Doctors May Do a “Brexit” from Medicare

American physicians have already been declaring independence from Medicare, states the Association of American Physicians and Surgeons (AAPS), but the imposition of new payment methods may lead to a rush to imitate the British in exiting the regime of a remote, unelected, unaccountable bureaucracy. Almost four in 10 physicians in solo and small group practices predict an exodus from Medicare within their ranks because of the program’s new payment plan, according to a Medscape Medical News survey.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) includes complex system of bonuses and penalties. The Centers for Medicare and Medicaid Services (CMS) predicted that 87% of solo practice physicians would be penalized. AAPS says that a physician’s compliance score is tied to resource use. Physicians will be increasingly pressured to make decisions that save resources for Medicare instead of decisions that are in the best interest of their patients. Compliance is also tied to mandatory use of government-certified electronic health records, which AAPS says are harmful to patient medical privacy and detract from face-to-face patient care. The government would gain even greater ability to access patient medical records. The rules allow all insurance-based care, not just Medicare, to be phased in to these “harmful payment models, according to AAPS.

AAPS executive director Jane M. Orient, M.D. said, “It is impossible to practice medicine under this rule, for ethical and practical reasons. The rule makes it impossible to protect confidentiality, and one is in a constant conflict of interest: What is best for the patient may be bad for the financial viability of the practice. It would take a dedicated team of legal specialists to even attempt compliance. Full compliance is probably impossible even with such a team, which is beyond the means of a small practice. Physicians need to withdraw from Medicare or any other program that subjects them to this rule.” AAPS offers detailed instructions on how to opt out of Medicare, and regular workshops on building a successful practice to serve patients without third-party shackles.

Group Proposes Replacement to Obamacare

With health care costs and insurance premiums rising, the National Center for Policy Analysis developed a plan to create accessible, affordable and high quality health care for many more Americans. NCPA senior fellow and author Devon Herrick said, “Our health care system is simply not sustainable under Obamacare. Reform is inevitable. The longer that takes, the more hard it will be on everyone, including consumers.”

Dr. Herrick outlines the following alternatives to the ACA:

  • Increased flexibility in health plan design.
  • Tax fairness regardless of where Americans get their health coverage.
  • Increased access to primary care by removing barriers to innovative medical practices and services.
    Reform of hospital regulations to better serve patients.
  • Reduced costs through price transparency to boost competition and innovation in medical services and prescription drugs.
  • Strengthened Medicare, Medicaid, and Veterans Health that better serve the needs of patients.
  • Changes in the financing of medical care so that people have control over their health care dollars and the means to pay for medical care over their lifetimes.

ER Doctors Say that “Affordable” Premium Policies Mislead Patients

Ninety percent of emergency physicians say that health insurance companies mislead patients by offering affordable premiums for policies that actually cover very little, according to a survey by the American College of Emergency Physicians (ACEP). Ninety-six percent say that emergency patients don’t understand what their policies cover for emergency care. Eighty percent of ER doctors say they are seeing patients with health insurance who have missed or delayed medical care because of high insurance costs – a more than a 10% increase over six months ago.

Jay Kaplan, MD, FACEP, president of the American College of Emergency Physicians (ACEP) says, “Each day, emergency physicians are seeing patients who have significant co-pays for emergency care of up to $400 or more. It might as well be $4,000 for some people…Insurance companies must provide fair coverage…and be transparent about how they calculate payments. They need to pay reasonable charges, rather than setting arbitrary rates that don’t even cover the costs of care. Insurance companies are exploiting federal law to reduce coverage for emergency care knowing emergency departments have a federal mandate to care for all patients, regardless of their ability to pay. When plan reimbursements don’t cover the cost of providing services, physicians must choose between billing patients for the difference or going unpaid for their services. The vast majority of emergency physicians and their groups prefer to be in network.”

Dr. Kaplan says that health insurance companies are creating narrow networks of medical providers to increase profits, making it more likely for patients to go out-of-network. The survey of ER doctors also reveals the following:

  • 62% of ER doctors say that most health insurance companies provide inadequate coverage for emergency care visits.
    More than 80% of ER doctors who are aware of reimbursement issues agree that insurance companies have reduced emergency care reimbursements.
  • 60% of ER doctors say that, in the past year, they have had difficulty finding in-network specialists to care for patients with a quarter of them saying it happens daily.
  • 91% of ER doctors say that a new rule by the Centers for Medicare and Medicaid Services (CMS) would make it harder to find specialists and follow-up care for patients. The CMS rule exempts health insurance companies from meeting minimum standards to ensure adequate networks.
  • 79% of ER doctors who are familiar with the Fair Health database say it’s the best mechanism to ensure transparency and make sure that insurance companies don’t miscalculate payments.
  • 87% say that insurance companies should pay the in-network rate when an emergency patient does not have access to an in-network facility or physician.

