Health Care Reform and the Private Practitioner

The health care dollar pie is a simple three piece pie – one piece for patients, one piece for providers, and one piece for insurers. What has never been simple is understanding the sizing of the pieces – over time, we have watch the patient and provider pieces shrink, while the insurer piece grow. Now that the six month anniversary of the signing of the Patient Protection and Affordable Care Act(PPACA), commonly known as Health Care Reform has passed, we are beginning to see a number of its provisions take effect. The pieces of pie are being reformatted. No one can say definitively how healthcare reform will ultimately impact private practitioners, but all indications are that it should be a “boon” to providers and patients alike. It is a good idea for therapists and patients to familiarize themselves with the different provisions as they begin to unfold and take effect.
Here are some new provisions now in effect:

  1. Insurance carriers can no longer exclude coverage for children / dependent policy holders under the age of 19 with pre-existing conditions . This is a huge development, because in the past, many children born with developmental delays were denied coverage based on this premise. This also means families of children with disabilities can now change their policy without fear of losing coverage for their child. The White House estimates 72, 000 uninsured will gain coverage because of this.
  2. Insurance carriers can no longer impose lifetime limits on benefits. According to the N Y Times, this will extend coverage to 20, 400 people that may exceed their limits each year.
  3. Anyone who previously reached his or her lifetime maximum on an existing policy can re-enroll. Restrictions on annual limits have begun, but will not be eliminated in full until 2014 . Additionally, insurers will no longer be able to drop insurance contracts(technically called rescissions) if they discover a technical error on their application. Rescissions now require a 30 day advance notice and are limited to fraud or intentional misrepresentation of material fact.
  4. Young adults can stay on their family health care plan until they turn 26 , regardless of student or marital status. (Certain states have extended this until age 29).

These provisions alone clearly will redistribute the pie pieces and offer more to patients, and in turn, providers. This new population, previously denied service, will seek out their new benefits, and this can increase demand for our services. Remember though, that the law is just one part of reform- there will be much needed regulatory work to be done to implement the new coverage.

Another provision also in effect concerns preventative care. Now, certain measures, recommended by a task force appointed by the U.S. Department of Health and Human Services such as colonoscopies, immunizations and mammograms must be covered without co-payment.

The parameters of preventative care, and what it will encompasses in the coming years have not been fully defined ,and, at the moment, do not include “lifestyle intervention services”. Many anticipate that lifestyle changes as a preventative measure will be among the future initiatives. OT are known to address prevention initiatives such as reducing falls, improving physical activity to mitigate chronic disease and secondary health conditions, and tailoring wellness programs for populations that have chronic conditions and disabilities, so we are well positioned to lead in this area. We can provide insight and interventions to increase physical activities among appropriate patients that will reduce excess body mass, improve health status, and reduce associated chronic disease risk. On the community level, we can work to offer evidence–based prevention and wellness. It is key to stay informed so that we can fully participate in health care reform, and work to carve out our piece of the healthcare dollar pie.

Comments are closed.