Health System Reform Insight - Sept. 20, 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.
As individual states begin implementing provisions of the Affordable Care Act (ACA), a series of AMA policy guides stands ready to help shape how key insurance provisions of the law are put into practice.
From medical loss ratio standards to essential health benefits, many aspects of the law's implementation are subject to state interpretation. These guides can help physicians and their state medical associations lobby legislators on important elements that will foster healthy insurance markets for physicians and patients.
State health insurance exchanges
One of the keys to achieving the ACA's goal of supplying access to health insurance coverage for everyone is the creation of sound health insurance exchanges. These exchanges should provide a place where patients, including those with low incomes and pre-existing conditions, can find affordable coverage that meets their needs.
How the exchanges take shape is important to maximize their benefits and prevent any unintended problems for physicians or patients. That's where the AMA's guide on health insurance exchanges can help.
This guide, one of 10 in the series, draws on AMA policy to outline five strategies for a healthy exchange:
1. Support the open marketplace model. This model would allow any qualified health plan to enter the exchange, providing greater options for patients and maximizing competition between insurers. The alternative model selectively contracts with qualified health plans, which would limit patient choice, restrict benefit and cost-sharing options, and exacerbate the concentration of entrenched insurers in that marketplace.
2. Ensure physician representation. Practicing physicians should be permitted to provide feedback from the front lines to help ensure such issues as benefit structure, plan certification and physician payment are addressed in the way exchanges are governed, developed and operated.
3. Promote network adequacy. Exchanges should provide a sufficient physician network so patients can get the care they need. Patients also should be given information to determine whether their physician is participating in the exchange plan they choose.
4. Manage patient churn. Exchanges should facilitate the movement of patients from one health plan to another, providing real-time information for physicians. Otherwise, continuity of care could suffer, and the frequent changes could impact physicians' ability to receive payment for the services they have provided.
5. Provide sustainable funding for exchange operations. States should plan exchanges that are self-supporting and must not turn to taxing physicians for funding.
Other insurance marketplace topics
Additional guides cover such issues as insurance subsidies, individual responsibility, high-risk pools, community rating, guaranteed issue and renewability, and patient navigators.
During this critical time as states are deciding how to implement certain provisions of the ACA, physicians can use these guides to help improve their state health insurance marketplaces for physicians and the patients they serve.
An AMA webinar at 1 p.m. Eastern time will examine what information physicians need to evaluate their payment under fee-for-service managed care arrangements. Register today.