such clinics, in order to improve overall access to care.
Elder Law attorneys may find themselves drawn into the changes in health care services from a variety of directions. Individual client needs may range from issues involved in signing up for ACA coverage, to coping with restrictions on the care that is available.
In turn, insurance companies, providers, and employers may need legal help to deal with the new incentives and constraints that they are facing.
Elder law practice in Washington is discussed by Cheryl and Ferd Mitchell in volumes 26 and 26A of Washington Practice (Washington Elder Law and Practice and the associated Elder Law Handbook). Probate practice is covered in volume 26B.