Declines in Physician Acceptance of Medicare and Private Coverage

By Tara F. Bishop, MD, MPH; Alex D. Federman, MD, MPH; Salomeh Keyhani, MD, MPH
Archives of Internal Medicine, June 27, 2011

A number of articles in the lay and medical press report a decline in the number of physicians who accept patients with Medicare; however, to our knowledge, recent trends in acceptance of different types of insurance have not been examined. Using data from a national survey of physicians, we examined trends in physician acceptance of different types of insurance and self-pay patients.

Results

The percentage of physicians accepting new patients did not vary significantly between 2005 and 2008, ranging from 94.2% to 95.3%. Physician acceptance of new Medicare patients dropped from 95.5% in 2005 to 92.9% in 2008 (P = .01). Physicians in private practice were largely responsible for the declining acceptance of Medicare patients as determined in stratified analyses (95.5% in 2005 vs 93.0% in 2008; P = .01) (eTable).

There was a more pronounced decline in physician acceptance of patients with private noncapitated insurance (93.3% in 2005 vs 87.8% in 2008; P < .001). A smaller percentage of adult primary care physicians accepted private noncapitated patients over the study period (97.3% in 2005 vs 89.9% in 2008; P < .001).

Rates of acceptance of new Medicaid and private capitated patients were lower than Medicare and private noncapitated insurance, but also showed a decline over the study period. Acceptance of self-paying patients was more than 96% in all years and did not change significantly over the study period.

While reports in the press highlight physicians’ dissatisfaction with Medicare, we found only a small decline in physician acceptance of Medicare patients between 2005 and 2008. In contrast, the decline in physician acceptance of noncapitated privately insured patients was more pronounced. Physicians continued to accept patients who were self-paying.

Although physician reimbursement under Medicare is often cited as the reason why physicians turn away Medicare patients, our findings that more than 90% of physicians continue to accept Medicare patients despite marginal increases in reimbursement suggest that anecdotal reports may be overstating access problems.

The observed decline in acceptance of private noncapitated insurance was unexpected and could be related to reimbursement but also to administrative burden. Acceptance rates of capitated insurance was lower and may reflect lower reimbursement in this model. Finally, the low and declining acceptance of new Medicaid patients is not surprising given the program’s historically poor reimbursement rate. Low rates of Medicaid acceptance may threaten access to care for the estimated 16 million Americans who will receive Medicaid coverage as a result of the Patient Protection and Affordable Care Act.

http://archinte.ama-assn.org/cgi/content/full/171/12/1117

eTable. Percentage of physicians accepting new patients by insurance type, practice type, and specialty, 2005-2008:
http://archinte.ama-assn.org/cgi/data/171/12/1117/DC1/1

The good news in this report is that the often stated claim that physicians are dumping Medicare patients in favor of privately insured patients is not really true, at least as of 2008. Although there has been a small decline in the numbers of physicians accepting Medicare, well over 90 percent still do. Contrary to claims otherwise, the decline in the acceptance of privately insured patients was even greater.

Examining the breakdown in the eTable (link above) reveals some other interesting though not unexpected findings. With the exception of community health centers, close to one-third of physicians do not accept new Medicaid patients. Even more do not accept privately insured capitated patients (paid a flat amount per month per patient rather than fee for service). Over half of HMOs do not accept self-pay patients, though acceptance rates for these patients is very high in private practices and community health centers.

Although cash paying patients had the best access, this report does not cover the potentially catastrophic consequences of being uninsured or inadequately insured (e.g, high deductibles). Having adequate insurance is essential. The new lower actuarial value standards of private insurance make them a less desirable model for expanding coverage. Also the chronic underfunding of Medicaid makes it a poor choice.

Although Medicare remains popular and is widely accepted, it does need to be improved. Once we do that then it would be the ideal program to cover everyone. Acceptance rates would be virtually 100 percent.

By Jonathan Oberlander
Journal of Health Politics, Policy and Law, June 2011

During the 2009 – 2010 health reform debate, secretary of Health and Human Services Kathleen Sebelius contended that “every cost-cutting idea that every health economist has brought to the table is in this bill” (Gregory et al. 2010).

