Telemedicine....lower caost of Medicine. Making care easier for everyone.

'bout time! Not only does telemedicine help patients, but it also lowers cost. Also...there an increase in the physicians quality of life (Can see patients from home)!

 

Big telehealth firm to go public as remote doctor visits gain traction

Jayne O'Donnell and Benjamin F Mitchell, USA TODAY10:55 p.m. EDT June 30, 2015

One of the largest companies in the telemedicine field is going public Wednesday in a move that signals how important remote doctor visits are becoming to the future of health care and efforts to reduce costs.

Shares in Teladoc, a growing but sometimes controversial player in the field, are priced at $19. Teladoc expects to raise gross proceeds of $180 million by selling 9.5 million shares, which includes 15% made available to the underwriters.

The expected proceeds exceed earlier estimates of about $130 million. Teladoc raised the share price from an estimated $15-17 and added more shares due to the positive reception during the investor road show.

"There was very strong reception by the investment community to the market opportunity, Teladoc's leadership position, our historical performance and our future opportunity," CEO Jason Gorevic told USA TODAY late Tuesday.

Teladoc's 700 board-certified doctors deal directly with consumers on the phone, which sets the company apart from much of the rest of telemedicine, which more often involves a physician with a sick patient who video conferences with another doctor who is often a specialist.

The company won a legal fight recently when a federal judge ruled that a Texas Medical Board regulation that prohibited doctors from diagnosing patients over the phone who they hadn't seen in person or on video was probably anti-competitive. The board was blocked from enforcing it until an antitrust suit Teladoc filed against the board was decided.

Teladoc started in 2002, and Gorevic, a former president of Empire Blue Cross Blue Shield, joined as CEO in 2009.

"I've been looking throughout my career for an opportunity to do something that could really improve quality of care, reduce the cost of care and was a win, win, win for the payers, whether the employers or the health plans, the consumer and the doctor and I finally found one," Gorevic says.

Even the telemedicine industry is conflicted about the best way to do this. Industry experts at an American Telemedicine Association conference in May debated the risks and benefits of over-the-phone consultations, saying that although it is possible to effectively and ethically treat mild conditions this way, some illnesses can't be safely treated over the phone or in a video call. Panelists noted 10% of prescriptions for pediatric sinus infections occur over the phone, and it's up to the industry to keep that number from growing since these children should be seen in person.

A RAND Corp. study commissioned by the California Healthcare Foundation found Teladoc physicians prescribed antibiotics at the same rate as doctors did during office visits.

Several studies show video is "by far preferred as the primary medium in telemedicine," says medical technology analyst Roeen Roashan.

"There is a comfort and level of intimacy that allows both physician and patient to end the session satisfied," he says. But phone consultations have "existed for many years and still play a big role today."

Though some mainstream family care doctors bristle at what they see as a risky practice, companies including PepsiCo, Bank of America and some major insurers use Teladoc as a way to cut soaring health care costs and make doctors more accessible. About 11 million of their employees and clients are Teladoc members.

Another Teladoc client, Rent-a-Center, saves an average of $754 per employee every time they do a phone consultation with a doctor, according to a Teladoc-commissioned study co-authored by Harvard Medical School associate professor and physician Niteesh Choudhry and Stanford School of Medicine professor and physician Arnold Milstein.

The biggest savings reflect what it would have cost if employees went to the emergency room instead. The authors acknowledge something Roashan points out: The savings from telephone consultations are partially offset by the number of times patients need in-office visits after the calls.

Gorevic boasts that his company does more than 500,000 of the 800,000 phone and video consultations a year that involve just one doctor and a patient. That's dwarfed by the 10 million video consultations a year that involve doctors consulting with each other about a patient, which Roashan says could double by 2018.

He's not convinced that's a good thing.

"A 15-minute video call is not the same as good health care," says Roashan, who is with IHS Technology. "There's no patient engagement, it's just a transaction."

Gorevic says his doctors offer patients the option of talking via Facetime or sending pictures or videos for doctors to see. All patients fill out medical histories before they are seen, which is typically within 10 minutes.

Teladoc was sued in early June by competitor American Well, which alleged Teladoc's technology infringed on an American Well patent. The suit seeks an injunction against Teladoc continuing to do business. Teladoc petitioned the U.S. Patent and Trademark Office in March to invalidate some of American Well's patents. Both cases are pending.

"The investment community recognizes Teladoc's opportunity to change the health care landscape," Gorevic says.

Obamacare Premium increases 50% to 30% in many States!

