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. Networks: What Do Consumers
Care About?
Anthony Wright
Health Access California
www.health-access.org
www.facebook.com/healthaccess
www.twitter.com/healthaccess
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
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. 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. The Policy Response
• Regulation (DMHC, CDI)
• Investigation (DMHC Survey)
• Negotiation (Covered CA)
• Litigation (Courts)
• Legislation (SB964 in 2014)
(SB137 in 2015)
6
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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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. 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. 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. 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. 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.
27. 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
28. 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