qotd: ACA exchange plans are creating new administrative headaches for physicians

Medical Group Management Association
May 2014
MGMA ACA Exchange Implementation Survey Report

Medical Group Management Association (MGMA) conducted member research in
April 2014 to better understand the impact of the Affordable Care Act's
(ACA) insurance exchange implementation on medical group practices.

Summary of Findings

MGMA noted three main themes within the findings.

OBTAINING COVERAGE INFORMATION

Practices have experienced difficulty identifying patients with ACA
exchange coverage and obtaining essential information related to that
coverage.

• 62% of respondents reported moderate to extreme difficulty with
identifying a patient that has ACA exchange coverage as opposed to
traditional commercial health insurance.

• Compared to patients with traditional commercial coverage, nearly 60%
of respondents indicated that for patients with ACA exchange coverage it
is somewhat or much more difficult to:

• Verify patient eligibility

• Obtain cost-sharing or network information

• Obtain information about the plan's provider network in order to
facilitate referrals

"We are going to have to hire additional staff just to manage the
insurance verification processs."

"Identification of ACA plans has been an administrative nightmare."

"We thought we would be able to identify ACA insurance exchange products
by their insurance card, but quickly found out this isn't so. "

PATIENT COST-SHARING

Practices are facing a number of challenges related to patient
cost-sharing for ACA exchange coverage.

• 75% of respondents reported that patients with ACA exchange coverage
are very or extremely likely to have high deductibles compared to
patients with traditional commercial coverage.

• Practices reported significant patient confusion about the substantial
cost-sharing related to many ACA exchange products, and practices are
working to help patients understand the complexities of their coverage.

• Practices cited some of the main reasons for not participating with
ACA exchange products were related to concerns about financial burdens
from patient collections (such as burdens related to collecting high
deductibles from patients and concerns about financial liability from
the 90-day grace period).

"Patients have been very confused about benefits and their portion of
the cost. Once the patients find out their deductible, they've cancelled
appointments and procedures."

"The at-risk piece of eligibility is tremendously hard to determine and
explain to patients."

"Patients don't always understand how health insurance works, so we've
been engaging in educational events for the community."

NETWORK LIMITATIONS

Practices have concerns about the impact of the network design of many
ACA exchange products.

• Almost half of respondents reported they have been unable to provide
covered services to ACA exchange patients because the practice is out of
network.

• 20% of respondents reported that their practice was excluded from a
narrow network that they would have liked to participate in and 10% of
respondents chose not to participate in a narrow network.

• Narrow networks may create challenges related to patient referrals for
appropriate treatment and hospital care. Even if the practice is
included in the network, without robust representation by a wide range
of providers, it may be difficult for a practice to coordinate a
continuum of care consistent with the patient's needs.

"Many patients purchased products with a very narrow network and didn't
understand the ramifications. They are very upset once they learn that
they can't go to the specialist or hospital of their choice. As primary
care providers, we are now faced with the extra burden of trying to find
them care within their new narrow network. Payer directories are
woefully inaccurate and impossible to rely on."

"Former patients were shocked to learn about their very narrow network
of providers. It was terrible to have to inform them of their lack of
coverage."

"We are consistently denied 'out of network' approvals for the very sick
who truly need to continue their care with providers who have worked
with the patient for years."

http://www.mgma.com/government-affairs/issues-overview/aca/aca-exchange-implementation-report/aca-surveyreport_online_2?ext=.pdf

Statement of Susan Turney, MD, MS, FACP, FACMPE, president and CEO of MGMA:

"Physician group practices are expressing dissatisfaction with the
complexity and lack of information associated with insurance products
sold on ACA exchanges. The more administrative complexity introduced
into the healthcare system, the less time and resources practices can
devote to patient care. Even though there hasn't been a huge influx of
patients into physician offices as many predicted, simple tasks such as
obtaining patient insurance coverage information or finding specialists
for in-network referrals have proven to be significant challenges."

http://www.mgma.com/about/mgma-press-room/press-releases/2007-2012/mgma-statement-on-effect-of-aca-exchange-implementation-on-medical-group-practices

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Comment by Don McCanne

Much has been written about the consequences of the high deductibles and
narrow networks of the ACA exchange plans in impairing access and
affordability for patients. This new survey demonstrates that these same
features add more administrative headaches for physicians who are
already overburdened by the administrative complexity of our
dysfunctional health care financing system. For those who could care
less about the physicians, keep in mind that these ACA plan features are
preventing physicians from assisting patients in obtaining the health
care that they should have. It is really about the patients.

The quotations in the report above are especially helpful to our
understanding of the problems because they reveal the real world
consequences of the highly flawed ACA exchange infrastructure.

Single payer would eliminate the confusion over coverage, the barriers
of patient cost sharing, and the loss of choice due to network
limitations. People would simply get the care that they need when they
need it.