Adequacy, transparency of provider networks among things to watch

Heather Johnson

About Heather Johnson

Heather Johnson is an Oakland, Calif.-based journalist, author and editor specializing in legal writing, general interest, health and fitness, entertainment and consumer and professional audio.

Narrow networks

Photo: Niklas Morberg via Flickr

At a recent San Francisco Bay Area chapter event, health journalists received a primer on the narrowing networks of current health plans and the delicate balance between managing health care costs and providing reasonable access.

Panelists Anne Price, director of the Plan Management Division of Covered California; journalist and “Ask Emily” columnist Emily Bazar of California HealthCare Foundation’s Center for Health Reporting; Larry Levitt of Kaiser Family Foundation; and Betsy Imholz of Consumers Union addressed narrow networks’ impact on consumers, insurers, and providers, as well as proposed government regulation. Marilyn Serafini of nonpartisan Alliance for Health Reform, the panel’s cohost, moderated the briefing.

Narrow networks predate the Affordable Care Act to the controlled HMOs of the 1980s and 1990s, Levitt explained. The ACA accelerated the trend as insurers sought new ways to cut costs under a law that capped deductibles, banned pre-existing condition denials and mandated certain preventative care benefits.

“Insurers have been able to attract big market shares by lowering their premiums through narrow networks,” Levitt said. Although a Kaiser Health Tracking Poll found that 51 percent of respondents would opt for a larger network with a higher monthly premium, Levitt noted that in other polls, uninsured individuals said they would prefer a lower premium plan with narrow network.

While health plans have trimmed their networks, there is little evidence that the plans available are legally inadequate, Levitt said. The ACA provides little guidance on the issue. However, for 2015 and 2016, the U.S. Department of Health and Human Services will apply a “reasonable access” standard and will investigate insurers suspected of not meeting this standard.

Imholz emphasized a need for greater transparency. “We need to be able to signal to consumers whether they are getting a broad network, a narrow network, or an ultranarrow network,” she said. “That’s another evolving policy we need to work on more intensely.”

Providers and consumers also want accurate provider directories. Price added that health plans, medical providers, regulators and consumers should share responsibility for accuracy.

“At Covered California, we have a responsibility to offer consumers reasonable choice, and we work with our contracted health plans to provide as much transparency as we can,” Price said. “We want our consumers to make educated plan choices.”

Price emphasized that Covered California is working to expand coverage in areas of Placer, Monterey, Santa Cruz and San Benito counties where consumers only have access to one or two carriers.

“Consumers are desperate for guidance,” Bazar said. Of the more than 2,100 e-mails she has received to date from frustrated consumers, most concern narrow networks. Bazar often hears from consumers that inadvertently receive treatment from an out-of-network provider while visiting an in-network hospital. The expensive mistake not only affects the consumer’s wallet, but also the out-of-pocket maximum.

The Affordable Care Act’s implementation came with a host of “growing pains.” Time and experience, the panelists agreed, could balance out the hiccups. That said, the health care industry and related agencies – as well as reporters – should keep a close eye on the adequacy of provider networks, transparency of the directories and premium cost.

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