Southeast to Take Brunt of ACA Pullouts

Michael Roberts, MD

First it was UnitedHealthcare, then Humana, then Aetna. One by one, major payers have announced they will withdraw from many Affordable Care Act (ACA) marketplaces at the end of this year, leaving residents of hundreds of counties with just one or two payers selling policies on the government-run exchanges. For a few weeks it appeared the marketplace for Pinal County, Arizona might have no plans at all, despite the law’s requirement that most Americans carry health insurance.

Exchange plans make up a small part of the overall insurance market, and the majority of counties will still have more than two payers, but this is little comfort to cancer patients in the affected areas who have such plans. They are already coping with ever-rising premiums, high deductibles and copays, narrow provider networks, and cumbersome preauthorization requirements. Now, they face the prospect of losing their insurance and possibly having to change their doctors in the midst of a course of treatment.

Michael Roberts, MD, of Arizona Oncology, a practice in The US Oncology Network, recently saw a patient in the Phoenix area who has multiple myeloma and was “more than ready” for a stem cell transplant. The approaching expiration of the man’s marketplace plan only added to the urgency of a speedy start to treatment, Roberts said.

“I was calling the transplanters to get him in sooner rather than later, because his insurance from this plan ends on November 1. I’m trying to make sure he gets on to his wife’s insurance, and he’s terrified,” Roberts said. “We spent a good chunk of a Friday afternoon trying to piece together what’s going on with him. I’m pretty sure at the end he’s going to get on the other insurance and be OK, but there was an hour when he was just kind of terrified.”

He noted that insurance plans are increasingly changing every year, or even more frequently, whether provided by a marketplace, employer, or Medicaid. Providers are added or subtracted, cost-sharing terms change, and new hurdles are imposed for treatment approvals. He described the new marketplace disruption as just the latest in the insurance market’s ongoing turmoil.

“This year’s going to be a little bit harder with the ACA plans because there are fewer of them and costs are going up, but honestly, I think each year it just gets more complicated,” Roberts said. “That’s been going on for quite a while.”

Oncologists like Roberts are having difficult conversations with their patients across the state and the country. In Arizona it appears that the marketplaces in every county but one will have plans from just a single carrier.¹ Exchange offerings have not yet been finalized, but the Kaiser Family Foundation estimates that 31% of counties nationwide could have just a single marketplace payer in 2017, up from 7% this year, and a similar percentage will only have two, up from 12% in 2016.² Open enrollment begins November 1.

Source: Kaiser Family Foundation

Currently, only Wyoming has a single marketplace carrier in every county, but Alabama, Alaska, Oklahoma, and South Carolina will likely join that list in January, according to the foundation. Single-carrier marketplaces have been concentrated in rural states, including West Virginia, Utah, South Carolina, and Nevada, and will become much more prevalent in Arizona and several southern states, most significantly Florida, Mississippi, Missouri, North Carolina, and Tennessee.

The big payers that are pulling back cite the small market size, greater patient expense on the exchanges, and continuous financial losses from those plans. In addition, Aetna, which is dropping out of 546 counties in 11 states, had threatened to leave the exchanges if the Justice Department opposed the company’s proposed merger with Humana. In July, the government sued to block the deal.

At least 85% of the roughly 11 million individuals who have marketplace plans receive subsidies in the form of tax credits, which should blunt any premium hikes and ease forced switches to new plans. Some 57% who have low incomes and choose silver-level plans—the second cheapest of four available plan levels—also benefit from cost-sharing reductions, which lower their deductible, co-pay, and coinsurance costs. When a plan is canceled, the marketplace automatically tries to assign its members to a similar plan from other carriers, said Karen Pollitz, senior fellow at the Kaiser Family Foundation. They may also choose new plans on their own. That said, all marketplace buyers—whether they are being funneled into new plans, or only seeing their existing policies updated for the new year—must be vigilant, Pollitz said. They should be careful to make sure that their plans continue to provide them adequate coverage with their current doctors, as well as needed pharmacy benefits.

