The federal health law has gotten most of the attention in recent months, but even before it came along, the country’s health care system was undergoing significant shifts. Here are some big changes in health care you’re likely to notice in 2014.

1. You might get more nagging from your doctor’s office.

For years, policymakers have talked about problems in the way health care is paid for, which rewards doctors and other providers for doing more procedures or seeing more patients, not for keeping them healthy and out of the hospital. Now the health care “payers” — that is, insurance companies and big government programs like Medicare and Medicaid — are working on changing that, a shift referred to as moving from paying for volume to paying for value.

Exactly how the new payment arrangements will work is still evolving, but it’s expected that doctors will increasingly be judged, and compensated, based in part on how well they perform on measures such as making sure their patients get appropriate screenings and preventive care, and making sure patients’ chronic conditions are well managed. That places a greater emphasis on taking a more active role in patients’ health and coordinating their care.

What does that mean for patients? Chances are, someone from your doctor’s office might remind you that it’s time for your annual exam, or you’ll hear about it if you miss a recommended screening.

2. Patients will become more aware of what their care costs.

As health care costs rise, patients are increasingly left to foot a larger share of the bill. And experts expect that will influence the decisions people make about their care, making them more price-conscious.

For many people, getting medical care now means paying a certain portion out-of-pocket. In 2013, more than three-quarters of people with employer-sponsored health insurance had a plan with a deductible — that is, a set amount of money they must spend before the plan begins reimbursing for coverage of most medical services, according to a survey by the Kaiser Family Foundation and the Health Research & Educational Trust.

The health plans sold through the state’s health insurance exchange — a new marketplace for coverage created by the federal health law — all have deductibles, some as high as $12,600 for a family (although some people with low incomes will have the option of buying plans without a deductible).

And some insurance plans are adopting more nuanced methods of getting members to think about costs, such as requiring lower cost-sharing if patients choose providers deemed more cost-effective.

Because insurers have traditionally paid most of members’ medical bills, people with insurance have traditionally had little idea of what the care they were getting cost, and little incentive to get the best price. But experts believe that as people start to pay more of the costs, they’ll become more price-conscious and potentially shop around for services like MRIs or lab work.

Still, some experts question how much shopping around patients will really do. And some worry that people will skimp on necessary care because of the costs.

Dr. Steven Wolfson, a cardiologist who practices in the New Haven and shoreline areas, said he’s already seen a change. “People are avoiding basic services,” he said, noting that some patients cancel their annual appointments. “What I’m seeing instead is the patients are calling for care because something has changed. And I’m seeing them in the emergency department or after people have already been admitted to the hospital.”

For doctors, the shift also means a potentially uncomfortable new issue: Instead of dealing with insurance companies to get paid, they face the prospect of having to go after patients for payment.

3. Narrow insurance networks: Will they come to Connecticut?

In the push to keep insurance premiums down, some insurers have chosen to offer policies that cover a limited range of doctors, hospitals and other health care providers. It’s a strategy that some experts think will become more common. More people are expected to buy insurance on their own in the coming years, many through state-based exchanges created by the federal health law, which are intended to make price comparisons between plans easier. Experts say those buying insurance on their own are particularly price-sensitive, and limiting provider networks is one way for insurers to offer competitive premiums.

Some states already have plans with limited networks being offered on their exchanges.

In Connecticut, this hasn’t been a major issue so far, with one exception. The state’s exchange, Access Health CT, has stricter provider network requirements than its counterparts in many other states, requiring that insurance companies selling plans through the exchange use networks that are substantially equal to the networks used in their other commercial insurance products.

But the issue has made its way into Connecticut in one high-profile way: UnitedHealthcare’s notice earlier this year that it intended to drop thousands of doctors from its Medicare Advantage network. In response to a lawsuit by two county medical associations, a federal judge temporarily blocked the company’s move to drop doctors affiliated with the two medical groups. 

4. Doctors are joining bigger groups or hospitals.

Independent medical practices with one or two doctors have long been common in Connecticut, even as the medical field has consolidated in other parts of the country. Now that’s changing here, too, driven by changes in how medicine is practiced and paid for.

Those include the need to buy costly electronic medical record systems (providers that don’t use them will soon face penalties) and new payment models that encourage doctors to take a more active role in patient care. It’s easier to hire a care coordinator, or to pay for electronic medical records, if you work in a practice with several other doctors, rather than on your own.

For many doctors, that’s meant trading in independent practice to become an employee of a hospital or affiliating their practice with a larger hospital system or physicians group. The exact arrangements vary, but there’s a common theme: It allows doctors to offload back-office functions and costs like billing, negotiating with insurance carriers and handling malpractice insurance.

But for some, there’s a big tradeoff: They’re giving up the autonomy to run their practices the way they see fit, which could mean seeing uninsured patients at little or no cost or setting their own policies. And some have questioned how the changes will affect physicians’ productivity.

Experts say there’s a generational shift, too: Many young doctors coming out of training — often saddled with more than $100,000 in debt — are opting for the security, infrastructure and better hours that come with being employed in a large organization, rather than running their own small businesses the way most of their predecessors in private practice did.

5. Hospitals are joining larger networks, and some are exploring going for-profit.

For years, a common line among health care experts in Connecticut was that the state’s hospital landscape would one day be dominated by two players: Yale and Hartford Hospital.

The wave of consolidation going on among hospitals in Connecticut hasn’t followed that script exactly, but it’s not too far off. Hartford Hospital’s parent company, Hartford HealthCare, now includes five hospitals. The Yale New Haven Health System now includes three hospitals (as well as the former Hospital of St. Raphael, which Yale-New Haven Hospital acquired in 2012), and it could soon include two more.

There are other hospital networks emerging, including Western Connecticut Health Network, which includes Danbury and New Milford hospitals. And a national for-profit hospital chain, Tenet Healthcare, could potentially own all or part of four Connecticut hospitals in the near future.

The reasons behind the trend toward consolidation include the need to access capital to pay for electronic medical record systems and facility upgrades. Hospital officials expect new payment models to require more efficient operations, something that makes economies of scale appealing.

The growth of larger hospital systems has also raised concerns among some experts, who worry that increased negotiating clout by hospitals could drive up health care costs. And the entrance of Tenet, a for-profit chain, into a state with only one for-profit hospital has drawn criticism from some groups, including unions representing workers at Waterbury Hospital, which is seeking regulatory approval to form a joint venture with Tenet. But proponents of the changes say for-profit status gives hospitals access to much-needed capital and makes hospitals into local taxpayers. Expect to hear more about this issue during the coming legislative session.

Arielle Levin Becker covered health care for The Connecticut Mirror. She previously worked for The Hartford Courant, most recently as its health reporter, and has also covered small towns, courts and education in Connecticut and New Jersey. She was a finalist in 2009 for the prestigious Livingston Award for Young Journalists, a recipient of a Knight Science Journalism Fellowship and the third-place winner in 2013 for an in-depth piece on caregivers from the National Association of Health Journalists. She is a 2004 graduate of Yale University.

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