Kaplan said, “Health insurance companies have a long history of not paying for emergency care and…discouraging their customers from seeking it. For example, United Healthcare was sued successfully by the State of New York for fraudulently calculating and significantly underpaying doctors for out-of-network medical services. They used the Ingenix database, which forced patients to overpay up to 30% for out-of-network doctors. The company, which, at the time, was led by the acting head of CMS, Andy Slavitt — paid the largest settlement to the state of New York and the American Medical Association. Part of that settlement created the Fair Health database.”

One-Third of Doctors Consider Quitting After Passage of the ACA

Thirty-six percent of all doctors, and 45% of private practice doctors say they are more inclined to leave the medical profession because of the Affordable Care Act (ACA), according to a study by CompHealth. Fifty-one percent of doctors surveyed view the ACA unfavorably while 30% view it favorably. Physicians in private practice are most pessimistic, with 61% saying they view the law negatively. Doctors also say the following about practicing medicine after the ACA:

  • 47% say the ACA has improved access to healthcare and insurance.
  • 44% say the ACA has had a neutral effect on their patients’ quality of healthcare.
  • 76% of all doctors, and 86% of private practice doctors say they are not properly compensated by ACA reimbursements.
  • 38% say their salaries have decreased.
  • 44% spend less time with their patients.
  • 68% spend too much time entering data.
  • 59% spend too much time doing paperwork.

To cope with challenging circumstances, 40% of doctors are supplementing their income by filling in for other doctors, moonlighting, and consulting.

Bill Would Prevent Over-Prescribing

A California bill would require doctors to check California’s prescription drug database before prescribing opiates. The Controlled Substance Utilization Review and Evaluation System (CURES) is the nation’s most advanced prescription drug monitoring program, but just 35% of California providers and dispensers use it. Carmen Balber, executive director of Consumer Watchdogs said, “California loses 4,500 people a year to preventable drug overdoses–more than any other state….The legislature can help…by requiring doctors to check the prescription database before recommending patients take the most dangerous and addictive drugs. It’s clear that making use of the database voluntary does not work.”

SB 482, by California state Senator Ricardo Lara, would require doctors to check California’s CURES database when prescribing Schedule II or III drugs like Oxycontin to a patient for the first time, and annually thereafter if the treatment continues. The Centers for Disease Control and Prevention issued new prescribing guidelines that recommend doctors use prescription drug databases every time they prescribe an opioid. Last month, president Obama proposed $1.2 billion in new federal funding to fight opioid abuse, including funds to expand the use of state prescription drug databases.

Twenty-two states mandate use of a state prescription database. States that track results have seen reduced doctor-shopping and lower opioid prescription rates. Also doctors say that the databases are useful to them in prescribing the right medications. The following states have seen improvements after mandating the use of a database:

  • New York saw a 75% drop in patients seeing multiple prescribers for the same drugs.
  • Kentucky found that opioid prescriptions to doctor-shopping individuals fell 54%. Also, overdose-related deaths declined for the first time in six years in 2013.
  • Tennessee saw a 36% drop in patients who were seeing multiple prescribers to get the same drugs. Tennessee prescribers say they are 41% less likely to prescribe controlled substances after checking the database, and 34% more likely to refer a patient for substance abuse treatment. Also, 86% of prescribers say the database is useful for decreasing doctor shopping.

Physicians Are Optimistic About New Payment Models

Physicians are cautiously optimistic about new payment and delivery models, such as pay-for-performance, patient-centered medical homes, and accountable care organizations, which tie reimbursement to quality and performance outcomes. Physicians say that these models may deliver better patient care and more efficient medical practices. Fifty-five percent of physicians participate in an alternate payment model, and more than one-third of them have been doing so for over three years. Eighty percent are open to an alternative payment system. Only 41% of physicians say that the fee-for-service model is optimal for delivering positive patient outcomes. That figure drops to 28% among doctors under 35.

How Major Players Are Driving Regional Networks

healthcare copyFollowing implementation of the Affordable Care Act, large players are consolidating the control of hospitals and physician organizations in the San Francisco Bay area, according to a recent report by the California HealthCare Foundation (CHCF).

