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    ACO, health insurance exchange pressures mounting

    Dermatologists must remain engaged, informed, proactive in documenting value their services provide

    National report — As healthcare reform advances, experts say, dermatologists face mounting pressure to prove their mettle to insurance exchanges and accountable care organizations (ACOs).

    Jack Resneck Jr., M.D., defines a healthcare exchange as a tool, usually a website, that individuals or small businesses (which the Affordable Care Act/ACA defines as having fewer than 50 employees) use to choose a healthcare plan. Dr. Resneck is associate professor and vice chairman of dermatology, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, School of Medicine, and a member of the American Academy of Dermatology (AAD) board of directors.

    Dr. ResneckAlthough only some dermatologists currently participate in healthcare exchange plans, he says, “What’s happening in the exchange plans will be spreading to other commercial insurance products, not at the government’s behest, but due to insurers’ desires."

    As of mid-April, 8 million Americans have signed up for state and federally run private insurance exchanges, published accounts say. Generally, Dr. Resneck adds, most Americans chose the lower premium Bronze or Silver level plans, which cover the same services as Gold plans but include higher deductibles and copays.

    “But while these higher deductible plans may be right for many patients, they don’t always realize what they are buying,” he says. “They sometimes think they have first-dollar healthcare insurance. Then they come to your office, have a visit or biopsy, and have to pay 100 percent of your negotiated rates with their insurer until they hit that high deductible. Who’s going to be the first to absorb that frustration after they get that bill? Often it’s you and your office staff.”’

    Narrow networks

    Other exchange elements proving troublesome for dermatologists include narrow networks and their ramifications, Dr. Resneck says.

    For starters, he explains, few dermatologists have joined exchanges at the sharply discounted payment rates offered by insurers. Therefore, some insurers are using contractual “all products” clauses to boost their networks.

    A few all-products clauses allow insurers to sign physicians up for any future insurance plans at lower rates, Dr. Resneck says. In other cases, he says, an insurer may require a non-exchange physician with whom the company has an existing contract to see exchange patients — but at the higher rate established by the existing contract.

    “You must watch carefully, though, and make sure they’re actually paying you that rate,” he says.

    To date, Dr. Resneck says that to keep premiums low, insurers are beginning to staff their exchange plans with doctors who have lower paying contracts and whom the insurers judge to use fewer resources on each patient. This often happens without regard to the sickness of each doctor’s patients or the quality of care provided, which insurers aren’t yet able to reliably account for, he says. Experts expected such narrow networks in the exchange plans. But some insurers have already begun to take that same approach with Medicare Advantage (MA) plans as well.

    “In the last several months, we’ve seen some insurers start sending letters to selected dermatologists in their MA plans, often the Mohs surgeons,” firing these physicians for being high-cost providers, Dr. Resneck says.

    “And we know that they’re doing that based not on any sort of value measure that compares your costs versus the quality of care you provide — insurers tell us they can’t do that right now. It’s usually purely based on cost,” he says.


    Next: Including quality, patient mix into measures of value


    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.


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