HOLD THE PHONE!!!! I thought Obama said I would receive a $2,500 savings on my premiums? So in a two to three year period Obamacare premium increases would double from those same 2014 premiums! So instead of saving $2,500, my premium will now cost me an extra $5,000. That is a $7,500 swing in the wrong direction!

More Obamacare Insurance Premiums to increase 30% 

by CHRISS W. STREET2 Jun 2015Newport Beach, CA 

Breitbart news

Recently, Breitbart News broke the story last week that major insurers in a number of states were proposing up to 51 percent healthcare premium increases for Obamacare policies. Now Illinois and Pennsylvania are also seeking 2016 rate hikes in the range of 30 percent.

The Obama administration late Monday afternoon disclosed more state Patient Protection and Affordable Care Act health insurance exchanges are also requesting stunningly large average health insurance premium hikes, including Blue Cross and Blue Shield of Illinois asking for an average 29 percent spike and Highmark Health Insurance Co. of Pennsylvania asking for a 30 percent spike, according to the Wall Street Journal.

This grim news follows reporting that New Mexico’s market leader , Health Care Service Corp. is asking for an average premium spike of 51.6 percent. In addition, Tennessee’s top insurer, BlueCross BlueShield of Tennessee wants an average spike of 36.3 percent; Maryland’s market leader, CareFirst BlueCross BlueShield, requested an average spike of 30.4 percent; and Oregon’s top insurer, Moda Health, is seeking a 25 percent spike.

Under Obamacare, insurers must file proposed premium rates with their local state regulator and the federal government by June for the following year beginning January 1. The 2015 rate requests ran to about three times of the 2 percent inflation rate, or 6 percent. At the time, insurance companies had only a little information about the health of the new customers they expected to sign up during the fall Obamacare expansion.

But now insurance companies across the nation are seeing their costs leap due to high utilization costs from people newly enrolled under Obamacare. Insurance companies demanding dramatically higher compensation are causing skyrocketing rates.

The steep rate requests are coming just 60 days after Democrats were ecstatic about a Robert Wood Johnson Foundation study that supposedly “Confirms that Obamacare is Saving States Money.” and a Kaiser Family Foundation study that reported similar findings for Connecticut, New Mexico, and Washington State. Researchers claimed Obamacare “expansion can produce savings in tax dollars and generate new revenue for state budgets.” As an example, Kentucky was expected to save an estimated $820 million, and Arkansas was supposed to save $370 million, according to Think Progress.

But both the Johnson and Kaiser Foundation analysis now look preposterous. Obamacare was sold as reducing the cost of healthcare inflation to below the national inflation rate. But with the current inflation rate slightly negative and the average of the Obamacare state premiums spiking by 30 percent, the exploding cost burden of Obamacare may explain a big part of the recent economic slowdown.

The new requests for huge premium hikes come as the Democrats and Republicans are under both under high stress as they wait to see what the Supreme Court will decide in King v. Burwell, which could decimate the Left’s biggest expansion of entitlements in 50 years. If the Supreme Court strikes down federal money for states that did not establish their own exchanges, 13 million people will lose about $120 billion in federal health insurance subsidies.

In the 2016 elections, the spectacular insurance premium increases should help Republicans that voted unanimously against Obamacare look smart. It may also serve as a dunce cap for Democrats that promised the law would “Cut the cost of a typical family’s health insurance premium by up to $2,500 a year.”

Who makes the decisions on Medicare reimbursements

On problem with outcome based reimbursements, and that is….Many patients do not want to be healed! Let’s face it…People like to complain (so there is no way a treatment will help), Americans have become so fat that the obese do not seek to recover from an illness or injury, and finally there is disability payments that the government will pay out (SSI). And….that’s the bottom line!

GAO: Medicare-Paid Physicians Decide How Much Money They Make

A committee of Medicare physicians controls how much doctors providing services to the government health care program’s patients are reimbursed for their services, but don’t ask to see the reasoning behind their decisions.

Physicians received more than $70 billion in such payments from the government in 2013.

The reimbursement panel withholds information about its members and voting records from taxpayers even though conflicts of interests are all but certain. The panel is comprised of doctors who benefit from its decisions, according to the Government Accountability Office.

The American Medical Association formed the Specialty Society Relative Value Scale Update Committee in 1991 to help the Centers for Medicare and Medicaid determine how much to pay physicians for each service. CMS relies heavily on the committee’s recommendations following nearly seven out of 10 of its recommendations.

