PODIATRIC ECONOMICS

Surviving and
Thriving with
the Affordable
Care Act
DPMs can adapt, change,
and be successful
under Obamacare.
BY MARK TERRY

dictate policy that adversely affects

he Affordable Care Act
Out-of-Pocket Costs
(ACA), kn ow n m ore
our offices, similar to the Medicare/
One trend that some people are
commonly (and som e
Medicaid programs. While its true
blaming on the ACA is the rise of
that we faced many changes (insur
tim es pejoratively) as
high-deductible insurance plans,
ance, coding, and handling) with
Obamacare, has resulted
higher co-pays, and, for the patient,
these programs, and we complained
in enorm ous and unprecedented
more out-of-pocket costs. In other
changes to the healthcare market
in the United States. The reaction
on the part of many is to panic and
One trend that some people are blaming
assum e the worst, which seems
questionable given that the full im
on the ACA is the rise of high-deductible insurance
plementation of the Act is several
plans, higher co-pays, and, for the patient,
years off.
Lynn Homimore out-of-pocket costs.
sak, PRT, princi
pal owner, con
sultant and coach
of SOS H ealth
heartily, we are still here. We adapt
words, when patients come into your
c a re M a n a g e
ed; and despite initial negative per
office, theres a very good likelihood
ment Solutions,
ception, many offices visited nation
that they will owe more money up
LLC says, Using
wide that accepted change experi
front for services. Although its clear
a broad brush, I
enced success.
that higher-deductible health insur
w ould say the
So with that in mind, this article
ance plans are indeed a trend, it cant
biggest hurdle for doctors across the
will look at several things that are
actually be blamed on the ACA. A
board (as with any new program) is
definitely happening that are at least
Kaiser Family Foundation study in
adapting to change. I do hear rum
partly related to the ACA, and how
dicates that these health plans have
podiatrists can adapt, change, and be
blings that because it is a product
been on the increase since at least
of the Federal Government, it will
successful.
Continued on page 72

www.podiatrym.com

SEPTEMBER 2014 | PODIATRY MANAGEMENT

PODIATRIC ECONOMICS
S u rvivin g ACA (from page 71)

2006 and were caused more by

health insurance companies pushing
more and more costs onto employ
ees. In addition, in 2003, Congress
passed legislation allowing health
savings accounts (HSA) to be paired
with high-deductible plans. Although
the ACA isnt a direct cause, it is con
tinuing the trend.
So what is a podiatrist to do?
We have to be more fiscally respon
sible than ever,
say s Jo h n V.
Guiliana, DPM,
MS, E xecutive
Vice P resid en t
of Nemo Capital
P a rtn e rs, LLC,
w h ic h am o n g
its n u m e ro u s
serv ices offers Dr. Guiliana
practice manage
ment consulting. We have to have
policies and proceduresit all boils
down to our business processes
that optimize the collections at the
time of service. That can mean com
municating to all the staff and the
billing company to be alert to a pa
tients balances, to be alert regarding
the patients co-pays, co-insuranc
es, and deductibles. Not only know
what their health plans say, but be
prepared to collect fees owed at the
point of patient contact.
F rank Kase,
DPM, with Bur
bank Podiatry As
sociates Group,
APC, and Chair
man of the Califor
nia Podiatric Med
ical A ssociation
(CPMA) H ealth
Dr. Kase
Policy Committee,
agrees. What a
podiatrist has to do to survive, more
importantly than ever, is to verify
eligibility. Those words are going
to become paramount in any office
practice. Youve got to verify eligi
bility and benefits; so, for example,
when patients come in, we know
what their deductible is, how much
has been met, and what their co-pay
is. So, when we perform a service,
we know what percentage of their
service is going to be covered, how

much is going toward the deductible,

how much toward the co-pay.
There are now a number of on
line services that provide immedi
ate access to that information. The

plementation of the ACA, but these

days the situation has become more
extreme. Insurance providers are
finding themselves in an increasingly
competitive marketplaceone that is

