Survey Reveals Drawbacks to Participation in ACA Exchanges

The challenges involved with the start of implementation of the Affordable Care Act (ACA)’s insurance exchange program are evident in the responses to an April 2014 survey by the Medical Group Management Association (MGMA).1

There were 728 respondents to the survey, representing more than 40,000 physicians. A majority (59.4%) of respondents viewed ACA insurance exchanges as being un­favorable to their practices, and most said that payment rates are no higher than those offered from traditional commercial products or traditional Medicare. Furthermore, 87.6% reported difficulty identifying whether patients had ACA exchange coverage. Most respondents also said that it is more difficult than with traditional insurance products to accomplish tasks such as verifying patient eligibility and obtaining information about patients’ provider networks to facilitate referrals.

“Some of these things I think are growing pains,” said Allison Brennan, MPP, senior advocacy advisor, MGMA, Washington, DC. “This is the first year. It is a transition for practices and patients and the insurance industry. So, some of these are going to get better over time.”

Ms Brennan and colleagues included the survey in an e-newsletter that they e-mailed to all 22,500 members of the MGMA. Although the response rate was only 3.2%, respondents hailed from all but 4 states and were from 42 specialties. Their practices included multispecialty practices with primary and specialty care (19.3%), orthopedic surgery practices (10%), family practices (8.3%), and obstetrics/gynecology practices (6.6%). Approximately three-quarters (75.1%) were independent medical practices, and the mean practice size was 55.7 full-time–equivalent physicians.

These are roughly similar proportions to those from the more than 1000 physician practices that responded to a September 2013 survey by MGMA.2 The earlier survey was intended to determine how practice administrators viewed the impending start of patient purchase of ACA insurance exchange products. The April 2014 survey results indicate that 15.1% of respondents regard the ACA insurance exchanges as very unfavorable to their practices, and 44.3% view them as unfavorable.

Approximately three-quarters (76.5%) of respondents said that their practices are participating with new health insurance plans under the ACA. The main reasons cited for participation are remaining competitive in the local market, replacing current charity care when uninsured patients obtain coverage, and providing care to underserved patient populations. The top reason cited for nonparticipation was the financial liability represented by the 90-day grace period for ACA exchange enrollees.

Among respondents whose practices are participating, 84.8% offer coverage through 5 or fewer plans. Only 19.9% of respondents, however, said that their practices had been excluded from a network in which they would like to have been included.

Just 25.8% of respondents said that their practice’s patient numbers had increased under the ACA, and approximately one-tenth (10.8%) said that their patient numbers had fallen. Furthermore, approximately one-third of respondents reported that payment rates under the ACA exchanges were somewhat lower than or equal to average payment rates from all of their traditional commercial contracts, at 32% and 36.6%, respectively. Just less than half (41.8%) said that rates were equal to those from traditional commercial products offered by the same payers. The situation was somewhat better compared with traditional Medicare and Medicaid, with 30.1% and 46.4% of practices, respectively, reporting higher reimbursement with the new exchanges than with these government programs.

When Ms Brennan and colleagues probed the practical aspects of the implementation, they found an abundance of pain for practices and patients. Approximately one-third (31.5%) of respondents said that it has been very or extremely difficult to distinguish between patients with ACA insurance coverage versus traditional commercial health insurance not related to ACA exchanges, whereas 56.1% found it slightly or moderately difficult. Only 12.4% said it was not at all difficult. Furthermore, 63.2% have found it more difficult to verify patient eligibility for coverage, 62.3% said it was more difficult to obtain cost-sharing information, and 58.6% have found obtaining information about the plan’s provider network to facilitate referrals to be more difficult than with traditional commercial coverage.

Fully 40.9% of those who completed the survey said that their practices had been unable to treat some patients, because their practices were not included in those patients’ insurance exchange networks. In addition, 94.8% of respondents said that it was likely that patients have high deductibles with the new products compared with traditional commercial 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,” wrote a respondent; another indicated that “payer directories [of providers in the practices’ networks] are woefully inaccurate and impossible to rely on.”

Ms Brennan said that she and her colleagues have heard these complaints from a number of providers, and that they represent significant problems for patients and physicians. However, she said that these difficulties, like most of the others associated with the early days of exchange network use, are being worked on and should improve over time.

References
1. Medical Group Management Association. MGMA ACA exchange implementation survey report. May 2014. www.mgma.com/government-affairs/issues-over view/aca/aca-exchange-implementation-report/aca-surveyreport_online_2?ext=.pdf. Accessed June 5, 2014.
2. Medical Group Management Association Legislative and Executive Advocacy Response Network (LEARN). ACA insurance exchange implementation, Sept. 2013. www.mgma.com/Libraries/Assets/Government%20Affairs/Advocacy/LEARN/ACA-Exchange-Implementation-LEARN.pdf. Accessed June 5, 2014.

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