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PPACA and the 'damage' to come: congress gets an earful from medical profession

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As the congressional examination continues into ObamaCare issues today, the United States House Committee on Oversight and Government Reform got quite an earful of testimony from the medical profession regarding the new exchange plans.

From a Neurologist at the Multiple Sclerosis Center of Atlanta, Dr. Jeffrey English, M.D. testified:

"No one in America will argue that the healthcare system did not need reform. The ACA took a bureaucratic, top down approach and the unintended consequences will be devastating. This is fact. Simply having an insurance card that does not guarantee access to providers nor medications is useless."

Dr. English asked the legislators a question, which he stated was the same question he asked representatives at the Centers for Medicare & Medicaid Services and United Healthcare, which recently downgraded him to a “non-preferred” status:

'Do you want me to stop taking care of patients with MS?'

"Do you want me to stop taking care of patients with MS or just stop taking good care of them and withhold their medications in order to meet metrics? Should my fellow physicians take care of only people who are young and healthy in order to meet metrics?"

Dr. English believes that the website problems are not the biggest problem with the Affordable Care Act:

"Physicians such as myself and those in the organization I represent, Docs 4 Patient Care, are dedicated to patient care. We have spent the time to read and understand the law, plus its almost daily addition of regulations, and have already predicted how harmful this law would be. ... Health care is a very personal interaction between an individual patient and their doctor in an exam room. Unfortunately, the doctor and the patient were completely left out of discussions when the law was written. The Affordable Care Act’s biggest problem is not its website which will be fixed some day."

Explaining what he sees as "the damage to come," Dr. English added:

"Despite the dedication of providers and staff at centers like ours, the ACA will punish us because we take care of the most vulnerable patients that only we are equipped to care for. Metrics are being set up by bureaucrats that have never taken care of a single patient. CMS (Centers for Medicare and Medicaid Services) will evaluate providers based on their compliance with these metrics. Failure to meet these arbitrary metrics will lead to penalties. The law actually states that failure to comply with these metrics can lead to removal of providers from government approved insurance plans." (He cited section 3002-3007 of the ACA.)

Jan. 2014: massive 'upheaval' coming

In her remarks, Dr. Patricia A. McLaughlin, M.D., an ophthalmologist in a solo practice located in New York City stated:

"My concerns are, first and foremost, for those that need and seek medical care. My responsibility is to take the knowledge handed down through years of supervised training, and ethically and morally deliver the best that I have to offer, to a patient seeking help to prevent or treat an illness or accident."

She added:

"Regardless of a physician’s individual perspective of the new health care law, physicians are only beginning to recognize the sudden and massive upheaval to business, as usual that is to come as of the first of January, 2014. Health insurance companies have been rather late in the game in announcing their creation of new limited networks, which will offer only in-network benefits. This, shockingly, is affecting long-standing health insurance plans with excellent benefits that served Small Business groups, such as mine, as well as plans offered to individuals through various State Exchanges and the Healthcare.gov site."

In closing remarks, Dr. McLaughlin testified:

"... by far my greatest concern for the doctor-patient relationship is the limited networks and greater numbers of insured lives. Patients with acute conditions together with their primary care physicians will lose precious time attempting to locate a qualified specialist and hospital to treat the condition expediently."

The testimony from Edmund F. Haislmaier, a Senior Research Fellow in Health Policy at the Heritage Foundation who has studied the PPACA (Patient Protection and Affordable Care Act), told the assembled congressional committee this:

"In the last several months there have been numerous reports of insurers limiting the provider networks for plans they offer through the exchanges. Reviewing the media stories on the subject from various parts of the country indicate that the phenomenon is both widespread and significant."

Haislmaier added:

"Even though insurers can adjust for the inability to use cost sharing to influence patient behavior by offering narrow network plans, that response creates another problem—one for which they do not have a solution. The new problem is that while relying on a limited network of providers accommodates lower-income enrollees who face only nominal cost sharing, it also makes the plan much less attractive to higher- income enrollees."

San Diego example

One example of this, provided by Haislmaier, comes out of San Diego:

"For instance, in San Diego, the premium for the second-lowest-cost Silver plan for a 40-year-old is $308 a month. Consider two 40-year-old enrollees living in San Diego; one with an income at 150 percent of the poverty level ($17,235 a year), and the other with twice that income at 300 percent of the poverty level ($34,470 a year). The first enrollee pays $57 a month for that plan, with the federal government paying the remaining $251 in a premium subsidy."

Haislmaier pointed to a Table which he stated "... shows that the government also pays the insurer a cost-sharing subsidy to lower the insured’s deductible to zero, and his physician co-pays to $3 and $5.
The second enrollee pays $273 a month for the same plan, with the federal government paying only a $35 a month premium subsidy. Furthermore, the second enrollee does not qualify for reduced co-pay amounts. The Table shows that his deductible is $2,000 and that his physician co-pays are $45 and $65. If the plan only pays for visits to a limited network of providers, that might be an acceptable trade-off for the first enrollee, but is likely to be an unattractive proposition for the second one—who is paying much more in premiums, has a substantial deductible, and is charged higher co- pays for each visit. Thus, the second enrollee is much less likely to buy the coverage."

It is a problem, he believes.

Federal Poverty Level, 1 person: $11,490

Understanding the "FPL" (federal poverty level) is important to the discussion. Over at FamiliesUSA, a Table of the 2013 Federal Poverty Guidelines can be seen. For a one person household, the annual income would be set at $11,490. The organization states that their calculations are "based on data from the U.S. Department of Health and Human Services."

The senior research fellow in Health Policy further stated:

"Because the PPACA’s cost-sharing subsidy design essentially forces insurers to adopt more limited provider networks for at least the Silver-plan level of exchange coverage, those plans will be less attractive to enrollees with incomes between 250 percent and 400 percent of the FPL—as they do not benefit from reduced cost sharing and also get much less in premium subsidies. That could result in enrollees in the bottom half of the exchange income scale (100 percent to 200 percent of the FPL) clustering in Silver plans while those in the upper half of the exchange income scale (200 percent to 400 percent of the FPL) gravitate toward Bronze-level plans that cover more providers and offer lower premiums, but impose higher deductibles and more cost sharing. Indeed, for those with incomes between 300 percent and 400 percent of the FPL, the premium subsidies offered for exchange coverage are so small that many might decide to instead seek coverage elsewhere."

In his closing statements, Haislmaier said this:

"... there is no way for government to either force providers to accept lower rates, or conversely, to force insurers to offer money losing plans. As long as the federal government insists on exchange plan designs that restrict the ability of insurers to use meaningful copays to induce enrollees to be prudent consumers of medical services, insurers will, of necessity, rely on restricting enrollee access to the subset of providers willing to accept lower reimbursement."

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