“Although the [committee] is currently the only comprehensive source of information regarding physician work, its recommendations may be undermined by … potential conflicts of interest,” GAO said.

Eliminating the conflicts of interest, however, is difficult since Medicare-paid physicians are among the few experts on how much their services are worth.

“This has got to have a lot of subjectivity to it,” said John O’Shea, a senior fellow at the Heritage Foundation and a practicing surgeon. He noted that a cardiologist and a primary care physician would disagree over how much each of their services were worth.

Instead, O’Shea suggested that Medicare switch to a system that pays for a patient’s outcome, rather than a physician’s service. In other words, doctors are paid for the quality and efficiency of their patients’ recovery.

“I think the system is starting to move toward that, but it’s a fairly slow process,” O’Shea said. “The fee-for-service system is going to be around in some shape or form for a while.”

However, O’Shea admitted that a system based on care would also be flawed, since patient outcomes are often beyond a doctor’s control. Two patients could receive the same treatment for the same illness, but could see opposite results.

If a patient-outcome system can’t be developed, there could at least be improvements to the current method.

“This system can be made better, realizing this system has some inherent flaws,” O’Shea said. He agreed with the accountability office’s finding that the relative value committee lacks transparency.

For example, the committee requires certain panels to “include a mix of physician and non-physician experts” to decrease conflicts of interest, but investigators found “detailed information on composition was frequently missing,” GAO said.

The committee argued that it doesn’t disclose voting records “to protect members’ independence through the deliberation process from, for example, outside lobbying and potential negative feedback from colleagues.”

Further, the relative value committee’s votes are usually unanimous, GAO said. “This unanimity typically results from members resolving disagreements about services during deliberation.”

O’Shea believes more transparency is needed. “They say the meetings are open and that the public can go to them, but if you go, you have to sign sort of a nondisclosure form,” he said.

Consequently, CMS can’t be transparent about the panel’s work, since it heavily relies on the opaque committee. A lack of transparency and data sources “may undermine payment rate accuracy,” GAO said.

Inaccurate payment values could incentivize physicians to provide services that would give them a bigger payday from Medicare, “which affects patient care … Mis-valuation can also lead to unwise spending of taxpayers’ and beneficiaries’ money.”

Bean Counters and Office Managers cause Physicians to limit time with patients!

It’s not that Physicians do not want to spend time with Patients…Physicians would like to spend time with those they care for. Problem is the “Bean Counters” have taken control of medicine, and force physicians to treat patients as a source of revenue! That’s just the half of it…the other half are office managers that are assigned (by the Hospital/Health system) to manage the office’s operation. Most (not all…I know several good ones) of these managers are incompetent (and are only taking orders from the Bean Counters & HR)!

Why it’s hell to be a doctor in America today

By Susannah Cahalan

August 23, 2014 | 3:00pm

NY POST

Dr. Sandeep Jauhar is mad as hell.

American health care is in upheaval. On one side, overhead and malpractice insurance costs keep increasing, while salaries stagnate. On the other, patients believe that expensive drugs are better, more people are on government-run insurance that pays less, while private insurance fights every claim.

 

Now doctors spend most of their time trying to game the system, requiring endless paperwork, protracted bureaucratic battles and “treadmill medicine,” seeing as many patients as possible in as little time. This problem will only intensify as millions join the ranks of the insured under the Affordable Care Act.

 

In this self-perpetuating cycle, doctors spend most of their time as businessmen — and care suffers.

 

It’s no wonder then that doctors no longer enjoy their jobs, explains Jauhar, director of the Heart Failure Program at Long Island Jewish Medical Center and author of “Doctored: The Disillusionment of an American Physician” (Farrar, Straus and Giroux), out now.

 

“This book is meant to be like the scene in ‘Network’ when [Howard Beale] opens the window and yells, ‘We’re not going to take it anymore,’ ” Jauhar says in an interview with The Post.

 

“I see an emotional emptiness created by the relentless consideration of money. Most of us went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income,” he writes.

In a 2008 study of 12,000 physicians, only 6% described their morale as positive. Even insurance claim clerks polled in a different study were happier.

As managed care has grown (by the 2000s, 95% of insured workers were in some kind of managed care plans), so has physicians’ discontent. In 1973, fewer than 15% of physicians reported any doubts about career choices. Today nearly 40% say that they would not choose to enter the medical profession if given the opportunity to do it all over.

 

If things continue as they are, the US can expect a shortage of 150,000 doctors by 2025, according to the American Medical College. Jauhar says that doctors on the online community SERMO are threatening to leave the country or scrap their private practices.

