Reform Update: Many docs still on the fence about exchange participation

A new Medical Group Management Association survey suggests that insurance coverage does not necessarily mean healthcare access. More than half the physician practices responding to the survey said they had not yet decided whether they will participate in health plans sold on the new state insurance exchanges.

Dr. Stephen Brotherton, president of the Texas Medical Association and an orthopedic surgeon practicing in Fort Worth, said physicians in Texas need more information before making up their minds. “That survey response is not unexpected,” Brotherton said. He added that only about a third of Texas doctors are taking new Medicaid patients and about 58% are taking new patients covered by Medicare. “It's a matter of what you can accept and still keep your doors open.”

In contrast, many hospital leaders in Texas and other states are eager to have uninsured people join exchange plans. In Texas, nearly 25% of non-elderly residents do not have health insurance, the highest uninsured rate in the country. Hospitals have to accept emergency patients whether they have insurance or not, while physicians do not.

Brotherton said physicians need to know which other physicians are participating in exchange health plans. He said, for example, that if he has a patient covered by an exchange plan who needs surgery, the patient may need to be cleared by a cardiologist before having the operation. If the cardiologist is not participating in the exchange plan's network, it could cause difficulties.

He said more information on payment rates is also needed. If health plans on the exchanges pay somewhere between Medicare and Medicaid rates, Brotherton said he expects fewer than half of the state's doctors to participate. If reimbursement is higher, then it's a different story. “If it was comparable to some of your better commercial payers, then people are going to jump all over it,” Brotherton said.

Of the more than 1,000 practices surveyed by the MGMA last month, 40.2% said they are still evaluating whether they will participate in exchange health plans, 29.2% said they plan on participating (with 26.8% of those reporting they have an “all-products” contract clause requiring them to participate), 16.2% said they just don't know, and 14.4% said they will not be participating.

One practice committed to participating in the exchange is the DuPage Medical Group, 370-physician, 45-location multispecialty group based in Downers Grove, Ill. “We have been anticipating healthcare reform and this is the first step in preparing for it,” said Maria McGowan, DuPage Medical's director of marketing.

With Congress deadlocked over the budget, observers say there is a diminishing likelihood that lawmakers will reach agreement on repealing and replacing the Medicare sustainable growth-rate payment formula, despite bipartisan support for doing so. It would require agreement on how to pay for the $139 billion budget hit over 10 years, and such agreement is unlikely.

For the last decade, Congress has passed a series of short-term fixes to avoid an SGR-driven Medicare pay cut. Unless a short- or long-term solution can be found this year, a 24.4% Medicare pay cut is set to take effect Jan. 1. Dr. Jeffrey Cain, chairman of the American Academy of Family Physicians board, made note of this in a letter he sent to congressional leaders last week (PDF).

“The SGR is symbolic of the long-term budget ramifications created by continuous short-term policy interventions,” Cain wrote. “This is why we continue to urge Congress to repeal the SGR and create a payment system that supports primary care and provides all physicians with the stability and appropriate reimbursement that the current system undermines.”

Cain also said the government shutdown is having “deep and lasting effects” on the nation's health. These include threats to food safety, failure to track the spread of influenza or other illnesses, delays in the start of clinical trials and slower processing of new applications for Medicare coverage.

“Vital functions of the federal government are delayed or suspended because of this failure to pass appropriations for federal agencies,” Cain said in his letter. “These and other functions of the federal government have serious consequences and the inability of the government to provide these and other needed health-related services affects lives long after the current impasse is resolved.”

California's $250,000 cap on pain and suffering awards in medical malpractice cases has been called both a key to ensuring access to healthcare services and a barrier to justice for victims of medical errors and negligence. Now the California Medical Association is saying that healthcare reform won't succeed in the state without it.

The CMA made this claim in a news release announcing it hired veteran political strategist Jim DeBoo to fight off a drive to repeal California's 1975 Medical Injury Compensation Reform Act, also known as MICRA.

DeBoo most recently served in the California Assembly Speaker's Office of Member Services, where he was responsible for multimedia, direct mail and social networking outreach and strategy, according to the release.

“The cause is particularly important to the success of the state's implementation of the Affordable Care Act,” the CMA release said. “If the trial lawyer's misguided efforts are successful, it could drive up healthcare costs, forcing physicians and clinics to go out of business and devastating access to care at a time when millions of previously uninsured Californians will be entering the healthcare system.”

While capping non-economic damages in medical liability cases has been shown to lower costs to liability insurers and lower liability premiums for physicians, it has not been shown to reduce medical costs for healthcare payers and consumers. And evidence is mixed on whether it increases the supply of physicians in a state.

Follow Andis Robeznieks on Twitter: @MHARobeznieks