What Spine Surgeons Need to Know About Insurance Premiums Next Year


SurgeonThe health insurance landscape will change dramatically over the next few months, as enrollment in health insurance exchanges begins Oct. 1 and coverage on Jan. 1, 2014. While the exact aftermath is uncertain, many are making predictions based on reports out about how the early exchanges have worked and the evolution of coverage in Massachusetts, which was a model for the Patient Protection and Affordable Care Act.

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A recent report out from the Kaiser Family Foundation found that 48 percent of people purchasing their own insurance today will qualify for subsidies under PPACA's individual insurance market, not including one million people currently purchasing individual insurance who will qualify for Medicaid in 2014.


The average subsidy for those who qualify will be $5,548 per family and the second-lowest-cost plan — the Silver Plan — available through the 2014 exchanges will cost an average of $8,250 per family.


"Patients purchasing high deductible plans on health insurance exchanges are likely to be more proactive consumers when choosing a provider for their spine surgery," says Adam C. Powell, PhD, President of Payer+Provider Syndicate in a Becker's Spine Review report. "As patients become responsible for more of their medical costs, they are likely to increasingly insist on being provided cost estimates for their spine surgeries before they are performed. Practices should train their staffs to be familiar with the rough costs of different procedures under all of their major payer contracts so that patients can easily be informed of their contribution."


Some have predicted that health insurance costs will increase significantly after the exchanges are implemented, and in states where the government is facilitating the exchange premiums are projected to skyrocket. Ohio forecasted a 41 percent increase for individual consumers paying through the exchange. However, HHS Secretary Kathleen Sebelius has said these predications are incorrect in a Reuters report. In fact, an HHS report predicts that competition and transparency will lower exchange plan premiums by 18 percent for the Silver plans.


Last month, the Maryland Insurance Administration approved premiums for the state exchange at levels as much as 33 percent lower than was proposed by insurance companies and Kaiser Permanente lowered its proposed rates for consumers in the new Washington, D.C., exchange by 4.4 percent for small business employees and 0.5 percent for individuals.


Additionally, a recent study from the Urban Institute and the Robert Wood Johnson Foundation shows that expected participants in nongroup insurances will likely have lower premiums because they are healthier. While a rate shock could occur with the opening of the exchanges, the report analysis predicts markets will normalize to lower exchange premiums over time.


The final health insurance rates for states with federally run exchanges will be released in September. There will be wholly federally-run exchanges in 26 states, which opted not to develop their own exchanges. States were either able to their exchanges independently, in partnership with the federal government or allow the federal government to wholly run the exchange.


Consider who will be in-network with the exchanges and work with patients who have coverage. "You don't want your patients to sign up for a plan when you are out-of-network," said Alex Tolbert, founder of Bernard Health, in a Becker's Spine Review report. "Many exchange options have linear or smaller networks than the broad networks people are familiar with. You need to pick a plan and help people sign up for that if they don't already have insurance."


As an alternative to traditional insurance plans, some employers are opting for self-funded plans and 5 percent are pursuing bundled payments, according to a Booz & Co. report. Another 16 percent of organizations surveyed said they are very interested and 50 percent were somewhat interested in bundled payments. These programs would pass more risk off to the providers, who would receive a single agreed-upon payment for the entire episode of care.


"As government and private payers pilot new methods of bundling payments for entire episodes of care — including site-of-care reimbursement, as well as device acquisition and fees for physicians and other healthcare providers — it will be more likely that surgeons will become more closely aligned with hospitals and ambulatory surgical centers," said Gunnar B. J. Andersson, MD, PhD, is the vice president and treasurer of the International Society for the Advancement of Spine Surgery in a Becker's Spine Review report. "Some will choose to be employed, while others may simply wish to contract with those entities while maintaining more autonomy. I suspect most surgeons would choose to maintain some level of independence until or unless it seriously impacts their ability to make a living."


More Articles on Spine Surgeons:
20 Spine Surgeons at Community Hospitals
5 Ways Surgeon Documentation Positively (or Negatively) Impacts Spine Practices
Outpatient Spine Surgery: 4 Myths Debunked

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