As insurers continue to shift toward narrow networks, states still are sorting out what actions will lead to appropriate access to care. Physicians are taking an active role in how their state governments handle the issue.
Listening in Nevada
In Nevada, the insurance commissioner recently concluded a month of listening sessions in preparation for developing regulations that are expected to be finalized in June. The listening sessions solicited input from physicians and the public regarding issues that need to be addressed in the regulations, which will be heard for the first time at a public workshop in May.
Physicians are particularly concerned about the adoption of narrow networks in that state.
“Nevada presently has a severe shortage of both primary care physicians and specialists, which at times makes it difficult for patients to access appropriate care,” the Nevada State Medical Association (NSMA) wrote in a Feb. 28 letter to the insurance commissioner.
Insurers that previously included out-of-state physicians in their networks no longer are doing so this year, causing disruptions of care and creating a dangerous situation for patients in these areas who may need acute care. The NSMA plans to work closely with the Nevada Division of Insurance in the development of these regulations. The AMA also has submitted comments outlining the key points the commissioner should address in the final rules.
Unproductive regulations in Washington state
In Washington state, the insurance commissioner in late April issued final regulations for the 2015 health plan year. Unlike an earlier version of the proposed regulations, the final rules don’t include stricter requirements for network adequacy. Rather, insurers probably won’t be required to go beyond simply saying that they attempted to contract with a sufficient number of physicians.
The Washington State Medical Association (WSMA), which actively participated in the commenting process, is opposing the final language, which the association views as worse than current law.
“The rules, as currently written, have the potential to decrease access to care for Washington’s patients,” WSMA President Dale Reisner, MD, stated in a letter asking the commissioner to withdrawal the regulations.
“The language … fails to adequately protect negotiations between insurers and physicians,” the letter states. “Furthermore the new rule does not contain the strong provisions needed to ensure patient access across the state to all categories of providers and services.”
Legislation introduced in Connecticut
In Connecticut’s legislature, meanwhile, a bill was introduced that is intended to add transparency to insurance networks and ensure that an adequate number of physicians are available to provide comprehensive and efficient access to health care services for patients in that state.
The Connecticut State Medical Society has supported the bill, which is based on an AMA model. The society has been heavily engaged in this issue since October, including filing briefs in support of a legal battle that sought to remedy massive network terminations.
More terminations in Missouri
In Missouri, the Medicare Advantage network continues to constrict as a large number of physician terminations are set to take effect July 1.
“These terminations, which fall in the middle of the patients’ enrollment year, constitute an alarming threat to long-established physician-patient relationships, and an unconscionable hardship for those with conditions that require continuity of care and/or access to specialists,” the Missouri State Medical Association stated in a strongly worded letter to Medicare Advantage carrier UnitedHealthcare.
Key national developments
Recent developments on the national level may help physicians and patients in individual states. For instance, the National Association of Insurance Commissioners in March responded to the AMA’s call for the group to revise its model bill on network adequacy. The group now is working with the AMA and others, including payers, on a new version that should address current trends.
In addition, the Centers for Medicare & Medicaid Services (CMS) recently issued greater regulation of network adequacy among Medicare Advantage plans and plans offered on federally facilitated health insurance exchanges.
As the nation continues to explore ways to expand access to care at an affordable cost, the AMA and organized medicine will remain engaged to broaden restrictively narrow networks so patients have access to the care they need from the physicians they trust.
