Sign Up for Email Alerts Visit us on Twitter Visit us on Facebook Visit us on YouTube Subscribe to RSS Feeds


Home > Past Briefings > Briefing Detail Page
 

Briefing Detail Page

Change Text Size:   Smaller Text Size   Larger Text Size   Default Text Size    

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
 
KEY BRIEFING POINTS
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

Photos



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.

 

Briefing for Reporters on State Health Initiatives


A governor met with reporters Friday, February 19 to discuss the latest health care innovations and changes they are pursuing or implementing. Gov. Asa Hutchinson, R-Ark., discussed his experience with the state's program to move newly eligible Medicaid beneficiaries to qualified health plans, and his intentions for changes moving forward.

Read More


Health Care Consolidation: What You Need to Know


A recent whirlwind of mergers and acquisitions has thrown health care industry consolidation into the spotlight. In 2014 alone, there were 1,299 mergers and acquisitions in the health care sector at a value of $387 billion, a new record. In this roundtable for reporters, featuring a top FTC official and two experts, panelists discussed the drivers behind this recent trend; the scope and extent of consolidation among doctors, hospitals and insurers; implications for consumers and other stakeholders; and the roles of the Department of Justice (DOJ) and the Federal Trade Commission (FTC).

Click here for video
Click here for transcript

Read More 

New Toolkit on Health Care Consolidation


There were 1,299 mergers and acquisitions in the health care sector in 2014 at a value of $387 billion, both record highs. A new Alliance for Health Reform toolkit, “Health Care Consolidation,” looks at the drivers behind this trend, as well as implications for key players in the health care system and regulatory issues surrounding the issue.  Critics argue that consolidation could have a harmful impact on consumers, including higher costs, while others say some amount of activity is necessary to reshape the health care industry following changes implemented by the Affordable Care Act.

Read More 

What Tools do Patients Need? Video


What is the key to creating a more consumer-friendly and patient-centered health care system? Leading experts address challenges and potential solutions in a new Alliance video featuring Benjamin Moulton of the Informed Medical Decisions Foundation, Robin Gelburd of FAIR Health, and Tim Skeen Anthem.

Click here for video.

Read More 

Video from Reporter Roundtable on Open Enrollment III


On October 5, speakers at a reporter roundtable held at the National Press Club on open enrollment III provided the latest information about premium trends and drivers, health plan availability and new comparison tools for consumers to use in choosing health plans. They discussed trends in the role of navigators and brokers, and increasing consumer expectations, particularly around the ease of the process.

Click here for video.

Read More 

Toolkit on Connection Between Health and Housing


A new Alliance toolkit, “The Connection between Health and Housing: The Evidence and Policy Landscape,” provides a detailed look into federal, state and local initiatives, as well as cost implications for health and housing programs.

Attempts to tie health and housing policy are gaining momentum, amid evidence that housing, a social determinant of health, is an important factor in the health status of various populations. More than 610,000 people experience homelessness in the U.S., and over 250,000 individuals within that population have a severe mental illness or a chronic substance use disorder, according to the Department of Housing and Urban Development.

Read More 

Toolkit on Biosimilars


The Alliance for Health Reform has released a new toolkit, “Biosimilars: Unpacking Complex Issues.”

The Affordable Care Act created an expedited licensure pathway for biosimilars, and, in March 2015, the U.S. approved the first biosimilar, leaving policy makers, regulators, providers and stakeholders to grapple with regulatory and financial questions.

Biosimilars are similar – but not identical – to biologic drugs, and cost less. Unlike traditional pharmaceuticals, biologic drugs are derived from living organisms and tissues, making them more complex and expensive to produce.

Read More 

Experts Discuss Workplace Wellness Programs


In a new interview video, Karen Pollitz, senior fellow, private insurance and health reforms, The Kaiser Family Foundation and Dan Newton, vice president, product/solutions development and behavior economics, Anthem Care Management discuss the impact of workplace wellness programs. They address questions about regulations and program design and analyze the scope of wellness programs.

Read More 

Toolkit on Long-Term Services and Supports (LTSS)


The aging of the baby boomers and the increase in the number of old-old persons (those 85 and older) are predictors for the increasing need for long-term services and supports (LTSS). Among persons age 65 and over, an estimated 70 percent will use LTSS. A new Alliance for Health Reform toolkit, “Long-Term Services and Supports: Changes and Challenges in Financing and Delivery,” provides a background on LTSS and discusses policy issues surrounding the topic.

Read More 

Copyright 1997-2016 Alliance for Health Reform
1444 Eye Street, NW, Suite 910 Washington, DC 20005-6573      202-789-2300      202-789-2233 fax      info@allhealth.org      Sitemap