Health Insurance Coverage and Care – The Shifting Landscape

by | Published on Apr 1, 2015 | Insurance Verification and Authorizations

Health Insurance Coverage and Care
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The Patient Protection and Affordable Care Act (ACA) was implemented to enable easier and more effective healthcare access to millions of Americans. Presently, the health insurance marketplace is witnessing significant changes as this domain has become increasingly consumer driven with important variations in the way care is paid for and delivered.

A new report released by the “American Hospital Association” reveals that as the increase in cost of providing health insurance continues, employers are pushing more of the cost of care onto their employees. They are selecting low cost plan options that restrict access to a less number of providers, and limiting employer contributions to insurance premiums to a fixed dollar amount. These significant changes in employer plans have crucial implications for hospitals.

A report from AHA “Trend Watch” reveals an increase in the total number of employees required to pay co-insurance (a percentage of the costs of healthcare services incurred, rather than fixed copay) for hospital admissions to 61% in 2013 from just 37% in the year 2008. Moreover, the number of enrollees for high deductible health benefit plans (at least $1,250 each year for an individual, doubled for family coverage) has also increased recording about 20% increase in 2013.

The report findings indicate that people are doing extensive research to identify the best physician and hospitals offering excellent quality care at reasonable cost. Hence, it is essential for organizations to provide accurate and reliable information that will allow them to make the correct decision.

Hospital leaders need to analyze the main problems that may arise due to the extra financial burden placed on healthcare consumers. Reports show that about 32% of people who have enrolled through private exchanges may skip care due to high price, thereby leading to an increased chance of high-acuity visits down the line. Moreover, this will create chances for hospitals to incur bad debts (due to higher out-of-pocket costs).

Another important trend in the health insurance landscape is related to narrow network of providers and limited patient access to hospitals and physicians. In most urban areas, more than 38% of networks included in ACA health benefit plans are narrow with 30-69% of hospitals included in the network. Another 38% are sub grouped as “ultra narrow” enabling patients to visit less than 30% of area hospitals. This may create problems for patients with rare disease conditions which require them to make frequent visits to highly specialized physicians.

It is extremely important for hospitals and health systems to implement innovative strategies to survive in a health insurance market place where consumers are engaged in the purchase of coverage and care delivery services. They need to promote patient and provider education and need to become more transparent about price and quality. Hospitals need to clearly communicate to consumers about the health plans that they participate as a preferred provider. It is crucial for them to review network contracting strategies there by evaluating branding and value to networks.

With the health insurance coverage landscape changing, it is essential for people to consider several factors before selecting a health benefit plan. Consumers who choose a particular coverage plan may not be able to know the full implications of the same until they need to seek care specifically for a serious health condition requiring hospitalization. Moreover, hospitals need to evaluate their market position and accessibility in payer networks. Even when more individuals will have full coverage, many will still be left underinsured, and as a result create significant financial challenges related to uncompensated care.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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