New health reforms impact doctors as well as patients

Shae Collins | 8/15/2012, 5 p.m.

Many of the reforms in the Affordable Care Act affect not only patients, but doctors as well. Insurance industry reforms make it illegal for insurance companies to deny coverage to individuals based on pre-existing conditions, place a dollar limit on the amount of coverage a patient can receive and cancel a patient's coverage because of an expensive health condition.

These reforms impact private practices differently than physicians in large medical groups.

Prior to passage of the Affordable Care Act, whenever insurance companies canceled a patient's coverage, doctors would not get paid for their services, says Dr. Paul Phinney, president-elect of the California Medical Association and a primary-care physician with Kaiser Permanente. He explains that these insurance industry reforms have a stronger impact on solo practitioners because such practitioners do not have the financial cushion or support in numbers from a large medical group or company.

Unlike private practices, Kaiser has a three-part system of health insurance, hospitals, and medical groups. Because Kaiser's patients are on the Kaiser Foundation Health Plan, which offers prepaid health plans and insurance, their doctors do not worry about not getting paid for services rendered.

On the other hand, private practices, which often accept many types of insurance, do not have such benefits and security. If a patient's insurance company chooses to drop or cancel coverage prior to their treatment, the doctor does not get paid for services given. Dr. Theodore Mazer, an otolaryngologist and officer of the California Medical Association, explains that often doctors will render a service, such as surgery, unaware that their patient's coverage was dropped because they were not notified in time. When this happens, they are not paid for their services.

The Affordable Care Act also provides more coverage to more people. According to the California Health Benefit Exchange, approximately 5 million people in California will have access to affordable health insurance by 2019. This new coverage will provide more business for doctors, as long as payment rates are adequate, explains Phinney.

However, Medi-Cal, the California Medicaid program that provides funding to low-income families, has one of the lowest Medicaid payment rates in the nation. The Affordable Care Act is trying to encourage primary-care doctors to take on more Medi-Cal payments by increasing the Medi-Cal payment rates. According to the California Department of Health Care Services, the reform will provide California with approximately $10 billion in federal funds to invest in the states' healthcare system.

A portion of the funds will upgrade physician payment of Medi-Cal to the levels paid by Medicare nationally for primary-care physicians until 2014. This upgrade allows more primary-care physicians to take on more patients who have the new coverage.

Despite this payment increase for primary-care physicians, the California Medical Association argues that the newly insured patients are still not guaranteed access to doctors they need, because coverage for Medi-Cal and Medicaid under the new reform remains underfunded. Mazer said that simply giving patients a Medicare card does not mean they will have access to physicians, because it is already difficult for Medicare patients to find doctors that will take them because of the low payment rate of Medicare.