Reform Update: Many docs don't know if they're in exchange plans, survey shows

Physicians in New York, Texas and other states are scratching their heads about whether they are actually participating in the health plans offered on their state's insurance exchange and if so, how much they can expect to be paid for providing care.

A recent survey by the Medical Society of the State of New York (PDF) found that one-third of responding physicians did not know if they were included in an exchange plan. Two-thirds said they had not received information about payment, said Moe Auster, the society's vice president of legislative and regulatory affairs, and the survey's creator.

The confusion comes as many are expressing concern about the narrowness of many exchange-plan networks and the potential exclusion of many hospitals and physicians from the plans.

“Many physicians don't know if an insurance carrier has included them in plans or not,” said Lee Spangler, vice president of medical economics at the Texas Medical Association, which has pushed for major changes in the Patient Protection and Affordable Care Act. He said the association was regularly fielding calls from physicians trying to determine their plan participation.

Contracts between physicians and insurers often contain an all-products clause, which requires a provider to participate in all of the plans an insurer offers unless the insurer decides to exclude the provider. Many Texas physicians operating under such agreements have been left scrambling, Spangler said.

“Some are trying to do provider searches,” he said, referring to the online search tools featured on many insurers' websites. “We tell physicians which carriers are operating in their counties and we encourage them to contact those companies themselves.”

Nearly three-quarters of Texas's 254 counties have only one or two insurers offering plans on the federal exchange serving Texas and 35 other states. So physicians in those Texas counties will only have to make a few phone calls, Spangler added. But in urban areas, physicians will have to contact as many as six insurance companies.

The association also has heard physician concerns about potential interruptions in patients' continuity of care because of provider network changes, and about the adequacy of reimbursement under exchange plans. Some doctors report that exchange plans are offering reimbursement rates close to Medicaid rates, though there are no definitive data on what plans are paying doctors.

“They're worried if they can afford to take patients from an exchange plan that has a different fee schedule,” Spangler said.

Dr. Stephen Brotherton, an orthopedic surgeon who serves as the Texas Medical Association's president, said neither he nor any of the other physicians in his Fort Worth-based practice intend to accept exchange plans. “We can't keep the doors open with those kinds of rates,” Brotherton said. He added that exchange plans are reimbursing at rates similar to Medicaid. “I think you'll see pretty low acceptance rates across the state.”

MSSNY President Dr. Sam Unterricht said that of his association's members who have received rate information from exchange plans, a significant majority indicated that the reimbursement generally was well below what the insurer pays in other contracts.

Of the more than 1,000 physician practices surveyed by the Medical Group Management Association in September, 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.

Hospitals with higher nurse staffing rates were less likely to be penalized under the federal government's Hospital Readmissions Reduction Program than hospitals that staff nurses at lower levels, according to a study in Health Affairs. Launched in October 2012, the federal government's readmissions program docks Medicare payments for hospitals with high readmission rates for heart attack, heart failure and pneumonia. On Oct. 1, the maximum penalty jumped from 1% to 2% for 2014. For the study, University of Pennsylvania researchers examined staffing data and publicly available readmission rates for more than 2,800 hospitals, covering fiscal 2013. Hospitals with high staffing levels—an average of eight registered-nurse hours per adjusted patient day—were 25% less likely to be penalized than low-staffing hospitals, which staffed at an average level of 5.1 RN hours per patient day. “Our findings point to management of nurse staffing levels and workloads as a potential system-level intervention through which hospitals can respond to the new regulatory environment,” they wrote in the study.

The Commonwealth Fund released a survey analyzing consumer experiences during the health insurance exchanges' rocky first month of open enrollment. Of those potentially eligible for coverage, 60% said they were aware of the exchanges and 17% reported visiting them. Just over 20% of those who visited said they enrolled in a plan, while others reported technical difficulties and uncertainty about affordability.

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