That assertion had considerable merit. The Patient Protection and Affordable Care Act (ACA) contained numerous items on health services researchers’ and health economists’ wish lists, including policies to promote accountable care organizations (ACOs), primary care medical homes, bundled payment, pay for performance (P4P), comparative effectiveness research (CER), and health information technology (HIT). Even economists’ longtime holy grail — limiting the tax exclusion for employer-sponsored insurance — made it, against the political odds, into the ACA. So too did proposals to create an independent Medicare commission and an innovation center, while the Obama administration additionally promised to authorize an Institute of Medicine study on reducing the geographic disparities in Medicare payment made (in)famous by Dartmouth researchers (Wennberg, Fisher, and Skinner 2002).

Not surprisingly, many policy analysts lavished praise on the new law’s promise to “bend the cost curve.”

Is there, then, reason to believe that the ACA will decisively rein in U.S. medical care spending? Alas, probably not. The enthusiasm for the cost-containment provisions in health reform is striking precisely because so many of those provisions are tepid. Put simply, the Affordable Care Act lacks systemwide, reliable cost control. It is in fact a retreat from the cost-control ambitions of the 1993 – 1994 Clinton plan, which had, whatever one thinks of managed competition, a serious theory of how to slow health care spending, and, beyond that, a National Health Board and a budget to enforce expenditure targets. That some analysts believe the new law encompasses all available cost-containment ideas says more about the parochialism of U.S. health policy and its inattention to international experience than it does about the robustness of the ACA’s spending limits.

But slowing federal expenditures on Medicare is not the same as controlling spending in the broader U.S. health care system that encompasses private insurance and other public programs (Marmor and Oberlander 2009). Outside of asserting Medicare’s powers, the ACA has three major policies that purport to control costs. The establishment of health insurance exchanges is expected to generate savings by concentrating purchasing power, reducing administrative costs, and promoting competition among health insurers. Yet the scope of the exchanges, and consequently their likely impact on national health expenditures, is limited: the Congressional Budget Office (CBO 2010) projects 24 million Americans will participate in them by 2019 (though enrollment could expand significantly over time). Moreover, Massachusetts’s experience to date with its Health Connector program provides little ground for believing that the exchanges will slow spending in the broader health system.

The second major cost-control instrument is the 40 percent marginal tax that will be imposed on high-cost insurance plans (policies exceeding $10,200 for individuals and $27,500 for families). The so-called Cadillac tax reflects many economists’ deeply held belief that insulating patients from costs leads to overconsumption of and higher spending on medical care (Vladeck and Rice 2009). That other nations spend much less than the United States on health care despite having comprehensive benefits and, in some cases, no cost sharing has so far not disturbed the view that moral hazard is the root of our high costs. Tax health insurance, advocates believe, and insurers and employers will trim overly generous benefits, patients will consume less medical care, and national health spending will slow.

The final piece of the ACA’s cost-control strategy is delivery system reform. Here the idea is to “modernize” U.S. medical care (Buntin and Cutler 2009) by providing better information and new incentives (CER, HIT), reorganizing how care is delivered (ACOs, medical homes), and changing how it is paid for (bundled payment, P4P). In addition, the law embraces prevention, including a new requirement that insurers must cover recommended preventive services without any cost sharing.

However, little evidence exists that any of these reforms — as politically appealing as their promise to improve health outcomes and health care delivery may be — will generate sizable savings in the short term (Marmor, Oberlander, and White 2009; Tanenbaum 2009). Moreover, in many cases the reforms are initially envisioned only as Medicare pilots and demonstrations, with the hope that they would spread throughout the program and then to the rest of the health system. This strategy for controlling costs is akin to throwing darts. Evidently, the idea is that since we don’t know how well any of these policies will work, we should try them all at once and see which ones actually stick.

There is good reason to be skeptical that delivery system reform will by itself provide reliable cost control. After all, other Organisation for Economic Co-operation and Development nations that spend less on medical care than the United States do so largely through concentrated purchasing, budgeting, and price regulation (Jost, Dawson, and den Exter 2006; Marmor, Oberlander, and White 2009; Vladeck and Rice 2009; White 1995, 2010). The ACA does not move the United States closer to that international standard (White 1995) as much as it maintains the American tradition of searching for technical fixes to the fundamentally political problem of slowing the flow of income to the health care industry (Barer and Evans 1992; Morone 1990; Reinhardt 1990; Vladeck and Rice 2009).

