MGMA ACA Exchange Implementation Survey Report. May 2014

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MGMA ACA Exchange

Implementation

Survey Report

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Overview

Medical Group Management Association (MGMA) conducted member research in April 2014 to better understand the impact of the Affordable Care Act’s (ACA) insurance exchange implementation on medical group practices. This research follows up our September 2013 study, which helped shed light on a number of ACA exchange implementation issues. The survey includes responses from more than 700 medical groups in which more than 40,000 physicians practice nationwide.

Almost 80% of survey respondents reported their practice is participating with new health insurance products sold on the ACA exchanges (ACA exchange products) and more than 90% of these practices have already seen patients with this coverage. Of practices participating with ACA exchange products, 85% are contracting with one to five products and almost 60% reported they are participating in order to remain competitive in their local market.

While more than 8 million consumers have enrolled in health insurance coverage through the ACA exchanges, 56% of respondents reported no change in their practice’s patient population size through April and 24% reported a slight increase. Practices expect a small shift in this trend through the end of the year. Thirty percent of respondents projected no change to their practice population size by the end of 2014 and 44% predicted a slight increase. These figures illustrate that most practices are not being inundated by new ACA exchange patients but do expect to treat somewhat more of these patients as the year progresses.

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Summary of Findings

MGMA noted three main themes within the findings.

Obtaining coverage information

Practices have experienced difficulty identifying patients with ACA exchange coverage and obtaining essential information related to that coverage.

• 62% of respondents reported moderate to extreme difficulty with identifying a patient that has ACA exchange coverage as opposed to traditional commercial health insurance.

• Compared to patients with traditional commercial coverage, nearly 60% of respondents indicated that for patients with ACA exchange coverage it is somewhat or much more difficult to:

• Verify patient eligibility

• Obtain cost-sharing or network information

• Obtain information about the plan’s provider network in order to facilitate referrals

“ We are going to have to hire additional staff just to manage the insurance verification processs.” “Identification of ACA plans has been an administrative nightmare.”

“ We thought we would be able to identify ACA insurance exchange products by their insurance card, but quickly found out this isn’t so. “

Patient cost-sharing

Practices are facing a number of challenges related to patient cost-sharing for ACA exchange coverage.

• 75% of respondents reported that patients with ACA exchange coverage are very or extremely likely to have high deductibles compared to patients with traditional commercial coverage.

• Practices reported significant patient confusion about the substantial cost-sharing related to many ACA exchange products, and practices are working to help patients understand the complexities of their coverage.

• Practices cited some of the main reasons for not participating with ACA exchange products were related to concerns about financial burdens from patient collections (such as burdens related to collecting high deductibles from patients and concerns about financial liability from the 90-day grace period).

“ Patients have been very confused about benefits and their portion of the cost. Once the patients find out their deductible, they’ve cancelled appointments and procedures.”

“The at-risk piece of eligibility is tremendously hard to determine and explain to patients.”

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Network limitations

Practices have concerns about the impact of the network design of many ACA exchange products.

• Almost half of respondents reported they have been unable to provide covered services to ACA exchange patients because the practice is out of network.

• 20% of respondents reported that their practice was excluded from a narrow network that they would have liked to participate in and 10% of respondents chose not to participate in a narrow network.

• Narrow networks may create challenges related to patient referrals for appropriate treatment and hospital care. Even if the practice is included in the network, without robust representation by a wide range of providers, it may be difficult for a practice to coordinate a continuum of care consistent with the patient’s needs.

“ Many patients purchased products with a very narrow network and didn't understand the ramifications. They are very upset once they learn that they can't go to the specialist or hospital of their choice. As primary care providers, we are now faced with the extra burden of trying to find them care within their new narrow network. Payer directories are woefully inaccurate and impossible to rely on.”

“ Former patients were shocked to learn about their very narrow network of providers. It was terrible to have to inform them of their lack of coverage.” “ We are consistently denied "out of network" approvals for the very sick who truly need to continue their care with providers who have worked with the

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1. Overall, how favorable or unfavorable do you think the impact of the ACA insurance exchanges

will be on your practice?

Very unfavorable

Unfavorable

Neutral

Favorable

Very favorable

15.1%

44.3%

26.8%

11.3%

2.5%

2. Is your practice participating with any new health insurance product(s) sold on an ACA exchange

(ACA insurance exchange products)?

Answer Options

Response

Yes

76.5%

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3. Practices not participating with any ACA insurance exchange products cited the following as

reasons why (check all that apply):

Answer Options

Response

Concerns about assuming financial liability during a 90-day grace period for ACA exchange enrollees

48.1%

Our practice was not approached by payers in our area with contracts for any ACA exchange products

41.8%

Concerns about financial burdens from patient collections (ex. from high deductibles)

41.1%

Based on low reimbursement rates, participating would pose a financial risk for our practice

38%

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4. Practices that are participating with ACA insurance exchange products cited the following as

reasons why (check all that apply):

Answer Options

Response

To remain competitive in our local market

57.6%

Opportunity to replace current charity care as our uninsured patients obtain coverage

39%

Opportunity to provide care to an underserved patient population

35.4%

Inability to select patients based on their insurance (ex. as a result of hospital affiliation)

22.8%

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5. How many ACA insurance exchange products is your practice participating with?

