Many states have their own exchange marketplaces, points out Arthur Vercillo, MD, FASC, regional president, Excellus Blue Cross Blue Shield. “We’ve seen an expansion of Medicaid and the individual market, and that’s really heating up,” Dr Vercillo believes, although if the system is expanded and affordable for everyone, younger, healthier individuals will have to be part of the expansion.
A concern for Ateev Mehrotra, MD, MPH, an associate professor of healthcare policy and medicine at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center, is the narrow provider networks that many exchange plans are utilizing. “The American public did not respond well to this the last time we tried in managed care to restrict networks,” he says. He is surprised that there hasn’t been more pushback, including negative press, this time around.
The difference, Dr Vercillo replies, is that today, consumers have more skin in the game, and the 40% required co-insurance for going out of network is an effective disincentive. They still want their doctor or their hospital, he states, but they are willing to go elsewhere if it will cost them much more. If individuals have the silver or bronze level health plans with a 30% to 40% out-of-pocket costs and high deductibles, they will move to someone else, he admits.
Dr Mehrotra thinks the situation is a bit more complicated, in that individuals signed up for these plans “because that was the one they could afford.” He believes that in the example Dr Vercillo described, the person was more informed in their choice.
In order to be on the state exchanges, plans must meet certain qualifications, including network adequacy, Dr Vercillo points out. Problems may arise, he acknowledges, when you have a higher cost physician or hospital that is no longer in the network, and patients find that if they want to return to them, they will have much higher costs.
New Research Challenges Assumptions About Hospital-Physician Integration, Medicare Patient Mix
April 22nd 2025On this episode of Managed Care Cast, Brady Post, PhD, lead author of a study published in the April 2025 issue of The American Journal of Managed Care®, challenges the claim that hospital-employed physicians serve a more complex patient mix.
Listen
Personalized Care Key as Tirzepatide Use Expands Rapidly
April 15th 2025Using commercial insurance claims data and the US launch of tirzepatide as their dividing point, John Ostrominski, MD, Harvard Medical School, and his team studied trends in the use of both glucose-lowering and weight-lowering medications, comparing outcomes between adults with and without type 2 diabetes.
Listen
Integrated CKD Care Model Cuts ED Visits by 30%, Boosts Specialized Treatment
April 21st 2025An analysis of an interdisciplinary care model for managing chronic kidney disease (CKD) shows hospital admissions dropped by 26% and emergency department (ED) visits decreased by 30% after clinic initiation.
Read More