Thus many American policy analysts continue to lament fee-for-service payment and argue for the “necessity” of switching to a “fee-for-value” system if costs are to be controlled — never mind that other nations that pay doctors fee-for-service, including Canada, control costs much better than we do. The American debate has lost sight of a crucial fact: it is not just about how you pay for medical care, but how much you pay for services. Rather than emulating policies that actually work to constrain spending abroad (e.g., global budgets, fee schedules) the United States seems intent on reinventing and reorganizing its way out of the cost crisis. Yesterday’s conviction that capitation and integrated delivery systems held the key to stemming medical costs has been resurrected in the current fad for accountable care organizations and bundling, with scant acknowledgment that we have been down this road before. An ever-increasing list of abbreviations (HMOs, HSAs, HIT, P4P, and so on) bear witness to Americans’ elusive, and now four-decade-long, search for magic bullets.

Proponents of the ACA have attempted to turn the absence of reliable cost control into a strength. The law is, they contend, diverse and flexible. By trying many approaches, “it does not rely on just one policy for effective cost control” (Orszag and Emanuel 2010: 603). Yet combining a series of potentially ineffective reforms does not make them any more effective. Moreover, the rationale for experimenting with an array of delivery systems and payment reforms reflects a sort of policy agnosticism, since, as Jon Gruber argues, “health policy experts can’t really say for sure how governments should best go about slowing cost growth” (Gruber 2010: 189). But international experience suggests that other nations do know how to slow medical spending; the United States is simply unable or unwilling to adopt those policies. Americans are, in other words, det
ermined to try all available cost-control options — except those that actually succeed elsewhere. Ultimately, the insistence that the United States has to try everything because nothing is certain to contain medical costs sounds less like agnosticism or intellectual curiosity and more like ignorance.

http://jhppl.dukejournals.org/cgi/reprint/36/3/477

Comment: 

By Don McCanne, MD

Read these excerpts from Jonathan Oberlander’s article, and you’ll understand much better why the Affordable Care Act will fail to control health care costs. Has our reform been driven by ignorance, as he suggests? With the great body of health policy literature available to us, how could that be? It seems more likely that ego and greed are much more powerful policy drivers.

Throwing Darts: Americans’ Elusive Search for Health Care Cost Control

By Jonathan Oberlander
Journal of Health Politics, Policy and Law, June 2011

During the 2009 – 2010 health reform debate, secretary of Health and Human Services Kathleen Sebelius contended that “every cost-cutting idea that every health economist has brought to the table is in this bill” (Gregory et al. 2010).

That assertion had considerable merit. The Patient Protection and Affordable Care Act (ACA) contained numerous items on health services researchers’ and health economists’ wish lists, including policies to promote accountable care organizations (ACOs), primary care medical homes, bundled payment, pay for performance (P4P), comparative effectiveness research (CER), and health information technology (HIT). Even economists’ longtime holy grail — limiting the tax exclusion for employer-sponsored insurance — made it, against the political odds, into the ACA. So too did proposals to create an independent Medicare commission and an innovation center, while the Obama administration additionally promised to authorize an Institute of Medicine study on reducing the geographic disparities in Medicare payment made (in)famous by Dartmouth researchers (Wennberg, Fisher, and Skinner 2002).

Not surprisingly, many policy analysts lavished praise on the new law’s promise to “bend the cost curve.”

Is there, then, reason to believe that the ACA will decisively rein in U.S. medical care spending? Alas, probably not. The enthusiasm for the cost-containment provisions in health reform is striking precisely because so many of those provisions are tepid. Put simply, the Affordable Care Act lacks systemwide, reliable cost control. It is in fact a retreat from the cost-control ambitions of the 1993 – 1994 Clinton plan, which had, whatever one thinks of managed competition, a serious theory of how to slow health care spending, and, beyond that, a National Health Board and a budget to enforce expenditure targets. That some analysts believe the new law encompasses all available cost-containment ideas says more about the parochialism of U.S. health policy and its inattention to international experience than it does about the robustness of the ACA’s spending limits.

