Physicians and Insurers: Can They Get Along?

Carol Peckham


October 21, 2014

In This Article

Impact of the Health Insurance Exchange Plans

At this time, physicians report that slightly over a third (36%) of their patients are covered through the health insurance exchange plans. Since the implementation of the ACA, more than 7.3 million people purchased health plans through the insurance exchanges and nearly 8 million low-income people enrolled in Medicaid. However, 30 to 40 million people remain uninsured.[7]

According to a recent brief from the HHS Office of the Assistant Secretary for Planning and Evaluation, in 2014, 191 organizations issued insurance under the federal exchange plans and 61 under the state plans; HHS anticipates a 25% increase of insurers for these plans in 2015.[8] Of patients who are in the health insurance exchange, slightly over a third (36%) are enrolled in the bronze plan, about a quarter (24%) are in the silver plan, and 27% are in either the gold or platinum plans.

Two thirds of physicians report having problems with health insurance exchange plans, with 29% saying they have "lots of problems." As physicians appear to have difficulties with all insurers, however, it isn't certain how much worse these plans are, or whether they even are worse, compared with others.

Regarding some of the problems, Judy Aburmishan pointed out, "With marketplace exchanges, patients might come in with a Blue Plan card, but if they haven't paid the premium the physician might not know they have been suspended, and later will have to chase the patient directly to be paid. Another issue with the exchanges is the popularity of the bronze plans, which can have very high deductibles. For example, if a patient has knee pain that could be treated but the first $5000 is on his own dime, he might say, 'never mind.' The downside is that the physician loses that business and the patient doesn't get that treatment, but the upside is that the patient is now aware of the cost of treatment and has become accountable for his own care."

Impact on Income

In the 2014 Medscape Physician Compensation Report, which was published in April, 43% of physicians expected their income to decrease under the insurance exchanges. According to employed physicians who responded to the current survey, fewer (33%) have actually experienced a decline so far in their practice income from the effect of the exchanges, with only 7% reporting any significant decrease. Thirteen percent reported an increase, and about half (53%) of incomes have remained the same.

Impact on Patient Volume

About a third of employed physicians (32%) reported an increase in patient volume in general since the introduction of the health insurance marketplace. About half (51%) reported no change and 17% experienced a decline in patient volume. In fact, one 2014 study[9] that looked at practice data found no difference in new-patient visits between states with high enrollments in the ACA exchange plan during the first 5 months and those with low enrollments.

Nor was there an increase in the intensity of services provided or in the percentage of patients with chronic diseases. There are several possible reasons for this lack of increase, according to the authors of the study, including the slow start-up related to computer system problems, persistence of patients seeking care in emergency rooms, a longer time than expected for patients to get an appointment, and the severe winter weather this year that might have prevented patients from making and keeping appointments.

Certainly, the full impact of the ACA has not been felt. Systems and websites still need fixing, and low reimbursement rates remain a concern as insurers compete for lower costs.[10,11] Still, in an interview in October, CMS administrator Marilyn Tavenner anticipates a 25% increase next year in enrollees, with far fewer system problems.[12]


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