The New York Times reported today that “On Health Exchanges, Premiums Maybe Be Low, But Other Costs Can Be High.” This is something we’ve been talking about for a couple of months now — often getting skeptical looks here in our super-blue home-town.  But it’s not about partisanship.  The ACA is simply accelerating the trend of payers pushing more responsibility onto patients — a trend that has been gathering momentum for many years.  It’s not unexpected if you’ve been watching how health plans have been evolving. Still, it is discouraging if you had hoped the exchange plans would offer better patient protection against big out-of-pocket costs — and it also means that the burden that practices face to collect more of their revenue from patients keeps growing.

The AMA’s 2013 National Health Insurer Report Card (NHIRC), published earlier this year, revealed that health plans across the country were placing about 25% financial responsibility for cost of care onto patients:











The target 2014 patient responsibility proportions that were set for all ACA plans skew even higher than this — even the “silver” level, where subsidies are targeted, pegs patient responsibility at 30%:

ACA Bronze

ACA Silver

ACA Gold

ACA Platinum






These “actuarial values” were fairly widely reported prior to the exchanges even opening (here’s one link from MSN), so it’s a bit of a mystery why the Times is reporting this as news at this point.  It’s critical that consumers understand what they’re getting into when they sign up for coverage, and the media should have been on top of this key information.  (Especially if you’ve not purchased coverage before, the terminology behind patient responsibility payments — co-insurance, deductibles, copayments, out of pocket — can be very confusing. Many new patients are likely to be confused and possibly quite disappointed.)

We expect that this means practices will need to be even more careful and sensitive in dealing with privately insured patients, especially in January, when deductibles re-set.  Some patients will be more confused than ever — and may owe more than they expect at time-of-service.  Other patients who had purchased their own insurance previously may be confused if they find their new exchange plans require much more shared financial responsibility than their prior plans did.

Above all, to us this signals that practices must continue to hone their skills related to patient collections and payment planning.  Because even though these new actuarial levels may apply only to independently insured patients now, it’s hard to imagine they won’t represent a new benchmark for payers.  As employer plans are modified over the next couple of years, and especially as the ACA’s impact on employer plans begins to be felt after next November, deductibles of $6K+ per individual and $12K+ per family (the current ACA maximums) along with out-of-pocket of 30% or 40% could be closer to the new normal.

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