Dr. Ira Kirschenbaum on Motivating Physicians to Accept ACA Plans

I recently spoke with Becker’s Hospital Review about why physicians to are hesitant to accept healthcare plans made available to the public through the Affordable Care Act (ACA, or commonly referred to as “Obamacare”). This is an important topic because of the current political environment, recent court rulings and the affordability of healthcare it can offer for patients. The health insurance plans available to patients under the ACA have changed rapidly over the past 12 months and since 2015.

There is a decreasing number of physicians willing to accept ACA plans due to issues such as low reimbursements, the possible lack of stability in ACS exchanges, and poor coordination for in and out of network care.

ACA Marketplace Plan Stability and Affordability

Throughout 2018, the ACA marketplace experienced a volatile year that involved double-digit premium hikes even for young and healthy plan participants. Another issue that I noticed this year was payer pullbacks. Some participants dropped out of the ACA entirely, leading to fewer participating physicians accepting coverage through the healthcare exchanges. The corresponding lack of stability in the ACA marketplace has put more patients at risk of losing their coverage.

Drops in Participating Physicians

I have taken a look at the reasons why physicians may be reluctant to participate in plans that are in the ACA marketplace. According to Sermo, from 2015 to 2016, the percentage of doctors accepting ACA exchange health insurance fell from 61 to 57 percent. The leading issue is low reimbursements compared to private health plans, poor coordination of patient care for in-network and out-of-network services and instability of the participating plans in the exchanges from year to year. In addition, the ACA marketplaces are hard for physicians to work with and are poorly developed.

Motivating Doctors to Join ACA Plans

In my opinion, raising the rate of physician reimbursement is only one of the necessary prongs in getting doctors to accept ACA plans. In addition to the consistent comments about low reimbursement rates, I’d say that the answers are clear in that the health maintenance organization plans listed on the ACA exchanges are not easy to deal with. Their relative newness to health services delivery slows down the process and increases the amount of red tape my colleagues and I have to deal with in order to provide the care that our patients need. I am also concerned about the financial solvency of the health insurance cooperatives under the ACA. In 2017, Health Republic Insurance of New York unexpectedly closed. Millions of dollars owed to physicians went unpaid.

I am concerned with the effects on patients when physicians choose not to participate in ACA health plans. Patients are suffering. In orthopedics for example, if someone in an ACA exchange plans my visit the emergency department with a fracture. The person’s emergency room visit is covered under the ACA. However, finding an orthopedic surgeon who is available to perform the necessary surgery could be a challenge on its own. If the surgeon does not accept the plan, the ED might not know where to send the patient.

Loss of Care Coordination

In the 1990s, physicians increasingly turned to coordination of care model for the delivery of health services. This care coordination will suffer if ACA plans do not accommodate the necessary reimbursement and benefits for specialist physicians. Only focusing on primary care leaves out sports injuries, fractures and other medical emergencies that require prompt treatment. These are all crucial issues to address.

Changes in the ACA for 2019

I do not see many positive changes for physician participation in ACA exchanges for 2019. Most orthopedic physicians do not take Medicaid, and most ACA plans leave our specialty services out. At the federal level, little is being done to try to attract physicians to including these plans. They need to work out a way to increase reimbursements if they want more specialty physicians to sign onto ACA exchanges.

What Federal Leaders Can Do To Get Physicians to Accept ACA Plans

In addition to fixing the money problem related to low specialist reimbursements, I believe that federal leaders could do more to create a market that is sensitive to improving care for patients. More creativity in risk-sharing agreements is one idea that I have had. I think that bundling care programs and adding incentives for specialists to accept ACA health exchange plans could also increase more specialist participation. Federal lawmakers are doing little to attract surgeons to these programs. The key solution is for federal officials to figure out innovative ways to offset the low reimbursements.

Overcoming Obstacles

As with any new program, unexpected issues arise. We need to sort out the consequences and adjust the health exchanges appropriately. There is nothing wrong with bringing health insurance to the people who need it. However, we need to make sure that the insurance covers what people need and appropriately reimburses the providers. Ultimately with any new possible changes, what we don’t want is for the same unintended consequences that accompanied the ACA to carry into any future new federal plans.

This is why value-based healthcare is something I support. This system focuses on the quality of care that patients get and the results they achieve.

About Dr. Ira Kirschenbaum

Dr. Ira Kirschenbaum is an orthopedic surgeon specializing in reconstructive and minimally invasive joint surgery along with hip, knee, and shoulder replacements. He has designed major joint replacement systems, along with having lectured extensively over the subject. He currently serves as the Chairman of Orthopedics and as the Director of Surgical Operations at BronxCare Health System in New York City.

Dr. Ira Kirschenbaum is a member of several notable organizations in his field including the Orthopaedic Research Society, the American Academy of Orthopaedic Surgeons, the American Association of Hip and Knee Surgeons, and the American Board of Orthopaedic Surgeon. Prior to his current position, Dr. Kirschenbaum served as the Director of Adult Reconstructive Surgery at Kaiser Permanente and operated under his own private practice. He can be contacted directly through BronxCare Health System.