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Network Adequacy: Seeking Balance

Friday, September 26, 2014

Some new health plans sold in the insurance marketplaces are offering consumers networks that exclude certain doctors, hospitals and other medical providers. While some claim that these networks hamper provider access and choice, others contend that this approach, if done the right way, helps consumers by creating competition and controlling costs.

The federal and state governments are now considering how to best regulate provider networks. The National Association of Insurance Commissioners (NAIC) is finalizing its update of model regulations for states, while the Department of Health and Human Services (HHS) is deciding what federal role, if any, it will assume. HHS already regulates networks for Medicare Advantage health plans, and some say this could serve as a model for health plans sold in marketplaces. Speakers include:

  • Mike Leavitt, founder and chairman, Leavitt Partners, former Utah governor and HHS Secretary under George W. Bush, addressed the issues surrounding network adequacy, and his preference to regulate networks at the state level.
  • Stephanie Mohl, senior government relations advisor, department of advocacy, American Heart Association, talked about research that assesses networks in a handful of states, and about challenges in making sure patients have access to specialty care.
  • Jolie Matthews, senior health and life policy counsel, NAIC, discussed model network regulations that the NAIC may release in November. She will also talk about how insurance commissioners are handling the issue across the country.
  • Gretchen Jacobson, associate director, Kaiser Family Foundation’s Program on Medicare Policy, described the current network adequacy standards for the Medicare Advantage program, which some see as a model for marketplace plans.

Two additional experts will join in the Q&A:

  • Steven Shapiro, executive vice president, chief medical and scientific officer, president of the physician services division, University of Pittsburgh Medical Center
  • Marc Barclay, vice president of provider networks and contracting, BlueCross BlueShield of Tennessee

Moderator: Ed Howard, executive vice president, Alliance for Health Reform

Follow the briefing on Twitter: #NetworkAdequacy

The event was sponsored by the nonpartisan Alliance for Health Reform, with the support of the University of Pittsburgh Medical Center and the Blue Cross Blue Shield Association
If you were unable to attend the briefing, here are some key takeaways:

  • Regulators should move slowly in developing an approach to allow sufficient time to understand early consumer experiences, said Mike Leavitt. He added that, as economic pressure is brought to bear, networks become more efficient.

  • Access to specialty physicians and facilities varies by region and health plan, according to a new Avalere study commissioned by the American Heart Association. Stephanie Mohl noted that one plan network covers 8 percent of certain specialty physicians, while another covers 83 percent. She emphasized the need for transparency, standardization, and up-to-date directories of professionals.

  • Health plans cannot keep directories of medical providers up to date without the help of providers, who often don't inform health plans when their work situation changes, said Marc Barclay.

  • The NAIC is hoping to complete its update of network adequacy model regulations by November or early December, said Jolie Matthews. If the NAIC addresses tiered networks, its recommendations will likely be limited to disclosure transparency, she said. Provider standards should be regulated at the state level, and not at the federal level, she said.

  • Federal network standards currently exist for Medicare Advantage plans, said Gretchen Jacobson. In 2015, she noted, if plans change networks mid-year, they must notify CMS 90+ days in advance, providers 60+ days, and enrollees 30+ days in advance.


Transcript, Event Summary and/or Webcast and Podcast

Transcript: Transcript (Adobe Acrobat PDF), 9/26/2014
Full Webcast/Podcast: Video

Speaker Presentations

Mohl Presentation (Adobe Acrobat PDF), 9/26/2014
Matthews Presentation (Adobe Acrobat PDF), 9/26/2014
Jacobson Presentation (Adobe Acrobat PDF), 9/26/2014

(If you want to download one or more slides from these presentations, contact us at info@allhealth or click here for instructions.)

