FPs Report Patients Realizing Health Benefits of ACA Coverage

Insurance Hassles, Not Patient Volume, Among Hurdles Seen to Date

July 16, 2014 09:45 am Michael Laff

Despite predictions that the nation's health care system could be overwhelmed by a flood of newly insured patients whose health coverage took effect this year, that's not the story family physicians are telling AAFP News. Although some have seen a boost in patient numbers, they say the influx is not overwhelming their practices.

[Doctor talking with elderly male sitting on exam table, pointing to hip area]

That's certainly been the case for one FP in Texas, which is one of several states that is not operating an insurance exchange and has seen only modest enrollment numbers. According to Lindsay Botsford, M.D., medical director for Physicians at Sugar Creek in Sugar Land, she has added only about 10 new patients in the past three months. "We're not inundated," Botsford said. "It's not more than we can handle."

For Botsford, managing the flow of newly insured patients is not the problem. It's finding willing subspecialists to whom she can refer patients. She related an example of having referred one of her new patients to a cardiologist, and her practice's referral coordinator scheduled an appointment with that physician. But when the patient called the cardiologist's office shortly thereafter to reschedule, office staff told him they were no longer accepting patients insured under the Patient Protection and Affordable Care Act (ACA).

Story highlights
  • Family physicians report being able to handle the volume of patients newly insured under the Patient Protection and Affordable Care Act, but say their offices have been juggling more insurance issues.
  • Some patients are unaware of what their insurance covers and their level of financial responsibility for their medical care.
  • Patients are benefiting from having access to primary care services -- some for the first time in many years.

In another case, one of her patients needed an otolaryngology referral, said Botsford. Although a total of 22 otolaryngologists were listed as participating in the patient's insurance plan, none of them would accept the patient. "Some specialists who are on the list said they didn't realize they were on the list," she explained. "Others admit they are listed but said they reached their cap on new patients."

After encountering several such roadblocks, it is now part of the practice's routine for the referral coordinator to call the subspecialist's office to verify that it will accept a patient with insurance obtained through the ACA. Botsford also advises patients to talk directly with their insurance carrier to confirm which subspecialists participate in their plan.

As for the health issues she has seen in these new patients, said Botsford, "most came in for wellness exams."

"I have not seen any patients with uncontrolled chronic illness, but many patients deferred preventive services like mammograms, pap smears and cholesterol screenings for a few years. Most were getting some patchwork care if they had high blood pressure or diabetes, but not consistently."

Overall, she said, "I think the ACA has provided access to primary care for these people for the first time in a while. While they have access to ERs when they are very sick, they have not had a continuous relationship with a physician. That is what they are getting now."

Shoring Up the Safety Net

Indeed, one of the main objectives of ACA was to expand the health care safety net by drawing in patients who were not receiving even occasional care and who faced the prospect of deteriorating health. In one North Dakota clinic, for example, many newly insured patients work in the region's booming oil industry in one capacity or another.

According to family physician Aaron Garman, M.D., the new patients he's seeing typically have low incomes and have gone long periods without basic medical care. Many are geriatric patients, but the area has also seen an influx of 20- to 40-year-old men who are primarily truck drivers or laborers.

"The majority are unhealthy patients who neglected to take care of their health," said Garman, who is medical director for Coal County Community Health Center in Beulah. "Not because they didn't want to but because they couldn't afford it."

Garman noted that the clinic can accommodate the 40-plus patients it has added, but the amount of administrative work has increased considerably. Clinic staff members devote more time to verifying and navigating insurance because patients often don't know what their health plans cover and are surprised that they are expected to pay a portion of the cost.

Indeed, said Milack Talia, AAFP senior strategist for practice environment, verifying coverage for traditional health plans might take a few seconds through an automated system, but conducting the same check with an exchange plan could require as much as 20 minutes.

At the end of the day, said Garman of his new patients, "They are happy to have insurance, but they are either unaware (of) or confused by what the plans cover."

Even so, he added, "I do think that (the ACA) has helped a lot of patients. There are still some glitches to work out, but those who have (coverage) are actually getting the care that they need."

Improving Health Literacy

Melissa Gerdes, M.D., of Methodist Family Health Center in Arlington, Texas, told AAFP News her practice has also had to educate newly insured patients about how health coverage works -- and that goes for two of her patients who previously paid in cash but now have obtained insurance through the federal exchange. Despite the fact that these patients were very knowledgeable about health care costs, she said, they didn't understand what their coverage included. So when talk turned to specific services, the patients were hesitant.

"They said, 'Wait, I can't do that now because of my deductible,'" Gerdes said. "I told them that preventive services are covered. This leads to a discussion about coverage, which I am happy to have with patients. In many cases, the services are preventive and covered at 100 percent."

According to Talia, who has extensively researched implementation of the ACA, improving overall health literacy will be a priority for both state and federal health officials in coming years. He noted that state officials in New York set the standard for patient education in advance of the ACA rollout with an aggressive campaign that taught enrollees how to use their insurance.

But in general, said Talia, "There is very little education on health literacy, so when some people get covered, it's hard for them to understand the terms of their plan, and then they don't use it."

Facing Cost Uncertainties

There's another issue related to patients' new health plans that FP Shawn West, M.D., raised with AAFP News.

For patients who fail to pay their premiums, the ACA grants a 90-day grace period before insurance is terminated. But it remains unclear who will bear the costs of care provided to for patients who eventually lose their coverage because of unpaid premiums. That concern has office staff members at Edmonds Family Medicine in Edmonds, Wash., where West practices, spending time trying to verify whether patients have been paying their premiums.

Thus far, said West, the practice has had a fair amount of trouble uncovering that information. So, by absorbing a modest increase in patients, the practice will have to hire additional staff for administrative purposes.

As for that patient increase, said West, with 30 physicians in the practice, the Edmonds facility can handle just about any spike in patient visits.

"Many were concerned about a pent-up demand (bringing in primarily sicker patients), but there's been a good mix," West said of the new patients his practice is seeing. "There are some young, healthy people who thought they didn't need insurance. Others have deferred care and it will take a while for them to catch up. We can accommodate the influx."

Recently, West provided care for a newly insured man in his 50s who came to the walk-in clinic with benign paroxysmal positional vertigo. The patient was reassured to know the cause of his symptoms, and West was able to discuss with him the importance of preventive health care services such as colon cancer screening and recommended adult immunizations.

"He was happy to have access to a primary care physician, and we were able to schedule him for a health maintenance appointment," West said.

Another notable visit involved a patient with type 2 diabetes who for years had not received treatment for his disease. West tested the patient's lipids and hemoglobin A1c and microalbumin levels and started him on metformin. He also scheduled the patient for a retinal exam.

West agreed with his colleagues that even though newly insured patients appreciate having access to care, they do not understand how to navigate the insurance market, and they still don't have a solid handle on what costs they're responsible for. But he acknowledged that it's difficult for patients to be savvy about health care costs because of the lack of transparency and wide price discrepancies for basic services.

"When patients understand the costs associated with care, that changes the conversation," West said. "Traditional expectations on the part of some patients to get whatever test or treatment they want are no longer realistic given the need to provide cost-effective care.

"For better or worse, it is now part of the conversation that family doctors need to have when caring for their patients."

As for his take on what effect the ACA rollout is having on physicians and their patients: "I think it will take some time to know if the ACA is an overall success, but it's hard to argue that improving access to health care for those who need it is a bad thing," West said.