WASHINGTON -- It's a given that several million people will have gained coverage under the Affordable Care Act -- roughly 3.9 million in Medicaid and more than 2.1 million in private insurance, according to the Obama administration. Those numbers are sure to grow as open enrollment continues through the end of March.
But there are other ACA-related issues America's physicians need to concern themselves with besides the increased number of people with health insurance.
MedPage Today reached out to a handful of experts to see what they think doctors should know and be aware of as the law's coverage expansion starts.
1. Many new plans will carry extremely high deductibles
Consumers who purchased coverage through the ACA's health insurance exchanges or marketplaces quickly found the cheapest option for them in many cases was "bronze"- or "silver"-level plans. However, those plans have the highest amount of cost-sharing via deductibles and copayments.
Many expressed concern that patients gaining coverage for the first time may not fully realize their insurance will not pay for everything until they incur a significant cost on top of their premiums.
For example, the average deductible is about $4,300 for a bronze plan -- often the cheapest of the ACA exchange plans -- and $2,500 for a silver plan, according to Avalere Health, a Washington health policy consulting firm.
"Doctors will have to decide whether to insist on payment up front, by cash or credit card, or to extend credit," Timothy Jost, JD, a health policy professor at Washington and Lee University in Lexington, Va., told MedPage Today. "If they extend credit, they may take on substantial bad debt liability. Of course, extending credit to patients in the grace period is also risky."
2. Docs will be on the hook during patients' 'grace period'
As Jost mentioned above, the ACA gives patients a "grace period" in which they are allowed to keep their coverage even if they miss payments on their premiums. Consumers can have up to 90 days of falling behind on payments before plans are permitted to drop that patient's coverage.
Here is the kicker for doctors: Insurance companies don't have to process claims on patients who haven't paid their premiums in the latter 2 months of the grace period, leaving doctors on the hook to recoup payment directly from those patients who are eventually dropped for nonpayment.
The American Medical Association's policy-making House of Delegates approved a policy at its interim meeting last year requiring health plans to notify physicians when their patients have entered that 90-day "grace period."
3. Narrow provider networks are more common
Insurance companies have assembled smaller physician networks in an effort to keep premiums as low as possible.
"Many patients will find out their physicians and hospitals are not in the new, narrow network," said Kip Piper, a healthcare consultant in Washington. "Many academic medical centers are not in the new, tight networks. Many physicians may be surprised to find they are not in as many networks."
Avalere Health Founder and Chief Executive Dan Mendelson said the question of network adequacy is a very localized issue, saying some networks will be more robust in some markets and less so in others.
4. January might be messy figuring out who is covered and who is not
HealthCare.gov -- the federally run web portal through which patients can sign up for coverage in states that opted not to run their own website -- had issues initially, and may still have issues, transferring consumer information to health insurers.
"Many patients in January may be covered but won't have confirmation in the form of an ID card," Piper said. "So many billings to insurance and charges for cost-sharing will have to be put on hold for at least a couple weeks."
Furthermore, with the constant pushing back of the deadline to sign up for coverage that starts Jan. 1, consumers haven't had a lot of time to pay their first month's premiums, creating difficulty for health plans. However, most major insurers are giving customers until Jan. 10 to pay their premiums, per a request from the Washington-based trade group America's Health Insurance Plans.
5. A lot of patients might be changing health plans
With the narrow provider networks and more limiting offerings from health plans, there may also be issues creating a smooth transition for patients currently in care. However, the Obama administration has asked health plans to be as flexible as possible in covering out-of-network drugs and doctor visits.
"The administration's request to insurers that they continue to cover such drugs for patients with acute conditions may help, but a regulatory fix may be needed," Bob Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians, wrote in his blog.
6. Quality is becoming a greater part of payments
The ACA is also accelerating use of quality measures by private health insurers, Mendelson told MedPage Today.
The 2010 health law implemented quality standards for Medicare advantage plans. Today, about 7.5% of payments to those plans are based on quality, and insurers selling ACA exchange plans are emulating their use.
"The physician needs to understand that the financial incentives are going to run towards pushing more of these quality metrics into their clinics," Mendelson said. "If a health plan is going to get paid more if the patient is immunized, the health plan wants to move that incentive to the doctor."