“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.