Plan designs change all the time. That is why the whole brouhaha over the “If you like your plan, you can keep it” was so amazingly stupid but effective.
As I was digging for articles for a post that I want to write on narrow networks, I saw this interesting piece from northwestern Pennsylvania:
It’s a call that local physician offices are getting more and more often.
Patients want to know if their doctor accepts Highmark’s Community Blue or UPMC Health Plan’s Inside Advantage insurances. And sometimes the answer is no.
Community Blue and Inside Advantage are called “narrow-network” plans because they either exclude certain hospitals and their physicians, or charge members a lot more out of pocket to seek treatment at those locations…
Offering a narrow-network plan is a way employers can reduce their costs. Insurers charge less because the hospitals and doctors in their network have agreed to accept lower reimbursements in exchange for the insurer funneling more patients to them.
Saint Vincent, Millcreek Community and Corry Memorial are what Inside Advantage considers “Tier 2,” which means members have access to those hospitals and physicians, but must pay higher co-payments and are covered only for 80 percent of their medical costs.
It’s not just the hospitals, though. The networks also may exclude hospital-owned physician offices and diagnostic centers, so members may find they have to switch their primary care physician or specialist when their employer chooses a narrow-network plan.
“There’s going to be an educational cycle with this,” Hamot President Jim Fiorenzo said. “Employers are going to find out whether these narrow networks are worth it if half of their employees have to switch their PCPs.”
Oh no, someone’s boss is making them change their PCP.
Given the way we finance healthcare in the US, a narrow network is one of the few ways that a strong “No” can be introduced into the system to avoid some of the highest cost providers that don’t have amazingly quality metrics which would justify the costs. Narrow networks were a trend in the group insurance market for a long time, and will continue to be a trend in both the group and Exchange markets going forward.
kindness
‘Some’ people will find a way to blame the ACA & President Obama.
Mnemosyne
It got a little frustrating for our open enrollment period this year because the Giant Evil Corporation has a self-funded plan that’s administered by a large insurance company. So some people were finding that the large insurance company was saying that their doctors were no longer covered, except that there was a separate pool of “GEC Doctors” that the insurance call center people weren’t always remembering to check. People were getting multiple answers depending on if the person they were speaking to remembered to check the separate pool.
dr. bloor
Sometimes for-profit insurers say “no” rather loudly. To wit, almost all of the surgeons at Rhode Island Hosptial, about two-thirds of those at the Miriam, and every cardiac cutter in the state are being tossed off of United Healthcare’s panel in RI.
No cause was cited.
You really don’t want to have any serious cutting done at any of the other in-state options.
kc
Also why it was kinda stupid to say “if you like your plan, you can keep it.”
liberal
I think it’s reasonable to say that we can cut costs without much loss in quality by not covering more expensive providers, but I’m not convinced it would have much more than a marginal impact. Far more important AFACIT (not an expert!) is not paying for things which aren’t effective (e.g. this ridiculous overuse of spinal fusion surgery), plus breaking the AMA cartel.
liberal
@kc:
Look, bub, if you come over to this blog and criticize The Holy One, you can just quickly escort your a$$ right back out!eleventy!
liberal
…meanwhile, NPR’s “marketplace tech” series is spending the whole week on BitCoin; today they interviewed a doc (previously an engineer) whose office takes BitCoin. Sigh.
piratedan
@kc: of all things, he underestimated the nefarious duplicity of the insurance companies who accepted the additional traffic while simultaneously fighting against the ACA. The heads of their CEO’s can go up on the pikes along with the Walls Street CEO’s, and the MSM news producers.
jheartney
My internist is not (for now) in my narrow ACA network. I generally like the guy, but it’s not worth the extra $4-5K/year it’ll cost to stay with him. Especially since in most years it’s just a couple of checkups.
dr. bloor
I’m curious to know what sort of “metrics” clearly differentiate one PCP from another. Surgical outcomes are one thing; what makes one family doc statistically preferable to another?
It’ll be interesting to see how this plays out when these networks get increasingly narrower as time goes on, i.e., reimbursements for docs are cut further. The future family practice, I suspect, will consist of one or two MDs and a football team’s worth of nurses and PAs. Which will be fine, until it isn’t.
Richard M.
