Local stakeholders, residents respond to the Affordable Care Act

Medical professionals in Central Texas are changing health care delivery models by adding services, launching pilot programs and using data to keep doctors accountable for treatment outcomes as a result of the Affordable Care Act, which was promoted as a tool to deliver more efficient and less expensive health care to customers.

The ACA requires all U.S. residents to be enrolled in a private or federal health insurance plan. For providers, the ACA mandates changes to the health care delivery system such as lowering health insurance premium costs, prohibiting denial of health insurance because of pre-existing medical conditions and offering prescription drug discounts, according to healthcare.gov, the website managed by the federal government for Health Insurance Marketplace plans. Starting in 2015 physicians will be paid based upon the quality of care they provide and not the number of patients they see, according to healthcare.gov.

"When that bill was passed everyone sort of woke up," said Dr. Norman Chenven, founder and CEO of Austin Regional Clinic. "The Affordable Care Act tells Medicare to contract with doctor groups or doctor/hospital combinations to provide care for a group of patients. If you can provide high-quality care and get the cost down, then there is a sharing of the cost saving."

Open enrollment for the Health Insurance Marketplace began Oct. 1 and closed March 31. Eligible applicants for health insurance through the marketplace must be a U.S. citizen or lawfully present in the U.S. Local health care agencies such as CommUnityCare, Foundation Communities and Lone Star Circle of Care led efforts to help people enroll for coverage.

The new marketplace insurance plans include ambulatory, hospitalization, surgery, maternity and newborn care, prescription drugs, and wellness and preventive care services.

Changing health care delivery

In an effort to increase visits to primary care providers and lessen trips to emergency rooms, physicians in Central Texas are pushing preventive care models.

ARC manages 18 locations in Central Texas and offers services such as primary and specialty care. An example of a preventive care initiative at ARC is its participation in a national program sponsored by the American Medical Group Association to offer free blood pressure screenings. ARC is also involved in partnerships with health insurance companies to compile data and measure the individual health of its patients.

"What we have been able to do is get the [health insurance] claims and match that with our own clinical data so that we have a much more rounded picture of what is happening to the patient," Chenven said. "We match that up with all of our clinical history, and we're able to come up with a [patient] profile."

The patient profile allows ARC to keep track of its patients, by noting where patients go to get care and what kind of care they are receiving.

Prior to having access to this data, known as Clinical Data Repository, Chenven said physicians might lose track of a patient if they did not come back to ARC.

Ashlee Mooneyham, provider contracting manager for CommUnityCare, said the organization recently began offering services such as cardiology, mammography, dermatology and gastroenterology. In Austin, other specialties such as behavioral health could also be a focus in the future, she said.

"I'm hoping [the new programs are] really going to change the focus more on preventive care, which will hopefully keep people out of the emergency rooms more and catching illnesses when they are first starting versus when they are already having an issue," Mooneyham said.

CommUnityCare health clinics primarily serve the underinsured and uninsured, and there are 24 clinic locations in Central Texas. Medical services offered include dental, pediatrics, pharmacy, primary care and HIV services. To keep up with rapid population growth and the rise in insured Texans who now have increased access to health care, CommUnityCare's clinic hours have been extended, CEO George Miller said. The company is also launching pilot programs to determine whether its clinics are needed in areas it does not serve, he said.

Rebekah Haynes, former director of communications at LSCC, said the ACA could prompt more people to go to the doctor for screenings and seek other preventive measures because health care costs might not be as much of a concern.

"We have patients who have insurance in some cases now for the first time in their life," Haynes said. "We're seeing how appreciative they are, but also you may see some of these people coming in for their checkup. Previously [they] may have put that off and only went to the doctor if they were actually sick or had some sort of ailment."

New patients who received enrollment assistance through LSCC can be seen at its clinics, as well as people below the federal poverty level who are not insured, said Maria Serafine, LSCC's director of member services.

"I'm guessing that we will continue to see more uninsured [people] since we went out promoting Lone Star Circle of Care [and helped] people with enrollment," she said. "There were probably people that [did] not qualify for some of the premium tax credits and subsidies. We will probably also see an increase in those people that did not get a plan through the marketplace."

Newly insured refugee and immigrant communities seeking health care are also creating a need for physicians that speak other languages such as Arabic, Burmese, Korean and Vietnamese, said Elizabeth Colvin, director of Insure Central Texas, the health insurance enrollment program run by Foundation Communities.

"I think [the ACA] is definitely going to change things," she said. "It is better for our community overall that people have access to health insurance now. There's going to be higher demand from Spanish speakers seeking assistance."

What happens next

The closing of open enrollment means those who have not signed up for a plan as of March 31 will face penalty fees when they file their 2014 federal tax returns. In 2014 adults without insurance will pay $95 for the year, $47.50 per child younger than 18 years old up to $285 per family—or 1 percent of the annual household income, whichever is greater, according to LSCC. In 2015 the penalties will increase to $325 per year per adult, $162.50 per child and up to $975 per family—or 2 percent of the annual household income, whichever is greater.

Penalty fees depend on factors such as household income and are scheduled to increase each year that a person is not signed up for health insurance. Exceptions are made for those with financial hardships, religious objections, qualifying Indian tribes and others.

Representatives of CommUnityCare, Foundation Communities and LSCC are still available by appointment to assist those who are eligible for a special enrollment period. A special enrollment period is generally granted for 60 days between now and Nov. 15 for people who have had mitigating circumstances that affected their ability to gain health insurance such as marriage, birth of a child, loss of health insurance or other changes in family status, according to healthcare.gov.

"The special enrollment period is only [for] 60 days after a qualifying event, so people need to act quickly to take advantage of their opportunity to enroll in insurance between now and November if they do have a qualifying event," Colvin said.

U.S. residents can sign up for health insurance or renew plans during the next open enrollment period, which is Nov. 15, 2014–Feb. 15, 2015. Colvin said she anticipates further collaboration with other agencies for education outreach to promote future open enrollment periods.

"There are still so many people who are learning to navigate the world of health care insurance, so we are still providing a lot of education for those individuals and continue to help them understand, what is your deductible, what is your prescription coverage " she said.