Do Doctors Order Unnecessary Tests

Three out of four physicians believe that fellow doctors prescribe an unnecessary test or procedure at least once a week, a survey released Thursday finds. The most frequent reasons that physicians order extraneous and costly medical care are fears of being sued, impulses to be extra careful and desires to reassure their own assessments of the patient, the survey said. The survey was completed for Choosing Wisely, a two-year old campaign devised by a foundation created by internal medicine doctors that has persuaded nearly 60 medical societies to identify overused tests and procedures. The goal is to cut back on needless medical care, which by some estimates may waste a third of the $2.8 trillion the country spends on health each year. The campaign focuses on encouraging conversations between patients and doctors about the suspect treatments it identifies. In the survey, 47 percent of doctors said one patient a week requests something unnecessary. While most doctors believe they are most responsible for interceding, 48 percent said that when facing an insistent patient, they advise against it but still order the test. Another 5 percent said they just order the test. I think we are afraid of not being liked, one doctor says, who happens to be a vice president at Hillcrest Hospital, which is part of the Cleveland Clinic Health System and located in Mayfield Heights, Ohio. Many doctors want to be the hero to the patient. Not surprisingly, few of the doctors agree with health policy analysts who believe that the financial rewards that come from extra procedures are a major reason why they are ordered. Only 5 percent of physicians said they are influenced by the presence of new technology in their offices. Just 5 percent believe the fee-for-service-system of payment, where physicians are paid for each thing they do rather than a lump sum for keeping a patient healthy, Initial efforts of the poll have been a success, with 21 percent of doctors saying they are aware of it and a majority of them saying they have reduced the number of times they order unneeded tests and procedures. The poll of 600 physicians was conducted by PerryUndem Research/Communication from Feb. 12 through March 21. It has a margin of error of +/- 4 percentage points.

Will Obamacare premiums rise significantly upon 2015 renewal

Health industry officials say ObamaCare related premiums will double in some parts of the country, differing from comments recently made by the Obama administration. The expected rate hikes will be announced in the coming months. Large premium increases would likely bolster the GOP’s prospects in November and hamper ObamaCare insurance enrollment efforts in 2015. The industry complaints come less than a week after Health and Human Services (HHS) Secretary Kathleen Sebelius sought to downplay concerns about rising premiums in the healthcare sector. She told lawmakers rates would increase in 2015 but grow more slowly than in the past. “The increases are far less significant than what they were prior to the Affordable Care Act,” the secretary said in testimony before the House Ways and Means Committee. Her comment baffled insurance officials, who said it runs counter to the industry’s consensus about next year. A senior insurance executive who requested anonymity said "It’s pretty shortsighted because I think everybody knows that the way the exchange has rolled out … is going to lead to higher costs". The insurance official, who hails from a populous swing state, said his company expects to triple its rates next year on the ObamaCare exchange. The hikes are expected to vary substantially by region, state and carrier. Areas of the country with older, sicker or smaller populations are likely to be hit hardest, while others might not see substantial increases at all. Several major companies have been bullish on the healthcare law as a growth opportunity. With investors, especially, the firms downplay the consequences of more older, sicker enrollees in the risk pool. After some stories were published about premium increase in 2015, the administration pointed to some independent analyses that have cast doubt on whether the current mix of enrollees will lead to premium hikes. ObamaCare also includes several programs designed to ease the transition and stave off premium increases. Reinsurance, for example, will send payments to insurers to help shoulder the cost of covering sick patients. Insurance officials are quick to emphasize that any spikes would be a consequence of delays and changes in ObamaCare’s rollout. They point out that the administration, after a massive public outcry, eased their policies to allow people to keep their old health plans. That kept some healthy people in place, instead of making them jump into the new exchanges. Federal health officials have also limited the amount of money the government can spend to help insurers cover the cost of new, sick patients. Insurers have been disappointed that young people only make up about 25% of the enrollees in plans through the insurance exchanges, according to public figures that were released earlier this year. The exchanges are hoping that changed with individuals their 20s and 30s signing up at the March 31 enrollment deadline. Many insurers, however, don’t share that optimism. Republicans frequently highlight President Obama’s promise on the campaign trail to enact a healthcare law that would “cut the cost of a typical family’s premium by up to $2,500 a year.” The Obama administration may have to backpedal on that,” according to some industry experts. Insurers will begin the process this spring by filing their rate proposals with state officials. Insurance commissioners will then release the rates sometime this summer, usually when they’ are approved. Insurers could also leak their rates earlier as a political statement. In some states, commissioners have the authority to deny certain rate increases, which could help prevent the most drastic hikes. In any case, there may well be a slew of bad headlines for the Obama administration just months before the election. “It’s pretty bad timing,” said one insurance official. There are other health experts who say predictions about premiums are premature. David Cutler, who has been called an architect of Obama-Care, said, “Health premiums increase every year, so the odds are very good that they will increase next year as well. None of that is news. The question is whether it will be a lot or a little. That depends in part on how big the insurers think the exchanges will be.” Jon Gruber, who also helped design the Affordable Care Act, said, “The bottom line is that we just don’t know. Premiums were rising 7 to 10 percent a year before the law. So the question is whether we will see a continuation of that sort of single digit increase, as Sebelius said, or whether it will be larger.” Political operatives will be watching premium increases this summer, most notably in states where there are contested Senate races. In Iowa, which hosts the first presidential caucus in the nation and has a competitive Senate race this year, rates are expected to rise 100 percent on the exchange and by double digits on the larger, employer-based market, according to a February 2013 article in the Business Record. So the question is will rates rise by more than the 7-10% on average prior to 2014?