But slowing federal expenditures on Medicare is not the same as controlling spending in the broader U.S. health care system that encompasses private insurance and other public programs (Marmor and Oberlander 2009). Outside of asserting Medicare’s powers, the ACA has three major policies that purport to control costs. The establishment of health insurance exchanges is expected to generate savings by concentrating purchasing power, reducing administrative costs, and promoting competition among health insurers. Yet the scope of the exchanges, and consequently their likely impact on national health expenditures, is limited: the Congressional Budget Office (CBO 2010) projects 24 million Americans will participate in them by 2019 (though enrollment could expand significantly over time). Moreover, Massachusetts’s experience to date with its Health Connector program provides little ground for believing that the exchanges will slow spending in the broader health system.

The second major cost-control instrument is the 40 percent marginal tax that will be imposed on high-cost insurance plans (policies exceeding $10,200 for individuals and $27,500 for families). The so-called Cadillac tax reflects many economists’ deeply held belief that insulating patients from costs leads to overconsumption of and higher spending on medical care (Vladeck and Rice 2009). That other nations spend much less than the United States on health care despite having comprehensive benefits and, in some cases, no cost sharing has so far not disturbed the view that moral hazard is the root of our high costs. Tax health insurance, advocates believe, and insurers and employers will trim overly generous benefits, patients will consume less medical care, and national health spending will slow.

The final piece of the ACA’s cost-control strategy is delivery system reform. Here the idea is to “modernize” U.S. medical care (Buntin and Cutler 2009) by providing better information and new incentives (CER, HIT), reorganizing how care is delivered (ACOs, medical homes), and changing how it is paid for (bundled payment, P4P). In addition, the law embraces prevention, including a new requirement that insurers must cover recommended preventive services without any cost sharing.

However, little evidence exists that any of these reforms — as politically appealing as their promise to improve health outcomes and health care delivery may be — will generate sizable savings in the short term (Marmor, Oberlander, and White 2009; Tanenbaum 2009). Moreover, in many cases the reforms are initially envisioned only as Medicare pilots and demonstrations, with the hope that they would spread throughout the program and then to the rest of the health system. This strategy for controlling costs is akin to throwing darts. Evidently, the idea is that since we don’t know how well any of these policies will work, we should try them all at once and see which ones actually stick.

There is good reason to be skeptical that delivery system reform will by itself provide reliable cost control. After all, other Organisation for Economic Co-operation and Development nations that spend less on medical care than the United States do so largely through concentrated purchasing, budgeting, and price regulation (Jost, Dawson, and den Exter 2006; Marmor, Oberlander, and White 2009; Vladeck and Rice 2009; White 1995, 2010). The ACA does not move the United States closer to that international standard (White 1995) as much as it maintains the American tradition of searching for technical fixes to the fundamentally political problem of slowing the flow of income to the health care industry (Barer and Evans 1992; Morone 1990; Reinhardt 1990; Vladeck and Rice 2009).

Thus many American policy analysts continue to lament fee-for-service payment and argue for the “necessity” of switching to a “fee-for-value” system if costs are to be controlled — never mind that other nations that pay doctors fee-for-service, including Canada, control costs much better than we do. The American debate has lost sight of a crucial fact: it is not just about how you pay for medical care, but how much you pay for services. Rather than emulating policies that actually work to constrain spending abroad (e.g., global budgets, fee schedules) the United States seems intent on reinventing and reorganizing its way out of the cost crisis. Yesterday’s conviction that capitation and integrated delivery systems held the key to stemming medical costs has been resurrected in the current fad for accountable care organizations and bundling, with scant acknowledgment that we have been down this road before. An ever-increasing list of abbreviations (HMOs, HSAs, HIT, P4P, and so on) bear witness to Americans’ elusive, and now four-decade-long, search for magic bullets.

