Uncertainty Colors Physicians' Watch List

The top issues on the Physicians Foundation Watch List for 2014 are related to healthcare reform. Some matters, such as health insurance exchanges, are no longer a theoretical concern, but an emergent and very real one.

Ambiguity around how various provisions of the Patient Protection and Affordable Care Act will be implemented is the core reason behind the top physician concerns on the Physicians Foundation 2014 Watch List.

The group released the list this week.

Last year, the Physicians Foundation used the word "nebulous" to describe the implementation of health insurance exchanges, fee schedules, accountable care organizations, and the Independent Payment Advisory Board. This year, significant uncertainty remains around all of those as well as the PPACA in general.

But heading into 2014 the issues are different because some, like health insurance exchanges, are no longer theory, they are being put into practice.

Last year's concern about exchanges centered on patient access to physicians. While that remains to be seen, it is more of a long-term worry that will take months, maybe years, to play out. Going forward, when HIX enrollees begin making appointments, physicians will face the potential problem of uncompensated care. It's a real issue, and there are two reasons why:

First, reports have surfaced that 1 in 4 files with information from exchange enrollees to insurers were incomplete or wrong. The Washington Post says, "The mistakes include failure to notify insurers about new customers, duplicate enrollments or cancellation notices for the same person, incorrect information about family members, and mistakes involving federal subsidies."

This has physicians worried that HIX patients who show up in their offices wanting services will unknowingly believe they are covered when in fact they are not. This is particularly a concern in states that have federally facilitated exchanges because of all the enrollment glitches and remaining back-end problems on the federal enrollment website.

Second, physicians have genuine reason to be concerned about the 90-day grace period that consumers have under PPACA when they don't pay their premiums. Under the healthcare reform law, certain individuals can't be terminated from coverage for failing to pay for 90 days. Health insurance plans pay claims for the first 30 days, but can deny or pend the claims for the remaining 60 days if the enrollees don't pay.

At issue for physicians is knowing when an enrollee has entered into the 90-day grace period.

"Providers are on the hook for services provided and everybody is very anxious about it," says Tom Holloway, executive vice president of the Missouri State Medical Association (MSMA), which, along with the Missouri Hospital Association, sent its second joint letter to the Center for Medicare & Medicaid Services asking the agency to address the 90-day grace period. CMS responded in September that it would publish "guidance" to establish notice parameters.

"We're waiting to see in the next three weeks if CMS addresses the issue," says Holloway.

So far, the only guidance from CMS remains an April directive to insurers requiring that they notify "all potentially affected providers as soon as is practicable," though that language is not strong enough for Missouri's provider associations or the American Medical Association.

The letter from Missouri's provider organizations states "practicable" doesn't go far enough, saying it is "an undefined standard that is subject to wide interpretation by the health plans."

The remaining four issues on the Physicians Foundation Watch List for 2014 include some other repeats from 2013, such as concern that industry consolidation could lead to monopolization. Again, this fear is a result, though indirectly, of healthcare reform.

As more healthcare organizations merge and/or partner to achieve business efficiencies, small physician practices feel pressure to align with larger groups or organizations because they can't achieve the same value proposition as the bigger guys in town.

The regulatory burden on physicians is listed in the second spot on the organization's watch list for next year. A survey from the Physicians Foundation in 2012 found that physicians spend nearly a quarter of their time on paperwork that isn't clinically related. ICD-10 rules that go into effect in October are listed as a significant source of the extra regulatory burden doctors will incur this year.

Technology is also listed as a watch list item for next year, though it is recognized separately from the regulatory burden, mainly because the issue for physicians is getting electronic health records to be interoperable with other providers.

The final issue for physicians to watch for is health system stalemates, a more direct result of PPACA. Included in this watch list item are several ongoing issues that physicians believed would be addressed in 2013: a resolution to the Sustainable Growth Rate issue, tort reform, and the practice of defensive medicine.