Insurers are going to be very carefully

evaluating what plans they offer to patients, and what
their contracts with providers are like.
key, however, is to try to change the
mindset of patients who expect to pay
later, even when its clear that they
owe money at the visit. Changing pa
tients attitudes about taking respon
sibility for their own healthcare may
be the biggest challenge of all.
Homisak also adds, Be trans
parent in your billing. Discuss fees.
Dont keep the patient in the dark
until its time for them to pay their
bill.
One interesting approach is a
credit card designed specifically for
healthcare services. There are a cou
ple of services currently available
th at provide a
credit card that
is healthcare serv ic e s -s p e c ific .
L arry K osova,
DPM, Family Po
diatry Center (Na
perville, IL), says
it comes down to
people trying to Dr. Kosova
pay off a deduct
ible with small monthly payments.
"If they have a $5,000 deductible and
theyre trying to pay $25 per month,
we try to put a stop to that. Were
more than willing to work with pa
tients, though. By utilizing a health
care credit service, the doctor gets
paid immediately, paying a slight fee
to offer the service, and the patient
arranges monthly payments with de
layed interest. Patients, of course,
could just use their own credit cards,
but healthcare practice credit pro
grams often offer low or delayed in
terested rates.
Reviewing ContractsCarefully!
The careful reviewing of con
tracts was good advice before the im

SEPTEMBER 2014 | PODIATRY MANAGEMENT

to the benefit of consumers, requir

ing those insurance companies to be
far more transparent in their costs
and what they cover. This is at least
partly due to the implementation of
health insurance exchanges, the socalled health insurance marketplac
es where people acquiring insurance
outside of an employer can shop for
plans. The result, at least on one
level, is that insurers are going to be
very carefully evaluating what plans
they offer to patients, and what their
contracts with providers are like.
Kase, speaking prim arily on
California issues, says, With Cal
ifornia Blue Cross/Blue Shield, the
policies Im most familiar with, po
diatrists take a substantial discount
on your standard BC/BS fees. More
importantly, if you agree to take the
substantial discount on your BC/BS
fees, in the case of Blue Cross, you
are now obligated to accept those
fees for all of Blue Crosss individual
plans. So, in other words, by taking
those Blue Cross reduced fees on the
exchange, youve now agreed to Blue
Cross reduced fees for all individual
plansnot the group, but the indi
vidual.
On a related note, Kase goes on
to speak of a notice that Anthem Blue
Cross recently sent to over 11,000
medical practices. The insurer had
added an addendum with new regu
latory requirements, some of which
are part of Covered California. Ac
cording to the California Medical As
sociation website:
One provision of significant con
cern is language in section 12 that
removes a participating physicians
ability to opt out of the individual/
exchange product without affecting
Continued on page 74

www.podiatrym.com

PODIATRIC ECONOMICS
Surviving ACA (from page 72)
the underlying prudent buyer con
tract, as is allowed currently. Effec
tive July 1, the only option for phy
sicians who wish to opt out of the
individual/exchange product is to ter
minate the underlying Prudent Buyer
PPO agreement...Physicians do have
the right to opt out of the Anthem ex
change product without affecting the
underlying Prudent Buyer PPO con
tract if Anthem receives notice before
the effective date of the addendum,
July 1, 2014. The notice must be re
ceived by Anthem by June 30.
So, says Kase, it is more and
more important to review your con
tracts. You have to know whats in
them, and if youre incapable of re
viewing a healthcare contract, you
have to get a healthcare attorney to
review them for you, or to review it
with you so they can advise you as to
the provisions youre signing for.
Decreasing Reimbursement
Again, although its clear that re
imbursement for healthcare services
are going down, this was a trend well
in effect prior to the implementation
of the ACA. Not surprisingly, accord
ing to a report released by CareCloud
and QuantiaMD, 65% of physicians
view declining reimbursement rates
as the biggest element negatively af

paid from the $5000 that the custom

er is responsible for. The solution,
just like with a concierge practice, is
that you have to provide value.
But before a discussion of value,
a discussion of basic business prac
tices is worthwhile. Typically in a
normal business (i.e., not health
care), if the core costs of a product

Pushing aside politics,

the overall aim of the ACA was what is called
the Triple Aim: to improving the experience of care,
improving the health of populations,
and reducing per capita costs of healthcare.
rise, the retailer/service provider tries
to pass the costs onto the customer
through higher pricing. Thats not al
ways possible in healthcare. Typical
non-medical businesses often hit re
sistance on raising prices as well, and
have to look at various approaches to
maintaining their profit margins.
As mentioned before, make sure
you get paid w hats owed. Aside
from ensuring that patients pay their
co-pays, verify that what you do sub
mit to payers is correct and payments
get made. Get a professional billing
service if too much money is slipping

