Observers say the surprising lack of participation by hospitals and physician groups in helping Americans sign up for exchange coverage and the expanded Medicaid program is due to a number of factors. These include lack of information among provider systems about these consumer assistance programs and political pressure not to participate from Republican leaders in many states who are opposed to the Affordable Care Act.
One hospital system that is participating in the navigator program is the University of Mississippi Medical Center. It's one of more than 100 organizations that received navigator funding from the CMS in August as part of the agency's outreach effort. UM's $831,986 grant will be used for a statewide educational campaign. The UM Medical Center draws patients from nearly all 82 of the state's counties—which makes it uniquely positioned to help guide residents through the open enrollment period that begins Oct. 1.
The hospital estimates that it sees more than 200 patients a day who would qualify to receive federally subsidized private coverage through the state exchange, which is being run by the federal government. “That's a huge stream of patients,” said spokesman Jack Mazurak. “One of the reasons that we applied for this grant is that we get this patient flow.”
Navigators across the country include universities, health departments, clinics, advocacy groups and religious organizations. In addition to the navigator program, the CMS also has designated some organizations as certified application counselors—a term for entities that are trained to help in the enrollment effort but do not receive federal funds. Certified application counselors also have to go through training and take an exam similar to navigators, but conflict-of-interest standards are more lenient and focus primarily on disclosure. Although a CAC designation is not required to help educate consumers, going through the program allows those groups to represent themselves as certified to help with the enrollment process.
Sabrina Corlette, a senior research fellow at the Georgetown Health Policy Institute, said the CAC program was set up for providers that want to help disseminate exchange enrollment information. As a CAC, they may feel more comfortable accessing patients' financial information, she added. “For providers, there's a lot of strong self-interest,” she said.
The Wayne State University Physician Group in Detroit has received CAC designation and will deploy a team of financial counselors to help guide people through the enrollment process. It is also fielding questions from other local organizations, such as public libraries, that are receiving ACA inquiries from confused consumers. The multispecialty physician is the only CAC in the Detroit area, which Barrett attributed to a lack of information among provider groups.
The Wayne State Physician Group has prior experience processing Medicaid and charity care applications, said Cathy Barrett, who oversees the group's revenue-cycle management.
In other Republican-led states, some providers have been discouraged from participating in the navigator or CAC programs. In Ohio, Cincinnati Children's Hospital Medical Center was awarded a $124,419 navigator grant. But the hospital returned the funds because of a new state law that prohibits groups that receive insurance payments from serving as navigators.
Ohio is not alone in its restrictions. Other states such as Texas, Georgia and Florida have established rules limiting federal and private efforts to help consumers enroll in exchange plans. They have cited various reasons such as conflict of interest, lack of training, and the risk of fraud and privacy violations.
But Corlette said such state efforts are intended to suppress enrollment. “Some of that seems so egregious,” she said, noting that the navigator program has clear provisions to protect against conflict of interest, including training.
The state restrictions could be having a chilling effect on provider participation. “Hospitals don't want to make political enemies,” Corlette said.
Still, some provider systems are engaging in exchange outreach efforts on their own initiative. At CHE Trinity Health, more than 87,000 employees in 21 states are helping to educate their friends and relatives. The system also has information available on its website, and is funding a multimedia campaign—including TV, print and radio—in some of its markets.
At 291-bed Mercy Hospital and Medical Center in Chicago, which received a CMS navigator grant, the hospital has hired eight people who will host educational events at its satellite campuses starting Oct. 1. About 38% of Mercy's patients currently are on Medicaid, and another 3% to 4% are self-pay, said Connie Murphy, vice president of marketing and development. While the enrollment effort will help those patients, it will also target individuals who have foregone care because they lack insurance.
“It's very important for us to grow our volume—and it's just good for our community,” Murphy said.
At the UM Medical Center, financial counselors will meet one-on-one with uninsured patients. In addition, the hospital has used its electronic health-record database to identify another 3,000 patients who would benefit from the insurance exchanges—and will target them with direct mailings and educational events.
Its 36 navigators have gone through 20 hours of training and are prepared to field any and every question. But the one question they don't know is how many individuals will sign up.
“We have our people trained and are ready to go,” Mazurak said. “There are still a lot of unknowns.”