Practice Survey Pinpoints Highs, Lows of Health Insurance Exchanges

Despite Patient Benefits, Verifying Coverage, Navigating Networks Can Be Tricky

June 18, 2014 02:48 pm News Staff

The Colorado-based Medical Group Management Association (MGMA) recently released the results of a survey( designed to gain a better understanding of how health insurance exchanges -- a critical component of the Patient Protection and Affordable Care Act (ACA) -- are affecting physicians' practices.

[People sitting in waiting room]

Conducted in April, the survey gathered input from 728 practices that represent some 40,000 physicians in 42 specialties. About 75 percent of respondents were independent medical practices.

Of the total number of medical practices surveyed, family medicine had the third highest participation rate at 8.3 percent, just behind orthopedic surgery (10 percent) and multispecialty groups that offered both primary and specialty care (19.3 percent).

Survey respondents pointed out some of the challenges related to patient participation in ACA exchanges (also referred to as the ACA marketplace). In particular, practices said they were having difficulty obtaining patient coverage information, sorting out patient cost-sharing issues and dealing with the impact of the network design of many ACA exchange products.

In a related statement(, MGMA President and CEO Susan Turney, M.D., noted that the survey highlighted physicians' dissatisfaction with the complexity and lack of information about insurance products offered on ACA exchanges.

"The more administrative complexity introduced into the health care system, the less time and resources practices can devote to patient care," said Turney.

Story highlights
  • The Medical Group Management Association released survey results that provide insight into how health insurance exchanges are impacting physicians' practices.
  • Practices reported problems such as verifying patient coverage and educating patients about out-of-network coverage and higher deductibles.
  • On the positive side, practices had not experienced the overwhelming surge of new patients that some industry leaders had predicted, and 94 percent of practices surveyed had seen patients in insurance exchanges plans.

"Even though there hasn't been a huge influx of patients into physician offices as many predicted, simple tasks such as obtaining patient insurance coverage information or finding specialists for in-network referrals have proven to be significant challenges," she added.

Key Findings, Practice Comments

Of practices responding to the survey, 62 percent said it was moderately to extremely difficult to determine whether a patient has ACA exchange coverage rather than traditional commercial health insurance.

In particular, respondents said exchange coverage made it more difficult to verify patient eligibility, obtain cost-sharing and network information, and gather information about a plan's provider network to facilitate patient referrals.

One practice, in fact, commented that it was going to have to hire additional staff "just to manage the insurance verification process." Another called the process of identifying ACA plans "an administrative nightmare."

Patient cost-sharing also has created issues for some practices. "Patients have been very confused about benefits and their portion of the cost," reported one practice, adding that some patients have cancelled appointments or procedures after finding out what their deductible would be.

Indeed, 75 percent of practices said patients with coverage provided through an ACA exchange were very likely or extremely likely to have high deductibles compared to patients with traditional insurance.

"Patients don't always understand how health insurance works, so we've been engaging in educational events for the community," one practice shared.

Network limitations also were a source of concern for practices; nearly half of respondents said they were unable to provide covered services to patients with ACA plans because the practice was out of network.

"Many patients purchased (less expensive) products with a very narrow network and didn't understand the ramifications," reported one practice, noting that these patients are often upset at discovering they can't go to the physician or hospital of their choice, "We are now faced with the extra burden of trying to find them care within their new narrow network."

AAFP Takes Action to Slow Network Narrowing

The AAFP is very familiar with the challenges related to health plans trimming their provider networks. In fact, in November 2013, AAFP President-elect Robert Wergin, M.D., of Milford, Neb., wrote a Leader Voices Blog post in which he chided UnitedHealthcare for cutting its Medicare Advantage provider network just weeks before Medicare open enrollment.

And late in December, the AAFP was one of 35 medical organizations and physician advocacy groups to join in amicus curiae briefs filed to support the Fairfield County Medical Association's and the Hartford County Medical Association's attempts to slow or halt UNC's effort to trim thousands of physicians from its Medicare Advantage plan network in Connecticut.

A UHC spokesperson spoke with AAFP News shortly afterward, saying that the insurer was cutting physicians from its networks "to encourage high-quality coverage at an affordable price."

Another practice bemoaned the fact that it was consistently denied "out of network" approvals for very sick patients "who truly need to continue their care with providers who have worked with the patient for years."

Practices Point Out Positives

The MGMA survey also held some positive news. For instance, of those practices responding to the survey, 76.5 percent said they were participating with at least one ACA exchange health insurance product. Of those practices:

  • 39 percent were participating with exchange products because they saw an opportunity to replace current charity care as uninsured patients gained coverage,
  • 35.4 percent said the exchanges gave them the ability to provide care to an underserved patient population, and
  • 14 percent said favorable reimbursement from the exchange plans was a good financial opportunity for the practice.

Furthermore, of those practices participating in ACA exchanges:

  • nearly 41 percent were participating in one to two plans, another 44 percent were participating in three to five exchange plans;
  • almost 94 percent had seen patients with ACA insurance exchange coverage;
  • 56.4 percent had seen no change in the practice's patient population size, and 24.4 percent said their patient panels had increased slightly; and
  • only 7.5 percent of practices expected ACA insurance exchange products to significantly increase their patient population by the end of 2014.

Finally, more than half of all respondents said they had not been excluded from a network in which they wanted to participate; that's compared to about 20 percent who said they had been excluded.

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