Get a professional billing service

if too much money is slipping out the door and make
sure the service is doing their job properly.
fecting their practices profitability.
The dichotomy here, of course,
is that if, as mentioned earlier, more
and more patients have high deduct
ibles, then your services are being
paid up front with cash instead of
by insurance plans. Guiliana says,
When the topic of concierge practic
es comes up and doctors are curious
about them, I often say you might
not realize it, but you could possibly
have a concierge practice right now
and not know it. The insurance car
riers are paying you virtually nothing
in some instances, and its all being

your regular medical supplier with

those of other companies. If you basi
cally lay out your inventory from the
previous year to a variety of vendors
who can supply the same customer
service and the same products, you
might get a better deal.
The APMA, for instance, has a
group purchasing plan through Office

out the door and make sure the ser

vice is doing its job properly. Guil
iana says, We have to look at our
expenses, seek out and do some due
diligence on how we can cut those
expenses, of course without compro
mising quality.
One idea Guiliana suggests for
reducing expenses is to consider
putting out a bid for your medical
supplies. Medical supplies are one
of those things that often creep up
wards, just like our insurance costs
can creep upwards. Many times, you
should be comparing the prices of

SEPTEMBER 2014 | PODIATRY MANAGEMENT

Depot. Kosova says, I think buying

things through a group club is the
way people are going to save in the
future; re-negotiating rents, re-nego
tiating with employees. 1 also think
using technology appropriately can
save money.
Guiliana is quick to point out a
related truism: This is something
that needs to be delegated. The phy
sician shouldnt be doing this. A po
diatrists time needs to be absolutely
cost-effective, because theres an ex
traordinary amount of waste in the
typical medical practice.
In short, yes, reimbursement is
going to be tighter and tighter. Faced
with this environment, a typical busi
ness responds in several ways: in
creasing business volume through
marketing and other methods, adding
secondary sales items, and increasing
efficiency and cutting costs in other
placesall topics covered through
out the year in the pages of Podiatry
Management.
About That Quality Thing...
Pushing aside politics, the overall
aim of the ACA was what is called
the Triple Aim: to improving the
experience of care, improving the
health of populations, and reducing
per capita costs of healthcare. On the
face of it, all three of those aims are
desirable. Meeting those goals, how
ever, is difficult and everyone has an
opinion as to whether the thousands
Continued on page 76

www.podiatrym.com

PODIATRIC

ECONOMICS

S u r v iv in g A C A (from page 74)

of pages of rules and regulations cre

ated by the ACA will do so. In some
ways, its an enormous social exper
iment, and only time will tell if its

Are we utilizing time optimally, are

we utilizing our physician extenders
optimally, delegating tasks to staff
to allow the schedule to flow better?
Weve really got to look at what pa
tients consider valuable by perform

By law, primary physicians

can only belong to one ACO. Specialists, like podiatric
physicians, can belong to more than one.
successful. In the meantime, staying
in business and continuing to provide
the highest quality healthcare are pri
orities, no matter how challenging.
Guiliana says, Now that patients
are footing most of this bill, they are
seeking value. And weve got to be
conscious again of our business prac
tices and some of the flawed process
es that led us into long waiting times,
how we schedule patients, and so on.

ing patient satisfaction surveys and

responding to those surveys.
As the expression goes, When
youre up to your neck in alligators,
its hard to remember that its your
job to drain the swamp. When youre
up to your neck in government reg
ulations and changes in insurance
policy, its hard to remember that its
your job to take care of the patient.
I have a sort of policy with pa

tients, says Kosova, that I dont

really look at their insurance. We get
a list of what they have and whats
covered, but I dont look at the insur
ance at all. I do that on purpose be
cause we have HMOs, and we have
insurance thats good and some that
arent good, but I dont want to base
my treatment on what insurance they
have. I think thats poor medicine.
If 1 cant do what I normally do to
treat patients and Im not going to
get paid for it, they might as well
go somewhere else because theyre
going to get poor treatm ent. Im
going to possibly set myself up for
a lawsuit because I didnt do some
thing that I normally do for someone
else because it just so happens that
XYZ HMO wont let me do it. I think
thats a problem.
A c c o u n ta b le C a re O r g a n iz a tio n s

One aspect of the ACA is the de

velopment of Accountable Care OrgaContinued on page 77

FOR 4 0 YEA R S...

#1 FOR R E LIA B ILITY ,
PERFO RM ANCE,
A N D SERVICE!

