As Obamacare Plans Limit Choices, Doctors Want Provider Network Scrutiny

February 23, 2016

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Source: Forbes

The move by insurance companies to sell more HMOs and health plans with narrow lists of medical care providers–particularly on public exchanges under the Affordable Care Act–has doctors calling for state legislation and closer scrutiny of insurer networks by insurance commissioners and the Obama administration.

The American Medical Association, the American Academy of Family Physicians and other lobbies are sounding the alarm about what they say is a need for more regulatory oversight of health plan preferred lists of doctors known as networks. Doctor groups are advocating state legislatures and the Centers for Medicare & Medicaid Services update their so-called “network adequacy” statutes to ensure patients have an ample supply of physicians in their communities.

“We think regulators need to keep a better eye on the insurers,” AMA president Dr. Steven Stack of Lexington, Ky., said in an interview. “Patients are strongly attracted to lower premiums and we’re relying on regulators to ensure that the product they are buying is a reasonable insurance product. Insurers should be required to have standard networks.”

The alarm by doctors comes as narrow network plans emerge as insurers look for ways to control rising healthcare costs, particularly for those sick Americans purchasing coverage on public exchanges under the ACA. Insurers like UnitedHealth Group UNH -0.10%, Anthem ANTM -0.68%, Aetna AET +0.72% and others admit they aren’t making money on individual policies they sell on public exchanges and are therefore pushing plans with narrow networks to control costs and shore up their risk pools.

The Blue Cross and Blue Shield Association said in a report last month that HMOs and so-called “exclusive provider organization products” that limit healthcare providers “within a predetermined network” increased to 52% of the health plan offerings on public exchanges for this year compared to 41% in 2015.

Because HMOs generally limit choices to the doctors and hospitals in their networks and exclusive provider organizations work in a similar way to keep costs low, consumers are picking these plans to save money, doctors say. “People are not being informed,” the AMA’s Stack said.

The AMA said network adequacy statutes of “various potency” exist in 28 states and the District of Columbia and at least 17 enacted the laws before the ACA was signed into law by President Obama. Thus, doctor groups say network adequacy statutes might need to be updated given these health plans operating on exchanges are still new to most Americans.

In California, which has strengthened its network adequacy standards in recent years, two health insurers were penalized hundreds of thousands of dollars because their network lists had many inaccuracies.

Stack said there are many actions state insurance commissioners, which regulate individual health plans, and lawmakers could do to ensure adequate networks. They could ensure patients don’t have to travel a certain distance to for a doctor or make sure there is a certain “minimum ratio” of network providers in a given area.

“Insurance products are regulated at the state level,” Stack said, adding that policymakers need to closely examine what is “reasonable and appropriate and available.”

The American Academy of Family Physicians encouraged the Centers for Medicare & Medicaid Services to “establish national network adequacy standards for plans offered in the federally facilitated Marketplaces as a means to reduce consumers’ confusion,” Dr. Robert Wergin, AAFP’s board chairman, wrote in a letter in January to CMS administrator Andy Slavitt.

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