Answer Options

Response

1-2

40.8%

3-5

44%

6-10

10.8%

11-20

2.6%

More than 20

1.9%

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6. On average, how do payment rates offered by ACA exchange insurers compare to:

Answer Options

Much

_lower

Somewhat

_lower

Equal

Somewhat

_higher

Much

Do not

_know

Average payment rates from all of your traditional

commercial contracts

18.2%

32%

36.6%

2.1%

0.6%

10.5%

Other traditional commercial products offered by the same

payer(s)

15.4%

30.2%

41.8%

2.1%

0.8%

9.7%

Traditional Medicare (i.e., not Medicare Advantage)

8.3%

17.1%

32.7%

23.5%

6.6%

11.8%

Medicaid

5.6%

6.9%

28.5%

28.8%

17.6%

12.7%

7. To date, has your practice seen patients with ACA insurance exchange coverage?

Answer Options

Response

Yes

93.9%

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8. What impact have ACA insurance exchange products had so far on your practice’s patient

population size?

Decreased

significantly

Decreased slightly

No change

Increased slightly

significantly

Increased

Do not know

1.2%

9.6%

56.4%

24.4%

1.4%

7%

9. What impact do you expect ACA insurance exchange products will have on your practice’s patient

population size by the end of 2014?

Decrease

significantly

Decrease slightly

No change

Increase slightly

significantly

Increase

Do not know

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11. Of the patients your practice has seen with ACA insurance exchange coverage, how difficult have

you found the following tasks compared to patients with traditional commercial coverage?

Answer Options

_easier

Much

Somewhat

_easier

_difference

No

Somewhat

more

difficult

Much more

difficult

Do not

know

Verifying patient eligibility

0%

0.5%

34.1%

25.5%

37.7%

2.3%

Obtaining cost-sharing information

0%

0.7%

31%

25%

37.3%

6%

Obtaining information about the plan’s provider network in

order to facilitate referrals

0.2%

0.7%

33.6%

22.1%

36.5%

7%

Obtaining information related to the plan’s prescription

drug formulary

0.3%

1%

38.7%

19.1%

24%

17%

10. How difficult has your practice found it to distinguish between a patient that has ACA insurance

exchange coverage as opposed to traditional commercial health insurance (not related to the

ACA exchanges)?

Not at all difficult

Slightly difficult

Moderately difficult

Very difficult

Extremely difficult

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Question 13 and 14 include all survey respondents.

13. To date, has your practice seen patients with ACA insurance exchange coverage that you were

unable to provide covered services to because your practice was not included in that ACA

insurance exchange product’s network?

Answer Options

Response

No

47.4%

Yes

40.9%

Do not know

11.7%

12. Based on the patients your practice has seen with ACA insurance exchange coverage, on average,

how likely are these patients to have high deductibles compared to patients with traditional

commercial coverage?

Not likely

Somewhat likely

Very likely

Extremely likely

Not applicable

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14. Many ACA insurance exchange products are using narrow networks/limited provider panels.

Has your practice been excluded from a network that you would like to be included in?

Answer Options

Response

No

50.5%

Yes

19.9%

Do not know

16.1%

Our practice chose not to participate in a narrow network

10%

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Respondent Demographics

Participation

Total

728 practices in which over 40,000 physicians practice

State

All but four states participated: North Dakota, Rhode Island, West Virginia and Hawaii

Practice Size

Mean

55.7 FTE physicians

Median

10 FTE physicians

Organization Type

Independent medical practice

75.1%

Hospital or integrated delivery system (IDS),

or medical practice owned by hospital of IDS

11.7%

Medical school faculty practice plan or

academic clinical science department

4.2%

Federally qualified health center, community

health center or similar practice

2.3%

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Respondent Demographics

Specialty

Total: 42 specialties participated

Highest participation by specialty

1. Multispecialty with primary and specialty

care

19.3%

2. Orthopedic surgery

10%

3. Family practice

8.3%

4. Ob/gyn

6.6%

5. Gastroenterology

5.3%

6. Pediatrics

4.7%

7. Urology

3.7%

8. Internal medicine

3.2%

9. Multispecialty with specialty care only

2.4%

10. Cardiology

2.8%

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About MGMA

The Medical Group Management Association (MGMA) helps create successful medical practices that deliver the highest-quality patient care. As the leading association for medical practice administrators and executives since 1926, MGMA helps improve members’ practices through exclusive member benefits, education, resources, news, information, advocacy, and networking opportunities, and produces some of the most credible and robust medical practice economic data and data solutions in the industry. Through its industry-leading ACMPE board certification and Fellowship programs, MGMA advances the profession of medical practice management.

Through its national membership and 50 state affiliates, MGMA represents more than 33,000 medical practice administrators and executives in practices of all sizes, types, structures and specialties. MGMA is headquartered in Englewood, Colo., with a Government Affairs office in Washington, D.C.