Medical Practice Management and the New Exchanges – What to Expect by 2014

The Affordable Care Act is set to expand coverage to a projected 32 million Americans. The primary mechanism for this expansion – and the one that is thus far not widespread in the American health care system except in limited capacity such as in the case of Massachusetts – is to be the state-run health insurance exchange. The ACA as passed by congress expanded coverage through Medicaid (though the states are not required to comply with this expansion as a result of the June 2012 Supreme Court ruling that upheld the constitutionality of the law), but the state exchanges are new institutions which all fifty states are required to establish by 2014. Due to the novelty of the idea, pushback at the state level, and the differences that are likely to arise since every state is responsible for creating its own exchange, there are levels of uncertainty over how they will take shape. Let us look at the possibilities and what medical practices may have to expect in 2014.

The states are at different levels of progress with implementation of the exchanges. Some were holding off until the final Supreme Court decision, and others were waiting for the results of the 2012 presidential and congressional elections to determine if the law would be here to stay. Since the outcomes of both the Supreme Court decision and the election have made the law all but a certainty for 2014, some states must put some effort into catching up. However, some states like California and Maryland have already made substantial progress toward meeting the 2014 open enrollment date.

There is some skew over how much influence physicians will have over the boards that will establish the state exchanges. The federal regulations prohibit boards from being composed of members a majority of which are “conflicted,” but the states have had it left to their own decision if a physician inherently has a conflict as a member of such a board. The American Medical Association is looking to have as many physicians serve on these boards as possible, even if that means the appointment of non-practicing physicians.

In practice, the exchanges are intended to de-concentrate the market for insurance. With the increased competition should come increased ability for physicians to provide care for their patients. California may implement an “active negotiating exchange” that uses competitive bidding, a plan that may constrict payment rates. Some exchanges may allow all plans to enter the market, a move that carries the potential of making the process of choosing care more complex and uncertain. Since insurers will wish to maintain some of their market share in the face of increased competition, their option may be to offer smaller networks that come with lower costs of service. With the Massachusetts Commonwealth Connector, the exchange established by the state’s 2006 health reforms and is acting as a template for the exchanges to be established by the ACA, such narrow, low-cost networks have arisen and have ended up being popular.

It is difficult to know for sure how the exchange system will play out, and just how much divergence we will see in plans and care across the country. However, one thing is certain: there will be an expansion of insured and an expansion of plan options for which medical professionals need to be prepared.

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