Insurers Fill Gaps in Health-Law Plans

I will keep you posted on how the below news will affect my office! -- Dr. Dale



Health insurers in several states are adding to the choices of doctors and hospitals in their health-law plans amid concerns among some consumers and state officials about access to care.

In states including New York, Connecticut and Ohio, insurers have bolstered their health-care provider networks in recent months. In California, three of the biggest insurers— WellPoint Inc.'s Anthem Blue Cross, Blue Shield of California and Health Net Inc. —have all added substantially to their lists.

"There have been quite a few network additions…and there are more to come," said Jeff Rideout, senior medical adviser to Covered California, the state's health-law marketplace. "We continue to ask the plans to expand their networks to meet the needs of the enrollees that we have."

CareSource, based in Dayton, Ohio, has added more than a half-dozen hospitals since the start of the year, and it hopes to roughly double the number it currently has to more than 50. Fidelis Care, a New York nonprofit focused largely on Medicaid, has added more than 4,500 providers, including 13 hospitals, since the start of the year. More hospitals and doctors have joined "as we've started to get more enrollment, and as we've shown that we are paying claims accurately and timely," said David Thomas, chief operating officer.

The insurers that are expanding their networks said they aren't responding to complaints. Instead, they said, the tweaks reflect more willingness by some health-care providers to join the new networks, which often pay them less than traditional employer plans, as well as adjustments to serve the specific populations who enrolled. CareSource, for instance, said it added a children's hospital in Cincinnati because the average age of enrollees was 41 years old and many had families.

But insurers also note that limiting the array of doctors and hospitals where services are covered can be a key tactic in keeping down costs. As a result, according to industry officials, narrow networks may expand in certain cases, but they will continue to be common among health-law plans.

A new analysis by McKinsey & Co. found that 48% of the networks in exchange plans nationwide have limited networks, which means plans with 70% or fewer of local hospitals participating as well as the tiered plans that have higher co-pays to use certain hospitals.

But among the least-expensive plans, 69% had the more-limited networks, according to the McKinsey report. In the most popular silver tier of coverage, the plans with smaller networks had premiums that were a median 17% cheaper than similar plans offering a broad hospital selection.

Because of the health law's requirements on other aspects of plan design, including how much patients could pay out of their pockets for care, networks were "certainly the biggest lever available" to affect price, said Shubham Singhal, a McKinsey director who leads the firm's health-care practice.

The relatively limited choice of doctors and hospitals in many health-law plans drew criticism from consumers and scrutiny from some regulators as the first year of plans went into effect.

In Connecticut, Access Health CT, the state insurance marketplace, had relatively stringent requirements to ensure plans offered a broad array of providers. Even so, the exchange got complaints from some consumers who wanted to see particular providers that weren't in their plans' networks.

"In the beginning, there were some holes, and the carriers have been working diligently to fill those holes" after exchange officials flagged them, said Julie E. Lyons, director of plan management. For instance, she said, they have added physicians located in bordering states.

The California Department of Managed Health Care, which regulates most of the state's marketplace plans, has gotten more than 200 complaints so far this year related to access to health-care providers. The agency has been following up with insurers, a spokeswoman said.

A San Francisco law firm has also filed a suit in state court seeking class-action status against Blue Shield of California, alleging the nonprofit misled consumers about its provider network.

Alex Talon, a San Francisco hair stylist and one of the plaintiffs, said he bought a plan from Blue Shield because he thought it used the insurer's broad network of providers, which included physicians he used.

When he got foot surgery in January, he said, it turned out the surgeon wasn't in the health-law network, so he owed "several thousand dollars out of pocket I wasn't planning on paying."

In a statement, Blue Shield said it believes "enrollees should be as informed as possible about the products they select" and is reviewing the complaint.

Blue Shield said that between April 2013, when it originally filed its plan designs with regulators, and this April, the number of hospitals grew by 19% and the number of physicians increased 70%.

Today, there are 254 hospitals and more than 36,000 physicians. Still, both totals are less than the numbers in the insurer's broader preferred-provider organization network. Blue Shield's increases represent a "strategic buildout" of a network that was already strong, said Ken Wood, a senior vice president at the insurer.

Competitors have made similar moves. Anthem Blue Cross has added more than 3,800 health-care providers to its network, as well as some prominent hospitals, since Jan. 1. In a Southern California health-maintenance organization network, Health Net's number of doctors has grown 68% since the start of the year, to more than 11,600, a spokesman said.

All three insurers said their moves reflected greater provider interest and efforts to enhance their offerings.