Pressure builds over narrow networks
Skip to main content
MDHC_Logotype_white
Subscribe
  • My Account
  • Login
  • Subscribe
  • News
    • This Week's News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • People
    • Regional News
    • Digital Edition
    • MH school health_i.png
      How the role of school health programs might expand because of the pandemic
      TriPoint Medical Center.jpg
      Cleveland's University Hospitals finalizes Lake Health addition
      Digital health funding hit $7.2B in Q1
      HHS allocates $145 million to health center look-alikes to fight COVID-19
    • MH school health_i.png
      How the role of school health programs might expand because of the pandemic
      HHS allocates $145 million to health center look-alikes to fight COVID-19
      The Check Up: Kevin Shimamoto
      The Check Up: Kevin Shimamoto of Valley Children's Hospital
      Covid_unit_Beaumont_Dearborn-main_i.jpg
      ER doctors 'manage chaos' amid COVID-19 surge in Michigan
    • Some healthcare associations moving full steam ahead with conferences starting in summer
      COVID hospitalizations in Michigan top fall surge; Beaumont seeing nurse 'burnout'
      Calls mount for Biden to track U.S. healthcare worker deaths from COVID
      Front-line workers want more assistance after a year of COVID-19
    • BlueCrossBlueShield_06_03_07_0.jpg
      Blue Cross bosses pocket pay hikes
      UnitedHealthcare sees Q1 profits rise and other key earnings takeaways
      California re-opens enrollment for health insurance coverage
      Insurers are partnering to offload the costs of kidney failure patients
    • HHS allocates $145 million to health center look-alikes to fight COVID-19
      Biden admin throws out Texas Medicaid waiver
      J&J vaccine pause a minor blip, but efforts must press on, experts say
      Effort to keep Arkansas Medicaid plan falls short in state Legislature
    • Private equity's estimated healthcare spending halved in first quarter
      UH reports $54.7M operating income for 2020 despite significant COVID-related costs
      CMS issues new guidance to enforce price transparency rule
      Massachusetts to crack down on highest-cost hospitals, insurers
    • Digital health funding hit $7.2B in Q1
      The Check Up: Kevin Shimamoto
      The Check Up: Kevin Shimamoto of Valley Children's Hospital
      Bright Health scoops up telehealth startup
      FCC to open next round of COVID-19 telehealth program applications
    • Michigan expands antibody treatment to cut hospitalizations
      J&J vaccine pause a minor blip, but efforts must press on, experts say
      A year into pandemic, federal officials design new mask guidelines to better protect more workers
      FDA pauses enforcement of in-person dispensing requirement for abortion pill
    • Oscar names new virtual-first care division president
      Redfield joins Big Ass Fans, which promotes controversial COVID-killing technology
      Next Up Podcast: Modern Healthcare's editor Aurora Aguilar talks new content direction
      Novant Health adds chief payor performance officer
    • Midwest
    • Northeast
    • South
    • West
  • Insights
    • ACA 10 Years After
    • Best Practices
    • Special Reports
    • Innovations
    • The Affordable Care Act after 10 years
    • A close-up of a woman receiving a COVID-19 vaccine.
      Providers in underserved communities work toward equitable vaccine distribution
      Josh Bradshaw
      How one rural Illinois county vaccinated 84% of its senior citizens by early March
      Dr. John Fischer
      Patient-reported outcomes tool for hernia surgery helps physicians improve care
      New care model helps primary-care practices treat obesity
    • Jennifer Pannone and her daughter Victoria.
      Mental health access for children needs attention
      A family photo of the the Hangens.
      Stressing the already burdened pediatric behavioral health system
      What's next for on-demand telehealth companies?
      A map of the U.S. with images of the coronavirus.
      The digital divide becomes a new social determinant of health
    • Ryan McGinnis
      Finding efficiencies in the OR using tech
      Dr. Daniel Hall
      UPMC pilots machine learning, telehealth to inform patient transfers
      A woman being recorded using her inhaler on a smartphone.
      Digital check-ins, connected inhalers help control asthma
      A phone screen showing the question, "Mary we hope this information was helpful and we'd like to keep guiding you. Are you interested in knowing when it's your turn to receive the vaccine?"
      Chatbots, texting campaigns help manage influx of COVID vax questions
  • Transformation
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Mayo Clinic launches two tech companies
      Diabetes patients at high risk for COVID-19 are managing conditions more effectively
      Nearly 1 in 5 Americans skipped care due to cost last year
      COVID-19 long-haulers need holistic treatment, providers say
    • Amazon gives out $12M under next phase of AWS diagnostics development initiative
      Malpractice premiums peak in 2020, AMA survey shows
      A rendering of a cancer research institute at the University of Southern California that will include 5G.
      Healthcare providers determine how to best use ultrafast 5G
      Two-thirds of largest hospitals aren't complying with price transparency rule
    • Hospitals face specialty pharmacy challenges with insurer competition
      Addressing long-standing barriers needed for mental and physical health integration
      A close-up of a woman receiving a COVID-19 vaccine.
      Providers in underserved communities work toward equitable vaccine distribution
      The waiting room of a Kaiser Permanente clinic at a Target location.
      Health systems revamp their approach to retail clinics
    • Payers, providers clash over telehealth reimbursement as Congress mulls changes
      When money talks. Why cash pay is becoming more popular
