8 Ways That the ACA Is Affecting Doctors' Incomes

Leigh Page


August 15, 2013

In This Article

Physicians Have to Deal With Higher Out-of-Pocket Payments

The ACA and the exchanges follow a rising trend toward higher out-of-pocket charges, which is forcing practices to rethink payment policies for patients.

According to surveys by the Kaiser Family Foundation,[4] the percentage of covered employees having a deductible for single coverage rose from 52% in 2006 to 72% in 2012. In 2012 the average general annual deductible for this population was $1097, an 88% increase since 2006, the Foundation reported.

Health insurance exchange plans will have relatively high out-of-pocket payments. In the benchmark "silver" plan on the California exchange, for example, an enrollee with a $45,000 annual income would have a $2500 deductible and copays of $45 to $65 for an office visit.[5]

Deborah Walker Keegan, PhD, President of Medical Practice Dimensions, a consultancy in Asheville, North Carolina, said that high out-of-pocket payments have the biggest impact on specialists with expensive services, such as orthopedic surgeons, but they can also be a problem for primary care practices because they can add up quickly.

Keegan added that it's difficult for a practice to calculate how much the patient owes at any given time, because the deductible changes each time the patient pays for care, although some payers provide real-time information on members' out-of-pocket levels.

To make sure that the out-of-pocket charge is collected, Keegan said that a practice has to collect these charges up front, prior to providing care. "If patients don't have the payment at the time of service, then you might ask them to agree to a budget plan and set up credit card payments," she said.

Aburmishan, the Illinois consultant, says that some practices are asking patients to provide their credit card number and give permission to draw payments from it. If the practice's first attempt to file a claim is denied, it would charge the card for smaller bills; for larger bills, it would take $500 off the credit card each month, she said.

Primary Care Gets a Boost

"The ACA is increasing the prestige of primary care,"said AAFP's Cain. He noted that many key aspects of the law favor primary care, such as enhanced reimbursements under Medicare and Medicaid, new models of care like the patient-centered medical home, and preventive and wellness services covered under the "essential health benefits."

Specifically, Medicare is paying primary care physicians a 10% bonus for primary care servicesfrom 2011 through 2015, and primary care physicians' Medicaid reimbursements for evaluation and management services and vaccinations are being raised to Medicare rates in 2013 and 2014. Due to start-up problems, the Medicaid payments are just beginning to come through.

Dr. Cain also pointed to new programs by commercial insurers oriented to primary care. WellPoint, for example, has increased reimbursement to primary care physicians for services such as "nonvisits" over the phone and will award them up to 50% more than they had been earning for reducing medical costs while maintaining quality.[6]

Dr. Cain said that a key outcome of the ACA's emphasis on primary care is that it "puts more emphasis on the need for these kinds of doctors."

New doctors have been heeding the call, partly due to new subsidies for primary care training. The number of medical students committing to primary care programs in the Match has increased every year since the ACA was passed in March 2010.[7]


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