On Thursday, California Gov. Jerry Brown signed legislation increasing scrutiny of provider networks in the state. The bill requires insurers to file annual reports with the California Department of Managed Health Care. The agency's assessment of that data will be posted on its website.
Tensions over narrow networks have been particularly intense in California, with multiple lawsuits challenging the provider networks of plans offered by Anthem Blue Cross, Blue Shield of California and Cigna. Two more cases alleging that consumers were deceived were filed this week in Los Angeles.
Similar issues have prompted concerns in other parts of the country as well. The National Association of Insurance Commissioners is in the process of revising its model regulations for network adequacy. A draft of its new policy is expected to be released by the end of the year. And the CMS indicated in a letter to insurers in March that it intends to apply heightened scrutiny to provider networks for plans that will be sold on the exchanges during the next open-enrollment period, which begins Nov. 15.
Richard Cauchi, a state health program director at the National Council of State Legislatures, points out that many state legislatures were far into their sessions, or had already adjourned by the time constituents began using state exchange health plans and subsequently encountered problems with provider networks. “This was a tricky year for legislatures to respond,” Cauchi said. “This is a topic that's quite likely to get increased attention in 2015 once there's a full year of information about results.”
On Friday, the American Heart Association released a study, conducted by Avalere Health (PDF), looking at exchange-plan inclusion of the specialists most frequently needed by heart disease patients. The study looked at 10 regions across nine states and found wide disparities in access to cardiologists, neurologists and radiologists.
In Los Angeles, just 8% of those doctors were included in the provider networks of three silver exchange plans scrutinized. By contrast, 83% of those in the Philadelphia region were included in provider networks.
“This is important because heart attack and stroke patients often don't have a choice as to which physician they're seeing when admitted to a hospital,” said Stephanie Mohl, senior government relations advisor at the American Heart Association. She made her remarks during a forum on network adequacy in Washington on Friday, sponsored by the Alliance for Health Reform.
The heart association study also looked at access to comprehensive stroke centers, which are certified to treat patients with the most complex conditions. Just 11% of those facilities were part of provider network for the silver plans studied in the Atlanta region, compared with 100% in New Jersey and Philadelphia.
But former HHS secretary and Utah Gov. Michael Leavitt, speaking at the same forum, warned against a rush to aggressively regulate provider networks. Leavitt pointed out that insurers, providers and consumers are dealing with a lot of unknowns in the fledgling marketplaces and that the markets likely won't stabilize for at least three years.
The ballot initiative in South Dakota is opposed by health plans operating in the state and large provider networks, particularly Sanford Health and Avera Health. They warn that it will drive up healthcare costs, resulting in higher premiums, by limiting consumer choices.
A recent study by healthcare researchers Stephen Parente and Robert Book (PDF) lends credence to that fear. By their calculations, premiums would spike by roughly $3,000 to $5,000 over the course of a decade, depending on what level of coverage a family chooses.
“They're well-meaning, but they usually come at a cost,” Parente said of the any-willing-provider mandates. “You can see who you want, but it's going to cost you.”
Eckrich, the surgeon who worked to get the issue on the South Dakota ballot, isn't buying those fears. He became dedicated to the cause after an elderly patient came back to see him for a follow-up procedure a year and a half after an ankle procedure. Eckrich was no longer in her plan's network, so she would have had to pay the entire cost of having the second procedure performed by her preferred doctor.
He's optimistic that voters will embrace what he sees as a common-sense consumer protection. “I don't know who would oppose a patient being able to choose their doctor,” Eckrich said.