A new insurance world

Many issues physicians face aren’t partisan and didn’t suddenly grow out of the Affordable Care Act, according to Jack Resneck Jr., M.D., professor and vice-chair of dermatology at the University of California at San Francisco.

The movement toward quality and value metrics and alternative payment models have been put in place by administrations from both parties, and the MACRA law was passed with overwhelming bipartisan support, he told colleagues recently at CalDerm Symposium 2016 (September 2016, Carlsbad, Calif.).

"For some of these longer-term trends, It's not about the left or right or whether the ACA survives or not," says Dr. Resneck, who spoke in two sessions during the continuing education seminar offered by the California Society of Dermatology & Dermatologic Surgery.

One issue that seems likely to linger no matter what happens in Washington D.C.: Insurance gaps  and hassles.

A few years ago, Dr. Resneck worked with a team of medical students posing as the children of Medicare patients. Their job: Call the dermatologists listed in Medicare Advantage health plan directories and try to make appointments for their "parents."

They didn't have much luck.

In California's Orange County, the two largest Medicare Advantage health plans listed 111 in-network dermatologists. But 35 were duplicates, four couldn't be located, and 14 were dead or retired.

"When this got published, the chief medical officer from a national insurer called. I had to hold the phone away from my ear because he was screaming so loudly," Dr. Resneck told "He was so upset about this, and he was questioning our methodology: 'When you called an office, and the receptionist said a doctor was dead, did you call the Social Security Administration to check to confirm they were really dead?'"

The good news, if you could call it that, was this: 41 of the listed dermatologists were available. That compares to just 15%-20% in other parts of the country, according to the study, which created a stir when it was released in 2014¹.

The issues he mentions have to do with one thing: Responses to the costs of healthcare.

'Skin in the game'

For some time, as Dr. Resneck notes, policymakers on both sides of the aisle have been trying to reduce costs by forcing patients to play a greater role in their healthcare. This trend explains the growth in co-pays and deductibles that punish patients if they go overboard on medical care.

"Maybe some patients will make more rational decisions if they have more skin in the game," he says. "But suddenly, they have a whole lot more skin in the game, and many can’t afford it."

As he notes, employers are seeking higher-deductible plans while patients choosing coverage through the ACA marketplaces are turning to high-deductible plans themselves.

The problem comes when patients, especially those with lower incomes, need care and are socked with unexpected expenses.

"If you have a $3,000 or $6,000 deductible, and you see your dermatologist and you need Mohs surgery, and your entire liquid assets are $766, you're going to have trouble," Dr. Resneck says. "We're all hearing from patients who are asking about how much things like biopsies are going to cost: 'Do you really need to do that biopsy on me?' And when they get the bill, they call upset saying 'I thought I had insurance.' This is something we're all dealing with."

Quality measurement

The new Medicare focus on quality and value measurement is yet another issue that won't vanish regardless of what happens to the ACA, Dr. Resneck says. "This isn't going away," he says. "Your quality is being measured by a lot of different people besides yourself, largely based on claims data that say nothing about how sick your patient is," he says.

But, he says, in terms of areas like Medicare penalties, the new system under MACRA is actually better for dermatologists than the one that was eliminated. The possible penalties have been reduced and delayed, and improvements have come in areas like "meaningful use" requirements where mandatory items are being condensed, he says.

"There's a lot to work on. This isn't all in beautiful harmony," he cautions. "There still aren't great quality measures for dermatologists, still too much of a burden on small practices, and still too much rigidity in electronic health record rules."

What's next? Dr. Resneck says there are opportunities for dermatologists to pinpoint how data will be gathered, control their own data with tools such as DataDerm, define "what makes a good and a great dermatologist," and uncover areas where care needs improvements.

"We're not the first to do this," he says, noting that dermatologists will follow in the footsteps of cardiac surgeons and ophthalmologists who have already had success in gathering valid data.

"This is our chance to show our value," he says, adding that he's optimistic about the future, especially in light of the quality of dermatologic residents who are coming up through the pipeline.

Disclosure: Dr. Resneck reports no relevant conflicts.

References

1 Resneck JS, Quiggle A, Liu M, Brewster DW. The accuracy of dermatology network physician directories posted by Medicare Advantage health plans in an era of narrow networks. JAMA Dermatol. 2014;150(12):1290-7.