Column: Affordable Care Act leaves lots of questions, confusion

When a patient came in for a recent visit, she was noticeably upset. When I asked her what was wrong, she told me she was annoyed that her other physicians would not accept her new insurance. She felt abandoned and blamed her doctors for not taking her coverage. When I inquired further about what type of insurance she procured, she responded, "one of the new affordable health care act plans" -- better known as Obamacare.

Millions of patients across the country have now enrolled in an Affordable Care Act insurance program only to find that many doctors are not accepting these programs. Patients and physicians alike are confused by the new programs and how they are structured. One of the first issues that is causing confusion is that the patients enrolled in these ACA plans have the exact same insurance card as a person enrolled in the same insurance company who pays for a traditional plan. This poses a major problem for doctors, especially when patients need to be referred for tests or consultations. For example, had I referred this patient for her scheduled endoscopy at the local hospital, neither the hospital nor the physician's fee would have been covered since they do not accept her new ACA coverage. Thus, had the patient gone for the test, she would have been personally responsible for its cost (likely thousands of dollars). Unfortunately, without giving the physicians a way to ascertain that an individual has an ACA plan, they risk referring patients to physicians and/or facilities that do not participate in the plan.

Another issue for physicians is that many insurance companies sent their panel physicians a letter stating that if the doctor does not "opt out" of a new ACA plan, it would mean that they were automatically assumed to accept these new plans. However, many doctors claim they never received these letters nor did they authorize these insurance companies to include them in their new ACA plans. Thus, even if a patient or physician researches online or in their provider coverage book to see if their doctor participates, many doctors who are listed by default, actually will not accept these new plans.

A main reason that many physicians and facilities have chosen not to participate in these ACA plans is the relatively low reimbursement rates. Most of the new ACA plans are extremely discounted with most paying very low rates for patient care. Unfortunately, while many doctors have expressed their desire to participate, from a business standpoint they cannot afford to. Several doctors I spoke with actually studied the reimbursement and stated that in some cases they will actually lose money if they were to see patients in one of these ACA plans.

Despite these issues, some practices have decided to accept these plans for now while they determine whether accepting ACA plans make financial sense for both the patient and the practice. Some have told me that they will reassess after three or six months and may then chose to opt out, leaving even more patients without a doctor to visit. Furthermore, as many hospitals and specialists have already opted out of these new plans, patients may find themselves without the choices they once enjoyed when they had their traditional plans.

The benefit of a discounted ACA plan is that the cost is considerably less than a traditional plan. However, with this discount comes a price -- unexpected reality that choices of doctors and institutions may be limited. I caution patients to be informed when changing to a ACA plan so that they understand this fact and recognize there could be some sacrifice in return for savings.

More Information
Fact box

Another hidden feature of the ACA plans is that many have very high deductibles. As such, patients should expect that they may receive a bill for services until they reach this deductible level. This is very confusing for patients who never had a deductible before and who expect that they simply present their new insurance card and pay their copay. Ultimately, when they do receive this bill, they are confused and believe the bill must be a mistake. As such, many may deliberately ignore the invoice and potentially may find themselves in collection for nonpayment. Patients are therefore advised to understand the plan they are signing up for and recognize the potential additional costs.

Regardless of her frustrations, my patient was inappropriately angry at me on behalf of all physicians and stated that very vocally in my office. Her belief was that regardless of the plan, physicians should be required to accept all of these new discounted programs and even be grateful to the government for enabling patients to enjoy insurance coverage. She did not want to hear about the financial realities nor did she seem to care that some doctors may risk their practice by accepting these policies.

Unfortunately, these are the financial realities. Just as an individual should not be asked to take a significant pay cut in his or her job or profession, many physician organizations believe that doctors should not have to either.

Before signing up with one of these plans, recognize that the provider list may be limited. Call your doctors to assure that they are on the provider list and also confirm that your local hospital participates. Do not schedule a test or procedure until you know whether the institution or physician is covered under your new program and especially notify your physician that you are being covered under the ACA program so that they can appropriately refer you. Be careful to make sure that your health care is being cared for under the Affordable Care Act.

Dr. Michael Schwartz is board certified in internal medicine with a private practice in Darien. For comments or questions, visit his website at