Managing Oncology Blindfolded: The Curse of the Health Exchanges

Dawn Holcombe, MBA, FACMPE, ACHE
President, DGH Consulting, South Windsor, CT

In every state, some version of new insurance plans offered through health exchanges was unveiled at the beginning of the year…well, partially unveiled. The focus of the media and plan administrators seems to be entirely on getting the “right” patients to enroll, increasing the visibility of offerings before open enrollment ends this month, and trying to ignore the technical glitches many patients have encountered. However, very little attention is being spent on actually communicating with those expected to provide the care, and that is leaving oncology managers, in particular, in a real bind.

Six Top Challenges Health Exchanges Present to Oncology Managers
(Private or Hospital Based)
1 Am I in or out? Most exchange offerings are presented by insurance carriers with an existing presence in the state. Many seem to rely on contractual language that grandfathers network panels for other insurance offerings into assumed networks for exchange insurance offerings. Still others seek to manage costs by narrowing networks so that healthcare providers might be excluded from some insurance offerings and not others. Very little information is forthcoming from health plans to providers— and word from the street is that even less information is coming in response to multiple phone calls and e-mails seeking provider lists. Published provider lists shown to enrollees on websites have been notoriously inaccurate. Providers need to know who they can serve, and patients in the middle of active treatment need to know if they will be able to continue treatment with their trusted caregivers.

2 How am I to be paid? Providers are not receiving fee schedules for health exchange insurance offerings. During the last few days of February, 1 practice in Connecticut, after multiple calls and e-mails, finally reached someone in the largest private insurer in the state to get a verbal statement as to how the fee schedule was planned in relation to Medicare and Medicaid rates. Businesses cannot stay in business if they provide services for 2 months with no idea of how they are going to be paid, especially when they have to purchase expensive oncology drugs and treat with them before submitting a claim.

3 Is my patient in or out? Of what? As patients start to appear with their insurance cards, some of the new cards make it very clear on the card itself that it is an exchange plan. Others do not. Some patients come in with printed enrollment forms, but are not recognized by the insurer when verification is done. Not only does this add significant confusion to a previously crowded insurance marketplace, but it also adds costs in terms of time and delaying treatment for patients facing cancer. In Pennsylvania alone, the health exchange market is covered by 9 payers, offering a total of 126 different insurance packages that were not in existence in 2013.

4 Is my patient covered? For what? Once the insurance plan is clarified, patient coverage is another elusive creature. Oncology managers are having great difficulty identifying what is covered, specifically in the insurance plan formularies. It makes a huge difference, because many plans are building narrow formularies as a response to having to open enrollment to patients with pre-existing conditions. If they cannot control costs on the front end, they can attempt to do it on the back end by narrowing approved treatments and drug formularies. However, if you are a patient or a provider, especially in oncology, and you find that the chosen drug for treatment is not on a given formulary, not only does the patient then have an out-of-pocket responsibility for that drug, but those payments also do not qualify against the patient’s other large deductibles and copay obligations for a given insurance plan in the exchange. This increases patients’ financial obligations as well as the likelihood that they will not be able to pay.

5 For how long is my patient covered? The biggest blind spot for oncology managers is whether their patient is covered for treatment at the time treatment is provided. If patients enroll in health exchanges but have not paid their premiums consistently at any point during the year, the plan has the right to determine retroactively to 3 months that the patient is not covered. A practice or cancer center therefore has to determine how, in its own state, it is able to broach to patients the question of whether they are current with their insurance premiums. The stakes are too high not to do this. Do you ask for a cancelled check before treating? So far, because the focus of the insurers is on enrollment of patients, it has been almost impossible for oncology groups to raise this topic with the insurers to work out alerts and real-time status of patient enrollment tied to premium payment.

6 Does underinsured count as uninsured? Is anyone truly uninsured under the Affordable Care Act (ACA)? What does that mean for patient assistance or “340B” programs? Patient assistance programs have become an essential resource for patients and practices to ensure access to needed treatment. However, such programs have limitations depending upon whether a patient has access to “other insurance,” if they are in a federal insurance program, or if they are insured at any level. The challenge for oncology managers is how this new category of patients will be classified. Determining whether patients are in a federal program will vary by state. The burning question is whether narrow formularies and narrow provider networks will create a new, large class of patients who are insured for some care, but possibly not the care they need, and whether the existence of minimal insurance then precludes those patients from certain patient assistance programs for which they might otherwise have qualified. If patients are considered eligible to sign up under the ACA and choose not to, are they then considered uninsured by choice and therefore no longer really uninsured? In particular, what will happen to hospitals and their indigent population counts? Or their disproportionate share counts that allow them to qualify for 340B drug pricing (a federal program intended to allow hospitals that care for a disproportionate share of indigent patients to buy drugs for outpatient care at a much discounted rate)? If those patients don’t count, and hospitals don’t qualify for 340B, how might that affect recent hospital oncology service expansion and acquisition of formerly private oncology groups?

We do not yet have answers to these questions. States, the federal government, payers, pharmaceutical manufacturers, policy advocates, patient advocates, and providers are all seeking answers that are not yet forthcoming by any of those running the exchange programs. I was in a meeting recently with someone working with state insurance commissioners. Their focus regarding exchanges seemed to be on whether the technology to enroll people was working and how much more we needed to get the enrollment up, especially among targeted populations. When asked about the top 6 issues addressed above, the response was, “We are taking notes and learning for 2015.”

We cannot wait until 2015. Our oncology practices and cancer centers are operating blindly. Many have chosen not to participate in the exchanges yet, for these very reasons. Large groups announced that they would not participate in the first quarter of 2014, but are now opening up their providers to participate in the second quarter. We still do not know what will happen to patients and providers as these programs unfold throughout the year.

What Can You Do in Your Group?

  • Reach out to your state insurance commissioner and insurance advocates. Help them to understand how the process is not working, as well as the information gaps that are affecting oncology patients and their access to needed treatment.
  • Document requests for fee schedule and formulary information to exchange plans, and report delays and lack of response to your state insurance commissioner and your local senators and representatives.
  • Quantify numbers of patients left on the sidelines regarding their access to cancer care related to the exchanges and ACA. This may be crucial information as we move into the next election cycle, no matter what your political persuasion may be. If we don’t document and track now, it will be as if it never happened 6 months from now.
  • Remember, insurance exchanges are not insurance marketplaces, no matter what they call themselves. There are a number of private insurance opportunities for every patient, and we are already hearing tales of patients finding better coverage for a lower cost in private offerings rather than in the exchanges, especially those who do not qualify for subsidies. Get the word out and help your patients (and even those who do not have cancer) understand that they have choices that are not limited to the options shown on the health exchange websites.

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