CMS recently unveiled a massive regulatory overhaul of Medicaid managed care requirements. Despite the fact that it’s being called a “mega-reg,” and taking some heat for its 1400+ page size, there’s certainly some interesting reading contained within, particularly for the telehealth community.
It’s all about network adequacy standards.
Health plans are regulated by states or CMS and measured based on their ability to demonstrate the adequacy of their in-network providers. How many are there? What’s the availability by specialty? Do consumers understand which providers are in-network? What does access look like in terms of wait times and distance? Answering these questions are the key to meeting the standard.
This has been my week to discuss networks (Internet and electricity), but I would be remiss if I didn’t spend a few moments on the networks that are most likely to rob us of personal choice and increase costs: Health care networks.
Wait, didn’t President Obama promise us that the new health care law would preserve choice for us? Didn’t he promise us lower costs? Well, in spite of much good that the law accomplished in terms of providing access to health insurance, these are two areas that have gone awry. For a variety of reasons–most of which have little to do with providing you with better care–the hospital world has grown more centralized. It’s done so to reduce competition and get better rates from insurance companies. It’s done so to create larger risk pools of patients under the “rate reform” that incorporates more bundled and capitated payments. It’s done so to keep you as a captive customer for your health care needs. It’s been aided and abetted by electronic health record companies that find a mutual advantage with their hospital colleagues in minimizing the ability of your EHR to be easily transferable to other health systems. As I’ve noted, we truly have created “business cost structures in search of revenue streams,” rather than a vibrantly competitive system focused on increasing quality and satisfaction and lowering costs.
Many people don’t even know they are part of a health care network until they discover its limitations. It might be that the insurance product they bought has different rates for in-network doctors and facilities from out-of-network doctors and facilities. It might be that their primary care physician subtly or not so subtly directs them to specialists in his or her network because they share in the financial reward of eliminating “leakage” to other systems. It might be that they discover that an MRI or other image taken in one health system cannot be transferred electronically to another, perhaps necessitating a second image and its accompanying cost.
A number of pundits are citing the systemic failure of ACOs, after additional Pioneer ACOs announced withdrawal from the program – Where do you weigh in on the prognosis for Medicare and Commercial ACOs over the next several years?”
Peter R. Kongstvedt
Whoever thought that by themselves, ACOs would successfully address the problem(s) of [cost] [care coordination] [outcomes] [scurvy] [Sonny Crockett’s mullet in Miami Vice Season 4]? The entire history of managed health care is a long parade of innovations that were going to be “the answer” to at least the first four choices above (Vitamin C can cure #5 but sadly there is no cure for #6). Highly praised by pundits who jump in front of the parade and declare themselves to be leaders, each ends up having a place, but only a place, in addressing our problematic health system.
The reasons that each new innovative “fix” end up helping a little but not occupying the center vary, but the one thing they all have in common is that the new thing must still compete with the old thing, and the old thing is there because we want it there, or at least some of us do. The old thing in the case of ACOs is the existing payment system in Medicare and by extension, our healthcare system overall because for all the organizational requirements, ACOs are a payment methodology.
A THCB reader in Connecticut writes:
“I’m a pretty level headed person. I’ve been following the Healthcare.gov story in the news and figured it was more of the usual partisan stupidity out of Washington. I decided to do my homework before getting too worked up.
I went on to my state exchange and compared the available plans. Gold. Silver. Bronze. All very logical. I spent some time comparing options and found a plan I liked. So far so straightforward. No complaints. No plan shortage in my state.
The problems started when I picked up the phone and attempted to communicate with a living breathing human being. I figured it would be a good idea to confirm that my OBGYN’s practice is covered. To make a long story short, I have a pretty serious pre-existing condition that could hypothetically kill me. My OBGYN is one of the best in the state. Moving to another practice is NOT AN OPTION.
Knowing how the system works, I called my OBGYN’s office and asked them to confirm that my doctor’s plan was covered. Should be a five minute call. No luck. Sorry. They don’t have the information yet. Probably yes. They helpfully suggest I give the health plan a call. Well, that’s logical, I think to myself. It takes time for new plans to about the plans to make it through the system. So I take their advice.
I call the health plan involved and politely tell them why I’m calling and what I need to know. Guess what? They don’t know either.