Government health officials worked diligently this year to improve consumer experience on Healthcare.gov and make sure people know what they are getting for their money when they pick health insurance. But one thing is out of the government’s control: whether doctors and hospitals will agree to accept patients who buy these plans.
Surveys and data are limited, so it’s difficult to gauge the extent of the issue, but anecdotal evidence from patients and providers show it is a struggle. Some newly insured patients wonder whether it’s worth paying for coverage they can’t actually use. Even when they do find a provider, reports show they face crippling out-of-pocket costs they didn’t expect.
Doctors or hospitals may be left out of insurance networks for many reasons; the decision is usually up to the insurance company, not the provider, but it usually comes down to reimbursement, which can be lower through plans obtained via the Obamacare marketplace.
“We have no idea what the plans are paying,” says David Howard, professor in the department of health policy and management at Emory University. “That’s closely guarded information. We can only draw conclusions based on anecdotal reports.”
The Obama administration has tried to address these issues during this year’s open enrollment, which began Nov. 1, by adding a search tool to help patients find out if specific doctors and hospitals are included in their plan. The data are still incomplete, however, and the search tool does not solve the problem of people being unable to find a doctor or hospital that will take them.
In an interview with reporters Oct. 30, Sylvia Burwell, secretary for the Department of Health and Human Services, said her agency did not have the authority to compel providers to accept the marketplace plans. The key, she said, was to create tools to engage consumers and to improve transparency so they can make educated decisions about health plans.
Clare Krusing, spokeswoman for America’s Health Insurance Programs, said in an email that the group does not have data on how many physicians are choosing not to accept insurance or participate in certain networks. “Our recent report on out-of-network charges show that consumers are increasingly paying very high, and in many cases, exorbitant charges for medical care when they are treated by an out-of-network provider,” she said.
In most states, doctors can choose not to participate in the networks offered in the marketplaces, also known as exchanges, created by the Affordable Care Act, President Barack Obama’s signature health care law. Then again, they can choose not to participate in any other type of health insurance plan as well. Some doctors opt out of Medicaid, the government’s health program for low-income Americans, and others opt out of Medicare, the government’s program for adults 65 and older. Others limit the percentage of patients they’ll accept who are covered by these plans.
“It’s not new to have providers turn down insurance plans, even before the Affordable Care Act,” says Dr. Ben Sommers, a professor in the department of health policy and management at the T.H. Chan School of Public Health at Harvard University.
Though no national data exist, there are some collected at the state level. An analysis of 2015 exchanges in Florida, California, Texas, Georgia and North Carolina by the market research firm Avalere Health found plans included 34 percent fewer providers than commercial plans offered outside exchanges.
But the choice to participate is not always up to the doctors or hospitals. Instead, the decision is made by insurance companies.
Obamacare implemented patient protections – such as being eligible for coverage regardless of pre-existing conditions – that in turn caused insurance companies to implement other strategies to reduce costs. One of these is creating narrow networks, with a limited number of doctors and hospitals that fall under a particular plan. In many cases, insurance companies offer specific providers a higher volume of patients in exchange for a lower reimbursement rate.
A study published in JAMA of 135 health insurance plans in 34 state marketplaces that were available during the 2015 open enrollment period found that one in seven plans didn’t provide access to in-network doctors for at least one medical specialty, with endocrinology, rheumatology and psychiatry being the most commonly excluded specialties.
On the hospital side, an Associated Press survey last year found that many plans sold on the exchanges exclude large cancer centers from their provider networks, and a survey by Avalere earlier this year found that a quarter of cancer centers still report they are excluded from the networks offered by most of their state’s exchange.
“Some doctors take that deal; others decline that deal,” says Devon Henrick, health economist and senior fellow at the National Center for Policy Analysis. “I believe it’s more likely to be a case where doctors limit the number of new exchange plan enrollees rather than outright refusing to see any of them.”
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Physicians are reluctant to speak to their decisions not to work with marketplace plans. One family physician who works in rural northeastern Pennsylvania spoke with U.S. News on condition of anonymity. He has been a physician for more than 35 years, and says the administrative burden, paperwork issues and associated care costs for marketplace patients is more than the reimbursement he receives for treating them. Reimbursement can be 30 to 50 percent less than what is offered through employer-provided plans.
Only a handful of his patients are on marketplace plans, as he has made special exemptions for patients he had already been seeing who later had to enroll in the marketplace due to life circumstances. “We are not soliciting additional patients [on marketplace plans],” he says. “We get calls every day from people who have those plans, but we can’t take them.”
He accepts Medicaid patients, saying that he sees that as his social responsibility. Medicaid patients make up 11 percent of his practice, and he estimates Medicare patients are about 35 percent.
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Another factor that has affected physicians’ decisions not to participate in the exchanges is the concern that they will have to swallow costs of new patients who do not pay their premiums. Under Obamacare, patients who receive tax subsidies through Healthcare.gov have a 90-day grace period in which to pay their premiums or be dropped from coverage. They can still receive care during that time, however, and providers are responsible for the costs the insurance companies refuse to pay.
The 90-day grace period can kick in at any time, so it is possible for a patient to pay premiums for nine months but receive 12 months of care, and shop for a different insurance plan the following year.
The physician social networking site SERMO conducted a poll on its website about marketplace participation and found that of more than 1,438 respondents, nearly 40 percent reported they did not participate in plans offered by federal or state exchanges. One ophthalmologist wrote of marketplace plans:”I stopped taking them after getting burned twice (one was a surgery) where the patients had stopped paying their premiums, but the insurer still had them listed as covered. Fool me once, shame on you. Fool me twice, shame on me.”
This year, Texas passed a controversial law that requires exchange plans that are subsidized to be labeled as such on insurance ID cards. While proponents said the law would help doctors remind patients to stay on top of their premiums, consumer advocates were concerned they would result in doctors refusing to work with these patients.
Dr. Linda Girgis, a member of SERMO’s medical advisory board and a family physician in New Jersey, says patients often don’t realize how much their health care will cost them until they arrive at her office. She accepts patients who receive coverage through the marketplace, but sees them struggle when they learn that low-premium plans have high deductibles, often leading patients to avoid getting the care they need. “They are choosing not to come in for follow up and will not come in for bloodwork,” she says. “I see that all the time.”
But Harvard University’s Sommers cautions that these issues should be seen as opportunities to improve on the law, not reasons to get rid of it. “The broader context shows access to providers has gotten better,” he says.
Source: US News
