Emergency Physicians: High-deductible Plans Delay Care

Patients "can't access the networks that their insurance companies are supposed to provide," says the chair of the American College of Emergency Physicians.

Seventy percent of emergency physicians say they routinely see insured patients in the emergency department who've delayed care because they can't afford high deductibles and copays, according to survey results from the American College of Emergency Physicians.

In addition, 73% of emergency physicians say they're seeing increased numbers of Medicaid patients who've delayed care because they can't find a physician in the narrow network provided by their health plan.

"The poll is a verification of what we are all seeing," says ACEP Chair Rebecca Parker, MD, an emergency physician in suburban Chicago. "As people are taking advantage of the Affordable Care Act, they are running into the barriers that we have been concerned about from the very beginning."

"I ask my patients who their primary care doctor is. I try to make sure they have access to care, and what I have seen is that their access to care is limited and at times their network is extremely narrow, even with the exchange patients," Parker says.

"I have seen that for years with our Medicaid patients, but our exchange patients are now facing high deductibles, high out-of-pocket expenses, and they can't access the networks that their insurance companies are supposed to provide."

ACEP's online poll of 1,433 emergency physicians and conducted last month found that:

• 60% of the doctors reported difficulty finding specialists for their patients because of narrow network plans that limit medical providers.
• More than 80% reported treating patients who said they had difficulty finding specialists to care for them, because health plans have narrow networks.
• 65% said they are seeing an increased number of patients in the emergency department, in large part because health insurance companies are failing to provide an adequate number of primary care physicians.
• 73% reported seeing increased numbers of Medicaid patients because insurance companies were failing to provide adequate numbers of primary care or specialty physicians.
• 20% reported contemplating or knowing other emergency physicians who opted out of health insurance networks, and 90% of them say the reason was because health plans were not willing to negotiate reasonable market rates for services.
• 67% said primary care physicians send patients to EDs for tests or procedures when health insurance companies refuse to cover office visits

"It's concerning to us that our patients are trying to get the access to care that they are paying for and that insurance companies are not providing it," Parker says.

"If you look at what the average silver plans across the country started off with this year, their average deductible is $6,000. That is supposed to be the medium, reasonable plan. And if you look at what most Americans have in their savings for any emergency it's about $700. There is a disconnect. If you put on top of that the limits to access we are seeing with these narrow networks and the third piece of the equation the cuts of up to 70% for the providers and the physicians, it's the insurance companies that are the winners."

Critics Knock Survey
Clare Krusing, communications director at America's Health Insurance Plans, says the ACEP poll is flawed in its methods and findings. "They are not interviewing patients. They're interviewing their members. These doctors are increasingly charging higher prices to patients and leaving them in the middle," she says.

"Our biggest criticism is that they're not interviewing patients for their perspective, and they're not outlining the prices they are charging for their services and whether those are reasonable to start with."

Katherine Hempstead, director of coverage issues at the Robert Wood Johnson Foundation, also finds the ACEP survey lacking. "There are undoubtedly many areas of disagreement between payers and providers, but this study does not add much information to the debate," she says.

"The survey questions were generally not objective, and were in many cases quite leading, and this may have affected the results. For example, the findings related to difficulty in finding a doctor are not consistent with results from other recent surveys, where consumers report much lower prevalence of having such problems."

While high deductible plans were designed to incentivize consumers to buy the most cost-efficient plan to meet their needs, Parker says that's not happening.

"There is certainly an argument for 'skin in the game,' but a $6,000 deductible is a lot more than just some skin," she says. "We want people to feel like they can access care when they feel they need it. Because we are the safety net, we're seeing that our patients are delaying their care because they are concerned about these high deductibles and that is not right."
Krusing says health plans aren't forcing consumers into high-deductible plans.

"Each consumer, when they shop for coverage, is making decisions on what policy is best for them based on more than just a premium," she says. "Our focus is to make sure consumers have a better sense of what they are spending per month on healthcare, what is their medical utilization, how often are they going to the doctors, do they want comprehensive drug coverage?"

And despite ACEP's criticism of inadequate networks, Krusing says "the report wants to ignore the fact that all of these networks have to meet state and federal requirements for network adequacy."

"It overlooks the importance of choice in the market. But consumers have a choice to pick the plan that works best for them. In many ways it discourages those individuals who are looking for a high deductible plan," she says.

"That might be the best option for them, but this report is saying we can't treat those people. I would go back this group and ask 'what are the prices you are charging and why did you choose not to participate in the health plans' network?'"