ObamaCare Coverage, Stay In Network Avoid Out of Pocket Costs

Here are some tips Obamacare Coverage: Stay In Network, Avoid Out-Of-Pocket Costs You purchased insurance through one of the online Affordable Care Act exchanges,or direct through the insuirnace carrier, possibly after a lengthy time of trying to get the site to work. Don't relax just yet. Joining the plan is the first challenge. Now you have to understand it. Policies sold through the online portals cover essential benefits and put a cap on your out-of-pocket medical costs. One needs follow the rules. The boilerplate explanation you got from the insurance company may not be easy to understand. What do members need to know about these plans that they probably don't? Carry your membership card with you at all times. Make a copy. It will save a huge amount of hassle if you have an unexpected doctor or hospital visit. Understand your plan's doctor and hospital network. Insurance companies negotiate participation and payment rates with a network of providers to control costs. "Many of these exchange plans, in order to stay affordable, have much smaller networks than people are used to. Just because their friend has a plan and can go to a particular hospital doesn't mean that you necessarily can too. You can check your carrier and plan's directory. Go online or sometimes part of the documents you receive when you enroll to find out if specific physicians are part of your network. You can call doctors' offices to confirm, too, but many times the doctotrs office ismn't always reliable. One thing for sure, Stay in the network! The Affordable Care Act states that, once you join a qualified plan, you won't pay more out of pocket per year than $6,350 for an individual and $12,700 for a family. This applies only to in-network care. Whether youre in an HMO that pays almost no out-of-network benefits or a PPO that covers some, the pocketbook protections don't apply if you use a non-network doc or hospital. Non-network providers also frequently bill you far more than what they charge patients in their networks for the same procedure. Try to stay in-network even if it's for emergency care. Insurance plans do have to pay for non-network emergency visits under the health law. If you're in a car crash far from home you can't choose which hospital saves your life. But non-network hospitals often "balance-bill" the difference between what your plan pays and what they charge, which is often much more. Avoid all emergency rooms unless it's really an emergency. Traditionally, health plans came with a modest copayment for an emergency visit of $100 to $200. Many policies sold under the health law, even those in the more expensive "gold" category, not only have ER copays of several hundred dollars but also subject ER charges to the overall deductible. Copays are flat fees for specific services. Deductibles are what you pay out of pocket before the insurance kicks in. That means you could be billed for the full cost of an emergency visit up to the out-of-pocket limit. This is a huge difference from traditional plans and will really hurt the an individual or family. "The new plans put a lot more people into that exposure. Broken leg, head to the hospital. Sprained ankle,maybe wait until the urgent care center or doctor's office opens. Pay monthly premiums on time and accurately. Do not wait, pay your premium; Otherwise that will be the end of your insurance and you can't sign up again until the next open season in November for a Jan 1, 2015 effective date. Open enrollment for 2014 coverage ends March 31. Open enrollment for 2015 begins Nov. 15. Even underpaying the premium by a few cents could give the insurance company grounds to kick you off, she said. Insurers allow a brief grace period if you get behind. Ssomewhat longer if you're receiving premium subsidies, but they will terminate coverage for nonpayment. Register online with your new insurance company. Insurance sites are good for tracking claims. Increasingly they also let you shop around for the best deals on non-emergency treatment. Your health plan might pay one imaging center half what it pays another imaging center. Save paperwork. Make sure you really owe what doctors and hospitals bill you for. Now is a good time to become a pack rat. If you have any concern, it really is worth it to make a call and get them to explain what they did. If you don't get satisfaction from providers or insurers, try regulators. Check the insurer's explanation of benefits detailing your claims. It may show a phone number for a consumer assistance program in your state to help deal with medical coverage. Do read the plan's summary of benefits and coverage. You might want to print it out, because that has the details of your plan, and how it works. What you have to pay in order to go to a primary care doctor? Is it before or after the deductible? How big is your deductible? How much does it cost to go to the emergency room? Remember your health is really important.