In a region with many segmented submarkets, major providers are expanding to manage care efficiently, serve more patients, and compete with Kaiser Permanente. The number of independent hospitals is shrinking as financial problems mount. Independent practice associations are seeking to diversify, raise capital, and keep private practice viable, especially for primary care physicians. Though none of the region’s remaining private safety-net hospitals appear threatened by imminent closure, several face an uncertain future. The safety net is strong, but faces capacity and access challenges resulting from Medi-Cal expansion. Safety net providers are particularly hampered by their limited ability to recruit and retain clinicians. For more information, visit www.chcf.org/almanac.

Insurance plans roll out free primary care visits

Health insurers in more than a dozen markets are offering plans through the Affordable Care Act exchanges that feature no copayments, coinsurance or deductibles for visits to in-network primary care physicians. The insurers hope that by removing barriers to primary care, illnesses will be caught and treated early. National Public Radio/Kaiser Health News (12/31)

The Downside of Narrow Networks and High Deductibles

The Downside of Narrow Networks and High Deductibles
Seven in 10 emergency physicians are seeing patients with health insurance who have delayed medical care because of high out-of-pocket expenses, high deductibles, or high co-insurance, according to a survey by The American College of Emergency Physicians.

Also 73% are seeing more Medicaid patients who delayed medical care because their health plan didn’t have enough primary care physicians (narrow networks). Sixty-seven percent of emergency physicians say that primary care physicians are sending patients to emergency departments to get medical tests or procedures because their health plan refused to cover an office visit.

Sixty-percent of emergency physicians say that they’ve had a hard time referring their patients to specialists because of narrow network plans. More than 80% have treated patients who had difficulty finding specialists because their health plans have narrow networks. Sixty-five percent are seeing more patients in the emergency department due, in large part, to the fact that health insurance companies don’t have enough primary care physicians. Seventy-three percent are seeing more Medicaid patients because insurance companies don’t have enough primary care or specialty physicians.

Jay Kaplan, MD, FACEP, president of ACEP said, “Health insurance companies are shrinking the number of doctors available in their networks, making it more likely that patients will be forced into out-of-network situations…Balance billing would not even exist if health plans paid what is known as ‘usual and customary’ payment in the insurance industry — what is also known as ‘fair payment.’  Emergency patients are especially vulnerable because health plans know that emergency departments never turn anyone away. Health insurers have been taking gross advantage of patients and medical providers since the Affordable Care Act (ACA) took effect, arbitrarily slashing reimbursements to physicians by as much as 70%. Patients and physicians should band together to fight these dangerous insurance industry practices.” Dr. Kaplan also questioned why four of the largest insurance companies had the resources to merge, given the ACA requires insurers to spend at least 80% of premium revenue on medical care.

What Consumers Look for In a Health Plan

When choosing a health plan, the cost of insurance premiums is the top concern for younger healthcare shoppers (under 45). In-network access to doctors ranks higher with older consumers (45 and over), according to a 2015 FAIR Health survey of more than 1,000 adults in the United States.

While older consumers place access to their doctors at the top of the list, all age groups are more concerned about whether certain doctors are in their plan’s network than they are about network size. This information comes at a time when more employers and health plans are introducing narrow and tiered networks to reduce healthcare costs. Consumers also have more access to health plan choices due to the growth of public and private healthcare exchanges.

“While consumers did not list the number of doctors in the network as a prime consideration when enrolling in a health insurance plan, if the primary care doctors consumers prefer are not in their network, it will factor into their decisions when selecting a plan,” said Robin Gelburd, president of FAIR Health.

Latinos, women, adults younger than 45, low-income households and people with children in their households are the most likely to say that cost usually or always influences their decisions when choosing a doctor:

  • 63% of Most Latinos (versus 48% of the general population) usually or always consider cost.
  • 56% of consumers with children in their household usually or always consider cost, versus 45% of respondents without children at home.
  • Sixty percent of those with annual household incomes under $35,000 always or usually consider cost, versus 48% of the general population.

Q: Which one of the following is your most important consideration when enrolling in a health insurance plan?

Age Monthly premiumcost Total out-of-pocket costs (Including co-pays and co-insurance) Primary care physician or family doctor accepts plan Deductible Number of doctors in the network
18-34 28% 25% 23% 12% 6%
35-44 28% 24% 16% 14% 9%
45-54 17% 22% 32% 9% 5%
55-64 20% 24% 32% 7% 4%
65+ 18% 18% 30% 4% 7%
Total Population 23% 23% 26% 10% 6%

Last Updated 09/22/2021

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