Proponents of the ACA have attempted to turn the absence of reliable cost control into a strength. The law is, they contend, diverse and flexible. By trying many approaches, “it does not rely on just one policy for effective cost control” (Orszag and Emanuel 2010: 603). Yet combining a series of potentially ineffective reforms does not make them any more effective. Moreover, the rationale for experimenting with an array of delivery systems and payment reforms reflects a sort of policy agnosticism, since, as Jon Gruber argues, “health policy experts can’t really say for sure how governments should best go about slowing cost growth” (Gruber 2010: 189). But international experience suggests that other nations do know how to slow medical spending; the United States is simply unable or unwilling to adopt those policies. Americans are, in other words, determined to try all available cost-control options — except those that actually succeed elsewhere. Ultimately, the insistence that the United States has to try everything because nothing is certain to contain medical costs sounds less like agnosticism or intellectual curiosity and more like ignorance.

http://jhppl.dukejournals.org/cgi/reprint/36/3/477

Read these excerpts from Jonathan Oberlander’s article, and you’ll understand much better why the Affordable Care Act will fail to control health care costs. Has our reform been driven by ignorance, as he suggests? With the great body of health policy literature available to us, how could that be? It seems more likely that ego and greed are much more powerful policy drivers.

By Susan Jaffe
Kaiser Health News, June 23, 2011

The Obama administration announced Wednesday that it is scaling back some of its earlier rules under the 2010 health law that governed consumers’ right to appeal denials by health plans, disappointing patient advocates and earning praise from industry groups.

The health overhaul gives members in group and individual health plans the right – many for the first time — to appeal the denial of coverage to an independent review panel. But the administration’s new rules provide beneficiaries less time to prepare their appeal, less information about why their claim was denied and limit what type of denials can be challenged.

A spokesman for America’s Health Insurance Plans, which had pressed the administration for changes, said the trade group was still reviewing the 95-page document, but the group’s overall impression was positive.

“The new regulations take important steps to simplify and streamline the appeals process so that patients can receive the most accurate and timely decision about their medical claims,” said the spokesman, Robert Zirkelbach.

Stephen Finan, senior policy director at the American Cancer Society Cancer Action Network, said Wednesday’s announcement would have the opposite effect. “Transparency and independence are critical to ensure that a fair and objective appeal is conducted,” he said. “Unfortunately, there are numerous barriers and burdens placed on the consumer that could prevent a timely and objective resolution to a denial.”

http://www.kaiserhealthnews.org/Stories/2011/June/22/External-Appeals-Reg-Jaffe.aspx

And…

Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes

Department of the Treasury
Department of Labor
Department of Health and Human Services

SUMMARY: This document contains amendments to interim final regulations implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets under provisions of the Affordable Care Act. These rules are intended to respond to feedback from a wide range of stakeholders on the interim final regulations and to assist plans and issuers in coming into full compliance with the law through an orderly and expeditious implementation process.

(Following is one example of the revised rules)

II. Overview of Amendments to the Interim Final Regulations
A. Internal Claims and Appeals
1. Expedited notification of benefit determinations involving urgent care (paragraph
(b)(2)(ii)(B) of the July 2010 regulations).

The July 2010 regulations provided that a plan or issuer must notify a claimant of a benefit determination (whether adverse or not) with respect to a claim involving urgent care (as defined in the DOL claims procedure regulation) as soon as possible, taking into account the medical exigencies, but not later than 24 hours after the receipt of the claim by the plan or issuer, unless the claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the plan or health insurance coverage. This was a change from the DOL claims procedure regulation, which generally requires a determination not later than 72 hours after receipt of the claim by a group health plan for urgent care claims. The preamble to the July 2010 regulations stated that the Departments expected electronic communication would enable faster decision-making than in the year 2000, when the DOL claims procedure regulation was issued.

