Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Networks: What Do Health Consumers Care About?

593 views

Published on

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

Published in: Government & Nonprofit
  • Be the first to comment

  • Be the first to like this

Networks: What Do Health Consumers Care About?

  1. 1. Networks: What Do Consumers Care About? Anthony Wright Health Access California www.health-access.org www.facebook.com/healthaccess www.twitter.com/healthaccess
  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: http://www.health-access.org Blog: http://blog.health-access.org Facebook: www.facebook.com/healthaccess Twitter: www.twitter.com/healthaccess 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

×