Healthcare

Sorry, we don’t take Obamacare!

Recently, I have been seeing the above headline or phrase in a growing number of news articles. 

The fact is there is no such thing as accepting Obamacare. There is no Obamacare health plan. 

Health plans offered via Obamacare exchanges are virtually no different than the coverage offered by most employers. They vary in deductibles, co-pays, out-of-pocket maximums, tiered  benefits and provider networks. 

Exchange plans employ the same strategies to minimize premiums that employer and union plans do, including self-funded plans. They restrict provider networks to better extract higher fee discounts. They use higher deductibles and in and out-of-network reimbursement schedules and they use high- deductible health plans (in the legal sense) to link with health savings accounts. 

In short,  based on the demands of consumers and plan sponsors for lower premiums and lower costs, health plans have shifted costs to the actual users of health care, limited access flexibility and increased their leverage for fee negotiations with physicians and hospitals.  

To say “we don’t take Obamacare” is as meaningless and misleading as saying “insurance accepted” when the provider does not actually contractually participate with a health plan. 

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Categories: Healthcare

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5 replies »

  1. Not at all correct. Generally, exchange plans reimburse providers at significantly lower rates than non-exchange plans. Just like Medicaid, given the lower reimbursement rates for a patient insured through an exchange policy (along with other administrative burdens), many providers have declined to participate in exchange plan provider networks – not as much as Medicaid, but getting there slowly but surely. So, clearly, the provider networks for say Anthem, Cigna, Aetna, UHC, etc. available in commercial contracts are different, and generally broader than the provider network for those same insurers for their commercial products; and, importantly, the network for PPO options for self-insured plans are even broader for some of the above insurers when acting as a TPA.

    See, for example:

    http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/10/30/top-hospitals-opt-out-of-obamacare

    http://www.americanactionforum.org/insight/health-care-providers-are-opting-out-of-obamacare-exchang-plans/

    See also: https://repository.tcu.edu/bitstream/handle/116099117/10331/FINAL_THESIS_ACA.pdf?sequence=1 which states, in parat: “… In a 2014 nationwide survey of ACA implementation done by Medical Group Management Association, physicians have expressed their issues associated with ACA products and how it is affecting their practices. Of the 40,000 physicians that participated, 23.5% will not be participating with any health insurance products sold on ACA exchanges (MGMA, 2014). Based on this sample size, American Action Forum estimates that 214,524 physicians of the 893,851 physicians nationwide are not participating (La Couture, 2014). …”

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      • No. I thought you said “there is no such thing as accepting Obamacare”. When you decline to participate in any/every exchange policy, that is what allows you to say you are not accepting exchange coverage. Right? So the statement “we don’t take Obamacare is accurate if you have declined to participate in all exchange insurance policy networks, no?

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      • I guess you could look at it that way, but more accurately is they may not accept a certain plan or plans offered through an exchange, but there is still no Obamacare plan and I suspect that a physician who simply does not want to deal with any exchange plan has more of an issue with Obamacare than the fees.

        My experience is that physicians who do not participate in plans are usually high with their fees overall.

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    • If low fees is the reason, then they should be leaving Medicare in droves. The real reason I suspect is that so many people are actually self-funding the first several thousand dollars in bills and it is tougher for docs to collect their money which is exactly what is happening in the private sector. Besides if fees were the driver that would mean that insurers would have to build all new networks rather than leverage off what they have in place. While that may happen in some areas, it’s not practical in the long run and more costly administer. If a doc takes private coverage and Medicare and perhaps even Medicaid there can be little fee reason not to take an exchange plan.

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