'Exchanges have become like Medicaid'

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Elisabeth Rosenthal of The New York Times reports on the growing push by providers to make up the difference from lost insurance revenue with a host of new charges:

As insurers ratchet down payments to physicians and hospitals, these providers are pushing back with a host of new charges: Ophthalmologists are increasingly levying separate ???refraction fees??? to assess vision acuity. Orthopedic clinics impose fees to put an arm in a cast or provide a splint, in addition to the usual bill for the office visit. On maternity wards, new mothers pay for a lactation consultant. An emergency room charges an ???activation fee??? in addition to its facility charges. Psychologists who have agreed to an insurer???s negotiated rate for neuropsychological testing bill patients an additional $2,000 for an ???administration charge.???

In some cases, such as refraction, the services were never typically covered by health insurance but had generally been performed gratis as part of an exam. In others, the fees are novel constructs. In any case, as insurers and providers fight over revenue in an era of cost control, patients often find themselves caught in the middle, nickel-and-dimed.

Some of the charges come directly out of patients??? wallets at the time of treatment and catch patients off guard. And if they do not write a check for the refraction fee, for example, many doctors will not dispense a prescription for the glasses ???

Cindy Weston of the American Medical Billing Association, an industry group, said it was up to physicians to decide what to include in their principal payment and what merited an extra charge. She said they now ???may be forced to charge??? for new services because the Affordable Care Act ???has shifted so much responsibility for payment from insurers to patients,??? and patients do not pay as reliably as insurers.

These new fees are worrisome to health advocates. At a time when the country is trying to hold down health care costs, payments from patients shift spending to a place where they cannot be readily tallied. Such fees often undercut mandates under the Affordable Care Act (ACA) that certain vital services for women???s health and preventive care be provided at no cost to patients: An intrauterine device is covered, but there is an insertion fee. An annual physical is covered, but not some of the blood work that a physician has ordered.

Now, this is just a temporary problem, right? It certainly couldn???t be that this will be an enduring challenge for Obamacare moving forward. Jayne O???Donnell at USA Today reports:

Now that many people finally have health insurance through the Affordable Care Act exchanges, some are running into a new problem: They can???t find a doctor who will take them as patients.

Because these exchange plans often have lower reimbursement rates, some doctors are limiting how many new patients they take with these policies, physician groups and other experts say.

???The exchanges have become very much like Medicaid,??? said Andrew Kleinman, a plastic surgeon and 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.???

Kleinman says his members complain rates can be 50% lower than commercial plans. Cigna and Aetna, however, say they pay doctors the same whether the plan is sold on an ACA network or not. United Healthcare spokeswoman Tracey Lempner says it???s up to their physicians whether they want to be in the exchange plan networks, which have ???rates that are above Medicaid.??? Medicaid rates are typically below those for Medicare, which in turn are generally lower than commercial insurance plans.To prevent discrimination against ACA policyholders, some insurance contracts require doctors to accept their exchange-plan patients along with those on commercial plans, unless the doctors??? practices are so full they simply can???t treat any more people. But lower reimbursement rates make some physicians reluctant to sign on to some of these plans or accept too many of the patients once they are in the plans.

If you want to know why Obamacare is so unpopular, even as it has increased insurance coverage generally, it is because that coverage lacks the level of access and the kind of coverage people have come to expect from the American health care system. The third-party-payer system has always insulated Americans from the true cost of care, but Obamacare was supposed to offer them much more than Medicaid for all.


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