 

The serious downside here is obvious: Unhappy doctors make for unhappier patients.

“The physician-patient relationship is the worst it ever was,” he says.

 

To hammer in this point, Jauhar quotes facts from the Commonwealth Fund: The US ranks 45th in life expectancy (“behind Bosnia and Jordan,” he adds) and compared to other developed countries near last in infant mortality and health-care quality, access and efficiency. We also have fewer physicians and hospital beds than average.

 

This “mid-life crisis in medicine” is reflected in Jauhar’s own writing.

Readers can follow his skepticism in “Intern,” his first book about his internship year at New York Presybterian, harden into disillusionment in “Doctored,” which chronicles his time at LIJ as he enters his middle age (he’s now 44).

 

“Doctored” opens with: “When I look at my career in midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.”

This “kind of doctor,” once so idealistic, now takes morally ambiguous speaking gigs with pharmaceutical companies and side-jobs at “sketchy” cardiologist private practices who push for expensive and often unnecessary tests for the reimbursements.

And this is where the book gets really bleak. Doctors — like his own brother, also a cardiologist — refer to patients as “commodities.” One physician at LIJ admitted that “sometimes you have to drag out” a hospital stay for a patient if you want to get paid.

He writes about one of his patients, a 50-something man who complained of shortness of breath. Fourteen doctors, 12 procedures, and hundreds of thousands of dollars later, he was released with minimal improvement.

 

This is a problem not only of milking income, which of course happens, but because doctors just don’t have the time to do their jobs. Primary care physicians (doctors who Jauhar believes are most unhappy) spend an average of eight to 10 minutes per patient.

It’s a self-fulfilling prophecy. With less time for each patient—studies show (no surprise here) that rushed doctors listen less — relying on expensive tests, which don’t necessarily lead to more accurate diagnoses. Med school advises doctors-in-training that you should be able to diagnose 80% of cases with a health history and an exam alone.

 

No further tests required.

 

But in this exam on-the-run environment, doctors are more likely to practice “defensive medicine,” or “cover your ass” medicine — costing us about $750 billion a year (of the $3.8 trillion we spend a year) in wasteful procedures that lead nowhere.

“After so many years in medicine, I am convinced of one thing: The vast majority of doctors aren’t bad. It is the system that makes us bad, makes us make mistakes,” he writes. “There is a palpable sense of grieving. The job for many has become just that — a job.”

Hospital's and Health Systems cannot afford to pay Physicians....so Phyicians back to private practices!

Just one problem….Many newly trained physicians are being taught to treat patients in an employed model! Let’s just see how it all works out. At any rate…Private Single Specialty practices will be growing in number, and at the end of the day patients will benefit!

Hospitals to reverse trend of employing doctors – consultant

Mar 3, 2015, 1:27pm EST Updated: Mar 30, 2015, 10:04am EDT

 

Carrie Ghose           Staff reporter- Columbus Business First

 

Hospitals and health systems nationwide are losing millions on physicians they've employed by acquiring practices, so a practice-management specialist predicts doctors will soon start spinning out on their own again.

"The pendulum has swung," Tom Ferkovic, managing director of Medic Management Group LLC. "We're starting to see hospitals can no longer afford to own all the practices."

As a result, he expects growth in the 154-person Akron-based firm, including its Columbus office, now with five employees.

The consulting and management outsourcing company renamed itself from SS&G Healthcare Services LLC in December, after BDO USA LLP acquired Cleveland accounting firm SS&G Inc. The health-care consultants were a 15-year-old separate company that co-branded with SS&G, and opted not to go with BDO. Partners in the former SS&G still own shares. The Columbus branch is currently hunting space to leave the BDO office on Spring Street.

Medic Management takes over a practice's back-office functions – billing, insurance reimbursement, payroll – to increase efficiency. As hospitals started acquiring its clients statewide, it formed a hospital division because the health systems didn't have infrastructure or experience running practices.

Nationwide, health systems lost on average $188,000 on each employed physician in 2013, and that increased last year, according to surveys by the Medical Group Management Association, which also is asking if " the tide has ebbed" on acquisitions. In Ohio it's slightly lower, about $187,000, Ferkovic said, and his group has helped hospitals stem such losses.

Physicians have started leaving hospital umbrellas in northern Ohio and out-of-state, he said.

"We're starting to hear discussions of it in (Central and) southern Ohio," he said. "It's coming. We're hearing noise from some of our clients about it."