Source Materials

Agenda (Adobe Acrobat PDF), , 9/26/2014
Speaker Biographies (Adobe Acrobat PDF), , 9/26/2014
Source List (Adobe Acrobat PDF), , 9/26/2014
Materials List (Adobe Acrobat PDF), , 9/26/2014
Ensuring Consumers’ Access to Care: Network Adequacy State Insurance Survey Findings and Recommendations for Regulatory Reforms in a Changing Insurance Market (Adobe Acrobat PDF), National Association of Insurance Commissioner, Health Management Associates, and The Robert Wood Johnson Foundation, 11/1/2014

Offsite Materials (briefing documents saved on other websites)

Implementation of the Affordable Care Act - Cross-Cutting Issues Six-State Case Study on Network Adequacy, Urban Institute and The Robert Wood Johnson Foundation, 9/1/2014
Physician Choice in Exchange Plans, Morning Consult, 9/22/2014
Narrow Health Networks: Maybe They’re Not So Bad, The New York Times, 9/9/2014
Hospital Networks: Updated National View of Configurations on the Exchanges, McKinsey Center for U.S. Health System Reform, 6/1/2014
High-Value Healthcare Provider Networks, Milliman Inc, 7/2/2014
Narrow Provider Networks in New Health Plans: Balancing Affordability with Access to Quality Care, Georgetown University Health Policy Institute and The Urban Institute, 5/1/2014
State Laws Related to Access to Healthcare Providers Network Adequacy, National Conference of State Legislators, 6/27/2014
Summary of Significant Changes to the CY2015 MA Provider and MA Facility Criteria [Section from CY2015 MA HSD Provider and Facility Specialties and Network Adequacy Criteria Guidance], Centers for Medicare & Medicaid Services, 12/20/2013
Obamacare: Anger over narrow networks, Politico, 7/22/2014
Reforming State Regulation of Provider Networks: Efforts at the NAIC to Re-draft a Model State Law, Community Catalyst, 8/29/2014
Narrow Networks Help Create Value in a More Regulated Healthcare Landscape, Becker’s Hospital Review, 7/9/2014
Network Adequacy Planning Tool for States, Center on Health Insurance Reforms, Georgetown University Health Policy Institute and The Robert Wood Johnson Foundation, 4/1/2014
Testimony of Mark Del Beccaro, MD, Seattle Children’s Hospital, Before the NAIC Network Adequacy Model Review (B) Subgroup: Regarding Revisions to the Network Adequacy Model Act, Seattle Children’s Hospital, 6/5/2014
ACA Implications for State Network Adequacy Standards, The Robert Wood Johnson Foundation, 8/1/2013
CMS may mandate wider exchange networks, Healthcare Dive, 7/22/2014
Controlling Health Care Costs Through Limited Network Insurance Plans: Evidence from Massachusetts State Employees, National Bureau of Economic Research, 9/1/2014
Doctors cut from Medicare Advantage networks struggle with what to tell patients, The Washington Post, 1/25/2014
Issue Brief: Network Adequacy, American Medical Association, Advocacy Resource Center, 2/6/2014
Kaiser Health Tracking Poll: February 2014, The Kaiser Family Foundation, 2/26/2014
Medicare Advantage Participant Bill of Rights’ Introduced - Weekly Capitol Hill Report - Issues for the week ending June 27. 2014, Highmark Inc, 6/27/2014
NCQA Updates Health Plan Accreditation to Address ‘Narrow Networks’, National Committee for Quality Assurance, 7/28/2014
Network Adequacy: What Advocates Need to Know, Community Catalyst, 1/1/2014
Network Adequacy & Exchanges, National Committee for Quality Assurance, 2/1/2013
Reflecting on Health Reform – Network Networks: Boon or Bane?, The Commonwealth Fund, 2/24/2014
To Prevent Surprise Bills, New Health Law Rules Could Widen Insurer Networks, The New York Times, 7/19/2014


Regulators should move slowly in developing an approach to allow sufficient time to understand early consumer experiences, Mike Leavitt, founder and chairman, Leavitt Partners, said at a September 26 Alliance Briefing, Network Adequacy: Seeking Balance. He added that, as economic pressure is brought to bear, networks become more efficient.


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