“WASHINGTON - Many health plans sold through Affordable Care Act marketplaces in 2015 are so limited that they don't offer patients access to some medical specialists such as endocrinologists, rheumatologists and psychiatrists, a study suggests.
That may be forcing some patients to pay thousands of dollars out of pocket for any care provided by these specialists.
"This translates into huge cost burdens for patients," said Stephen Dorner, lead author of the study, which was published by the Journal of the American Medical Association.”
“To test the extent of narrow networks, researchers at the Harvard T.H. Chan School of Public Health looked at provider directories in a sampling of 135 Silver health plans being sold in the 34 states that relied on the federal HealthCare.gov marketplace in 2015.
They expected to find plans with only a handful of physicians in some specialties. Instead, they discovered that nearly 15 percent of the plans did not include a single in-network physician for at least one specialty.” - Some ACA Plans May Exclude Specialists, Study Finds, 10/28/2015, insurancenewsnet.com
Link to the entire article appears below:
https://insurancenewsnet.com/oarticle/2015/10/28/some-obamacare-plans-may-exclude-specialists-study-finds.html
"In addition to financial barriers to care, there are non-financial ones – mainly caused by the narrow networks that have emerged in the insurance company race to the bottom. These networks often exclude the best doctors and the best hospitals. A study by Avalere found that there were no cardiologists in the networks of plans offered in Los Angeles. There were no diagnostic radiologists in the networks of plans offered in Chicago. In seven of the nine urban areas, fewer than half of specialists sampled belonged to provider networks in Obamacare exchanges. Patients can be forced to pay 100 percent of the cost of out-of-network services.
Here is another problem: millions of Americans are being forced to switch to the wrong kind of insurance. For example, many employees of fast food restaurants have mini med insurance, which covers the first few thousand dollars of care. These employees tend to be young and healthy and mini med plans pay for primary care – which is about the only care they are likely to need. The Obama administration considers that kind of insurance “under insurance,” however, and the new law insists that people have coverage for catastrophic care, with no annual or life time limits. Yet this kind of “comprehensive coverage” often has very high deductibles – forcing the young and the healthy to pay for primary care out of pocket.
About half the newly insured will get insurance through Medicaid, where there is little or no cost sharing. But here again, there are serious non-financial barriers to care. According to a study by the inspector general of the Department of Health and Human Services about half the doctors who are listed by insurers as serving Medicaid patients are not available to treat them. Those who are available often require long waits:
“For example,” the report said, “a number of obstetricians had wait times of more than one month, and one had wait times of more than two months for an enrollee who was eight weeks pregnant. Such lengthy wait times could result in a pregnant enrollee receiving no prenatal care in the first trimester of pregnancy.”
“Primary care providers, such as family doctors, internists and gynecologists, were less likely to offer appointments than specialists, the report said. But specialists tended to have longer wait times, with a median wait of 20 days, compared with 10 days for a primary care provider.”
These problems will almost certainly get worse in January when an end comes to a special Obamacare subsidy that has been enhancing the fees of Medicaid doctors for the last two years. According to the Washington Post:
“A study … from the nonpartisan Urban Institute estimated fee reductions will average about 40 percent nationwide. But they could reach 50 percent or more for primary care doctors in California, New York, New Jersey, and Illinois — big states that have all expanded Medicaid under the health law.
A system-wide problem will add to these woes: we are about to experience a severe rationing problem. If the economic studies are correct, the newly insured will try to consume twice as much health care once they have insurance and there may eventually be 25 million of them. Along the way almost everyone else is being forced to have more generous insurance than they previously had and with these new benefits they are likely to seek more care. The result: we are in the process of greatly expanding the demand for care while doing virtually nothing about supply.’ - Is Obamacare Working? John Goodman, Forbes, 12/15/2014
Link to the entire article appears below:
http://www.forbes.com/sites/johngoodman/2014/12/15/is-obamacare-working/
"More directly, Obamacare is eliminating access to many of the best specialists and best hospitals for middle-income Americans. To meet the law's requirements, major insurers all across the country are declining to participate in the exchanges, or only offering plans that exclude many of America's best doctors and hospitals. McKinsey reported 68% of Obamacare insurance options only cover narrow or very narrow provider networks, double that of one year ago." -If you like choice in health care, look to Republicans, Scott Atlas, CNN
http://www.cnn.com/2014/11/18/opinion/atlas-obamacare-failings/index.html
Atlas is correct, the vast majority of the choices on the ACA exchange are that of narrow networks regarding the 2015 offerings (effective 01/01/2015).
