Reform Update: Insurers, providers may need to work harder to educate ACA's newly covered

Millions of Americans gained health insurance coverage under the Patient Protection and Affordable Care Act this year, but the influx apparently has not yet translated into patients packing doctors' offices. That may reflect a lack of understanding about how and where to seek care—and a lack of outreach by their new plans and providers.

“If coverage expansion is allowing patients to establish new relationships with physicians, we would expect to see physicians devote a greater share of their calendars and work effort to caring for new patients,” wrote the authors of a report released this week by the Robert Wood Johnson Foundation and Athenahealth, a company that sells cloud-based health information and practice management technology.

But that is not what they found. Though it may seem counterintuitive, the organizations discovered that during the first five months of 2014, all specialties—with the exception of pediatrics—experienced lower rates of new-patient visits than they had in the year-ago period. This was based on data taken from more than 14,000 providers across specialties.

For example, the proportion of visits from new patients to primary-care physicians in the sample from January to May 2014 was 18.8% compared with 19.3% during that same five-month period in 2013.

The study did not analyze what caused this decline, but the authors suggest that one reason is that the newly insured are continuing to go to emergency departments instead of physician offices. That explanation seems consistent with studies that showed increased emergency department use after pre-ACA expansions of health insurance in Massachusetts and Medicaid in Oregon.

“It's not unexpected at all,” said Stephen Zuckerman, co-director and a senior fellow in the Health Policy Center of the Urban Institute. “Given what we know from survey data, people are quite confused about a lot of the basic features of health insurance plans. This is true for people who have had insurance, and it's even more of an issue for people who are becoming newly insured.”

In an analysis released Tuesday, more than 80% of outreach programs surveyed by the Kaiser Family Foundation said consumers seeking their assistance didn't understand or were confused by the Affordable Care Act. And nearly three quarters of people coming to them for help had difficulty understanding basic insurance concepts, including deductibles or provider networks.

Health insurers say they have known this for a long time and have been dealing with it well before the Affordable Care Act went into effect, according to Susan Pisano, spokeswoman for the trade organization America's Health Insurance Plans.

“We as a community have been very focused on health literacy as an endeavor within the industry,” Pisano said. “But it's been amped up.”

Outreach and educational efforts from AHIP's members have included new-member kits, outbound calls to newly insured individuals, webinars, reminders for gender- and age-specific preventive coverage, and the use of multi-language materials and interpreters.

“We have been making new-member calls for as long as I can remember,” said Ed Harden, spokesman for McLaren Health Plan, based in Flint, Mich. “Every new member we enroll gets a call to welcome them to the plan and ask if they have any questions, if they've selected a primary-care physician and to coordinate scheduling an appointment for them if they need one immediately.”

McLaren also distributes newsletters, operates a website with educational information and assists members in getting enrolled in disease management programs and health counseling services.

Seeing a doctor may soon be a matter of a virtual visit, thanks to initiatives from big insurers that include WellPoint and Aetna. Both have begun expanding telemedicine options for their patients, offering them the opportunity to have virtual consultations with their doctors for non-urgent issues such as a sore throat or a sinus infection. “Whether Web chats or structured telephone calls, these virtual alternatives can deliver effective healthcare solutions that also help both doctors and patients save time, which makes everyone happier,” according to Hartford, Conn.-based Aetna. The insurer plans to expand online physician access to 8 million members by 2015.

Insurers are putting pressure on policymakers to make changes to a rule under the Patient Protection and Affordable Care Act that they say costs the industry millions of dollars in consumer rebates each year. The medical-loss ratio rule requires that insurers spend at least 80% of revenue from premiums on healthcare costs and no more than 15% on administrative costs for large groups or 20% for small groups. If an insurer doesn't meet the ratio, they must return the difference to their consumers as a rebate. But insurers are asking that brokers' fees be removed from the calculation of administrative costs. According to a recent GAO report, excluding these fees could reduce rebates by a significant 75%. If the change had been in effect in 2011 and 2012, insurers would have returned just more than $400 million to their customers instead of $1.1 billion returned in 2011 and $520 million in 2012. "The medical-loss ratio imposes an unprecedented federal cap on health plan administrative costs that will have significant unintended consequences," a statement by America's Health Insurance Plans said. It cited reduced access to agents and brokers, increased costs, reduced efforts against fraud and abuse, and less investment in initiatives for quality and safety of patient care.

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