What Patients Want and Need From Health Exchange Plans

The American Journal of Pharmacy Benefits, March/April 2015, Volume 7, Issue 2

Health insurance is now attainable for millions of Americans. However, research shows that patient protections must be strengthened and plan information must be made more readily accessible.

The insurance market reforms, health insurance exchanges, and subsidies put in place by the Affordable Care Act (ACA) represent a significant step forward for the patient community. The law has made health coverage more accessible, while the tax credit subsidies and cost-sharing reductions make insurance more affordable. However, the reformed marketplace must better serve people with chronic diseases and disabilities to guarantee that the ACA achieves its goals of ensuring coverage despite preexisting conditions, curbing costs responsibly, and increasing access to quality, affordable healthcare for all. We must continually improve the patient experience by enhancing patient protections and creating decision-support tools to provide marketplace enrollees with the essential information they require to choose the plans that best meet their needs.

To understand the impact of the ACA on people with chronic diseases and disabilities, the National Health Council engaged Lake Research Partners, a nationally recognized public opinion research firm, to evaluate the patient experience for exchange enrollees with chronic conditions.1

The research project began with 6 focus groups in Atlanta, Chicago, and Los Angeles, with participants of mixed gender, race, education, and income. It is important to note that all of the research participants and respondents were either patients, or parents of patients, with chronic conditions who utilized the new health insurance marketplace to choose an insurance plan. To our knowledge, a study focusing solely on patients living with chronic diseases and on their interactions with the marketplace has not been done before.

To test the qualitative findings from the focus groups, Lake Research conducted a national online survey during the 2015 open enrollment period (November 17-24, 2014) when patients were engaged in insurance decision making. Again, all 412 respondents were exchange enrollees, or parents of exchange enrollees, with chronic conditions. The margin of error for the entire survey is ±4.9% at the 95% confidence interval.

Seventy percent of the survey respondents indicated they were very favorable or somewhat favorable toward their health insurance plans; in the focus groups, many participants expressed how thankful they are for affordable coverage. Yet, no matter what level of plan they ultimately purchased (gold, silver, or bronze), they did not feel they had all the necessary information they would have liked about the health insurance plans available through the exchanges (Figure). Additionally:

While premiums were easy to find, information on other plan features was not as readily accessible.

Nearly half of patients (47%) reported premium costs were very easy to find. In contrast, only 30% of respondents said deductibles and copays were very easy to find, while 24% and 16% of respondents, respectively, said lists of participating providers and of prescription drugs were very easy to access.

• Enrollees want more information about their benefits when selecting exchange coverage.

Enrollees in gold plans reported they had the information necessary to pick a plan 42% of the time, while patients in silver and bronze plans reported having necessary information 37% and 24% of the time, respectively. This could suggest that patients with more information choose plans with additional cost-sharing protections.

• Transparency standards are needed to help patients choose a plan that includes their providers.

The vast majority (79%) of patients checked to see if their provider was covered before picking a plan. However, more than one-third (36%) of enrollees thought it was difficult to find a list of providers. Several focus group participants reported gaps in accessing care because of confusion about the provider network when picking a plan.

• Likewise, it was difficult to understand if their medications were covered.

More than one-third (34%) of patients were confused about medication coverage when picking a plan: 13% did not know if their medications were covered; 13% were not sure if their medications were covered, but assumed insurance would provide a discount; and 8% thought their medications were covered, but had incorrect information. Focus group participants acknowledged they reviewed cost-sharing information for drugs, but failed to check if their medications were covered by plans.

• There was misunderstanding about the coverage offered by the same carrier inside and outside the exchange.

Nearly half (47%) of patients reported they picked their plan because they thought the coverage offered by the carrier would be the same as what they knew about the same carrier outside the exchange, which is not always the case.

Participants in both the focus groups and the online survey reported they would welcome additional tools to help them choose a health insurance plan that meets their healthcare and budget needs. Eighty-eight percent of survey respondents said a standardized list of covered providers would be helpful, followed by a provider search tool (87%), a standardized list of covered drugs (85%), a prescription drug search tool (85%), and a calculator to estimate out-of-pocket costs (83%).

As one woman in a Chicago focus group described it, she would like the selection process to operate something like searching the Internet for a cake recipe. “You could type in what you have sugar, eggs, flour, and milk and then pull up the recipes that have all those ingredients,” she said. “This is what I’m looking for, what I need, to find the best health plan out there for me.”

Raising the Bar

The research study found that people with chronic conditions are conscientious shoppers, and they want to pick a plan that meets their individual needs. However, the exchanges must provide them with the tools to make an informed decision possible. In particular, we need:

• Exchange websites that help patients consider plan design features other than premiums, including the role formularies play in plan coverage and the consequences for out-of-pocket costs.

• Transparent, accurate, and standardized information on plan features, including additional disclosures that benefits inside and outside the exchange may differ, and easy-to-access, standardized provider lists and formularies.

• Useful decision support tools, including provider and drug search tools as well as calculators for out-of-pocket costs.

The patient advocacy community has called on the federal government to create better transparency standards and patient protections in the exchanges. The good news is, the administration is attempting to address many of the challenges the patient community has raised, and will improve the patient exchange experience by ensuring transparency and accuracy of information and non-discrimination in benefit design during the 2016 open enrollment period.2

Health insurance is now attainable for millions of Americans who previously struggled to gain coverage. However, our job is not done. There is work yet to do to empower and protect patients and ensure that they have access to necessary and affordable care. We must continue to strengthen patient protections and make certain that the information needed to pick the right insurance plan is more readily accessible.