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Networks: What Do Health Consumers Care About?


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Health Access California reviews the issues of access to care, argues for the patient protections needed to ensure timely access to care, adequate provider networks, and accurate directories. March 2015

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Networks: What Do Health Consumers Care About?

  1. 1. Networks: What Do Consumers Care About? Anthony Wright Health Access California
  2. 2. Health Access California • California’s statewide healthcare consumer advocacy coalition • Created in late 1980s over patient dumping • Fought for: – 1990s: HMO Reform, Patient Bill of Rights – Hospital Overcharging; Prescription Drug Prices – State Budget Battles – Health Reform & Coverage Expansions: Children’s, Medicaid, Employer, Comprehensive, Etc. – The Affordable Care Act & CA’s implementation
  3. 3. BFD Biggest Congressional Action for Consumer Protections; Coverage Expansion; Cost Containment
  4. 4. CALIFORNIA IMPLEMENTS Millions with new consumer protections; financial assistance 4+ million Californians with new coverage already Uninsured cut in half; Average rate hike 4.2% CALIFORNIA IMPROVES EARLY: Low-Income Health Programs Children with pre-existing conditions Maternity coverage BETTER: Exchange that negotiates & standardizes Medi-Cal express lane enrollment options Coverage of legal & DACA immigrants LGBT inclusion
  5. 5. Network Issues • Headlines in the News • “Narrow Networks” • New Access Concerns • Consumers and Providers • “Mad As Hell And Not Going To Take It Anymore.” • New Scrutiny Under the Affordable Care Act and Covered California • Centrally Important: Need to Get Right 5
  6. 6. The Policy Response • Regulation (DMHC, CDI) • Investigation (DMHC Survey) • Negotiation (Covered CA) • Litigation (Courts) • Legislation (SB964 in 2014) (SB137 in 2015) 6
  7. 7. With ACA, Networks Matter More • More Californians covered, more impacted • Standardized benefits means consumers now need to shop on price and network. Need tools to do this. • Not just more people, but more diverse: more education about the network and using it. • Lower-income families now in the market: Going out-of-network is expensive for many; for lower-income families it is prohibitive. 7
  8. 8. Insurers’ New Constituency Median income in California is just below 400%FPL; new subsidies and enrollees under 400%FPL. What does an annual out-of-pocket limit of $6,600 mean for one living on less than $47,000 a year? 8 2015 U.S. HHS Poverty Guidelines Family Unit 100% 138% 200% 300% 400% 1 $11,770 $16,243 $23,540 $35,310 $47,080 2 $15,930 $21,983 $31,860 $47,790 $63,720 3 $20,090 $27,724 $40,180 $60,270 $80,360 4 $24,250 $33,465 $48,500 $72,750 $97,000
  9. 9. Out-of-Network Costs Not An Option 9
  10. 10. The Basic Promise of Managed Care • The core principle and premise of managed care: insurers must provide networks so that consumers can get the care they need when they need it • Consumer agree to a limited network—insurers promise that the network is adequate and appropriate. Otherwise it is consumer fraud. • Managed Care, Limited Networks, ACOs work only if the consumer is guaranteed: The Care You Need, When You Need It, at In-Network Cost Sharing 10
  11. 11. Health Access’ Perspective • Not advocating for “any willing provider.” • Not against “narrow networks.” • Support an active purchaser Exchange that bargains with health plans for lower premiums and higher quality • Covered California: a large group purchaser for the individual and small group markets • Supports health plan bargaining with providers for lower costs and improving quality • The ability to bargain and say “no” to providers– balanced with need to ensure access for patients. 11
  12. 12. Confusing the Consumer • Consumers need reliable, up to date information— including provider directories--about who is in and who is out of a network: – For shopping for a plan before purchase – For using the plan after purchase • Medical groups, IPAs, Preferred Provider Groups: complicate networks for consumers: – Many of the complaints about CCI are about the delegated model: consumers do not know that when they pick one doctor, they are locked into a medical group • Different networks for different products: confusing! 12
  13. 13. Covered California • Provider directory and provider search tool essential to consumer choice • Some consumers will prefer and even pay more for wider networks (MA experience), all are price sensitive • Californians expect limited networks but also count on adequate networks 13
  14. 14. Network Adequacy Goal A health plan should have: - The right kinds of providers - In the right places - Available at the right times - In sufficient quantity to meet enrollee needs in a timely manner
