Reform Update: Exchanges need better tech or better info on narrow networks, experts say

Experts and consumer advocates have faulted the Obamacare insurance exchanges for not providing clear, accurate and up-to-date information to consumers about which providers are in the health plans offered on the exchanges. Experts say in the future, exchanges will have better technological tools to offer accurate provider information. But for now, they say, such tools don't exist and insurers have to do a better job themselves at making sure their lists are up to date.

A Commonwealth Fund survey of consumers who had used the exchanges that was conducted in June illustrates the problem: 25% of adults who selected a plan did not know whether their plan had a narrow network or not, and 39% of adults overall didn't know which doctors were included on their plan.

Not knowing what providers are in their plan's network can have serious financial consequences for consumers because receiving treatment from out-of-network providers can lead to thousands of dollars in additional out-of-pocket costs. At a recent meeting in Oregon on network adequacy, a consumer advocate said several of her clients had relied on plan network information posted on Cover Oregon, the state's exchange site, and ended up owing thousands of dollars.

Even experts acknowledge having difficulties figuring this out. “I chose a narrow network this year to save money on my deductible, and the technology I used was not robust enough to clearly differentiate what hospitals were available and what providers were available,” said Dan Schuyler, the senior director for exchange technology at consultancy Leavitt Partners. “So I had to call my broker.”

For now, calling a broker or a navigator for personalized help is Schuyler's best recommendation. But that's not workable for exchange customers en masse, he said.

This problem has led some to call for the federal and states exchanges to deploy more effective information technology tools on their websites to present more accurate information about which doctors, hospitals and other providers are in a plan's network. The “transparency was not what it should've been, and part of that was the shortcomings of the federal exchange,” said Paul Ginsburg, a professor of medicine and public policy at University of Southern California.

“We have much more ability now than in the 1990s to have that transparency because of the information technology,” he said. “It's more feasible to provide enrollees or people contemplating enrollment much more information about networks than it would've been possible in the past.”

At a meeting this week sponsored by the Alliance for Health Reform on network adequacy, Michael Chernew, a Harvard University professor of health policy cited an “enormous new movement” to provide consumers with more information, including strong interest from startup companies and venture capitalists to help present that information effectively. The firms he had in mind, he said, were Castlight Health, which he thinks will get into helping customers select plans, and Picwell, a Philadelphia-based predictive analytics startup.

“We are just at the very beginning of understanding how well these new tools take advantage of big data, information sciences (and) quality measurement (of a given network),” he said, “We just simply don't know how well we're going to be able to translate that knowledge into things that consumers can use.”

Joel Ario, managing director at Manatt Health Solutions and a former HHS director overseeing development of the federal exchange, said an important advance would be in predictive, personalized algorithms like Amazon's or Google's. In the future, he speculated, you might see patients upload their electronic health records to the exchange and have an algorithm point out which of their providers were in each plan's network, as well as each network's overall level of specialists who treat their particular medical conditions.

“You're never going to get the average consumer to understand all this detail,” Ario said. “You actually need people who are very skilled at creating the algorithms and other kinds of data analysis tools that help people sort these things out and put things in very simple terms.” And that information needed to be tailored and personalized.

Schuyler said constantly changing networks make it difficult to keep provider lists up to date, but ensuring information on each plan's network is accurate is of the highest importance.

At the Oregon conference, one insurance representative suggested putting a freshness date on the network information for each plan, to indicate when it was last updated. A proposed Washington state insurance rule change would mandate monthly updates. Schuyler thinks it's an issue the insurance industry needs to work on, though there's “no perfect solution to the problem.”

Such uncertainty also afflicts the search for new technology to better present such information. Andy Slavitt, the CMS' new principal deputy administrator, said last week that adding a specific tool on the HealthCare.gov website to help consumers identify each plan's network is off-the-table for the upcoming 2015 enrollment period. Instead, insurers will be encouraged to post accurate and up-to-date lists of providers.

Schuyler expects that such tools might have to wait a year or two until a product emerges that does a satisfactory job. The top priority is ensuring a smooth overall enrollment experience. But, he said, there's plenty of interest among vendors. “It offers a great opportunity to anybody who wants to provide a technology platform that can do a decent, reliable job,” he said.

A study from the Robert Wood Johnson Foundation found that states passing up Medicaid expansion are also passing up $423.6 billion in federal funding between 2013 and 2022. For hospitals, that means missing out on $167.8 billion in reimbursement during the same time period. In addition, states are missing out on nearly 350,000 in job gains, the brief states.

The number of uninsured people in Connecticut has dropped by half since 2012, when 7.9% of the state's population was uninsured, according to data from the Access Health CT, the state's insurance exchange.

"Nobody expected us to be down to 4%," said exchange CEO Kevin Counihan, whose exchange is considered one of the most successful state-run exchanges in the country.

Follow Darius Tahir on Twitter: @dariustahir