My niece is going through this. She has celiac disease, has to go to the doctor frequently, and specialists, and ER visits are not uncommon. While going to law school, she was covered under the university’s health network. She got an apartment near both her PCP and a covered hospital. Recently accepted a position at a law firm, which then announced it was going to a narrow network – which of course does not include any of the medical providers she has been seeing or her local hospital. It sounds as though her network is primarily physically located in a distant part of town, more convenient for the suburbanites. I understand the cost aspect for the employer, but it still seems an imposition on the employees and there is something about decreasing diversity of options that seems short-sighted.
Mike in NC
@dr. bloor: We got a letter from United Healthcare stating that basically they were not ACA compliant, thus they were dropping everybody from healthcare insurance in 2014, but they would offer some sort of ‘wellness’ coverage where they’d let you sign up for a plan that paid for physicals, mammograms, prostate exams, etc.
They can go piss up a rope. Our new plan will save us $700 a month.
jl
@Richard M.: Cynical me wants to keeps cost function and selection function of network design in mind, when I read about narrowing.
mikeyes
@liberal:
As part of the ACA, there is a significant cost cutting aspect that is about to kick in. This includes hospitals and larger entitities having to set up organizations that look for cost cutting and medical effectiveness which in turn ferrets out the the overly expensive doctors and the ones who are not effective. The AMA has signed on to this plan as far as i can tell.. If not, they such at being a cartel because it hasn’t worked very well.
ACA is a comprehesive plan in which the insurance is only a minor part. it will also be a pain in the ass to implement until the bugs are worked out, but the “Affordable” part of the plan is for real at all levels.
mclaren
As usual, Richard Mayhew neglects to inform us of the reason why so many hospitals refuse to deal with so many insurance plans. Why are so many doctors locked into exclusive agreements with one particular hospital, one particular insurance company, one particular imaging clinic?
Greed.
Sweetheart contracts and nondisclosure agreements insure that out-of-network doctors and imaging clinics and hospitals and radiology centers with lower prices can’t compete with the overpriced greed-crazed imaging clinics and radiology centers which just happen to have contracts locking in sky-high prices and also preventing said doctors from disclosing those insanely high prices. In many these imaging clinics and radiology centers are owned by groups of doctors — classic cartels, a perfect example of anticompetitive restraint of trade designed to drive up prices and reduce the quality of health care.
Source: “Experts warn of medical industry cartels’ power,” The San Francisco Chronicle, 21 February 2010.
It’s all restraint of trade, corruption, greed, and cronyism. All to make money, money, money, money, money.
jl
I hope there is an analysis of McCain’s plan, as soon as details are available.
McCain Introduces Obamacare Repeal And Replacement Legislation
http://talkingpointsmemo.com/livewire/mccain-obamacare-replacement-bill
negative 1
@kindness: I bet a lot of folks will, and that was strangely one of my first thoughts when the whole ‘if you like it’ stuff started. I’m responsible for purchasing the insurance for my company, so I have a little familiarity with the industry prior to the ACA. For a couple of years in this state BCBS was pushing these narrow networks as the wave of the future, but they hadn’t really caught on. It occurred to me that they would catch on right as the ACA was kicking in and that people will blame the ACA when it is really a product that predates the whole thing. I’d still bet our annual insurance bill on it.
Mike in NC
@jl: McPOW’s plan probably involves marrying a wealthy heir or heiress. Such a sore fucking loser…
jl
@Mike in NC:
” McPOW’s plan probably involves marrying a wealthy heir or heiress. ”
He did say it would be portable, and spouses fit that description, at least until the messy divorce.
Edit: to be serious about it, since McCain knows so little about economics or healthcare, I guess whether it is totally ridiculous or not depends on who wrote it up for him, and how McCain is planning to position himself for his next election or career move, or retirement placement in big corporate world.
jheartney
@jl: It’ll be the same old Republican wish list: Tax cuts, tort limits, and allowing insurance companies to sell across state lines. Bupkis for unemployed and/or uninsured. No attempt to address any real problems.
lahke
@dr. bloor:
What’s funny is that some MD groups will be sending their cardiac patients up to Boston and will still save money over using the Rhode Island docs and hospitals.
On rating PCPs, you do it by seeing if their patients get all of their preventive care–do women get pap smears and mammograms, do the diabetics get their eye exams? A tremendous portion of the care delivered by PCPs is purely preventive.
