“This is a political issue that goes back to that promise that nothing would change and people could keep their physicians,” said Ron Williams, former chairman and CEO of Aetna and founder of the Boca Raton, Fla.-based consulting firm RW2 Enterprises. “Something they weren't told is that when they enter the exchanges, in order to have an affordable premium, they may have to change doctors.”
Legislators in at least three states—Mississippi, New Hampshire and Pennsylvania—are considering bills that would put in place new requirements on insurers. In Mississippi, the legislation would require insurers to accept any provider that meets the terms of its contract, similar to the any-willing-provider laws that were passed by a number of states during the anti-HMO backlash of the 1980s and 1990s. Washington state's insurance commissioner has proposed tighter review of provider networks in the wake of a lawsuit by Seattle Children's Hospital over being excluded from most exchange plan networks.
Narrow networks are also at the center of a federal lawsuit in Connecticut contesting UnitedHealth Group's efforts to eliminate thousands of doctors from its Medicare Advantage plans.
Insurers say they have narrowed provider networks to control costs and quality and offer competitively priced products. A study by the McKinsey Center for U.S. Health System Reform classified 70% of networks for exchange plans as either narrow or ultra-narrow.
Under the CMS proposal issued last week, an insurer selling plans through the federal exchanges for 2015 would be required to submit a list to the CMS of all in-network providers and medical facilities covered. The CMS would review the lists in conjunction with state regulators to ensure that there is “reasonable access” to all types of providers.
In addition, the CMS proposed new standards for providing access to “essential community providers,” which serve predominantly poor and medically underserved neighborhoods. Exchange plans would be required to include at least 30% of such providers in the market, compared with 20% for the 2014 plan year. If plans fail to provide that level of access to essential community providers, they would have to explain why their product should still be allowed to be sold on the federal exchange. The CMS would decide if that explanation is adequate.
Insurers are wary about popular and political backlash over narrow networks, expressing concern about the effect on costs as they prepare products for the 2015 open enrollment period. They have to submit plan details for their federal exchange plan offerings for 2015 by June 27.
On a call with investors last week, Aetna CEO Mark Bertolini indicated that he expects “doc shock”—his term for the narrow network backlash—to be a major issue in the coming months. “We do pay a lot of attention to it because it does impact pricing,” he said.
“If states and the federal government want to examine networks and push for additional providers to be included, that's going to impact the ability to keep prices down,” said Leslie Moran, senior vice president of the New York Health Plan Association.
Follow Paul Demko on Twitter: @MHPDemko
Follow Virgil Dickson on Twitter: @MHVDickson