Greater transparency about health plans' provider networks is needed to help consumers understand which doctors and hospitals they can go to without incurring very high out-of-pocket costs, experts agreed at a forum Tuesday sponsored by the Federal Trade Commission.
Health plans with narrow networks are pervasive on Obamacare exchanges and increasingly are being offered by employers as well. by McKinsey & Company found that nearly half of the 2,366 unique provider networks qualified as narrow networks, meaning less than 70% of hospitals in a coverage area were included.
Narrow-network plans were a primary focus Tuesday at the FTC's summit on healthcare competition in Washington, co-sponsored by the FTC and the Justice Department's Antitrust Division. Participants agreed that tailored networks, including those with different pricing tiers, are likely to become a fixture of the insurance landscape. But they differed on the steps needed to ensure that consumers can make informed choices about which products will meet their needs.
Lynn Quincy, Consumer Union's associate director for health reform policy, said most consumers have little understanding of provider networks. “They may not even know they're in a narrow-network product or tiered-network product,” she said. “We have a lot of work to do.”
Paul Ginsburg, a healthcare policy expert at the University of Southern California, said more sophisticated measures for assessing network adequacy need to be developed. In particular, he said, assessing the quality of available providers and the accessibility of specialists are particularly thorny tasks. “How would you access the adequacy of networks for diseases you don't have?” he asked.
James Landman, director of healthcare finance policy at the Project Japan Financial Management Association, noted that patients can sometimes get stuck with expensive medical bills for out-of-network costs that were impossible to avoid. In some cases, he noted, a surgeon at a hospital might be included in an insurer's network, but the anesthesiologist might not be.
The National Association of Insurance Commissioners is drafting a model law that states can look to for guidance in regulating provider networks. HHS has also expressed concern about the adequacy of networks for health plans sold on the state and federal exchanges. But the federal agency has indicated that it will hold off on introducing additional regulations until the NAIC process has concluded.
Kim Holland, vice president for state affairs at the Blue Cross and Blue Shield Association, applauded the NAIC's process for seeking input from all interested parties, but also noted that it's a laborious process. “It's like making sausage,” she said. “It's not very pretty sometimes.”
Holland also expressed concern about “any willing provider” proposals that have surfaced in several state legislatures in response to concerns about narrow networks. Such proposals were common in the 1980s and 1990s as part of the backlash against HMOs, but their resurgence has prompted concerns that they will hamstring insurers in creating affordable products.
Participants in the forum agreed on the need for greater transparency about provider networks. Insurer directories have sometimes been riddled with errors or have been hard to use.
HHS is trying to address the issue with new exchange marketplace rules for 2016. The agency is requiring that insurers continuously update their lists of providers and that these lists be easily accessible. In addition, HHS is requiring that provider networks be made available in “machine-readable” formats. That way, independent organizations will be able to extract the data and create tools to help consumers better navigate their plan choices.
“The first imperative is to ensure that the plans they purchased deliver the benefits they were promised,” Quincy said.
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