America's neurology practices may get busier after Jan. 1, 2014, when an estimated 12 million Americans gain insurance coverage, courtesy of the Affordable Care Act (ACA).
As of that date, the ACA requires that the vast majority of US residents purchase health insurance, provides federal subsidies to help low-income individuals pay for the coverage, and authorizes insurance exchanges to help people compare insurance options and make their purchasing decisions. The law prohibits insurers from discriminating on the basis of health status, pre-existing conditions, age, occupation, or other factors.
By 2021, the insurance exchange market is expected to double, creating the largest expansion of health coverage since the Medicare program started nearly 50 years ago.
For some neurology practices, this may bring on a financial boon. “It depends on where you are and it depends on the nature of your practice,” said Joel Kaufman, MD, chairman of the AAN Payment Policy Subcommittee. “If you're in a practice at a safety-net hospital where you a see a lot of patients who don't have insurance or who have Medicaid, I think it will be a benefit.”
For other practices, the increased demand from newly insured patients may require changes in practice. David Evans, chief operating officer at Texas Neurology, encourages his colleagues to look at the number of uninsured people in their communities and the capacity of neurology practices to handle a surge in demand.
“It will obviously vary based on the community, but I think some people will need to explore new models of care in order to accommodate the increase in patients,” he said.
WHAT THE INSURANCE LOOKS LIKE
Insurance sold through the exchanges must provide a minimum level of services in 10 categories called “essential health benefits,” or EHB, according to the ACA. [See “The Affordable Care Act's Essential Health Benefits.”]
Rather than setting a national standard for EHB, the government is allowing each state to choose a “benchmark plan,” which must be one of the largest health plans in the state. Any covered benefit under the benchmark plan would be an EHB for that state. For example, if the benchmark plan allows only 20 habilitative therapy sessions a year, that would be the minimum for any plan.
The government has not yet published its final rule for EHB; that will happen later this year. In general, the Academy supports the government's plan for EHB, Daneen Grooms, who has a master's in health services administration and is the AAN manager for regulatory affairs, said, although the plan is pushing it a bit.
For example, many health insurance plans do not provide habilitative services — listed as an EHB — so the benchmark plan in some states may not include habilitation for neurodevelopmental disorders and other conditions. In its proposed rule, the government suggests that states could define the habilitative services benefit or leave it up to the individual plans, with certain restrictions.
In a December letter to the Department of Health and Human Services (HHS), the AAN encouraged the government to give states the authority to determine the minimum benefit level for habilitative services. “However we encourage HHS to include federal oversight mechanisms to ensure that states are choosing the appropriate coverage for habilitative services,” the Academy said.
WHAT NEUROLOGISTS SHOULD KNOW
“Neurologists should pay attention to which payers are going to participate in the exchanges and see whether they want to be in those networks based on how well those payers pay or don't pay,” said Dr. Kaufman, executive director and chief executive officers of Lifespan/Physicians Professional Service Organization in Providence, RI.
While all polices sold through in the state must cover the EHB, plans will vary in the level of cost-sharing such as deductibles, co-pays, and coinsurance they require. Insurance-shoppers will choose from four levels of cost-sharing: bronze (very high level of cost-sharing); silver (high level); gold (medium level); and platinum (low level).
The annual out-of-pocket maximum for all types of cost-sharing for in-network provider will be about $6,500 for a self-only plan and $13,000 for a non-self-only plan in 2014; that amount will be adjusted each year. There are no limits on out-of-network cost-sharing.
Thus, neurologists need to be aware that some patients who are newly insured through the exchange may not be able to afford the treatments they need. “It may be that someone's picking the bronze plan because that's all they can afford, which means they are going to have trouble meeting that big out-of-pocket responsibility,” Dr. Kaufman said.
HOW TO MEET INCREASING DEMAND
Neurology practices that already have long waits for appointments may be challenged to accommodate newly insured patients who need services. Evans, who serves on the executive committee of Business and Research Administrators In Neurology Society, encourages practices to consider adjusting their business model to increase patient access to services and operate more efficiently.
Texas Neurology has hired 10 nurse practitioners and physician assistants to increase the number of patient visits the practice can handle. After a neurologist has examined the patient and diagnostic testing is complete, the mid-level practitioner can assume responsibility for monitoring the patient's progress during treatment, educating the patient about the disease process, and coaching the patient to comply with treatment regimens.
“There's a big concern that there is a limited-access issue in neurology,” he said. “This has been the biggest evolution that we have done in our organization to be considerate of access needs out there.”
WHO ARE YOUR NEW PATIENTS?
The 2010 reform law sought to make coverage available through two mechanisms: Medicaid expansion and health insurance exchanges. In 2012, the Supreme Court ruled that states do not have to expand their Medicaid programs, and some may choose not to do so. For that reason, some states will see a greater increase in insurance coverage than others.
“When the exchange population is combined with the ACA's new Medicaid beneficiaries, the result is a distinctly different customer base for the health sector,” according to a white paper published by the PwC [PricewaterhouseCoopers] Health Research Institute.
They will be relatively young — median age of 33 — and report being in good health, according the PwC's analysis. The majority will be white, and about 20 percent will speak Spanish or another language other than English at home. Although nearly 60 percent of adults who buy insurance through the exchanges will be employed full-time, nearly 90 percent will receive subsidies in 2014.
Roughly three-quarters will not hold a college degree, compared with nearly 60 percent of the private insurance market currently.
The newly insured patients are unlikely to overwhelm the health care system or substantially increase health care spending after they gain coverage, PwC forecasts. However, they will be unfamiliar with how insurance works and require more assistance navigating the healthcare system than most current patients do.
THE AFFORDABLE CARE ACT'S ESSENTIAL HEALTH BENEFITS
* Ambulatory patient services
* Emergency services
* Maternity and newborn care
* Mental health and substance use disorder services, including behavioral health treatment
* Prescription drugs
* Rehabilitative and habilitative services and devices
* Laboratory services
* Preventive and wellness services and chronic disease management
* Pediatric services, including oral and vision care
For more on the essential health benefits, see http://1.usa.gov/b0CCA4.
FOR FURTHER READING ON HEALTH REFORM INITIATIVES: