MEDICAL ECONOMICS
Untested waters Marketplace means decisions for doctors
BY AMY LYNN SORREL It got off to a really rough start, but the federal government launched the insurance marketplace under the Affordable Care Act (ACA) on Oct. 1. And physicians could encounter their own challenges if they are not vigilant in their business practices with the health plans in the marketplace that take effect Jan. 1, Texas Medical Association officials say. Topping the list is widespread physician uncertainty about whether having existing contracts with insurers means they’re already included in an exchange network. Right after that is a federal rule that jeopardizes physician payments if patients with subsidized marketplace coverage don’t pay their premi- ums. Exchange regulations give those patients three months to pay their pre- miums and allow health plans to deny or later recoup payments from doctors for services provided to patients who end up delinquent.
That risk is a big factor in Texas On-
cology’s decision to hold off on partici- pating in any exchange plans, at least for now. But it’s not the only factor. “If we assume care for a patient and
“At this time, there are too many
start rendering services, and if in anoth- er month or two that patient isn’t able to make a premium payment and loses coverage, Texas Oncology has already committed to a course of costly treat- ment,” only to see payments recouped, said Chris Henderson, executive director of payer and public health relations for the statewide cancer group, the largest in Texas. For cancer patients, treatment tends to be a long-term commitment that also requires an adequate referral network of hospitals and other specialists — something Texas Oncol- ogy says it doesn’t see among the health plans participating in the marketplace. That puts doctors in a tricky situation if they don’t have privileges at the participating hospitals, for example. Nor is it clear how cancer care is covered, and the Medicaid-based payment rates most exchange plans offered to Texas Oncology wouldn’t cover the group’s business costs. “At this time, there are too many unknowns,” Mr. Henderson
said. “We want to be able to treat all patients who need us. But we at least want to make an informed decision about whether
unknowns.”
the risks [of joining exchange plans] are tolerable. We have to make sure we are here to take care of the next generation of patients.” For similar reasons, Austin Regional Clinic (ARC) has been selective about the exchange plans the multispecialty clinic decided to join. Thus far, that number is less than a handful. Most insurers that approached the group were unbending in their take-it-or-leave-it payment offers that fell below the non-exchange rates it receives, “and that’s not the way we’ve done business historically,” ARC founder and Chief Executive Officer Norman Chenven, MD, said. “It’s a business calculation, like any other. We [physician practices] only have so many seats on the plane, and you want to fill them, but you don’t want to fill them all with very low payments.” Moreover, ARC has yet to get a grasp on the different types of ex- change plans, like high-deductible plans, and how the benefit structures affect patients’ care options and prac- tices’ ability to collect money. “This is a new thing. It’s going to evolve. Things will go wrong, but then they will be corrected. So it behooves us to go slowly and learn as we go so that we can figure out how best to pro-
vide services to members of exchange products for their good and ours,” Dr. Chenven said. Texas physicians are not alone: Uncertainty surrounding the
insurance marketplaces has 40 percent of physician practices nationally still evaluating whether to participate in exchange plans, according to a Medical Group Management Associa- tion (MGMA) survey conducted in September just before the marketplace launch. The research included responses from more than 1,000 medical groups that represent upwards of 47,500 individual physicians. Read the full survey at http://
bit.ly/1c8YWzh.
Meanwhile, a good number of physicians, like Austin ophthalmologist Dawn Buckingham, MD, remain uncertain whether their contracts already include them in an exchange network because not all carriers are reaching out to them. “I
December 2013 TEXAS MEDICINE 37
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