As we welcome a new president with very different views of healthcare from his predecessor, the Affordable Care Act, also known as “Obamacare”, is being replaced. While we do not yet know what its replacement will look like, we can still learn from the ACA’s mistakes to keep history from repeating itself. The instability of the ACA marketplace was not only due to premium hikes and insurance company withdrawals, but also the low number of physicians who accepted the coverage.
In 2016, the number of doctors participating in health plans on public exchanges dipped 4 percent to 57 percent of physicians in “health insurance plans offered in the federal or state exchanges under the ACA,” according to SERMO, a doctor social media network.
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Lawmakers can use lessons learned from the ACA to create a more effective, coordinated plan. The first step? Make the plan more attractive to physicians.
Why were physicians hesitant to accept ACA plans?
The primary reason physicians didn’t accept ACA plans was low reimbursement. However, raising reimbursement levels wouldn’t have solved the problem. There was widespread doubt in the stability of the system amongst physicians, as well as frustration with the synchronization of in-network and out-of-network care.
In addition, it was difficult for physicians to work with the health maintenance organization plans offered on ACA marketplaces because they weren’t well developed. Physicians were also wary of the solvency of health insurance co-ops created under the ACA. When ACA exchange health insurers faltered, reimbursements weren’t paid to physicians. In the end, it all comes down to worrying about getting paid.
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Were there repercussions of physicians not accepting marketplace coverage?
When physicians didn’t accept marketplace coverage it disrupted the effectiveness of the law and, more importantly, the coordination of care suffered. As Chairman, Department of Orthopaedic Surgery and Director of Surgical Operations at Bronx-Lebanon Hospital Center, I saw this first-hand. For example, what happens if someone with an ACA Marketplace plan goes to the emergency room with a fracture and needs a surgeon quickly? If the surgeon doesn’t accept the plan, they will not know where to send the patient. As a result of the lack of coordination, patients suffered.
What can lawmakers do to make the ACA replacement more appealing?
Physician participation won’t increase on its own. Lawmakers need to figure out a way to attract surgeons when designing the new healthcare act. If a reimbursement fix can’t be provided, initiatives need to be put in place to offset low reimbursements.
While increasing reimbursements is the easy choice, a market sensitive plan to improve care is the ideal option. Physician incentives to accept health plans could also be put in place. Moving away from only focusing on primary care is also necessary, along with adding benefits for specialist physicians. Injuries like fractures and tumors are necessary issues to address. These types of injuries shouldn’t be considered secondary and neither should the physicians who treat them. In addition to better out-of-network benefits for specialists, lawmakers could also develop more creative risk-sharing agreements, like population risk sharing based on special premiums.
Bundled care programs are another great option. Hospitals participating in these programs project an estimated cost of the procedure, and no matter what the final total is, patients pay that projected cost in just one payment. Often, that cost will be lower in a bundle than if they were to pay each bill separately. If that is the case, the patient is not required to pay off the extra costs. However, if the projected bundle payment ends up being more than the actual bill, the hospital keeps the overflow of money. This helps patients because the overall outcome will most likely be less expensive. In addition, the program may lead to higher quality and more coordinated care at a lower cost to Medicare.
The ACA was established to help the patient, but when physicians don’t accept a healthcare plan, the effect is the opposite. Appropriate changes need to be made in the new healthcare plan to make it more favorable to physicians than the ACA, thus establishing a more stable marketplace.
Photo: Danil Melekhin, Getty Images
