The story behind narrow networks and balance billing Seth Trueger, MD, MPH

1. Seth Trueger MD MPH
Northwestern University
@MDaware
Crossing State Lines
Narrow Networks
&
Balance Bills

2. DISCLOSURES

3. STATE LINES
selling insurance across

10. not a solution

11. not a solution

12. philosophical

13. states’ rights

15. not happening

16. 6 states + ACA

17. race to the bottom

18. race to the bottom

19. out of state regulators

20. race to the bottom

21. race to the bottom

22. adverse selection

27. healthy

28. sick healthy

29. adverse selection

30. prices

31. but wait
…there’s more!

32. it’s the network

37. # enrollees
how sick?
practice
intensity
out of
pocket
costs
provider
consolidation
# insurers
payer mix reimbursement
rates
premiums

39. it’s the network

40. # enrollees
how sick?
practice
intensity
out of
pocket
costs
provider
consolidation
# insurers
payer mix reimbursement
rates
premiums

41. # enrollees
how sick?
practice
intensity
out of
pocket
costs
provider
consolidation
# insurers
payer mix reimbursement
rates
premiums

42. it’s the network

43. it’s the network

44. it’s the network

45. it’s the network

46. it’s the network

47. it’s the network

48. it’s the network

49. it’s the network

52. ¯_(ツ)_/¯

54. NARROW
NETWORKS
just how terrible are

55. NARROW
NETWORKS
just how terrible are

58. # enrollees
how sick?
practice
intensity
out of
pocket
costs
provider
consolidation
# insurers
payer mix reimbursement
rates
premiums

60. premium
s
payment
s

62. We can think of the extraordinarily high overhead
imposed on insured individuals and patients in the
United States as the price they seem to be willing to
pay for the privilege of choice among health insurers
and, for each insurer, among multiple different
insurance products. US consumers seem so fanatic
about this choice that to keep it, they have been willing
to give up their erstwhile freedom of choice among
physicians, hospitals, and other clinicians and health
care facilities. Citizens of most other countries have
made that trade-off in exactly the opposite direction.
One can only hope that for the high price US
consumers seem willing to pay for choice among
insurers, they get their money’s worth in extra benefits.
Uwe Reinhardt, PhD

63. premium
s
payment
s

64. BALANCE
BILLING
what can be terrible is

65. balance billing
out of network ED

66. balance billing
out of network ED
insurance has to pay

67. balance billing
out of network ED
insurance has to pay
how much?

68. balance billing
out of network ED
insurance has to pay
how much?
ED bill balance

69. balance billing

70. balance billing
surprise bills

71. balance billing
surprise bills
surprise lack of coverage

82. 1) the average amount negotiated with
in-network providers for the emergency
service furnished

83. 1) the average amount negotiated with
in-network providers for the emergency
service furnished
2) the amount for the emergency service
calculated using the same method the
plan generally uses to determine
payments for out-of-network services
(such as the usual, customary, and
reasonable charges)

84. 1) the average amount negotiated with
in-network providers for the emergency
service furnished
2) the amount for the emergency service
calculated using the same method the
plan generally uses to determine
payments for out-of-network services
(such as the usual, customary, and
reasonable charges)
3) the amount that would be paid under

87. ¯_(ツ)_/¯

88. ntrueger@gmail.com @MDaware

89. lower premiums?

93. “Under the law, no one can be denied
coverage because of a pre-existing medical
condition.”

98. BAD THING
OTHER BAD
THING
NOT BECAUSE
OF OBAMACARE
BECAUSE
OBAMACARE
MAGNITUDE
TIME

99. BAD THING
OTHER BAD
THING
NOT BECAUSE
OF OBAMACARE
BECAUSE
OBAMACARE
MAGNITUDE
TIME
OBAMACARE
BEGAN