Last year, James and Jane Goodfellow would have had a tough time discerning what was a broad or narrow network of providers as insurers used their pet names regarding what was broad or narrow. This go around, after the insurers pet name appears, regarding PPO's (preferred provider organizations), there is inserted the term "board network" or "limited network" as a clarification for consumers.
However, once you get outside the PPO, the HMO (health maintenance organization) offerings do not explain or add a clarification what an HMO is and how it functions. One might say the HMO was/is the original narrow network (only those inside the HMO are one’s providers).
CMS and 1600 Pennsylvania Avenue are stating that one can keep one’s premium level (current ACA policyholders) or with a slight increase by switching insurers i.e. buy one of the new offerings. They fail to point out the particulars of their claim of level or slightly increased price. By switching to a more narrow network or from old insurer narrow network to new insurer narrow network, one might keep premium increases modest. However a secondary and as important phenomena is at work regarding the claim of modest price increase by switching insurers: anti-selection. How so?
Consider 10/01/2013 and the initial availability of ACA with effective date 01/01/2014. Crowded at the starting line, like a group of marathon runners awaiting the starting pistol, were hundreds of thousands of chronically ill people. This group, the existence thereof caused by a variety of reasons, wanted to obtain coverage immediately and so they did. Hence the initial group of insurers that appeared on the ACA exchange for the 2014 offering ended up with large numbers of chronically ill insured’s. Stated alternatively, rather than attracting a wide variety of homogeneous exposure units spread over a wide geographic area they attracted an inordinate number of chronically ill exposure units.
The initial group of insurers offering ACA products, attracting the chronically ill, suffered losses that that drove up loss ratios and hence premium increases were called for to offset losses.
Now comes the 2015 offerings and a new set of insurers appear. The new insurers have the knowledge that anti-selection has already occurred regarding the initial insurers. They also know that the chronically ill are less apt to change insurers for a lower price but healthy insured’s, face with a price increase yet having made no claims are very apt to change insurers based on price. The new insurers offer a slightly lower premium rate to attract the healthy away from the initial insurers. Hence the new insurers attract the healthy exposure units while the initial insurers, in the main, lose the healthy but retain the chronic.
The entire process ends with the initial insurer faced with few new entrants into their plan due to spiraling price increases and an ever increasing exodus of healthy insured’s must close the book of business regarding the offered plan and transition the remaining insured’s to a new plan or merely exit ACA.
“The insurance industry responds that critics are confusing legitimate cost-control with bias. Some state regulators, however, say there's reason to be concerned about policies that shift costs to patients and narrow their choices of hospitals and doctors.
With open enrollment for 2015 three months away, the Obama administration is being pressed to enforce the Affordable Care Act's anti-discrimination provisions. Some regulations have been issued; others are pending after more than four years.
More than 300 patient advocacy groups recently wrote Health and Human Services Secretary Sylvia Mathews Burwell to complain about some insurer tactics that "are highly discriminatory against patients with chronic health conditions and may ... violate the (law's) nondiscrimination provisions."
Among the groups were the AIDS Institute, the American Lung Association, Easter Seals, the Epilepsy Foundation, the Leukemia & Lymphoma Society, the National Alliance on Mental Illness, the National Kidney Foundation and United Cerebral Palsy. All supported the law.
Coverage of expensive drugs tops their concerns.
The advocates also say they are disappointed by how difficult it's proved for consumers to get a full picture of plans sold on the new insurance exchanges. Digging is often required to learn crucial details such as drugs covered, exact copayments and which doctors and hospitals are in the network.”
“Much of the concern is about coverage for prescription drugs. Also worrisome are the narrow networks of hospitals and doctors that insurers are using to keep premiums down. Healthy people generally shop for lower premiums, while people with health problems look for access to specialists and the best hospitals.”