Finding Health Plans that Include Your Doctors

Shopping for doctors isn't always easy. CoveredCa, California's health exchange seems to be making it tougher. Ask someone looking for a doctor.Many individuals are looking to use Covered California to get a policy that lets him keep a handful of doctors they like. But like many applying for coverage, the choices are not always to their liking. "My internist is not on the plan",individuals say. Neither is my orthopedist or any of the specialists recommended the individuals primary care doctor. As a result, many are having a difficult choice to make: Keep looking for an affordable plan with the doctors they like, pick a plan with new doctors, or sign up for a plan that allows care by out-of-network docs, typically at a higher cost. Many consumers who currently have insurance and are shopping for a new plan through Covered California are finding it difficult to locate policies that include the doctors and hospitals they're accustomed to seeing. Insurance brokers aren't finding the process any easier. Three words: It's a nightmare, says insurance agents. Most of the insurance companies on the exchange are offering provider networks that are far narrower than the other plans they're selling outside of the exchange. Just how much narrower, however, isn't clear. It is hard to determine. Covered California issued a report last week saying that more than 58,000 physicians were available through the exchange's plans, compared with the 63,000 to 72,000 physicians in the state's largest commercial networks. But how that plays out for consumers probably depends on the specific plan they choose. Blue Shield, the San Francisco-based nonprofit insurer, says it is offering a network through its exchange plans that represents roughly 50% of its full network. In many cases, even doctors themselves are unsure of their status in the new plans. Insurers have a long history of inaccurate and outdated provider listings, which the law does nothing to fix. And the provider lists found on Covered California have themselves been riddled with errors. There are quite a few inaccuracies. The changing and shrinking provider networks do pose a challenge for consumers, but then again that's nothing new. Even before the Affordable Care Act, networks changed because health plans and physician groups reached different agreements on costs. One of the benefits of the Affordable Care Act may make coverage more expensive. Plans must now provide standard benefits across all of their products. Annual limits on out-of-pocket costs apply, and, of course, they must now accept all comers and cannot charge people with preexisting medical conditions more than the healthy. To make insurance affordable, insurers are seeking to control costs in part by limiting the number of doctors and hospitals included in their networks. The question for consumers, is whether they can locate a plan that has good doctors and hospitals at an affordable price. And that's a question that many people are wrestling with for the last couple of months. Most individuals are concerned with how do I decide if I continue to see my primary care physician? Consumers shoudl be to go to any doctor they want. Unfortunately that's not the case. Experts offer some tips for consumers in the market for a plan that includes the doctors they wish to see. Do your homework. Check directly with both your health plan and your doctors and hospitals, particularly if your choice of policies is based on keeping the doctors you like. Unfortunately, you'll need to check each plan's network individually for your doctor. But, beware; Even if your doctors of choice are listed as participating with your plan, be sure to inquire as to whether the office is taking on new patients. Don't be afraid to switch plans. Open enrollment runs through the end of March. If you're unhappy with the plan you purchased early in the year, or learn that you don't have access to the doctors you thought you did, you can switch to another plan before March 31, 2014. Enlist the help of an insurance agent. Local insurance agents certified to sell you a health plan through Covered California can be invaluable. For some reason there is a misconception that if you use an agent you'll have to pay. It costs you nothing extra to have a certified insurance agent who can help you with the decision.Once you're signed up, an agent often works as your advocate when problems with your insurance plan arise. Finding the right plan has been frustrating for many, but keep a sense of humor. As one individual says "Right now I'm starting to look to see if there's a psychologist in the network, because I'm going nuts".

