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A big factor in pricing will be what


Lee Green of Scott & White Health Plan describes as “pent-up demand” within a previously uninsured population. The health plan also applied to participate in Texas’ exchange with its network of 3,000 physicians and hospitals in Cen- tral and West Texas, where it currently operates.


When a significant number of people suddenly gain coverage after being un- insured for years with a potential host of untreated chronic diseases, “that could create quite a spike in demand for ser- vices and utilization beginning as early as Jan. 1, 2014,” and some sticker shock, said Mr. Green, the plan’s vice president of sales and marketing. “Pricing will be higher than it is today,” although subsi- dies will offset some of that. That demand also could put pressure on the health care delivery system, Mr. Green adds.


Aetna and UnitedHealthcare have not


said whether they would participate in Texas’ exchange specifically, but in gen- eral the plans have announced they are evaluating selected states.


Staying vigilant


Many of these issues add up to a certain level of unpredictability for physicians, as well. That means doctors must re- main vigilant when evaluating contract- ing issues, patients’ coverage, and health plans’ conduct, TMA officials say. Participation in an exchange plan is


voluntary, so physicians must indepen- dently choose whether to opt in, says TMA Vice President for Medical Econom- ics Lee Spangler. He also cautions that physicians must look closely at exchange contracts. Some insurers, for example, may amend exist- ing contracts to include exchange prod- ucts using their current networks, while others may develop brand new networks and contract offers. Also, Medicaid man- aged care companies may offer commer- cial exchange plans, as well, and may apply Medicaid payment rates to com- mercial fee schedules.


“Physicians need to pay attention to what they are signing and scrutinize contracts to determine whether Medic- aid rates would apply to commercial fee


schedules for plans offered in the ex- change and whether those rates would be sufficient to cover their business costs,” he said. A pair of TMA-backed bills that be-


came law will help physicians with that process. Under Senate Bill 822, TMA’s “silent PPO” legislation, health plans must give physicians the opportunity to evaluate their fee schedules separately and can no longer share or sell physi- cians’ contracted discounts without per- mission. Similarly, Senate Bill 1221 re- quires health plans to notify doctors in advance if they apply their discounted fees under Medicaid or CHIP to commer- cial products. Ms. Kinney adds that patients’ cost- sharing under exchange plans will vary, too. And it may not be readily apparent whether a patient is covered by an ex- change policy versus other commercial products.


The Blues’ Dr. McCoy said patients with an exchange policy “will carry iden- tification indicating they are covered by one of our products, and physicians will still be able to interact with the same customer service [channels] related to the rest of our products.” But federal exchange regulations give patients a three-month grace period to pay their premiums and allow health plans to hold claims during that time if patients don’t end up paying. Health plans also must look to the federal gov- ernment to receive subsidy payments pa- tients are eligible for.


The American Medical Association’s


2012 comments on the proposed rules warned HHS officials that the grace-peri- od provisions “unfairly shift this burden to physicians and other health care pro- viders and puts them in the position of potentially providing health care to pa- tients for two months without payment” and could create “a major disincentive for physicians who are considering par- ticipating in qualified health plan net- works.” Barring any changes to the rules — which did not come about — AMA urged HHS to ensure that exchanges require participating health plans “to provide accurate, binding, and real-time notifica- tion to physicians and other health care


providers” when patients fall into the grace period so doctors are aware that claims submitted on their behalf may be halted or denied. Neither CMS nor TDI responded to


Texas Medicine’s inquiries as to whether or how they would hold health plans ac- countable for paying physicians for ser- vices rendered during that window. For now, TMA officials say the rules mean physicians participating in ex- change plans must stay on top of verify- ing the status of patients’ eligibility for health care services.


New Walgreens pain medication policy could harm prescription access


Texas Medical Association officials say they are monitoring a new Walgreens policy that allows the nation’s largest pharmacy chain to limit or possibly re- fuse to dispense controlled substances, largely pain medications, as part of an effort to combat prescription drug abuse. TMA and the Texas Pain Society are in conversations with Walgreens’ general counsel to ensure the store policy does not harm access to legitimate pain pre- scriptions, after hearing complaints from Texas physicians that some patients have


All articles in Texas Medicine that mention Texas Medical Association’s stance on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. That law requires disclosure of the name and address of the person who contracts with the printer to publish the legislative advertising in Texas Medicine: Louis J. Goodman, PhD, Executive Vice President, TMA, 401 W. 15th St., Austin, TX 78701.


August 2013 TEXAS MEDICINE 53


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