  15. 15. Timely access Care delayed is care denied. • Timely access to care is an indicator of adequate network and financial solvency • With a narrow network, timely access monitoring by DMHC is more important for providers and consumers. • Based on standards filed by plans since 1975, but which plans could not demonstrate compliance with 15
  16. 16. Timely Access to Care • In 1975, law said: ”All services shall be readily available at reasonable times to each enrollee consistent with good professional practice.” • In 1997, Health Access sponsored AB497: – same-day urgent care – non-urgent care in ten days – answer the phone in four minutes • In 2010, regulations impose time-elapsed standards: – 48 hours for urgent care – Telephone triage within 30 minutes – Non-urgent care: • 10 days for primary care • 15 for specialty
  17. 17. SB964: Adequate Network, Reliable Info • Consumers need to be able to count on their health plan to have an adequate network—or to send them to the necessary out of network provider at in-network cost sharing • Covered California products and Medi-Cal managed care plans should meet the same standards as commercial health care service plan products • SB964: if a plan uses a different network for a different product, then DMHC should determine network adequacy for each network 17
  18. 18. Recent Efforts • 2014: SB964 – Annual reporting on network adequacy – Annual reporting on timely access – All products regulated by DMHC: group, individual, Medicaid, Exchange – Separate reports for separate networks • Many commercial plans use different networks for Medicaid than for commercial • Some use different networks for individual market than for employer market
  19. 19. Language Access • Not either/or with timely access • Critical in California, especially with the new constituency under the ACA • Various ways to meet the demand with trained personnel: in-person; video medical interpretation; Language Line as backup; NOT untrained staff or family members 19
  20. 20. After the ACA, we all need to:
  21. 21. Networks: The Quadruple Aim • Networks should be designed to advance the quadruple aim: – Better health outcomes – Better health care – Lower costs for consumers and purchasers – Reduced disparities • Networks that work improve all four, and not one or two at the expense of the others. 21
  22. 22. Networks: Driving the Quadruple Aim • Easy to “lower” costs by worsening disparities: – Dumb: Cost shift to consumers=worsening disparities, worse care, worse outcomes – Smart: Safer care=more cost effective care, better care, better outcomes • Easy to “lower” costs by advantaging providers that serve high income populations – Dumb: Readmissions penalties that fail to take into account social determinants of health – Smart: Aligning incentives so plans and providers reduce ER use and admissions for pediatric asthma by better management – Smart: Align incentives so plans and providers reduce ER use by frequent flyers 22
  23. 23. Provider Directory • California’s experience to date: What a mess! • Nonroutine surveys of Anthem and Blue Shield in 2014: – Directories 2-3 years old – 25% or more of providers not correct! • Medi-Cal managed care worse! • Law designed for pre-Internet era and not as good as the Yellow Pages
  24. 24. Quality and narrow networks? • Low cost should not mean low quality. • Quality measures for physicians, physician groups and hospitals as well as health plans • Quality measures at the regional level and by line of business (Medi-Cal, CoveredCA, commercial) • Quality for CoveredCA products comparable to large employer plans? 24
  25. 25. Ideas for the Future • How to convey the quality of network to consumers? • New constituency & including essential community providers? • People don’t live by county or state lines: How to easily convey the geographic boundaries of a network? • Can an insurer design a network to maximize excellent care for someone with a chronic condition (AIDS, asthma, diabetes, etc.)? Can we shift from running from risk to an incentive to serve them better? 25
  26. 26. 2015 Efforts • Provider Directory: SB137 (Hernandez) – Standards across plans/insurers – Allow people to shop for Medi-Cal managed care, exchange, off- exchange, group coverage: it is a multi-payer world – Find in-network provider accepting new patients • Surprise bills at in-network facilities: AB533(Bonta) – Consumer pays in-network cost sharing unless voluntarily consents to out of network provider • Annual out of pocket maximum: limited to individual cap: AB1305 (Bonta) • Timely Access monitoring • California Department of Insurance emergency regulations
  27. 27. For more information Website: Blog: Facebook: Twitter: Health Access California 1127 11th Street, Suite 234, Sacramento, CA 95814 916-497-0923 414 13th Street, Suite 450, Oakland, CA 95612 510-873-8787 1930 Wilshire Blvd., Suite 916, Los Angeles, CA 90057 213-413-3587