      CMS wants to bump pay for hospices, SNFs next year
      CMMI pauses new Direct Contracting model applications
  • Data/Lists
    • Rankings/Lists
    • Interactive Databases
    • Data Points
    • Health Systems Financials
      Executive Compensation
      Physician Compensation
  • Op-Ed
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
    • Dr. Alan Kaplan
      The risks, rewards of taking organizations 'where they haven’t gone before'
      Wellstar CEO calls adapting for the pandemic her bold move
      Howard P. Kern
      Recognizing the value of telehealth in its infancy
      Dr. Stephen Markovich
      A bold move helped take him from family doctor to OhioHealth CEO
    • Drs. Hal Paz and Joshua J. Joseph
      Mobilized to fight the COVID crisis: a blueprint for community and academic partnerships
      Dr. Stephen Markovich
      Making sure we're aligned along the path to achieving inclusion
      Barry Ostrowsky
      Ending racism is a journey taken together; the starting point must be now
      Laura Lee Hall and Gary Puckrein
      Increased flu vaccination has never been more important for communities of color
    • It's time we fulfill the ACA's promise to broaden access to lower-cost drugs
      Five lessons for securing our children's future
      We're losing engaged providers, and healthcare will pay the price
      Dr. Chris DeRienzo
      How COVID-19 broke health systems and made them stronger
    • Letters: Eliminating bias in healthcare needs to be ‘deliberate and organic’
      Letters: Maybe dropping out of ACOs is a good thing for patients
      Letters: White House and Congress share blame for lack of national COVID strategy
      Letters: VA making strides to improve state veterans home inspections
    • Sponsored Content Provided By Optum
      How blockchain could ease frustration with the payment process
      Sponsored Content Provided By Optum
      Three steps to better data-sharing for payer and provider CIOs
      Sponsored Content Provided By Optum
      Reduce total cost of care: 6 reasons why providers and payers should tackle the challenge together
      Sponsored Content Provided By Optum
      Why CIOs went from back-office operators to mission-critical innovators
  • Awards
    • Award Programs
    • Nominate
    • Previous Award Programs
    • Other Award Programs
    • Nominations Open - Top 25 Innovators
      Nominations Open May 10 - Top 25 Minority Leaders
      Nominations Open May 24 - Top 25 Emerging Leaders
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Minorities in Healthcare
      • - Luminaries
      • - Top 25 Minority Leaders
      • - Minorities to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Excellence in Nursing Awards
    • Design Awards
    • Top 25 COOs in Healthcare
    • 100 Top Hospitals
    • ACHE Awards
  • Events
    • Conferences
    • Galas
    • Webinars
    • COVID-19 Event Tracker
    • emburse certify modern healthcare custom media webinar logo lockup
      Sponsored Content Provided By Emburse
      Webinar: Making it easy to manage costs
      virtualmed staff modern healthcare custom media logo lockup
      Sponsored Content Provided By VirtualMed Staff
      Webinar: Best practices for creating a successful telepsychiatry program
      telehealth visit man touching neck while speaking to doctor on computer
      Sponsored Content Provided By Accumen
      Webinar: How telehealth has evolved into a standard of care
      Webinar: Avoid interoperability penalties. Modern Healthcare. Sponsored by Hall Render
      Webinar: Avoiding interoperability penalties
    • Women Leaders in Healthcare Conference
    • Social Determinants of Health Symposium
    • Healthcare Transformation Summit
    • Leadership Symposium
    • Virtual Briefings
      • - Hospital of the Future
      • - Mental Health
      • - Patient Safety & Quality
      • - Strategic Marketing
      • - Virtual Health
      • - Workplace of the Future
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Minority Leaders Gala
    • Top 25 Women Leaders Gala
  • Listen
    • Podcast - Next Up
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
    • Next Up Podcast: Managing the COVID-19 vaccination rollout with Dr. Gary Little
      Next Up Podcast: Modern Healthcare's editor Aurora Aguilar talks new content direction
      Dr. Chris DeRienzo
      Next Up Podcast: Building team spirit in the wake of COVID-19
      Mikelle Moore
      Next Up Podcast: Mikelle Moore on recognizing all hospital workers during the pandemic
    • Beyond the Byline: Kids' unchecked mental health needs pose long-term consequences
      Beyond the Byline: How COVID-19 has impacted hospital finances
      An older man sitting on a hospital bed with his back toward the camera.
      Beyond the Byline: Upcoding could explain why hospitals are increasingly billing for the most complex treatment
      Beyond the Byline: Insurers are betting on virtual-first plans as COVID-19 shifts care pathways
    • James garvert neustar healthcare insider podcast image
      Building on basics
      Healthcare Insider Podcast Episode Art - Premier
      Why Roger Weems and other consultants are leaving the big firms to join Premier
      James garvert neustar healthcare insider podcast image
      Outreach during COVID-19
      ann barnes healthcare insider podcast image
      Leading with intention to promote diversity and inclusion
    • The Check Up: Kevin Shimamoto
      The Check Up: Kevin Shimamoto of Valley Children's Hospital
      The Check Up: Dr. James E.K. Hildreth
      The Check Up: Dr. James E.K. Hildreth of Meharry Medical College
      The Check Up: Matt Eyles
      The Check Up: Matt Eyles of AHIP
      The Check Up: Dr. Tom Shanley
      The Check Up: Dr. Tom Shanley of Lurie Children’s Hospital of Chicago
    • ivana naeymi-rad one on one intelligent medical objects
      Video: Ivana Naeymi Rad of Intelligent Medical Objects
  • MORE +
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Physicians
February 08, 2014 12:00 AM

