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
Dr. Ira Kirschenbaum is chairman, Department of Orthopedic Surgery and Director of Surgical Operations, Bronx-Lebanon Hospital Center. Kirschenbaum runs an innovative program overseeing a large staff of orthopedic surgeons who deliver orthopedic care to one of the largest clinic populations in the country.
Recently, Kirschenbaum took on the position of Director of Surgical
Operations where he works with the Operating Room Committee and hospital leadership to improve daily OR operations.
In July 2014, Orthopaedics Services was expanded into an entire floor at the Bronx-Lebanon Health and Wellness Center. New York Yankee pitcher Mariano Rivera even visited the wing to meet Kirschenbaum and his patients.
In addition to his notable career as an orthopedic surgeon, Kirschenbaum has in-depth and wide-breadth entrepreneurial, corporate and non-profit experience in operations leadership, process reengineering, information technology, and innovation design.
He is currently Chief Medical Information Officer at the SwiftPath Program, which helps doctors safely, effectively and profitably execute outpatient or enhanced recovery joint replacement into their practices or ASCs, and Chief Medical Officer at DTC Healthcom, a medical information technology innovation company. Kirschenbaum is also Managing Partner of Sprocket Health, a new venture that has the product Referral Pad MD, a "Clinician-to-Specialist" referral tool.
Kirschenbaum’s affiliations and awards past and present include The American Academy of Orthopaedic Surgeons, The American Board of Orthopaedic Surgeons, The American Association of Hip and Knee Surgeons and The Orthopedic Research Society.
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