JPL
@jl: McCain is teaming up with my rep who is a doctor. The idea is buying insurance across state lines in order to do away with pesky regulations. In GA that means, no more free mammograms or insurance coverage that must continue if you get sick. Health insurance would be affordable because it would be like that gal in FL who paid $50 a month for no hospitalization.
also, too.. There is not a member of MSM who will quiz these folks about coverage. If you like your dental plan that pays thirty percent, well guess what, that is their plan for health insurance. f..k..em
Madeline
I’m more of a lurker than a poster here, but am despondent and need some help. I’m single, no children, healthy, self-employed and have been paying for my own, really good insurance (HMO plan, $35 copays, $500 deductible – no drug or dentail coverage tho) for 15 years. I smoke. When I turned 50 and saw my premium jump because of my age, I was able to manage the increase because I could drop maternity coverage, which reduced the premium by a little over $100/mo and kept the policy semi affordable. That policy costs me about $500/mo now, which wasn’t easy to come up with during the recession. Things are much better now, but who knows how long that will last?
But, o happy day, I’m turning 55 next week, which puts me into the next age band. My existing policy is going up to $673/mo, which is not affordable. Went on the exchange earlier this week, and policies similar to what I have now (golds and platinums) are even more expensive, in the $700-$800/mo range. I’m in stupid WI, where we didn’t take the medicaid money, or setup our own exchange.
I really don’t know what to do. I don’t care about copays, because I rarely go to the doctor and am pretty healthy, but I do care about enormous deductibles and co insurance, because I just don’t have spare thousands of dollars lying around if God forbid, something happens to me.
Any advice? Or am I just stuck with the choice of either paying more money for my health insurance premium than I pay for my mortgage or drastically reducing my coverage to keep it affordable? How do people make this choice?
Zifnab25
@liberal: Does he hold on to them for any length of time? Because if so, he just lost a whole shitload of money.
dr. bloor
@lahke:
This will be true for patients like myself. Mrs. Dr. Bloor had her gallbladder removed last year at Mass General (great hospital, btw). It was no sweat, because we’re upper-middle class, self-employed professionals with flexible schedules and ready transportation. Making sure that Junior Bloor wasn’t locked out of the house after school was the biggest logistical issue.
The problem is, those docs got tossed off of plans that disproportionately serve the elderly and lower SES groups. These are the folks who have a hard time getting to my office, and I’m on a bus line in the middle of Providence. Mass General may as well be on the planet Dagobah for them.
This is a rational approach, but how many of those PCPs are getting tossed for failure to tend to these issues? “Working cheaper” is the only real criterion I can come up with for dumping as many docs as they are.
Monala
@kc: Ya know, the Dems are always being criticized for being too wonkish and nuanced, and not knowing how to speak in sound bites that people can understand. But the problem with the latter (and why Dems tend to avoid it) is that dropping the nuance automatically results in less accuracy.
So if PBO had said, “You’ll be able to keep your plan, provided it meets the minimum standards of a quality health plan as set by the ACA, and provided your insurance company acts in good faith to follow these guidelines, blah blah blah,” it would have been all good, right?
Monala
As Richard wrote, this is not a new trend. On more than one occasion during my career, I’ve had employer-based insurance reduce their network.
So good news: my diabetic husband will have insurance as of Jan. 1, after not being covered for 2 years!
The bad news: because I am covered through work with an affordable plan, he couldn’t get a subsidy through the exchanges.
The good news: the plan we purchased is still less than we thought it would be!
Xantar
Anybody know about refugee issues? Non-profit I work with places refugees and would like answers to these questions:
1. Elderly people who have been in the US for 7 years and have not become US citizens will lose their benefits. Will the ACA have any effect on this (for Medicaid/SSI benefits)?
2. Should we wait until after the 8th month (refugees are on Medicaid for 8 months) to enroll or can it be done in advance to avoid a lapse in coverage? I guess the question is if someone reaches the end of their 8 months outside of open enrollment, will they be able to enroll in ACA benefits?
Violet
@Madeline: Do you qualify for a subsidy? Have you called the phone number? Did you try talking to a Navigator or call an insurance agent to see if they can help? There may be a way to keep the costs down.
Since you say you are pretty healthy, perhaps a Silver level plan would work for you. Would keep costs down and be there if heaven forbid, something did happen to you and you needed it.