“Shopping for the lowest premium is great, but if you’re in treatment with an oncologist who’s in the network of one plan and not in the network of another plan, it’s not going to help you that much if your premium goes down, if all of your bills become out-of-network bills,” Pollitz said. “This is true for everybody, but I think cancer patients probably wake up to this pretty quickly—that you need to take a comprehensive look at your plan in determining what your affordability is going to be.”

Pollitz said patients can look for help from federally funded navigators in every state or ask their oncologist’s billing office for assistance. Figuring out the best choice can be difficult, especially in an environment of reduced plan options, but it’s particularly critical if a patient has already started chemotherapy or another course of treatment. “If the ACA plan that we’re contracted with no longer exists, we may not be able to see the patient, even in the middle of the treatment,” Roberts said. “They’ll be able to see somebody else and hopefully they’ll get very good care—and most of the time they do—but having to change providers whom you trust is stressful.”

“A lot of times it really is a huge problem in terms of maintaining the continuity of their care. That can be a huge issue,” said David Eagle, MD, of Lake Norman Oncology in Mooresville, North Carolina. “Unfortunately, a lot of times patients are very surprised that their insurance plan changed. They don’t anticipate that it’s going to create a problem continuing care in the same way in our office, but sometimes it does.”

UnitedHealthcare is pulling out of the ACA marketplace in Eagle’s area, leaving only Blue Cross Blue Shield plans. He said the practice will do what it can to ease the transition for those affected.

“We try to have our billing office counsel patients to the extent they can, but we’re not their insurance company; we’re their doctors. We have to be careful about how we do that,” said Eagle, a past president of the Community Oncology Alliance. “At the end of the day it’s individual patients’ choices that guide what insurance plans they want to be on.”

Roberts said in the past he has lost patients mid-treatment when they’ve been switched to narrow-network plans that do not include Arizona Oncology. In those cases the practice tries to persuade the payer to at least cover the remainder of the patient’s current chemo or radiation. “Sometimes they will, and sometimes they won’t,” he said. Arizona Oncology also has a department dedicated to helping needy patients get help from charities and drug manufacturers, he said.

Teri Guidi, CEO of Oncology Management Consulting Group in Florida, said all the private practices she knows do their best to help patients handle insurance problems, depending on the manpower they are able to dedicate to them. For better or worse, in the last three years they have gotten used to coping with an evolving assortment of new insurance products and their often burdensome requirements, she said.

“What a lot of practice staff spend their time doing is trying to get authorizations and precertifications, trying to negotiate contracts with payers in the first place, and then learning their particular billing rules and chasing payments, and so forth--and that work went up every time you got another patient and a plan that you’ve never seen before,” she said. “A lot of the plans on the marketplace are different and increased that backoffice work. It became quite a hassle.”

When marketplace plans debuted in 2014, some were considered “decent” and worth taking, she said. Practices were happy there would be fewer uninsured patients they had to turn away.

But many of the plans have added more restrictions to what they will cover, offer insufficient reimbursements, take months to pay, consume considerable staff time, and now are being canceled altogether by some of the nation’s leading payers. Guidi said the oncology practice administrators she talks to say they’re tempted to simply stop accepting marketplace plans.

Eagle said policies that don’t cover the true cost of care are really not serving patients adequately, and further degradation of marketplace offerings due to insurance company financial difficulties will only leave patients worse off. But both he and Roberts also said it is still far better to have such plans available than to return to the days when more people went bankrupt when they got sick or made the terrible choice to not be treated at all.

“I don’t want to see this many insurers go out of the marketplace because it reduces competition and gives people fewer options,” Roberts said. “If I had a choice of no insurance versus this insurance, this would be much better.”

References

1. Alltucker, K. New ‘Obamacare’ insurer comes to Maricopa County as another exits. The Arizona Republic website. http://www.azcentral.com/ story/money/business/health/2016/09/15/new-obamacare-insurercomes- maricopa-county-another-exits-centene-corp/90416374. Published September 15, 2016. Accessed September 21, 2016.
2. Cox C, Semanskee A. Preliminary data on insurer exits and entrants in 2017 Affordable Care Act marketplaces. Kaiser Family Foundation website. http://kff.org/health-reform/issue-brief/preliminary-data-on-insurer-exitsand- entrants-in-2017-affordable-care-act-marketplaces. Published August 28, 2016. Accessed September 21, 2016.