The Unintended Side-Effects Of Health Reform: Increased Consumer Responsibility And Decreased Provider Revenues

By Lisa Maki,

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It has been over 5 years since the President signed the Patient Protection and Affordable Care Act (ACA) into law providing healthcare reform from meaningful use to extended Medicaid and more. Probably one of the most controversial mandates of the ACA was universal health insurance coverage which has been in effect for over a year. Now in year two of universal coverage, it is safe to say there have been a number of surprising and unintended outcomes, both positive and negative.

Overall, healthcare reform has supported an on-going industry trend to shift the cost of care to the consumer. This can be observed in the increase of consumers and employees enrolling in High Deductible Health Plans (HDHPs) which increases the individual’s expected out of pocket costs for basic care. At PokitDok, we find that this trend can be positive by placing purchasing power into the hands of the healthcare consumer, just like any other industry, which naturally leads to improvements in the consumer experience. However, the ACA has also resulted in unintended side-effects for consumers and healthcare providers including out-of-pocket costs consumers can’t afford and lower reimbursement revenues for healthcare providers who serve an increasing number of patients who have not met their deductible.

The reduction in reimbursement revenues for healthcare systems and providers is a particularly complex problem. Current revenue cycle and practice management systems, often integrated with the provider’s electronic medical record solution, still bill for each patient’s encounter as if it will be covered by insurance. However, with the increase in popularity of HDHPs (65% of employers are predicted to offer at least one by 2017), a majority of consumers may not satisfy their deductible until the end of the benefit year resulting in the bulk of their basic care being paid for out of pocket. For providers this means a significant amount of what was, under the pre-ACA system, reimbursed by a patient’s benefit plan, must now be billed directly to the patient. Couple this with the number of patients now receiving care prior to satisfying their deductible and healthcare providers are seeing as much as 20% of their accounts receivable going to collections due to their patients’ inability to pay.

In response, healthcare systems and providers are seeking “health-enabled” ecommerce tools that will help them capture payment from HDHP members at the time of booking an appointment or service as well as identify patients at financial risk before those patients have the procedure, not afterward when it’s too late. At PokitDok, we support solutions to address both the consumer’s financial need and the healthcare provider revenue cycle two ways:

  1. Health system e-commerce and scheduling solutions that include real-time eligibility and pre-adjudication to identify and collect appropriate payment--co-pay, partial or full payment including past due amounts--prior to the appointment
  2. Our newly released Health Credit Outcome (HCO) service that identifies not just a patient’s ability to pay, but also the provider’s ability to obtain payment, either from the patient or their insurer. HCO can include connections to potential sources of financial aid as a benefit to both the patient and the health provider.

At PokitDok, we provide a platform of cloud-based web services to meet the challenge of a changing healthcare market from solutions that reduce operational cost to support for new business models that deliver both increased patient value and margin improvement. Our customers include 24-hr imaging services with price elasticity based on the time-of-day to health systems testing discounted, same day cash payments without impact to current EMR or payer infrastructure and processes.

This broad overview offers just a few of the complexities of patient and provider financial responsibility in the post-ACA healthcare market and how PokitDok views and addresses them.

The opinions expressed in this blog are of the authors and not of PokitDok's. The posts on this blog are for information only, and are not intended to substitute for a doctor-patient or other healthcare professional-patient relationship nor do they constitute medical or healthcare advice.

  Tags: Dev, Enterprise, Providers


  Comments: 1

  1. Clinton Phillips

    Lisa, this is a great article. Through innovation PokitDoc is addressing some real issues in this new marketplace. Thank you.

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