Health System Reform Insight - Aug. 24, 2012
The AMA has developed Health System Reform Insight to help you better understand new physician payment and care delivery models, and improve patient care.
A national group of regulators is guiding states' efforts to implement insurance exchanges under the Affordable Care Act (ACA). The AMA is at the table in these discussions, shaping the group's recommendations to ensure exchanges are created in a way that benefits physicians and their patients.
The National Association of Insurance Commissioners (NAIC), which consists of the chief insurance regulators from all 50 states and the District of Columbia, has been helping states understand the policy issues involved in implementation of the ACA and has taken the lead on providing guidance for implementing health insurance exchanges.
Health insurance exchanges
In addition to model legislation outlining the basic elements of ACA-compliant state exchanges, the NAIC now offers a set of white papers describing recommendations for implementing exchanges. The five white papers cover network adequacy, accreditation and quality, marketing and consumer information, form review and rate review.
As the only voice for physicians involved in the NAIC, the AMA was instrumental in shaping these guidance documents. For instance, the AMA successfully urged the NAIC to remove a prohibition of balance billing from the network adequacy white paper.
While the intention was to minimize disruptions in care when a physician's network participation changes, the AMA explained that prohibiting balance billing would give private payers the ability to unilaterally set rates for physicians who have not contracted with them. Such a scenario would eliminate any incentive for private payers to contract with physicians on financially and ethically viable terms.
Alternatives to insurance exchanges
At its summer meeting, the NAIC created a forum for interested insurance commissioners to discuss the alternatives to implementing a state-based exchange that complies with the ACA. Commissioners also are using the forum to identify opportunities for states to continue to innovate and regulate outside of a federally facilitated exchange.
The AMA is closely monitoring this activity and will comment as appropriate to ensure that physician and patient protections continue to exist in insurance markets outside of an exchange.
In addition to its work on insurance exchanges, the NAIC was tasked by the ACA with recommending which medical services covered by Medigap plans should require a copayment. The goal is to reduce unnecessary use of high-cost medical services without discouraging access to the service for those who need it.
Services initially included imaging services, power mobility scooters, outpatient surgery and physician office visits. The NAIC ultimately removed copayments from physician office visits because of the complexity involved with coding for those visits; the AMA was involved in the discussions about physician office visits. Discussion continues on which services should be subject to a copayment.
As state implementation of the ACA gets under way, the AMA will continue to participate in the work of the NAIC, providing education and insight on issues affecting both physicians and patients.
An AMA webinar at 1 p.m. Eastern time will explain what physicians need to know about new systems of payment known as "budget-based" models before signing a managed care contract. Register today.
Physicians interested in starting a Medicare accountable care organization in 2013 must submit an application to CMS by this date. Applications are now accepted annually. Learn more.
Congress' summer recess ends. Physicians have an opportunity to interact with lawmakers on important topics in medicine as they meet with constituents in their districts during the recess. Learn more.