Madeline
@Violet: No, I don’t qualify for subsidy. I do OK, but I’m not swimming in money, by any stretch of the imagination. $600/mo is a lot of money to me. My current plan is a kind of a legacy insurance plan, not even sold anymore. Maybe I will call a navigator tomorrow – I talked to my insurance co yesterday and did come up with a way to reduce my premium about $50/mo with some minor plan modifications, but that’s still over $600/mo. I was really hoping to stay at around $500. On the exchange, it’s the combination of smoking and age, I think.
It’s crazy – at this age, nobody really wants to insure you so they charge a fortune, Why don’t they just let us buy into Medicare at 50? I blame Joe Lieberman.
liberal
@Zifnab25: no. Sounds like he’s fond of the concept but doesn’t want to be exposed to currency risk.
JPL
@Madeline: I couldn’t find Richard’s email address but he is the one to help you. The silver plan has a high deductible but does cover well visits. If the cost is low enough you could put aside the extra money to cover the deductible. Since I’m healthy, I wouldn’t choose the gold plan but would put aside an amount to cover the deductible each month just in case. There is a cap on how much that deductible can be.
also, too… Sorry but the pregnancy thing seems odd to me. I’ll probably never have diabetes so can I buy insurance that doesn’t cover that. It’s a pet peeve of mine to use that one thing cuz we all had mothers.
Madeline
@JPL: I started looking for his email yesterday, after my depressing insurance saga and couldn’t find it either, so have been waiting for him to post something, in hopes he’d take pity on me and give me so advice.
Edit: Pregnancy thing? You mean the default inclusion of maternity in exchange plans?
Mnemosyne
@Madeline:
It might be cheaper to quit smoking. You could put the money you’re spending on cigarettes towards the deductibles as well.
Sorry, I’m on kind of a crusade right now. We’re edging up on the one-year anniversary of my father’s death at the age of 74 and every single one of the five causes of death listed on his death certificate was because he was a smoker.
Every. single. one.
Madeline
@Mnemosyne: Well yes, that would help me. But won’t help on insurance rates for about a year after I quit smoking, I believe. Sort of was hoping to using that money for retirement savings though, not for health insurance deductibles.
I know smoking is bad for you. But in my family, even the smokers live to almost 90. It’s become an awfully expensive habit though.
JPL
@Madeline: This is the comment that bothered me because if folks picked and chose, insurance would be meaningless. If you have a family history of breast cancer, then your insurance would be un-affordable . because I could drop maternity coverage, which reduced the premium by a little over $100/mo and kept the policy semi affordable. Pick and choose coverage would only lead to no coverage.
Good luck on your search but I think smokers should be penalized. (I smoke)
Madeline
@JPL: Ah. I understand. That was only to illustrate one method I used to keep my insurance affordable as I aged, pre-ACA. Of course maternity coverage should be a default. Women aren’t the other.
Look, even if I didn’t smoke, at my age, I’m still looking at premiums of mid $600-ish, instead of $700-$800ish in this age band, if I want to keep the type of coverage I have now. Which isn’t terribly affordable without a subsidy. And I can’t really control my age. Now, part of this for me is due to my stupid governor and his choices. Those rates would be better if Wisconsin did what it was supposed to do.
But there’s some work to do – doesn’t seem right that at the point in people’s lives that they may start having aging-related health issues, they have to start reducing their coverage in order to afford good insurance.
Richard Mayhew
@Xantar: If they are here legally, and since they are under a refugee visa, they are exchange and exchange subsidy eligible. If they don’t make enough, and are in a non-fuck you state, they are Medicaid expansion eligible.
Richard Mayhew
@Madeline: yeah, it will be the combination of smoking and age. I’m looking at HealthSherpa for a random Madison WI zip code for a 55 year making over 400% FPL which is roughly what you describe. The base rates aren’t bad for a silver plan (420 to ~500) but the tobacco surcharge is killing you.
You won’t qualify for cost sharing assistance Silver plans as you make too much. You’re probably stuck for a year at either an on-Exchange plan or talking to a broker to see if you can get something off Exchange that may be cheaper or sticking with what you have.
Long run, quitting smoking is the way to save money on both the front end @ 5 or 6 bucks a pack and on the premiums at $150 to $200 a month.
Now if you make under 400% FPL, the subsidies are probably worth a $100 a month for you