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Uncertainty on how AHA will impact DHM services

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POSTED January 21, 2014 1:40 a.m.

It’s not too tough to guess the No. 1 topic of conversation these days around the doctors’ lounge at Doctors Hospital of Manteca.

The Affordable Healthcare Act impacts every physician and patient directly or indirectly. And the guy who perhaps has the most critical job in Manteca when it comes to dealing with its implementation is Doctors Hospital of Manteca Chief Executive Officer Nicholas Tejeda.

In a typical year Tejeda and the staff that runs the 78-bed hospital can plan on 28,000 emergency room visits, 4,000 admissions, 2,800 surgeries, and 800 babies being delivered.

“It’s pretty consistent,” Tejeda told Manteca Rotarians during a talk on Thursday at Isadore’s Restaurant. “You could project a coming year with almost 100 percent certainty.”

That all changed on Jan. 1 when the AHA’s insurance coverage went into effect. Now the workload is anyone’s guess depending upon how many people previously uninsured sign-up and how many people are forced to shift insurance coverage.

And given the fact the hospital is Manteca’s largest private sector employer the impacts go beyond just the health of potential patients.

There are some things that can be planned on using what one might best describe as educated guesses. One example is bariatric surgery. Now that many people previously uninsured may be able to afford the fairly expensive weight loss procedure, it might increase 400 percent.

But what could happen to other numbers depends on where the newly insured through Covered California end up going with as well as others forced into the exchange with the cancellation of their individual policies that didn’t conform to the new AHA rules for coverage.

In San Joaquin County there are four insurance exchange players — Anthem, Blue Cross, Blue Shield, and Kaiser.

With 23 percent of those insured in the county prior to Jan. 1, Kaiser is a closed system that means it won’t impact Doctors Hospital in terms of additional insured.

The new insurance policies set rates based on age, ZIP code and household size. That is one thing from Tejeda’s perception does not bode well for San Joaquin County residents getting insurance via the exchange.

 That’s because everything from air quality to poverty have impacts on health in geographical areas. So even if you aren’t likely for whatever reason to come down with an illness, that isn’t the case for the risk group as a whole. That means insurance can cost you more simply based on where you live much like pre-existing conditions did previously. The big difference now is you can’t be denied coverage because of pre-existing conditions but at the same time rates are impacted by those who live in your community regardless of how healthy you might be.

That’s just one of the quirks in the AHA that Tejeda personally believes could work against affordability.

Another is the provision that allows adult children to stay on their parents’ health plan though age 26. Tejeda noted that seems counterproductive when the push is to get as many healthy young people from age 18 to 34 into the exchanges to help absorb the cost of covered individuals that are older that tend to use medical services more often and those that are sicker. The latest figures show 38 percent of those who have signed up on the exchanges are between the ages of 18 to 34 while 52 percent are ages 45 to 64.

Many physicians haven’t been informed by Covered California whether they are part of the new exchange coverage. Tejeda said many are calling him to find out

Adding to the confusion is the fact Covered California requires physicians and hospitals to see patients retroactive to Jan. 1 for medical care prior to the first premium payment being made in mid-January. Doctors are seeing patients that say they are covered but office staff has no way of verifying. But they also cannot see them under the law.

“There is a very good chance that services are being provided that doctors and hospitals won’t receive payment for,” Tejeda said if premiums aren’t paid.

And although having almost everyone covered under existing insurance programs, the exchanges or Medicare and Medi-Cal means hospitals for the most part will be assured payment the pressure will be on to make sure there are adequate physicians available.

Tejeda noted a surge in insurance coverage means more people will be accessing medical care just as a number of physicians are approaching retirement in Manteca. There hasn’t been a new general practitioner open a practice in Manteca for the past seven years. So that means the community has the daunting task of trying to attract doctors to not only replace retiring physicians but also to meet the needs of the newly insured.

Adding to the uncertainty is the expansion of Medi-Cal to cover those additional people who can’t afford insurance through the exchanges. That poses a problem because there are no doctors in Manteca, as an example, that accept Medi-Cal.

“You could have a lot of people who will get insurance through Medi-Cal that will want to access health care services but no one will take them,” Tejeda said.

Tejeda noted that the AHA is not going away and that the goal now needs to be to make it work.

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