While some commenters supported the 24-hour rule (particularly consumer advocates and medical associations, including mental health providers who noted the 24-hour standard was especially important for people in psychiatric crisis), concerns were raised by many plans and issuers regarding the burden of a 24-hour turnaround. Some commenters argued that some of the claims constituting “urgent care” and thus qualifying for the expedited timeframe really do not need to be made within 24 hours. Moreover, a number of commenters highlighted that the 72-hour provision was intended only to serve as a “backstop”; as the general rule under both the July 2010 regulations and the DOL claims procedure regulation requires a decision as soon as possible consistent with the medical exigencies involved, making the change to a 24-hour timeframe unnecessary for the most serious medical cases. Some commenters cited the Emergency Medical Treatment and Labor Act (EMTALA), which generally requires hospitals to provide emergency care to individuals with or without insurance or preauthorization and, therefore, mitigates the need for expedited pre-service emergency claims determinations in many situations. Finally, some commenters stated that a firm 24-hour turnaround for urgent care claims will adversely affect claimants, as plans and issuers will not have sufficient time to properly review a claim, adversely affecting the quality of the review process in cases where the provider cannot be consulted in time, and leading to unnecessary denials of claims.

After considering the comments, and the costs and benefits of an absolute 24-hour decision-making deadline for pre-service urgent care claims, this amendment permits plans and issuers to follow the original rule in the DOL claims procedure regulation (requiring decision making in the context of pre-service urgent care claims as soon as possible consistent with the medical exigencies involved but in no event later than 72 hours), provided that the plan or issuer defers to the attending provider with respect to the decision as to whether a claim constitutes “urgent care.” At the same time, the Departments underscore that the 72-hour timeframe remains only an outside limit and that, in cases where a decision must be made more quickly based on the medical exigencies involved, the requirement remains that the decision should be made sooner than 72 hours after receipt of the claim.

http://www.ofr.gov/(X(1)S(jsllnf4ps0f4ieewh0fb4pee))/OFRUpload/OFRData/2011-15890_PI.pdf

Comment: 

By Don McCanne, MD

Was reform intended to benefit patients or insurers? As the reform process evolved, the insurers were dictating the policies. Understandably, they took care of their own interests first. Their lack of concern for patients is confirmed by the fact that their policies will leave 23 million people without any coverage and tens of millions more with inadequate coverage.

Officials of the Obama administration, along with leaders in Congress, were complicit with the insurers during the legislative process that led to the Affordable Care Act. You might think that they would show some remorse by tailoring the provisions of the act to better benefit patients. No.

The example of the rule change for determinations involving urgent care shows where their heart is. If a patient requires urgent care, the system should be designed to ensure that the necessary care is provided immediately. Yet read the contorted explanation leading to the revised rule above. It is being revised to ensure that the insurers are allowed three days instead of one to make a decision. That might even save them money should the patient die in the interim.

The administration’s rule: first do no harm – to the insurance company. And the patients? Who’s making these rules anyway? The patients need to butt out.

What would be the appeals process for a determination of urgent care under a single pa
yer national health program? Appeals? What are you talking about? If the patient urgently needs care, the patient gets care – now! Period.

HHS Scales Back Rules On Health Insurance Appeals

By Susan Jaffe
Kaiser Health News, June 23, 2011

The Obama administration announced Wednesday that it is scaling back some of its earlier rules under the 2010 health law that governed consumers’ right to appeal denials by health plans, disappointing patient advocates and earning praise from industry groups.

The health overhaul gives members in group and individual health plans the right – many for the first time — to appeal the denial of coverage to an independent review panel. But the administration’s new rules provide beneficiaries less time to prepare their appeal, less information about why their claim was denied and limit what type of denials can be challenged.

A spokesman for America’s Health Insurance Plans, which had pressed the administration for changes, said the trade group was still reviewing the 95-page document, but the group’s overall impression was positive.

“The new regulations take important steps to simplify and streamline the appeals process so that patients can receive the most accurate and timely decision about their medical claims,” said the spokesman, Robert Zirkelbach.

Stephen Finan, senior policy director at the American Cancer Society Cancer Action Network, said Wednesday’s announcement would have the opposite effect. “Transparency and independence are critical to ensure that a fair and objective appeal is conducted,” he said. “Unfortunately, there are numerous barriers and burdens placed on the consumer that could prevent a timely and objective resolution to a denial.”

http://www.kaiserhealthnews.org/Stories/2011/June/22/External-Appeals-Reg-Jaffe.aspx

And…

Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes

Department of the Treasury
Department of Labor
Department of Health and Human Services

SUMMARY: This document contains amendments to interim final regulations implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets under provisions of the Affordable Care Act. These rules are intended to respond to feedback from a wide range of stakeholders on the interim final regulations and to assist plans and issuers in coming into full compliance with the law through an orderly and expeditious implementation process.

