What the proposed changes mean to physicians.
Earlier this week, the Trump Administration released a proposed rule for market stabilization of the ACA designed to help convince insurers to remain in the marketplaces while Congress drafts a replacement plan for the ACA.
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Provisions in the rule address changes such as special enrollment periods, guaranteed availability, timing of the annual open enrollment period, network adequacy standards and actuarial value requirements.
The proposed regulations are meant to entice insurance companies to stay in the markets by reducing the number of days people have to sign up and by requiring more documentation of eligibility.
Kent Bottles, MD, Thomas Jefferson University College of Population Health, says the news brings into sharp focus the difficult balancing act that the GOP has to tackle since it has repeatedly announced that it wants to repeal the ACA.
“The problem with repealing the ACA is that it would take insurance away from about 20 million Americans who recently achieved coverage. They will be mad if that happens,” he says. “The Republicans have also not revealed what they would replace the ACA with, because no matter what they decide on, there will be winners and losers under a new system. Insurance companies need to decide soon if they will sell on the exchanges in 2018 and are nervous because they don’t know what rules will apply.”
Bottles says there are two schools of thought from doctors on the issue: one is most concerned about physician autonomy and physician income and they have never been big fans of the ACA. Another group likes the ACA in that it has provided many of their patients with insurance for the first time. This means that these doctors get paid something rather than giving charity care.
Interestingly enough, a 2017 New England Journal of Medicine survey of primary care physicians found that only 15% wanted to repeal the ACA. It did note that there are things that need to be improved in it, but most physicians believed it has helped their patients.
Peter Angood, MD, and CEO and president of the American Association for Physician Leaders, notes this initial rule is less about providing improved healthcare and more about setting a focus of expectation designed to help stabilize the payers’ perspective on the insurance market. This is a transient and temporary rule targeting the insurance providers and providing the federal administration time to coordinate their ultimate approach for repealing and improving the ACA.
“This rule should provide a temporary sense of relief to physicians that patients in their groups are able to maintain insurance coverage,” he says. “The benefit of this is that patients will be more compliant and continue to consume needed medical services or purchase needed medications.
“Without insurance, patients tend to avoid accruing costs by avoiding optimal care,” he continues. “Physician practices will be able to continue providing optimal care plans with a stabilized market because patient compliance remains higher.”
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For example, a patient with a chronic condition who requires regular physician follow-up, testing and treatment is more likely to follow through now.
“When the patient is insured, they remain more compliant with care because personal costs are controllable and usually known,”Angood says. “Without insurance, the opposite occurs in terms of costs, and so patients will avoid care in order to avoid personal expenses that are unpredictable-especially if they are in lower or middle socio-economic groups.”
Susan Nedza, MD, senior vice president, clinical outcomes, for MPA Healthcare Solutions in Chicago, says that for physicians, the proposed rule defers to state reviewers in determining network adequacy.
“It is likely that narrow network plans will be less likely to be challenged, as many states do not currently have robust, transparent methods for evaluating network adequacy,” she says. “This means that physicians may face increasing price pressure during negotiations, be left out of networks and be at risk for bad debt related to out of network services.”
For primary care physicians, they may find fewer specialists to whom they can refer patients. Additionally, she says, they should have frank conversations with patients regarding plan selection, narrowing of the enrollment period and new plan options.
There are still significant unanswered questions affecting patients, providers and insurers alike, including: removal of the individual mandate and its effect on rates, pre-existing conditions, changes to essential health benefits and expanded Medicaid coverage.
“Our physicians are committed to the patients they serve and the anxiety about maintaining coverage exists for both the patients and health center staff alike,” says Sabra Matovsky, executive vice president of Integrated Health Partners. “As a trusted source of information, patients are turning to their providers and we just don’t have the answers they are seeking yet.”