Regulatory Oversight of Narrow Network Plans
The Alliance for Health Reform held a meeting that focused on “Network Adequacy: Balancing Cost, Access and Quality” on July 21. The meeting was very well attended for mid-summer, indicating substantial interest in the trend towards smaller networks particularly in qualified health plans offered through the ACA Exchange marketplaces. Several of the panelists mentioned a recent McKinsey study that found that 92 percent of consumers using ACA plans have access to narrow network plans while 90 percent of ACA plans offer broader networks.
The panel participants emphasized the value that smaller networks bring to consumers in offering substantially lower premiums. For example, a recent Milliman report for AHIP found that high value networks can reduce premiums by 5 — 20 percent. However, it is important that plans select the providers based on quality and performance and not just on price. Paul Ginsberg pointed out that smaller networks also can support integration of care and that these plans are moving in the same direction as payment reform e.g. making payment based on episodes of care or bundled payment. Katherine Arbuckle from Ascension Health noted that providers in smaller network plans can benefit from being connected to the same electronic health record system which further benefits clinically integrated care.
All of the panelists agreed that there needs to be adequate regulatory oversight of network access. Currently the NAIC is in the process of updating their Model Network Adequacy Act which has not been modified since 1996. The goal is to have an updated model by the end of the year. NAIC is focusing on new provisions on essential community providers, tiered networks, formularies, provider directories and updates, continuity of care and consumer protection from unanticipated bills and broadening the act to all types of managed care plans. NAIC wants to retain state flexibility to deal with local conditions, for example, provider access standards should be very different in Wyoming than Los Angeles. Paul Ginsburg noted that passing any willing provider laws is an overreach and will offset the advantages that smaller networks, carefully chosen, can bring to the marketplace.
NAIC does not have regulatory jurisdiction over Medicare Advantage plans. CMS is considering making changes to MA access standards to deal with mid-year network changes beginning in 2015, for example by allowing enrollees to switch plans if their doctor leaves the network mid-year without cause. Senator Sherrod Brown and Rep. Rosa DeLauro have introduced legislation to prohibit MA plans from dropping physicians mid-year without cause.
Resources
Find out what provisions in the final marketing guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes in a webinar next Wednesday, July 23.