Pressure builds over narrow networks

Paul Demko and Virgil Dickson
  • Tweet
  • Share
  • Share
  • Email
  • More
    Print
    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.

    Insurers are facing a growing backlash over the narrow-network plans they are selling through the Obamacare insurance exchanges.

    Federal regulators and state lawmakers across the country are proposing ways to push insurers to open up their provider networks. The CMS indicated last week that it would require insurers to provide more evidence that they're offering customers adequate access to providers.

    Some experts are nervous about how such restrictions could hamper insurers' ability to keep premiums down, since plans can pay providers less in return for steering more patients to them. On the other hand, congressional Democrats are uneasy about narrow networks turning into an election issue in November.

    “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

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    Mich. cardiologist pays $2 million to settle case alleging unnecessary testing
    Mich. cardiologist pays $2 million to settle case alleging unnecessary testing
    By the Numbers: Medicaid-to-Medicare physician fee ratios, by state
    By the Numbers: Medicaid-to-Medicare physician fee ratios, by state
    Sponsored Content
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS
    • Instagram

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    MDHC_Logotype_white
    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2021. Crain Communications, Inc. All Rights Reserved.
    • News
      • This Week's News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition
    • Insights
      • ACA 10 Years After
      • Best Practices
      • Special Reports
      • Innovations
    • Transformation
      • Patients
      • Operations
      • Care Delivery
      • Payment
    • Data/Lists
      • Rankings/Lists
      • Interactive Databases
      • Data Points
    • Op-Ed
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Awards
      • Award Programs
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top 25 Innovators
        • Minorities in Healthcare
          • - Luminaries
          • - Top 25 Minority Leaders
          • - Minorities to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Nominate
      • Previous Award Programs
        • Excellence in Nursing Awards
        • Design Awards
        • Top 25 COOs in Healthcare
      • Other Award Programs
        • 100 Top Hospitals
        • ACHE Awards
    • Events
      • Conferences
        • Women Leaders in Healthcare Conference
        • Social Determinants of Health Symposium
        • Healthcare Transformation Summit
        • Leadership Symposium
        • Virtual Briefings
          • - Hospital of the Future
          • - Mental Health
          • - Patient Safety & Quality
          • - Strategic Marketing
          • - Virtual Health
          • - Workplace of the Future
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Minority Leaders Gala
        • Top 25 Women Leaders Gala
      • Webinars
      • COVID-19 Event Tracker
    • Listen
      • Podcast - Next Up
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • MORE +
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing