Starting Tuesday, New Hampshire residents and small businesses will be able to compare and purchase state-approved health insurance plans through a federally operated health insurance exchange website. Those who buy plans through the exchange qualify for federal subsidies depending on their income and will have coverage beginning on Jan. 1. The enrollment period represents the first step toward the individual mandate of the Affordable Care Act, which requires most Americans to have health insurance or pay a penalty.
DHMC and other New Hampshire hospitals may face an initial surge of patients seeking treatment after Jan. 1, similar to what hospitals in Massachusetts experienced following the implementation of the state's 2006 health care reform law, Geisel School of Medicine professor William Weeks said. The 2006 law mandated a minimum level of insurance for Massachusetts state residents.
"People who were previously not insured now have a benefit they previously didn't," Weeks said.
Because many more patients will have primary care access, the demand for hospitals' emergency room services and acute care services might drop.
The likely economic impact of these changes on nonprofit hospitals like DHMC is still unclear, Weeks said, but he predicts a general trend of consolidation for New Hampshire hospitals and those across the country to reduce fixed costs.
"It'll make [hospital administrators] think more on a population basis, which would probably force some care coordination across different health care settings, so there is less waste," Weeks said. "What you'll see is hospitals forming mergers and acquisitions happening to a few dominant players in each market."
Under the new law, Medicare reimbursement will be streamlined, with a move toward bundled payments that focus on paying a group of physicians or specialists for one episode of care rather than each individual treatment session. This strategy is characteristic of the accountable care organization model. To explore how particular accountable care organizations could best improve care and reduce spending, the Centers for Medicare and Medicaid Services launched its pioneer accountable care organization model initiative in 2011. DHMC was one of 23 health care organizations to participate in the program, which has quality metrics referred to as "pay for performance," said Carrie Colla, a health policy professor at The Dartmouth Institute for Health Policy and Clinical Practice.
"Under pay-for-service, [physicians] got paid to do every little thing, so if the physician called the patient, they wouldn't get paid [for an in-office visit]," Colla said. "When you move to an accountable care model, thinking about the total cost of the patient as a whole over the course of a year, a physician might be more likely to give the patient a phone call and follow up with them if they don't need to come in, rather than force the patient to come in to the office."
The Centers for Medicare and Medicaid Services are starting to measure hospital readmission and pay hospitals differently based on their readmission rates.
"The insurers can be Medicare or Medicaid, and Medicare is certainly leading the way with this, but commercial insurance programs are also starting to make accountable care contracts, where the providers are more responsible for cost and quality than they have been in the past," Colla said.
Approximately 11 percent of New Hampshire's population is currently uninsured, according to a report from the Kaiser Family Foundation. Under the Affordable Care Act, insurers will no longer be able to deny coverage to individuals on the basis of pre-existing conditions or charge varying premiums to applicants of the same age in the same geographical location. In addition, all insurance plans sold on the New Hampshire Exchange will include the benchmark set of "essential" health benefits found in the Matthew Thornton Blue plan.
New Hampshire is still engaged in debate on whether to expand Medicaid eligibility up to adults earning less than 138 percent of the federal poverty line. The state's expansion of Medicaid would provide eligibility to 51,000 uninsured adults, according to the Center on Budget and Policy Priorities. A New Hampshire commission tasked with deciding whether to expand the program is required to submit its recommendations by Oct. 15, the Associated Press reported.
DHMC representatives did not respond to multiple requests for comment.
