How to Guide Patients Through Health Exchange Open Enrollment

Q&A with Dr. Victor Villagra, Associate Director Of UConn’s Health Disparities Institute


What is the state of our health exchange marketplace?

Health insurance exchanges across the country are facing challenges because large insurance companies like Aetna and UnitedHealthcare are pulling out, reducing the number of choices. Premium costs are also a major concern. Thanks to the Affordable Care Act (ACA), nine out of 10 individuals in Connecticut now have health insurance, with more than 100,000 enrolled in commercial plans (called Qualified Health Plans) and many more in Medicaid. Through the exchange, many people can get premium subsidies. The state is in its fourth year of offering state-based health insurance coverage plans through its exchange, Access Health CT. It makes health care and coverage more accessible and affordable for our state’s lower-income and uninsured residents.


What’s new for 2017 for the exchange?

During open enrollment, qualifying residents can purchase an insurance plan, and current participants can change their plan to better fit their medical needs or budget. This year, the landscape is limited, with some participating companies dropping out, forcing people to choose new plans. Also, our state recently lowered the income-level eligibility for adult Medicaid coverage, which could leave thousands without insurance and seeking coverage under the exchange. As a result, doctors’ offices may have to deal with some of their Medicaid patients now lacking insurance.


How can we better navigate health insurance complexities?

Among the most common question physicians and their staffs receive is: “Will my insurance plan pay for this?” Health insurance literacy is generally low and a big problem for patients, especially when it comes to calculating their out-of-pocket costs. This is especially difficult for those with limited English language proficiency and the newly insured. Even though they now have health insurance coverage, patients don’t always know how to use it. Complicated terminology and rules about what is and is not covered are challenging for the majority of people to understand, even medical professionals.

Doctors, and especially their office staff, need to familiarize themselves as much as possible with the jargon and each insurance plan’s elements, so they don’t prescribe something that is not covered by their patient’s plan. It is important for office staff to remain up to date on the latest insurance data to answer patient questions and to confirm coverage with the insurance company. Doctors’ offices want to avoid, at all costs, a patient being hit with a large, non-covered medical bill, because it could not only harm the patient-doctor relationship, but also be financially injurious, leading to the patient’s non-payment. For example, last year more than 12,000 medical providers had to go to small claims court to try to collect payments from their patients. With more health insurance plans having high deductibles, bill collection is becoming even more challenging for physicians’ offices. Health care is the leading cause of personal bankruptcy.

Access Health CT Patient Resources

UConn Health Works to Reduce Complications, Costs In Common Procedures

illustration of a nervous man from the Operation Board Game receiving a partial large intestine transplant. Illustration by Yesenia Carrero / UConn-University Communications

Just seven procedures account for most of the costs and complications of emergency surgeries in the U.S. each year, according to a study in The Journal of the American Medical Association April 27.

UConn Health’s surgeon-in-chief Dr. David McFadden is not surprised. These seven procedures are some of the most common, including gallbladder and appendix removal, and it makes sense that the most common surgeries are also responsible for most of the costs. And since UConn Health is on a constant quest to provide the best care possible, the surgery department was already working on some of the issues discussed in the study.

Just seven procedures account for most of the costs and complications of emergency surgeries in the U.S. each year.

For example, UConn Health participates in the National Surgical Quality Improvement Project (NSQIP), a service that tracks surgical complications such as infections, strokes and heart attacks, and alerts the surgeons to patterns. Catheter-associated urinary tract infections are one such common complication that happens in hospitals across the country. UConn Health surgeons decided that they would no longer accept that.

“We have started a focused, all-out war on catheter-associated urinary tract infections,” says Dr. Stephen Lahey, chief of the Department of Cardiothoracic Surgery and vice chair of quality improvement in the Department of Surgery. The NSQIP data has shown that there are subsets of patients who are much more likely to get urinary tract infections. The surgery department now focuses on those patients and has significantly reduced this type of infection. Reducing post-operative pneumonia in vulnerable populations is the department’s next project, Lahey says.

UConn Health’s work in this area is part of a national focus on improved population health care that stems from the passage of the Affordable Care Act, commonly known as Obamacare. Medicare has begun listing surgical complications that should happen rarely or never, and will lower or deny reimbursement to hospitals where they commonly occur. Private insurers are following suit. This can be a potent incentive for hospitals to support what medical personnel want to do anyway: find and reduce or eliminate the sources of complications.

“While lowering or denying reimbursement for certain patient events such as hospital readmission is a powerful incentive for hospitals to minimize their occurrence, we must never lose sight of the primary reason we do this — providing the best and most appropriate care to our patients,” Lahey says.

The main goal, he says, is “to alleviate suffering and improve the health of the population we serve. If we do that well, the finances will take care of themselves.”

How Does the Supreme Court’s Latest ACA Decision Impact Physicians?

Q&A With UConn Law Professor John A. Cogan Jr.


What was the immediate effect of the Supreme Court’s ruling in King v. Burwell?

The major effect was to cement the federal government’s implementation of the law. The case dealt with a very specific issue: the subsidies offered to low- and moderate-income people. Unlike the previous ACA case, King v. Burwell wasn’t a constitutional challenge, it was based purely on a question of statutory interpretation: Could the government give out subsidies? The Supreme Court said yes. Since the constitutional and major statutory challenges have failed, we may see opponents attempt to chip away at portions of the ACA they do not like, but I think it’s safe to say we won’t see any more major cases attempting to unravel the whole law.


In the wake of the decision, we saw announcements by insurer Aetna that it intended to buy competitor Humana, and then that Anthem would buy Cigna. That would bring the number of major health insurers in the U.S. from five to three, with UnitedHealth the third. How will these mergers benefit the insurance companies, and how will they affect health care providers?

The post-merger companies will each have a larger share of the market, thereby consolidating their power. Consolidation allows insurers to increase profits through efficiency gains. But these larger insurers will also gain bargaining power with healthcare providers. This is important because providers are paid directly by insurers. If you have doctors and hospitals negotiating with several different insurers, they have the ability to walk away from any one of those insurers, giving providers some leverage. But if there are only two insurers, that leverage is diminished. Major hospital systems and large physician groups will still have some bargaining power because of their size, but individual physicians will see their bargaining power diminish further.


Will the effect of the mergers be in line with the intent of the law?

The ACA’s express intent was to expand coverage, and it worked. There’s nothing in the ACA regarding industry consolidation. Nevertheless, the fallout of the ACA’s expansion of coverage – efforts by insurers to consolidate market share – was foreseeable. Now that the ACA is here to stay, federal and state regulators will have to wrestle with consolidation issues.