Health Reform 101: Use this primer to navigate the changes ahead

The tax credit program lasts in this form through 2013. In 2014 and 2015, the size of the credit jumps to 50 percent of employers’ premium contributions. However, to qualify, businesses must buy coverage through the state health insurance exchanges slated to begin in 2014.

Many small otolaryngology practices would be eligible for the credit based on the number of employees, but the wage restriction could rule out some of them. Although physician owners’ salaries aren’t factored into the average wage calculation, employed physicians’ salaries are. Employed doctors make more than $50,000 a year and could put average employee wages above that mark. In addition, doctors often employ highly trained staff whose earnings are above the law’s limit.

Insurance Claims Streamlining

Physicians’ interactions with health insurers on routine matters should become easier thanks to some administrative simplification provisions in the reform law. HHS is required to develop national standards insurers must follow regarding patients’ insurance eligibility, claims status transactions, electronic fund transfers, payment and remittance advice, enrollment and disenrollment and premium payments.

“Physicians should benefit from the changes, which will make it easier to track claims and, in many cases, should improve physician revenue cycles and reduce overhead costs,” the American Medical Association (AMA) states in its booklet, “What Health System Reform Means to Physicians and Patients: The Patient Protection and Affordable Care Act” [http://www.ama-assn.org/ama1/pub/upload/mm/399/hsr-booklet.pdf]. HHS is supposed to finalize the first of the standards by mid-2011, and regulations are to be phased in between 2013 and 2016. Beginning in 2014, health plans that fail to meet the requirements will face fines.

New Care and Payment Models

The ACA creates several programs designed to test new models of care delivery and payment. These efforts include the voluntary Medicare Shared Savings Program, which promotes accountable care organizations (ACOs) and Medicare’s national physician-hospital payment bundling pilot program. The ACO project, set to begin in 2012, aims to create incentives for health care providers to work together to treat patients across care settings, including doctor’s offices, hospitals and long-term care facilities, according to HHS. Providers will be able to share savings with Medicare. HHS issued its proposed ACO rule in March 2011.

The bundled payment project, which is to begin in 2013, will involve eight acute conditions to be selected by HHS. Providers, including doctors and hospitals, will receive combined payment for care provided three days before admission through 30 days after discharge.