Obamacare is going to have a doctor problem

An aspect of the American Affordable Care Act (aka Obamacare) which I hadn't appreciated until this week was the degree to which it may be scuppered by primary care physicians (PCP, the USA equivalent of a GP). Chatting with a middle-aged friend who is moving to a small-ish American town and changing jobs, she opened my eyes to the mysteriously unpublicised problems which the implementation of the ACA is about to cause everyone.

She was visiting her new town last week, sorting out her house and meeting her new workmates in preparation for moving there for good in June. One item on her list was sorting out a new PCP. She had the details for her new insurance plan with one of the state providers, so dropped by a doctor's office near her house to register. No joy, that doctor wasn't accepting new patients. OK, so go back to the insurance provider website to identify a wider shortlist of providers in town.

No joy at the first doctor. Or the second. Or the third. This was getting ridiculous. She had a friend already working in her new workplace, so asked him if he could help. His doctor wasn't accepting new patients either, but the friend had a good relationship with the doctor, so asked him directly. Still no luck. Eventually my friend managed to find a large medical center open to new patients - over 60 miles away. She signed up, because that was the best offer there was.

There was one doctor in a nearby town open to new patients, but after a quick check on his reviews it became rapidly clear why. It sounds like he hadn't progressed much past the "trial by ordeal" approach to illness, and was still reading pre-Pasteur literature on infection control.

Why this insanity of unavailability? It turns out that the coming avalanche of patients signed up on ACA-compliant plans is not making doctors sleep well at night. Not only are these patients much more likely to be sick than their current patients, the main concern of practices is that they're going to lose money on treating these patients. The remuneration rate for doctors for ACA patients is - at least in some states, and I suspect all - based on 80% of the standard practice fees from 3 years ago. That's not great, but much worse is the experience with Medicare (federal medical coverage for the elderly). My friend used to work in a doctor's office, and they had a profitably employed office employee whose sole job was to push back against government agencies spuriously denying payment for Medicare claims. If there were any abnormalities at all in a claim, Medicare would deny it in the hope that only solidly valid claims would be retried. A denial is, after all, cheap.

I digress, but bear with me. Do you older readers remember when The Simpsons started and they introduced us to Marge's sisters Patty and Selma, stalwart misanthropic employees of the local Department of Motor Vehicles? There's a reason why the American viewers of the show laughed, and it wasn't to do with absurdity. There's no-one more un-fireable than a federal or state bureaucrat, and their attitude to their customers is exactly what you'd expect - entirely down to their general disposition to humanity. That's what the doctors' billing teams are going to be dealing with. Only by being better acquainted with the rulebook will they be able to get their due payments out of the ACA system, and even then those payments will be small and paid late.

Having a new government agency and new set of rules means that small practices are extremely worried about their costs and ability to maintain existing patients. Because (I believe, from chatting to the front desks of a few offices) you can't be selectively open to new patients based on their particular insurer, the easiest option for small providers is to batten down the hatches until the picture is clearer. Only the very large healthcare centers can take advantage of their economy of scale to accept the new stream of ACA-covered patients - and with them the standard employer-covered and easier to manage new patients.

I wonder whether this problem with finding doctors is behind the proposed rise in rates for ACA-compliant plans? Perhaps you will be able to look at the rate rise in the next few years and extrapolate the "marginal cost of doing business with government". As it stands, the best they can hope for is to break even:

Cigna, which is selling Obamacare plans in five states and is considering whether to expand that further in 2015, has said it won't make money on the business this year. It expects to have signed up as many as 100,000 new members under the program for this year.

So for the Affordable Care Act, if you're sick then you may be able to get coverage where you couldn't before, but sure as heck if you're outside a major city then you're going to find it a challenge to get a primary care physician to see you and get your care started. Now I'm wondering what the ER departments of ACA-plan-accepting hospitals are going to experience in the next year.

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