Networks: What Do Consumers Care About?

Anthony WrightHealth Access Californiawww.health-access.org

www.facebook.com/healthaccesswww.twitter.com/healthaccess

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

BFD

Biggest Congressional Action for Consumer Protections; Coverage Expansion; Cost Containment

CALIFORNIA IMPLEMENTSMillions with new consumer protections; financial assistance

4+ million Californians with new coverage already

Uninsured cut in half; Average rate hike 4.2%

CALIFORNIA IMPROVESEARLY:

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

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

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The Policy Response

• Regulation (DMHC, CDI)

• Investigation (DMHC Survey)

• Negotiation (Covered CA)

• Litigation (Courts)

• Legislation (SB964 in 2014)

(SB137 in 2015)

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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.

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Insurers’ New ConstituencyMedian 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?

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2015 U.S. HHS Poverty Guidelines

Family

Unit100% 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

Out-of-Network Costs Not An Option

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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

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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.

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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

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

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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

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

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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

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

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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

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

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After the ACA, we all need to:

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.

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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

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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

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?

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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?

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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

For more informationWebsite: http://www.health-access.orgBlog: http://blog.health-access.org

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