MGMA ACA Exchange Implementation Survey Report
Medical Group Management Association, May 2014
Medical Group Management Association (MGMA) conducted member research in April 2014 to better understand the impact of the Affordable Care Act’s (ACA) insurance exchange implementation on medical group practices.
Summary of Findings
MGMA noted three main themes within the findings.
OBTAINING COVERAGE INFORMATION
Practices have experienced difficulty identifying patients with ACA exchange coverage and obtaining essential information related to that coverage.
- 62% of respondents reported moderate to extreme difficulty with identifying a patient that has ACA exchange coverage as opposed to traditional commercial health insurance.
- Compared to patients with traditional commercial coverage, nearly 60% of respondents indicated that for patients with ACA exchange coverage it is somewhat or much more difficult to:
- Verify patient eligibility
- Obtain cost-sharing or network information
- Obtain information about the plan’s provider network in order to facilitate referrals
“We are going to have to hire additional staff just to manage the insurance verification processs.”
“Identification of ACA plans has been an administrative nightmare.”
“We thought we would be able to identify ACA insurance exchange products by their insurance card, but quickly found out this isn’t so. “
Practices are facing a number of challenges related to patient cost-sharing for ACA exchange coverage.
- 75% of respondents reported that patients with ACA exchange coverage are very or extremely likely to have high deductibles compared to patients with traditional commercial coverage.
- Practices reported significant patient confusion about the substantial cost-sharing related to many ACA exchange products, and practices are working to help patients understand the complexities of their coverage.
- Practices cited some of the main reasons for not participating with ACA exchange products were related to concerns about financial burdens from patient collections (such as burdens related to collecting high deductibles from patients and concerns about financial liability from the 90-day grace period).
“Patients have been very confused about benefits and their portion of the cost. Once the patients find out their deductible, they’ve cancelled appointments and procedures.”
“The at-risk piece of eligibility is tremendously hard to determine and explain to patients.”
“Patients don’t always understand how health insurance works, so we’ve been engaging in educational events for the community.”
Practices have concerns about the impact of the network design of many ACA exchange products.
- Almost half of respondents reported they have been unable to provide covered services to ACA exchange patients because the practice is out of network.
- 20% of respondents reported that their practice was excluded from a narrow network that they would have liked to participate in and 10% of respondents chose not to participate in a narrow network.
- Narrow networks may create challenges related to patient referrals for appropriate treatment and hospital care. Even if the practice is included in the network, without robust representation by a wide range of providers, it may be difficult for a practice to coordinate a continuum of care consistent with the patient’s needs.
“Many patients purchased products with a very narrow network and didn’t understand the ramifications. They are very upset once they learn that they can’t go to the specialist or hospital of their choice. As primary care providers, we are now faced with the extra burden of trying to find them care within their new narrow network. Payer directories are woefully inaccurate and impossible to rely on.”
“Former patients were shocked to learn about their very narrow network of providers. It was terrible to have to inform them of their lack of coverage.”
“We are consistently denied ‘out of network’ approvals for the very sick who truly need to continue their care with providers who have worked with the patient for years.”
Statement of Susan Turney, MD, MS, FACP, FACMPE, president and CEO of MGMA:
“Physician group practices are expressing dissatisfaction with the complexity and lack of information associated with insurance products sold on ACA exchanges. The more administrative complexity introduced into the healthcare system, the less time and resources practices can devote to patient care. Even though there hasn’t been a huge influx of patients into physician offices as many predicted, simple tasks such as obtaining patient insurance coverage information or finding specialists for in-network referrals have proven to be significant challenges.”
By Don McCanne, MD
Much has been written about the consequences of the high deductibles and narrow networks of the ACA exchange plans in impairing access and affordability for patients. This new survey demonstrates that these same features add more administrative headaches for physicians who are already overburdened by the administrative complexity of our dysfunctional health care financing system. For those who could care less about the physicians, keep in mind that these ACA plan features are preventing physicians from assisting patients in obtaining the health care that they should have. It is really about the patients.
The quotations in the report above are especially helpful to our understanding of the problems because they reveal the real world consequences of the highly flawed ACA exchange infrastructure.
Single payer would eliminate the confusion over coverage, the barriers of patient cost sharing, and the loss of choice due to network limitations. People would simply get the care that they need when they need it.