Since the Affordable Care Act (ACA) was passed in 2010 and enacted in 2012, we’ve seen a surge of insured patients. With our payer mix switching from 53 percent uninsured in 2011 to 25 percent uninsured in 2015, it would seem that the Affordable Care Act was indeed effective. However, what we have found is that having insurance is not necessarily equal to having access to healthcare. The reason is because the marketplace has now been flooded with so-called affordable plans that offer average premiums but very high, almost unobtainable, deductibles. These are called catastrophic health plans, and they do meet the minimum requirements set by the ACA for insurance coverage. The result is a patient who pays the premium every month but cannot afford to use their insurance. This makes the coverage essentially useless, unless a major event or emergency occurs. These catastrophic coverage plans have become the new norm, especially for states that declined Medicaid expansion, such as Texas.
To complicate matters, many of these underinsured patients no longer qualify for community resources that are available to those without insurance. With deductibles unmet, low-income patients are forced to choose between visiting their doctor, getting their labs done, at full price, or purchasing their medicines.
Fortunately, with challenge comes innovation. CommuniCare Health Centers, a community-based primary care group, have had to find new ways to improve access to care since the newly insured no longer qualify for sliding discount fees. One of the ways CommuniCare is bridging this gap is by creating a new product that provides unlimited access to many of their services, basic labs and imaging, for a low monthly subscription. Under this model, the patient continues to pay their insurance premiums and can visit their primary care physician as often as needed without paying the fee for service, despite their unmet deductibles.
But this does not solve the problem of access to specialty care. The patient who needs the non-emergent but necessary procedure or intervention must pre-pay if the deductible has not yet been met. For example, the patient with the palpable neck mass who is referred for a biopsy will need to pay for the procedure at the time of the visit. Furthermore, should the pathology reveal a diagnosis requiring further procedures, such as a resectable thyroid cancer, then the patient must be able to finance the operation before the surgeon will even schedule it. With deductibles as high as $6000, the patient in this scenario will have paid for most of the care before the insurance even kicks in, all while still paying the monthly premium.
“This new class of underinsured patients presents a new set of challenges, and we will meet these challenges.”
By partnering with specialists who agree to offer services at discounted rates for self-pay patients, CommuniCare has begun to develop some solutions, but much more is needed. Until specialists begin to develop community oriented care plans, hospitals will continue to see advanced stages of preventable diseases, such as acute myocardial infarction, rather than reversible ischemia.
Medications continue to present a challenge for both uninsured and insured populations. For self-pay patients, several resources are available to help them obtain medications, such as the “Any Baby Can” program. Diabetics who qualify are able to get their much needed insulin through medication assistance programs. Once insured, patients no longer qualify. Many of the insulins are expensive, and most of them are not covered by the new catastrophic plans. The insulin medications that are covered are placed in high tiers, making them unaffordable to many patients. We have been able to offset this by partnering with select pharmacies that offer drug discounts and co-pay assistance. Furthermore, many pharmaceutical companies have stepped up and offered assistance programs as well as co-pay cards, a new arsenal in the continuing battle to find resources for low-income patients. Private charities have also begun to recognize the need to fill gaps in insurance coverage, such as the HealthWell Foundation.
With reimbursement rates transitioning from volume based to outcome based, primary care clinics are incentivized to help their patients find access to affordable resources, therefore improving compliance. Otherwise, they may face reduced revenues. For primary care physicians working at the front lines of prevention in community-based clinics, we have become accustomed to the challenge of finding resources for uninsured patients. This new class of underinsured patients presents a new set of challenges, and we will meet these challenges.
For more information on CommuniCare Health Centers visit CommuniCare or call 210.233.7000.