This has happened before: In the 1990s hospitals started selling off practices acquired in a previous wave. But in 2008, health systems said things were different this time because they would base physician pay on productivity. Hospital employment stretched from primary care to specialties; Central Ohio's last independent cardiology practice group closed in 2014.

But insurance reimbursement still didn't match what hospitals pay doctors. Systems would make that up with lab tests, imaging and procedures – but now Medicare and private insurers are cutting reimbursement rates for those, Ferkovic said.

Doctors who leave aren't going back into untenable solo or two-person offices, he said. They're forming large 30-plus doctor groups, and smaller independent practices are consolidating. Central Ohio Primary Care Physicians Inc. and Orthopedic One – themselves the products of acquisitions and mergers – are among fewer than a dozen independent practices statewide with more than 30 doctors. Expect more, he said.

"Large private groups in the state have done very well over the last few years," he said. "Some are doing really creative things with quality measures and contracting for risk and bundled payments. They're faster, they're more nimble when they have an issue on fixing those, because its their money."

 

Obamacare - Patients lose! Insurance Companies and Bureaucrats win!

ObamaCare stinks even with subsidies

By Marc Siegel          March 9, 2015 | 8:22pm

NY Post

 

Last week’s Supreme Court arguments on ObamaCare struck me as a bit irrelevant, and not just because the case won’t impact New York.

The case is about whether federal subsidies are actually legal in states that didn’t set up their own insurance exchanges — but the truth is, ObamaCare is a bad deal even with the subsidies.

Down here in the medical trenches, the harsh reality of the Affordable Care Act continues to play out.

My patients continue to report delays in signing up for ObamaCare policies and are rarely happy with what they end up with. They all have high deductibles and a narrow network of doctors to choose from.

This isn’t their fault — it’s all they can afford. Of course, without the subsidies, my blue-collar patients, many of whom work part-time jobs, wouldn’t be able to afford ObamaCare insurance at all.

Keep in mind that federal subsidies cover 75 percent of ObamaCare premiums nationwide, so if the high court upholds the written language of the law, and not the Obama IRS’s decision to ignore that language, 7.5 million people will likely lose their coverage.

But, again, even with the subsidies, it’s no bargain.

When you use the insurance, you find that you have to pay out-of-pocket for your x-ray, ultrasound or lab work — and keep on paying for tests until you spend enough to cover your $5,000 deductible.

You can’t afford the test, so you delay it.

You also have to pay out of pocket to see your doctor (me) when you’re sick, and even though I may charge you half price for a visit, you find that the prominent dermatologist I’d usually refer you to for your severe psoriasis isn’t part of your new network and won’t give you a discount.

The skin doctor I come up with instead is less prominent and devises a treatment plan that doesn’t work that well.

Here in New York, the law has put in jeopardy the entire way I practice as a primary-care physician. The law is so heavy with restrictions and penalties, and so light with actual improvements to care, that it isn’t working well even with the subsidies.

I spend more than half of my time on any given day on computer documentation, pre-approvals, contesting billing errors by labs or hospitals and choosing unknown specialists from ObamaCare lists to refer patients to.

I see no evidence that the federal subsidies are going to pay for essential health care. Instead, they bolster rising premiums and help keep insurance companies solvent and profitable.

Now here come the Supremes, wading into ObamaCare deep water once again. If they enforce the wording of the law — so that subsidies can’t go to those 7.5 million people in 34 states that refused to set up health exchanges — it should be the straw that breaks the back of the so-called Affordable Care Act.

Or how about this: the final nail in ObamaCare’s coffin.

It will be a happy day for doctors and patients everywhere.

Congress and the president will have to come up with something else.

ObamaCare was falsely conceived. If Washington wanted to provide a health-care safety net for the have-nots, it could’ve hired the doctors and built the clinics to deliver it.

Instead, it built another bloated, self-justifying bureaucracy that makes the insurance companies richer and the doctors and patients poorer.

Here’s hoping that SCOTUS grabs this final straw.

Dr. Marc Siegel is a professor of medicine at NYU Langone Medical Center and a Fox News medical correspondent.

 

Everyone that I know that has been forced into Obamacare tell me their previous insurance was more affordable, they were able to see doctors of their choice, and was much less complicated. The two group of Americans that are “doing okay” with Obamacare are Insurance Companies, and Bureaucrats!

Obamacare….buy a plan….and you most likely will have trouble finding a physician/Health System that can afford to accept you!

