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High Out-of-Pocket Costs, Narrow Insurance Networks Fuel ER Visits

Some insured patients delay or skip necessary medical care, ACEP survey finds

A survey by the American College of Emergency Physicians (ACEP) has found that patients are having trouble finding specialists in their health insurance network and are delaying medical care due to fear of high out-of-pocket expenses such as deductibles and co-insurance.

According to Fierce Healthcare, seven out of 10 emergency department (ED) doctors reported seeing patients who delayed seeking care because of those high costs. Two-thirds of those surveyed also said primary-care physicians are sending patients to the ED for medical tests or procedures that insurance won't cover during office visits.

"Many patients are motivated by fear of costs and not by the seriousness of their medical conditions," ACEP President Jay Kaplan, MD, said in a statement, criticizing insurers for shifting more costs to patients and providers. "They call it cost-cutting when in reality it is profit-boosting."

In other findings, 60% of the emergency physicians said they have trouble finding specialists in their patients' health insurance networks for referrals, and more than 80% said their patients reported having trouble finding in-network specialists on their own.

A report released earlier this year by the McKinsey Center for U.S. Health System Reform said that 45% of plans offered on state health insurance exchanges have narrow networks, and 17% are defined as "ultra-narrow networks." About three-quarters of those surveyed by ACEP also said they are seeing more Medicaid patients because insurance networks didn't include enough primary care or specialty physicians. Such concerns have already drawn the attention of the National Association of Insurance Commissioners, which is developing a new model network adequacy law to include measures of network adequacy, including provider-covered person ratios by specialty and accessibility of providers by geographic area.

As a result of the challenges, 20% of the ACEP emergency physicians said either they or other ED doctors they knew were considering opting out of health insurance networks. Nearly 90% cited insufficient reimbursement rates from insurers. "Balance billing would not even exist if health plans paid what is known as 'usual and customary' payment in the insurance industry — what is also known as 'fair payment,'" Kaplan said. "Emergency patients are especially vulnerable because health plans know that emergency departments never turn anyone away."

Source: Fierce Healthcare, October 26, 2015.

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