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Obamacare, Doctor Pay, and the Access to Care

Jeff Cohen

The Affordable Care Act is about insuring the uninsured. Insurance is one thing, but actual access to a doctor or a provider is another.

If reimbursement rates to doctors stay low under Obamacare, more doctors could reject plans offered by it.

One variable plays an important role in determining the quality of care that patients will get: how much doctors are paid. 

Doug Gerard had a patient in one of his exam rooms complaining of joint pain. He checked her out, asked her a few questions about her symptoms, and then did a few tests before sending her on her way.

For a typical quick visit like this, Gerard could get reimbursed $100 or more from a private insurer. For the same visit, Medicare pays less -- about $80. Now, with the new plans under the Affordable Care Act, Gerard said he would get something closer to Medicare rates from the big commercial insurers.

That’s not something Gerard is willing to put up with. He opted out of two of the three insurance plans offered in Connecticut’s exchange. "Potentially commercial-type reimbursement rates were now going to be reimbursed at Medicare rates," he said. "You have to maintain a certain mix in private practice between the low reimbursers and the high reimbursers to be able to keep the lights on."

Three insurers offered plans in Connecticut in 2014: Anthem Blue Cross Blue Shield, Connecticare, and Healthy CT, a co-op started in part by doctors. Gerard is only accepting one. He wouldn't say which, but he did say it pays the highest rate. "I don’t think most physicians know what they’re being reimbursed," he said. "Only when they start seeing some of those rates come through...will they realize how low the rates are they agreed to."

Gerard is by no means the norm, but he is an example of something officials in Connecticut are concerned about. If reimbursement rates to doctors stay low under Obamacare, more doctors could reject plans offered by it. That could mean people will get access to insurance, but not get access to doctors.

That worries Kevin Counihan, who runs Connecticut's health insurance marketplace. "I think it could lead potentially to this kind of distinction that there is these different tiers of quality of care," he said.  His agency, Access Health CT, recently approved rules geared at getting more providers into plans on the exchange. The goal is to make sure that everyone gets good care, regardless of their income.

"The different tiers of quality of care mean somehow people think that just because my income is below 400 percent of the federal poverty level, I’m going to get inadequate care, or lesser care than someone making above 400 percent," Counihan said. "That’s been something, at least in our state, that we’re trying to work against, and the carriers are, as well."

"There's this balance between how much do you want to cost to provide that service, and how much you can pass along in your premiums rates. It's a balancing act."
Ken Lalime

WNPR asked all three of the insurers on Connecticut’s exchange to comment. Two declined. One agreed. Ken Lalime, CEO of Healthy CT -- the insurance co-op -- said insurers face a real challenge: paying doctors enough so they accept their patients, but not paying them so much that the price to the consumer is so high that no one buys it. That’s kind of what happened to Healthy CT in 2014. Of the three insurers, it only got three percent of the market share.

"Every time you increase payments to providers," Lalime said, "you have to offset that with increased reimbursements from the consumer. There’s this balance between how much do you want to cost to provide that service, and how much you can pass along in your premiums rates. It’s a balancing act."

Lalime said he thinks low reimbursement rates are forcing some doctors to decide against accepting insurance under the Affordable Care Act.

Bob Russo is sure of it. He's a radiologist, and president-elect of the Connecticut State Medical Society. He said that the low rates and administrative burdens that come along with the ACA could make it a financial loser. It isn't yet in his office. But that's because few patients have come to him with Obamacare insurance.

"You get what you pay for," Russo said. "If you can't convince people that they're not losing money doing their job, then it's a problem. They haven't been able to convince people of that. There's no question that Medicaid, under its old rates, wasn't working. Have we just invented a new Medicaid that kind of slid the scale up a little bit more to make access a little more?"

The experience of these doctors is a good reminder that the Affordable Care Act is more than a thought exercise in health care. It's happening. Here's another reminder: open enrollment for 2015 begins in just over three months.

Jeff Cohen started in newspapers in 2001 and joined Connecticut Public in 2010, where he worked as a reporter and fill-in host. In 2017, he was named news director. Then, in 2022, he became a senior enterprise reporter.

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