Gold Standard for Debridement Mac hines

T i r e d o f f o r e i g n p r o d u c t s ' p o o r v a c u u m s , w e a k h a n d p i e c e s , a n d b a d s e r v ic e ?
T h e n b u y J a n I,!

S e e a ll o u r m o d e ls , o n e f o r e v e r y b u d g e t a n d p r a c t ic e s ty le ,
d e s i g n e d , a s s e m b l e d a n d s e r v i c e d i n M o u n t M o l ly , N J, b y

Jan

L's

Sm art Pro Features:

Counter or Floor Positioning

v is itin 8 w w w .ja n lin c .c o m .

I o r I n f o , c a ll: 6 0 9 .2 6 1 .1 1 3 3 .

Portable-Carry Handle and Attached Handpiece Holder

H an d piece-30,000 RPM, Large Opening for Superior Collection, Surgical Type No Slip Tw ist Bur Lock,"Built In" System O n/O ff Switch
Control Panel- Variable Vac and Drill Control w ith Large Speed Display, F/R, Real Controls Iden tifiable by Touch Alone, Ft. Control
Circle # 4 1
SEPTEMBER 2014 | PODIATRY MANAGEMENT

www.podiatrym.com

PODIATRIC ECONOMICS
Surviving ACA (from page 76)
nizations (ACOs), which are essen
tially a push for networks of physi
cians and hospitals. Ive written ex
tensively about this in The ABCs of
ACOs (Podiatry Management, Sep
tember 2013), but its unclear how
big an impact ACOs will have on
podiatry. As I wrote then, Cutting
costs and increasing the quality of
healthcare might be a good thing and
ACOs might be a path toward that
goal. There is the concern of being
cut out of what is probably going to
be the trend in healthcare.
By law, primary physicians can
belong to only one ACO. Specialists,
like podiatric physicians, can belong
to more than one. Some local restric
tions by medical associations may
exist, but by law, podiatrists can be
long to more than one. My sugges
tion for podiatric physicians who join
ACOs is to get involved in the lead
ership positions, the financial posi
tions, and the governance positions,
says Kase.

as Lynn Homisak says,

ACA is likely not the
final iteration of public
healthcare in our life
time. Endeavor to be
the best. Successful po
diatrists continue to be
successful. PM

M a rk T e rry is a freelance w riter, editor,

author and ghostw riter specializing in
healthcare, medicine and biotechnology.
He has w ritte n over 700 magazine and
trade journal articles, 20 books, and dozens
o f w hite papers, market research reports
and other materials. For m ore information,
visit his websites: w w w .m a rkte rryw rite r.
com and w w w .m arkterrybooks.com .

PRIVATE LABEL

40% UREA
STICK
Qots ov\ dry!
Your Practice Name
& Your Nam e Here

T a k e a Deep B re a th ...

The full name of the ACA is The

Patient Protection and Affordable
Care Act. It is over a thousand pages
long. Government agencies and in
surers have responded with tens of
thousands of pages of rules and reg
ulations and laws to implement it. It
is, without a doubt, disruptive ... at
the moment.
One of the goals of the ACA is to
provide health insurance coverage
for everyone in the United States
that means an additional 30 million
or more potential patients. It also
legislated that insurers couldnt turn
down potential patients on the basis
of pre-existing conditions; it allowed
kids to stay on their parents health
insurance plans until the age of 26.
It also ended lifetime limits on cov
erage, forces insurance companies
to publicly justify any unreasonable
rate hikes, and ended arbitrary with
drawals of insurance coverage. There
are many very positive things in the
law, primarily for patients. Its effects
on healthcare providerspodiatric
physicians, hospitals, laboratories
are dramatic, and arguably nega
tive, at least in the short term. But
www.podiatrym.com

Offer patients a revolutionary new way to apply 40% urea with

a twist-up stick that goes on dry and only where needed.
No Mess - No Waste
No Hand Washing
No Oozing Between Toes

"This stick is so much easier to

use than those goopy creams.
I don't have to rub it in or wash
my hands afterwards."
- Ted P., carpenter

M+DPrivateLabel.com
Toll-Free: 8 8 8 -4 4 5 -3 3 6 8 Local: 4 0 2 -3 3 9 -8 8 2 5

Visit MDPrivateLabel.com to get started

Circle # 4 8
SEPTEMBER 2014

| PODIATRY MANAGEMENT

Copyright of Podiatry Management is the property of Kane Communications Incorporated

and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder's express written permission. However, users may print, download, or
email articles for individual use.