Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices in 2013. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or requiring enrollees to switch to other, often more expensive, ones. In November, in an effort to stem the mass cancellations, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year. That attempted fix has not been so straightforward, however. Many insurers were reluctant to reissue cancelled policies, and multiple states, which have the authority to regulate insurance sold within their borders, declined the administration’s request.
If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance.
—Robert Berenson, MD, senior fellow, Urban Institute, Washington, D.C.
The Long View
Despite the intense focus on the first few months of health insurance enrollment, it may take several years before the markets begin to settle and other insurers waiting on the sidelines decide whether to participate. If they eventually succeed, the ACA exchanges could have several long-term consequences.
“If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance,” says Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy. Over many years, employers could begin moving their employees into exchanges rather than providing direct healthcare benefits.
If they prove viable, the exchanges also may help accelerate the trend toward more consolidation of physician practices or increase pressure to align with larger entities. Despite concerns over skinnier networks, for example, the more tightly controlled access to providers under certain plans dovetails with the ACA’s heightened emphasis on more integrated accountable care organizations (ACOs).
In fact, ACOs and other lower-profile provisions that enjoy more bipartisan support could ultimately play key roles in reshaping how healthcare is delivered in the U.S. Many of these reform efforts have been launched as pilots or demonstration projects. Salt Lake City-based healthcare consulting firm Leavitt Partners tallied nearly 500 ACOs through the end of July 2013, more than double the total in June 2012.
Other Obamacare provisions are levying fines based on excessive hospital-acquired conditions or readmissions and adjusting reimbursements based on e-prescribing, the Physician Quality Reporting System (PQRS), value-based purchasing, meaningful use of electronic health records, and other mandates.
“The overall theme is that the ACA is speeding up the move away from fee-for-service payment toward new payment methodologies that are going to be increasingly based on quality measures,” Dr. O’Malley says. “All of these are basically efforts to shift incentives away from rewarding volume of services toward value and quality of care for patients. And the crux of all of them is to try to get physicians to work together, not only with other specialists and their primary care colleagues, but also with other inter-professional members of their team.”
For hospitalists, it means relying more on nurses, physician assistants, and other support staff.
“In a collaborative agreement, where it’s a physician-led healthcare team, I think non-physician healthcare providers could help to support the physician hospitalists,” Dr. Lenchus says.
That extra help may be essential.
“I do think the workload will increase, and not just because we’ll have more people clamoring for healthcare and more patients who are sicker—remember, there are no more pre-existing conditions,” Dr. Lenchus says. “The other piece to this that goes outside the patient-physician interaction is that there’s a lot of additional regulations and administrative burdens, if you will, as individual hospitalists and as hospitals on the whole.”