The article is written by Adam C. Powell, PhD, President of Payer+Provider Syndicate, a consulting firm which uses teams of economists, health services researchers and physicians to provide precise answers to operational challenges faced by health insurance companies and hospitals.
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The increased availability of health insurance exchanges has the potential to increase the number of people in the individual insurance market by both making it easier for employers to drop coverage and by making coverage more accessible to the formerly uninsured. People shopping for their own health plans are particularly likely to seek plans with low premiums, as their coverage is not being subsidized by an employer. To save money, people pick plans with higher deductibles, narrower networks and no branded drug coverage.
Spine surgery practices may be impacted by these changes in the following three ways:
1. Patients purchasing high deductible plans on health insurance exchanges are likely to be more proactive consumers when choosing a provider for their spine surgery. As patients become responsible for more of their medical costs, they are likely to increasingly insist on being provided cost estimates for their spine surgeries before they are performed. Practices should train their staffs to be familiar with the rough costs of different procedures under all of their major payer contracts so that patients can easily be informed of their contribution.
2. Health plans with limited networks typically cost less than open network plans, and thus are more popular to people shopping on health insurance exchanges. Spine surgery practices should be conscious that more people will be constrained by their health plan's provider network – and the price tiering within that network. Practices experiencing inadequate volume may wish to contract with additional health plans and to offer payers the pricing necessary to get more favorable tiering.
3. As many health plans sold on exchanges only include generic drug coverage, patients that have purchased coverage on health insurance exchanges are likely to be more sensitive to the cost of branded prescription drugs. When patients are not able to afford their drugs, they are less likely to be compliant. Physicians should consider the affordability of the drugs they are prescribing to patients and make generic substitutions when feasible. In cases where good generic substitutes do not exist, physicians should proactively justify their decisions to prescribe expensive medications in order to boost compliance and express empathy for their patients.
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