BY LAURIE UDESKY CHCF Center for Health Reporting December 20, 2013;
The Affordable Care Act has placed most physicians in a state of conflict. I don't know any physicians who would not want all their patients to have good health and wellness. Wellness is always a less expensive alternative and pursuing it adds to the quality of life immediately.
While the Affordable Care Act has these components as part of the basic standard many physicians cannot participate in the roster of providers who will accept patients in Covered California, the state exchange.
Surveying other exchanges may reveal the same situation repeated 50 times. Much of it depends upon the rates for reimbursement set by insurers, and is individualized by each insurer.
The California Health Care Foundation did a survey of physicians in California and found that 70-80% of physicians who studied the reimbursement plans, (about 70% of the Medicare rates) decided to not participate in Covered California (the Health Benefit Exchange run by the state.
Medicare rates have already been decreased almost 50% since 1988. This in spite of inflation and skyrocketing administrative costs for providers due to increased regulatory requirements in order to be an eligible provider for CMS.
Dr. Steven Larson, the CEO of the Riverside Medical Clinic (140 providers), said he was taken aback when he saw what insurance companies were willing to pay. “The rates were 70 percent of Medicare [reimbursement]. It doesn’t leave room for making a living,” he said. “It’s potentially a huge problem,” said Larson, who also is the chairman of the California Medical Association Board of Trustees.
The clinics serve 300,000 patients under a variety of plans, including many Medicare patients who are not affected by the new exchanges. But the patients who want their care covered under a health exchange plan will now to have to look elsewhere for a doctor.In some cases they are trying to decide whether to join. In other cases they are finding that they have been dropped from plans. And many are just trying to get information about whether they are listed in an exchange plan or not.
Covered California maintains that the plans offered through the exchanges include 80 percent of the state’s physicians. “We arrived at the 80 percent by comparing our network to the two largest commercial networks,” said Covered California spokeswoman Anne Gonzales. This reveals the lack of expertise and knowledge that state health agencies have about health care in the market place. A recent survey of California Physicians showed that 70-80% would not participate.
About a year ago numerous insurers (or Covered California ) sent out letters of intent asking providers if they would participate in the exchanges. At that time there were no speciffics as to reimbursement or other provisions, which are left to the insurers as long as their policies conformed to the ACA benefits.
This amounted to asking providers to sign a 'blank check'.
Recent analysis of insurer directories reveal they are inaccurate for many reasons. The directories are prepared annually with many months of lead time. California Medical Association President Dr. Richard Thorp. “Many times when we look at their physician directories, they include names of people who have moved out of state, are retired or dead. ”Some physicians have even been listed in the exchange after they refused to participate because of the low reimbursement rates.
The challenges to participate in Covered California are as great for providers as it is for patients.
The scenario is unbelievable, except that it is fact.
Health Train Express reviewed California Health Care Foundation statements as well as the California Medical Association. The following are some of the examples:
Insurers are required to notify doctors if they’re included, according to Lisa Folberg, vice president of medical and regulatory policy for the California Medical Association.
That hasn’t always happened in Riverside, according to the executive director of the Riverside Medical Society. “Basically doctors don’t know if they’re in or out of the network,” she said. The society has told doctors to call the plans directly.
If the present situation is confusing, unfortunately the future, despite the government's intention to organize health reform, looks even more grim. Insurance c ontracts are usually an annual renewal. At any time after the first year and later as the system matures it will be in the purvey of these "guardians of Covered California' to alter the rates. Debt ceilings, national catastrophe, conflicts will all effect health.
The current GDP incorporates the sixteen percent due to health enterprise. The ACA has added more levels and administration to an already bloated health system.
If the present situation is confusing, unfortunately the future, despite the government's intention to organize health reform, looks even more grim. Insurance c ontracts are usually an annual renewal. At any time after the first year and later as the system matures it will be in the purvey of these "guardians of Covered California' to alter the rates. Debt ceilings, national catastrophe, conflicts will all effect health.
The current GDP incorporates the sixteen percent due to health enterprise. The ACA has added more levels and administration to an already bloated health system.