(Following is one example of the revised rules)

II. Overview of Amendments to the Interim Final Regulations
A. Internal Claims and Appeals
1. Expedited notification of benefit determinations involving urgent care (paragraph
(b)(2)(ii)(B) of the July 2010 regulations).

The July 2010 regulations provided that a plan or issuer must notify a claimant of a benefit determination (whether adverse or not) with respect to a claim involving urgent care (as defined in the DOL claims procedure regulation) as soon as possible, taking into account the medical exigencies, but not later than 24 hours after the receipt of the claim by the plan or issuer, unless the claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the plan or health insurance coverage. This was a change from the DOL claims procedure regulation, which generally requires a determination not later than 72 hours after receipt of the claim by a group health plan for urgent care claims. The preamble to the July 2010 regulations stated that the Departments expected electronic communication would enable faster decision-making than in the year 2000, when the DOL claims procedure regulation was issued.

While some commenters supported the 24-hour rule (particularly consumer advocates and medical associations, including mental health providers who noted the 24-hour standard was especially important for people in psychiatric crisis), concerns were raised by many plans and issuers regarding the burden of a 24-hour turnaround. Some commenters argued that some of the claims constituting “urgent care” and thus qualifying for the expedited timeframe really do not need to be made within 24 hours. Moreover, a number of commenters highlighted that the 72-hour provision was intended only to serve as a “backstop”; as the general rule under both the July 2010 regulations and the DOL claims procedure regulation requires a decision as soon as possible consistent with the medical exigencies involved, making the change to a 24-hour timeframe unnecessary for the most serious medical cases. Some commenters cited the Emergency Medical Treatment and Labor Act (EMTALA), which generally requires hospitals to provide emergency care to individuals with or without insurance or preauthorization and, therefore, mitigates the need for expedited pre-service emergency claims determinations in many situations. Finally, some commenters stated that a firm 24-hour turnaround for urgent care claims will adversely affect claimants, as plans and issuers will not have sufficient time to properly review a claim, adversely affecting the quality of the review process in cases where the provider cannot be consulted in time, and leading to unnecessary denials of claims.

After considering the comments, and the costs and benefits of an absolute 24-hour decision-making deadline for pre-service urgent care claims, this amendment permits plans and issuers to follow the original rule in the DOL claims procedure regulation (requiring decision making in the context of pre-service urgent care claims as soon as possible consistent with the medical exigencies involved but in no event later than 72 hours), provided that the plan or issuer defers to the attending provider with respect to the decision as to whether a claim constitutes “urgent care.” At the same time, the Departments underscore that the 72-hour timeframe remains only an outside limit and that, in cases where a decision must be made more quickly based on the medical exigencies involved, the requirement remains that the decision should be made sooner than 72 hours after receipt of the claim.

http://www.ofr.gov/(X(1)S(jsllnf4ps0f4ieewh0fb4pee))/OFRUpload/OFRData/2011-15890_PI.pdf

Was reform intended to benefit patients or insurers? As the reform process evolved, the insurers were dictating the policies. Understandably, they took care of their own interests first. Their lack of concern for patients is confirmed by the fact that their policies will leave 23 million people without any coverage and tens of millions more with inadequate coverage.

Officials of the Obama administration, along with leaders in Congress, were complicit with the insurers during the legislative process that led to the Affordable Care Act. You might think that they would show some remorse by tailoring the provisions of the act to better benefit patients. No.

The example of the rule change for determinations involving urgent care shows where their heart is. If a patient requires urgent care, the system should be designed to ensure that the necessary care is provided immediately. Yet read the contorted explanation leading to the revised rule above. It is being revised to ensure that the insurers are allowed three days instead of one to make a decision. That might even save them money should the patient die in the interim.

The administration’s rule: first do no harm – to the insurance company. And the patients? Who’s making these rules anyway? The patients need to butt out.

What would be the appeals process for a determination of urgent care under a single payer national health program? Appeals? What are you talking about? If the patient urgently needs care, the patient gets care – now! Period.