Bottom line: Physicians and healthcare systems have to make money to stay open (just like any other business), and Obamacare is a looser with its low reimbursement rates. I find it interesting that USA today will never call the Affordable Care Act “Obamacare” when the article has a negative fib. Just saying……we can all call it Obamacare! 

Some doctors wary of taking insurance exchange patients

Jayne O'Donnell, USA TODAY    7:18 p.m. EDT October 28, 2014

Now that many people finally have health insurance through the Affordable Care Act exchanges, some are running into a new problem: They can't find a doctor who will take them as patients.

Because these exchange plans often have lower reimbursement rates, some doctors are limiting how many new patients they take with these policies, physician groups and other experts say.

"The exchanges have become very much like Medicaid," says Andrew Kleinman, a plastic surgeon and president of the Medical Society of the State of New York. "Physicians who are in solo practices have to be careful to not take too many patients reimbursed at lower rates or they're not going to be in business very long."

Kleinman says his members complain rates can be 50% lower than commercial plans. Cigna and Aetna, however, say they pay doctors the same whether the plan is sold on an ACA network or not. United Healthcare spokeswoman Tracey Lempner says it's up to their physicians whether they want to be in the exchange plan networks, which have "rates that are above Medicaid." Medicaid rates are typically below those for Medicare, which in turn are generally lower than commercial insurance plans. To prevent discrimination against ACA policyholders, some insurance contracts require doctors to accept their exchange-plan patients along with those on commercial plans unless the doctors' practices are so full they simply can't treat any more people. But lower reimbursement rates make some physicians reluctant to sign on to some of these plans or accept too many of the patients once they are in the plans.

"I definitely feel like a bad person who is leeching off the system when I call the doctors' offices," she says. Shawn Smith of Seymour, Ind., spent about five months trying to find a primary care doctor on the network who would take her with a new, subsidized silver-level ACA insurance plan.

Last week, Smith found a practice that would accept her as a patient. Caroline Carney, chief medical officer of MDwise, Smith's insurer, says some doctors "might be participating with us, but just not able to take on new patients. It's at the doctor's discretion."

Jon Fougner, a recent Yale Law School graduate, sued Empire Blue Cross this month because he couldn't find a primary care doctor in his new ACA exchange plan.

Fougner's experience underscores how important it is for consumers to check out doctor and hospital networks for plans before they purchase them -- and to call doctors to make sure they are accepting new patients with their policies.

Among 30 doctors he called, Fougner said, they either weren't taking new patients, weren't in the plan or didn't return calls, or the contact information proved incorrect.

"It's absolutely their right to take whatever plan they want to take," Fougner says of doctors. But he says he found Empire's records are often "erroneous about whether the doctor takes the plan and/or other information essential to seeing the doctor."

Empire declined to comment as the litigation is pending.

Insurers are also moving to smaller networks of doctors and hospitals in their exchange plans. These "narrow networks" help them reduce costs, but they can also lead to problems when consumers look for doctors who will take them.

Among complaints from doctors about how the whole system is working:

• If consumers have a federally subsidized plan, they get a 90-day grace period before plans are canceled if they don't pay their premiums. That means doctors have to pursue patients to pay for their services for most of that time as insurance companies refuse to pay the claims.

• Plans sold on the exchanges with the lowest premiums require consumers to pay the most out of pocket. Many of these customers have insurance for the first time and don't understand how much they have to pay, so doctor's offices have to spend a great deal of time explaining benefits packages, says Ripley Hollister, a primary care doctor in Colorado Springs.

Doctors' offices want it to be clear on insurance cards that a patient has an exchange plan so they know whether they want to accept the plan and whether the person is receiving subsidies — which can reduce out-of-pocket costs — or has high cost-sharing. Doctors in Texas are trying to get the state to require insurance cards to make clear whether the plans were purchased on the exchange and what metal level they are, says Austin King, president of the Texas Medical Association and a head-and-neck surgeon.

Meanwhile, the National Association of Insurance Commissioners is developing a new standard for what is an adequate number of doctors and hospitals in insurance networks. Beginning next year, the Centers for Medicare and Medicaid Services will be certifying that these networks for plans sold on HealthCare.gov are big enough. Under the ACA, consumers who have trouble finding a doctor covered by their exchange plan can file a complaint on HealthCare.gov, CMS says.

There is some good news: The number of counties with two or more insurers is up from 81% for the last open enrollment to 95% this year, which Department of Health and Human Services spokesman Kevin Griffis says "should mean more doctors to choose from."