How to motivate physicians to accept ACA health plans: 4 questions with Bronx-Lebanon Hospital's Dr. Ira Kirschenbaum

While ACA marketplaces undergo a volatile year of double-digit premium hikes and payer pullbacks, an often overlooked issue affecting the stability of ACA marketplaces is the dwindling percentage of physicians who accept marketplace coverage.

The percentage of physicians who accept public exchange health plans fell 4 percent to 57 percent from 2015 to 2016, according to physician social media network Sermo. For a number of reasons — like low reimbursements, shaky confidence in the stability of ACA exchanges and poor coordination in terms of in-network and out-of-network care — physicians are refusing to accept ACA health plans and disrupting the health law's effectiveness.

Raising reimbursements is only a sliver of the battle for increasing the number of physicians accepting ACA plans, says Ira Kirschenbaum, MD, chairman of the department of orthopedic surgery at New York City-based Bronx-Lebanon Hospital Center. Dr. Kirschenbaum spoke with Becker's Hospital Review about why physicians are wary of participating in public exchange health plans and what changes are needed to address the issue.

Note: Responses have been lightly edited for length and clarity.

Question: What are the main reasons physicians are refraining from participating in health plans offered on ACA exchanges? 

Dr. Ira Kirschenbaum: The data is pretty clear. The major reason is the reimbursements. The reimbursement rates are one step below horrible. Another reason is that health maintenance organization plans offered on ACA marketplaces are hard for physicians to work with. They are not well developed.

Lastly, physicians are afraid of the solvency of health insurance co-ops created under the ACA. Take Health Republic Insurance of New York's closure last year for example. It was a large ACA exchange health insurer. But when it faltered, millions in reimbursements weren't paid to physicians. Physicians are worried about getting paid.

Q: What are some of the effects stemming from physicians not networking with ACA health plans?

IK: The No. 1 issue is coordination of care is suffering. A classic example is in orthopedics. Someone with an ACA marketplace plan goes to the emergency department with a fracture. The person is covered in the ED, but the individual needs a surgeon and has to find one quickly. What if the surgeon doesn't accept the plan? The ED doesn't know where to send the patient.

Overall, coordination of care is going to suffer if federal officials can't figure out benefits for specialist physicians under the ACA and move away from only focusing on primary care. Fractures, tumors, sports injuries — these are all necessary issues to address. It's not like all of a sudden they are elective.

Q: How do you see physician participation in ACA exchange coverage changing in the next year? 

IK: First of all, I don't see it working itself out, because the physicians who accept Medicaid are going to continue to take Medicaid and ACA exchange plans. However, as an example, a lot of orthopedic surgeons do not take Medicaid. Federal officials aren't doing anything at this time to attract surgeons to these programs. If officials aren't going to figure out a reimbursement fix, they need to figure out innovations to offset low reimbursements.

Q: What do federal lawmakers need to do to get more physicians to accept ACA plans?

IK: Lawmakers don't have a lot of options outside of the money. They have to find a market sensitive plan to improve care. Increasing reimbursements is the easy one. Lawmakers could also develop more creative risk sharing agreements, like population risk sharing based on specialist premiums, in addition to better out-of-network benefits for specialists. 

Other creative solutions include bundled care programs and incentives to accept ACA health plans.  

But one thing is for sure — there's nothing wrong about more people getting insured under the ACA. What you don't want is the unintended consequences that accompanied the ACA. I'm not surprised there are issues in a new program, but now we need to figure what the consequences are and make appropriate adjustments.  

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