Doctor Networks Supporting ACA Compliant Plans

Health coverage is only as good as the doctors who accept it, an important truth when buying a policy from Covered California, the state’s new medical marketplace or an insurance carrier directly.

The doctor networks supporting plans in CoveredCa (new health exchange) which is the place for uninsured Californians to purchase subsidized policies, as well as carriers directly are getting more attention as individuals compare and consider offerings from different insurance companies.

While the policies listed on the new exchange each have a price clearly displayed, finding out which doctors are included can take a bit more digging. Big providers like Sharp HealthCare and Kaiser Permanente each offer their own plans backed by their own doctor networks. In other cases, the connection between insurance companies and providers is not as obvious.

Carriers like Anthem Blue Cross, Blue Shield of California and HealthNet have worked their own deals with local doctor and hospital providers to back the plans they offer on and off the exchange. Anthem has partnered with UC San Diego as its top-tier provider, while Blue Shield has selected Scripps Health.

Executives with in each health care system say they agreed to take less reimbursement dollars from insurers in hopes that the exchange would deliver a healthy new volume of patients. Paul Viviano, chief executive of UC San Diego Health System, said he believes the university can work with Blue Cross to keep patient costs low.

“Lower cost was the the focus of our conversation. We felt that we could develop a product that was useful and attractive,” Viviano said.

Likewise, Scripps CEO Chris Van Gorder said his organization decided that it was important to participate in the exchange even if it meant taking lower reimbursement than previously offered.

“I’'d be surprised if anybody didn'’t discount their rates,” he said. “We assume we are going to get volume in return, but we didn'’t negotiate any guarantees. We just believed we had a community obligation to participate.” Neither executive would disclose how much their organizations agreed to discount services in order to cement a deal with their exchange insurance provider.

These partnerships have created fewer doctors and narrower lists of participation in some, if not most plans than currently exist for individual policies that have been available from the same carriers prior to 1/1/14.

There are about 2,233 doctors supporting Blue Shield of California’s health exchange offerings in San Diego County. That number represents only about 53 percent of Blue Shield’s total affiliated doctor network in the region.Those who buy Blue Shield exchange policies will be able to use 12 of San Diego County’s 20 hospitals. UC San Diego Health System said all of its 820 local doctors are included. Anthem and HealthNet have not released the numbers for its doctors and hospitals. 

This pattern for trading discounts for relationships that could deliver high volumes of patients, does not appear to be unique to San Diego County.  “It is a common for hospitals and doctors to negotiate these types of arrangement where providers hope to gain more volume. But this strategy has not worked so well in San Diego County.

Dr. Ted Mazer, an ear, nose and throat doctor and spokesman for the San Diego County Medical Society, said he did not participate in some Blue Cross plans due to reimbursement rates offered. He said many doctors who work in partnership with the larger health systems in the area do not realize that they have been signed up for exchange plans through their affiliation with that larger partner. Mazer predicted chaos in the provider world when patients start showing up, insurance card in hand. “Most of the doctors don’t know what they’ve got, and they don’t know, really, if they’re in or out,” Mazer said. He added that inaccuracies in Covered California’s online doctor directory also have persisted in some cases, despite attempts to make corrections.

The big question, then, is whether the doctor networks assembled by insurance companies will be adequate to support demand. So far, local providers seem confident that their new patients will be able to get a doctor appointment with their newly purchased policy.

Johnston, the health plan association CEO, said "we expect that people are going to be very happy with the tailored networks set up in each region of California to provide care. Does that mean every doctor and hospital is included? No. The test should not be whether every provider is included but whether consumers have good care, reasonably available,” Johnston said.