When I quit my job last May, I also quit my health insurance plan. Not on purpose, really. Like every other health plan I’ve been on during my adult life, it was provided and mostly paid for through my employer. But now that I am footloose and fancy freelance, I’ve got to pay for my own insurance. So I got one through the Affordable Care Act (ACA) exchanges.
I paid a little extra to get a plan that had both my primary care physician and the ENT who has been making my sinuses slightly less terrible. But when I got my insurance card, I had a different physician listed. At the ENT office, they seemed surprised that they were even listed there. “We’re not in any of the ACA networks,” they said. “We’re already in so many networks that it’s not worth it.”
I liked those doctors a lot. But none of them are in any ACA networks. And they aren’t the only ones. According to a study by Avalere Health, plans offered through the ACA exchanges have 34% less providers than the average employer-based or individual non-exchange plan. So you may be able to keep your doctor if you like them, you just have to pay full price for services.
According a report by the Robert Wood Johnson Foundation, 40% of ACA plans are considered small or extra small – that means that less than 25% of available providers are within their networks. I’m lucky; I live in New York City, so I can find another primary care provider nearby. But can you imagine the huge hassle it must be if you live in a small town? 25% of doctors could be one.
Insurance companies are narrowing networks in order to lower the rates they charge. They get pickier about the doctors they use – they want a high quality to efficiency ratio. On the face of it, that seems pretty good, right? You get solid, waste-free doctors, sawbones who get the job done without cost overruns.
But this isn’t exactly right. When the insurance companies narrow their networks to lower costs, it’s not just because they are being choosy. The costs go down because they reimburse less for procedures. Doctors will join these narrow networks because the limited number of available doctors means that more patients will be sent to each individual practice. Narrow networks create volume-based health care providers.
So why are some doctors not on any ACA networks at all?
“The exchanges have become very much like Medicaid,” says Andrew Kleinman, president of the Medical Society of the State of New York . “Physicians who are in solo practices have to be careful to not take too many patients reimbursed at lower rates or they’re not going to be in business very long.”
The short answer is that doctors who take a lot of ACA patients like me will go broke. Now that we get to see the actual costs of insurance instead of having secretly tacked on to the end of our pay as a benefit, we want cheaper plans. But that means lower reimbursements to doctors (the whole reimbursement dance is clusterfuck for another post), which means less doctors sign up. Klienman says the reimbursement rates can be less than 50% of what the commercial plans pay. Plus there the huge deductible you have to burn through before insurance kicks in a pays anything.
On top of that, I have a 90-day grace period for my insurance payments, but the insurer won’t pay reimbursements unless my account is paid up. Doctors on the network have to take me, but won’t get paid until I remember to write that check.
We’re creating a two-tiered system for insurance. People like people who don’t get insurance through their job have less access to providers. On top of that, we get access to doctors who are willing to take lower rates for more patients – either doctors without enough patients, those willing to run a volume business, or new doctors. Single payer, where for art thou?
I still thought I was getting what I wanted. But no, the directory was wrong. And that’s a growing problem. Brian Hoyt, managing director at Berkeley Research Group, wrote in a recent white paper that “Provider directory inaccuracies represent a growing and significant risk both to consumers and health plans. Inaccurate directory information may limit a consumer’s ability to verify if a preferred doctor is in-network, or to know how many and what types of providers would have to be accessed under a particular product offering.”
These inaccuracies have led to lawsuits against the insurance providers. Which is going to raise my health insurance premiums.
I know this is the beginning of a new system. Under the old system, I would have gone for the cheapest plan possible, which was no insurance at all. This way, at least I’m covered if I get hit by a car and they find a brain tumor. But I’m less likely to consider getting that checkup to catch the tumor early.