Insurance Exchange Triage
Long wait times, changes in coverage for those covered under high risk
pools, and changes in provider networks are some of the problems which have
occurred with the national insurance exchange implementation. This article provides
pragmatic advice for those seeking insurance through an exchange, working with
an agency who has to implement some of the mandates, and who want straight talk
on how to accomplish your mission. First and foremost, apart from the standardization
of insurance coverage and national role out of a quasi national health care
policy, much of the griping over the exchange implementation is merely a ramped
up “open enrollment process” which occurs annually for those covered by private
insurance plans. To help allay some of the misconceptions, each of the concerns
are addressed below.
Timely Processing of Insurance
Exchange Applications
Firstly, we can all acknowledge that the federal exchange roll-out has
been problematic and now let’s move on to the concern of a delayed application,
which is-will I still have medical coverage. If you applied timely, provided
all of the documentation, such as proof of income, address, family information,
and plan selection your application will be processed with the date you
requested. The federal law isn’t effective until January 1, 2014 which is the
earliest your exchange plan will be effective. If you miss the December 15th
enrollment deadline, you can still enroll for a plan with an effective date of
February or March of 2014. Since the majority of the people purchasing
insurance on the exchanges are uninsured, this is not a crisis as these people
do not have insurance now. Secondly, if
you are having trouble getting through on the phone or the web site for
exchange enrollment, get a paper enrollment form and attend one of the free
sessions at local libraries on how to enroll on the insurance exchange.
Limitations on Provider Networks
Health care clinics or hospitals in the insurance exchange offerings
may not be the same as other private sector plans outside the exchange. The
reason for this is the insurance companies had to meet both price and strict
benefit guidelines to participate in the exchanges and the way they were able
to achieve this is to negotiate with hospitals and other providers. Provider
limitations or changes Is nothing new in the insurance industry, as there are
contract changes every year. For example, Premera has aligned with Virginia
Mason as its main hospital for their Washington State Insurance Exchange Plans
in Seattle. For me, this is not a negative as Virginia Mason has annually had one
of the best patient safety records of all Washington State hospitals, based on publicly
available data.
It is the insurance applicant’s
job to review the provider/insurer network information and discern whether it
is adequate for their needs. And hold the phone, if you doctor doesn’t have
privileges at your in-network hospital, you can obtain a referral to someone
who does. The primary concern shouldn’t be that you may have a different
hospital network, it should be about having the safest facility.
Here is a list of the latest patient safety rankings by the LeapFrog Group,
a nonprofit patient safety advocacy and research group that conducts an annual
hospital survey on patient safety, as mentioned in Unraveling U.S. Health
Care-A Personal Guide. Leapfrog Group identifies five patient safety criteria
for prevention of medical errors including: prevention of medication errors,
appropriate intensive care unit staffing, steps to avoid harm to patients
(ex. falls), managing serious errors (ex. surgical site mistakes), and safety
focused scheduling (ex. post discharge follow-up). There were only four
hospitals in the entire State of Washington that met all of these criteria 100%
of the time for the 2012[1]
reporting period and these stellar performers are:
Swedish Hospital-Issaquah
Swedish Hospital-Cherry Hill
Swedish Hospital-First Hill
Virginia Mason Medical Center
Access to Doctors
One of the primary concerns with the implementation of the insurance
exchanges has been how this newly insured population will access health care
since many do not have a doctor. This is a huge issue and is also one of the
reasons the federally qualified health centers known as community health plans
have taken a lead in enrolling folks without insurance. Group practices are
better able to integrate new patient populations. Also, most clinics these days
employ an array of health care professionals, from nurse practitioners, to
physician assistants, and licensed practical nurses, so seeing a doctor doesn’t
necessarily mean an M.D. Being under the care of a good group practice will
mean the organization has oversight and adheres to guidelines for primary health
care treatments. And finally, since many of these people have not been insured
at all, having access to a clinic is still an improvement in the potential for
care. So, if in doubt on where to find a health care provider, look for a
community health clinic or a group practice, like Group Health Cooperative or
Virginia Mason as an initial point of entry.
Cost of Health Care and Individual
Responsibility
Though the grousing about premiums has been somewhat minimized, U.S.
health care is the most expensive in the world because we tolerate over
charging and tremendous system inefficiencies. Because of these factors we have
to pay taxes and premiums to finance our health care system, which is primarily
based on user fees. Medicare recipients pay copayments and premiums for their
plans, just like the private sector insured. This will not change in this
country, you will have to pay for your insurance (unless you are very poor). So
please consider whether you are better off paying for a higher insurance
premium for a more comprehensive medical plan or a low premium for catastrophic
coverage. In essence you are making a philosophical decision about how you want
to spend your money and how much risk you are willing to take up front.
In the United States if you want health care, you must pay for it, via
an insurance plan and/or at the point of service. To make this manifest you may
actually have to do something, like read a brochure, complete an application,
go to a free seminar at the library (which have had sparse turnouts), and make
a decision to enroll. Failure to do so will result in a tax penalty in 2015,
unexpected medical expenses, or the inability to obtain care. For those of you
who still have questions on the 2014 health care mandates or the Gordian knot
of U.S. health care system, pick up a copy of my book, Unraveling U.S. Health
Care-A Personal Guide, published by Rowman & Littlefield in July. http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972
And if you can’t afford to buy it, your local library may have a copy to
borrow.
And this is the healthpolicymaven signing off wishing you a safe and
merry holiday season-lights up and on!
Leapfroggroup.org Washington State Hospital Survey
2012 results
