Posted on 12/29/2013 12:56:11 PM PST by mdittmar
Purchase certain Anthem health insurance plans outside Colorado's new health care exchange, and health care provider choices abound.
Buy one through the exchange? Not so much.
Across the nation, an increasing number of insurance carriers are narrowing their physician networks, hospitals and other health care facilities. The trend is particularly evident in health insurance marketplaces, including Connect for Health Colorado.
Narrowing health care options is uncharted territory
The marketplaces were established as one-stop shops for insurance plans after passage of the Affordable Care Act, or Obamacare.
In Colorado, at least three health insurance companies on the exchange, including Anthem, are offering narrowed networks, and insurance carriers across the industry say the trend will become more prevalent in the coming years.
Insurance companies frame the strategy as a means to control insurance prices - a priority, they say, in light of federal requirements mandating 10 "essential" benefits in each plan, including behavioral and maternity care.
"I think everybody is looking for a way to control some of the health care costs that's going on," said Cindy Palmer, Colorado Choice Health Plans' chief executive. "And you do that with tighter alignments between payers and providers."
In doing so, insurance carriers are betting that plan prices will likely trump most other considerations - including a plan's network of hospitals, physicians and other facilities - for people shopping on insurance exchanges.
Many people likely shopping on the exchanges are uninsured, insurance executives reason, meaning they don't have an attachment to a doctor and thus won't mind if a network is narrowed.
The issue, though, could become a focus for the 250,000 Coloradans who faced cancellation letters this year from their insurance carriers. Even if the majority of those people opt to keep their current plan for one more year - courtesy of a widely offered loophole known as "early renewal" - they still must find new coverage by the end of 2014.
When they do, advocates and insurance company representatives say they'll need to shop carefully to ensure their current doctor is still covered - especially if they're shopping through the state's marketplace.
"There is going to be some trade-off ." said Janet Pogar, Anthem's regional vice president for provider engagement and contracting. "There potentially could be some network disruption."
Colorado's scene
For plans effective in 2014, Colorado Choice Health Plans constricted its network by 10 to 15 percent, Palmer estimated.
Rocky Mountain Health Plans decided to offer two plans with a narrow network of physicians - in one instance, offering a plan focused on Colorado Springs Health Partners doctors, said Neil Waldron, the carrier's chief marketing officer and vice president of strategic initiatives. But for balance, the carrier also offered traditional broad-based networks on different exchange-based plans.
Anthem's plans for 2014 offer the most vivid example of narrower networks in Colorado.
The company typically offered plans with broad networks and expects to continue doing so - just not on the state's exchange, where executives believe uninsured shoppers will value price above all else, Pogar said.
Every individual and small group plan sold by Anthem on Connect for Health Colorado would have a narrowed network, she said.
In Colorado Springs, Anthem's exchange-based plans cover Memorial Hospital and its other health care facilities, as well as Children's Hospital, but not the Penrose-St. Francis Health System. In Denver, University of Colorado Health, Children's Hospital and HCA hospitals are covered, but St. Anthony Hospital and others aren't.
A full state accounting of insurance carrier networks does not yet exist, and several insurance companies - including Kaiser and United Healthcare - did not providedetails about the scope of their networks.
Given the lack of a good database and the newness of exchange-based plans, the true effect of any narrowed networks likely won't be felt until people start visiting their doctors on new plans beginning Wednesday, said Adam Fox, of the Colorado Consumer Health Initiative.
"There is a question as to what point does narrowing networks start to decrease access to care," he said. "We don't necessarily know when that point's going to be reached, or how it's going to play out for your average consumer."
A varied strategy
The trend is more prevalent in other states, including Washington and New Hampshire. Only one insurance carrier of seven on Washington's exchange covers treatment at an advanced cancer treatment center, The Seattle Times reported. And four of the seven carriers don't cover the state's only Level 1 trauma center and burn unit.
An Anthem plan in Maine drew the ire of state regulators after it excluded six of the state's hospitals, Kaiser Health News reported. In New Hampshire, Anthem's plans on the exchange failed to include more than one-third of the state's hospitals, according to the news service.
The impulse to narrow networks isn't across the board - but it also isn't surprising, said Karen Pollitz, a senior fellow of the Kaiser Family Foundation, a health care research organization.
In past years, insurance companies could use other means to control prices - such as excluding customers with pre-existing conditions or offering bare-bones policies.
"Those options are no longer there," Pollitz said. "So I think, at least in some markets, insurers are offering plans that have a narrower provider network than the perhaps offered previously."
Some companies in Colorado have elected not to follow suit.
SeeChange Health, an insurance company with about 4,000 customers in Colorado, chose to only offer small group plans - all of them featuring a broader-based network with 125 hospitals, 6,500 physicians and 19,000 specialists, said Alan Katz, the company's executive vice president.
Company officials bet that small-business owners would want broader networks when purchasing for a large number of people - whereas hospital choice might play second fiddle to price for people purchasing plans on the individual market, Katz said.
Denver Health also expanded its network to include University of Colorado Health and Children's Hospital as part of its first foray into the individual market.
Observers say Colorado's exchange is well-poised to help people navigate changing networks. The website features a search function that allows shoppers to search for doctors based on the plan they'd like to purchase - a tool few other states offer, Colorado marketplace officials say. Whether consumers take advantage of that tool remains to be seen.
"We don't necessarily know how it's all going to play out yet," Fox said.
The exchange policies are superior, Obama said so.
I heard him say that the policies these people already had were inferior.
i'm confused, if Dr.A and Dr.B and Dr.C and Hospital 1 and Hospital 2 and Hospital 3 ALL make a contract with an insurance company that says they will accept the same payment of $X, why would an insurance company care what Doc they see or which facility the goto? now it the contracted prices are different, i understand, but all things being equal, i don't...
Two words: utilization review. If doctor a orders twice as many tests as doctor b, they’re not going to sign with a. Same result for doctors who typically treat more complex patients. Essentially, the insurers are repeating the experiment that didn’t work out in the HMO era.
I’ve always wondered if doctors get kickbacks for each prescription they write. And if the lab and specialists the doctors refer you to give them a kickback.
OK, that'd do it... but would you say the treatment of more complex patients is more specialty driven or simply a case of say a PCP with a higher % of AIDS cases or older patients etc?
Commonly a mathematical norm for whatever category the physician practices in. The degree to which that computation sorts out “over prescribers” from the norm instead of excluding competent physicians and rewarding idiots is determined by how well the categories are drawn and how much sophistication is involved in making the judgements. I don’t have a lot of faith in the ability of the average insurer to make those calls properly.
All three of the circumstances you mention could wrongly put a PCP out of the running unless each individual physician’s practice is carefully examined. I haven’t seen an excess of “carefully” among the company folks I’ve met.
Be wary if your assigned doctor is a graduate from a correspondence school in Pakistan or India.
India offers top-tier medical treatment for its upper classes and those are the same physicians who tend to come here. I have known several.
....graduate from a ....correspondence school.... in Pakistan or India.
Yeah. We don’t.
I want to know what the government is ‘kicking in’... with Medicare Advantage it’s a massive amount of money. Are Chinese firms involved?
My endocrinologist is from India, and she is excellent.
The nephrology specialty is seemingly a club open only to those of Indian descent -- and my experience has been uniformly excellent.
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