“Some plans are requiring patients to pay 30 percent or more for drugs that go for several thousand dollars a month. HIV drugs, certain cancer medications, and multiple sclerosis drugs are among them.
Although the law sets an overall annual limit on what patients are required to pay, the initial medication cost can be a shock.”
“The insurance industry trade group America's Health Insurance Plans says there's no discrimination because patients have many options on the insurance exchanges. Gold and platinum plans feature lower cost-sharing, but have higher premiums. Standard silver plans generally require patients to pay a greater share of medical bills, but some have fairly robust drug coverage.
"There are plans on the exchanges that are right for people who have these health conditions," said Brendan Buck, a spokesman for the group.” - Groups claim insurance discrimination in new forms, MSNnews, 08/17/2014
Upon further review, the purchase of health insurance upon the ACA exchanges was advertised as being much like, if not exactly like, the experience consumers have when shopping at Amazon. Implicit in the advertised mantra was consumers with great knowledge in the field of health insurance. Stated alternatively, the implicit argument is that consumers when shopping at Amazon, with great knowledge of blue jeans, shoes, toasters and microwave ovens also have the same basic knowledge in health insurance.
Price really is a signal. Yep, that platinum colored microwave seems nice, but that silver microwave is less expensive. But the bronze microwave is cheap!
Total price as a signal, that is, premium outlay, maximum out-of-pocket (MOOP), doctor office co-pay, specialist co-pay, drug co-pay, network width and breath …..that was merely a shopping experience like Amazon. Total price was considered every time, all the time: Consumer knowledge was king!
Maybe not so much, huh?
Link to the entire MSN article appears below:
http://news.msn.com/us/groups-claim-insurance-discrimination-in-new-forms
The Affordable Care Act was supposedly aimed at insuring the previously uninsured. Unfortunately a woefully low percentage of previous uninsured are attracted to ACA whereas the vast majority of applicants are the previously insured merely looking for a tax credit to lower rates [subsidy]. (1)
Moreover, regarding the uninsured or the previous insured seeking subsidy, an implicit assumption by the central planners of ACA is that potential health insurance consumers are web savvy and informed consumers of health insurance. Maybe not so much regarding the uninsured which is the supposed target market of ACA.
Lower middle income and lower income people, making up a large segment of the previously uninsured, are not exactly the segment of the population with computers, computer skills and web savvy. Hence the central plan designers of the ACA have designed a delivery system known as the market place exchange web site that does not match the target market’s access point and skill set.
The same population that makes up the uninsured market, if they manage to find a computer, acquire computer skills and navigate the web site, are further assumed to be informed consumers by the central planners. Would an uninsured person or an insured person be more informed regarding health insurance? Would a person consistently uninsured in the realm of health insurance over long periods, in the main, be familiar and informed regarding health insurance?
One ends with a mismatched delivery system regarding its target market with the target market being additionally populated with uninformed market participants. Central planning at its zenith!
What are the results? Abysmal. However, highlighting two of the uninformed results may be of interest:
(a) when comparing seemingly like-kind insurance plans on the ACA web site the consumer defaults to lower price. Unfortunately the lower price many times means the consumer has purchased the ultra-narrow or narrow provider network. Hence when the time comes to use the insurance the consumer finds few takers. One might call this procedure being “informed” the hard way, (2)
(b) the supposed informed consumer will realize, without any doubt, that once his or her policy is issued they will need to request a HIPPA Release Authorization Form from their insurer, sign such form, and return it post-haste. Huh? Without the form only the named insured can access insurance information, claims paid or pending information, etc. A single person without a HIPPA Release Authorization Form filed will find no outside person can help. If a spouse is involved, sorry no information unless the form is on hand. Yes, one spouse is considered the named insured and the other spouse can only gain access if the named insured submits the HIPPA Release Authorization Form. Of course the model informed consumer of the central planner surely knows this information without a second thought. (3) (4) (5)
The plans differ; the planners are all alike... - Frédéric Bastiat
Notes:
(1) Aetna could be forced out of Obamacare: CEO, CNBC, 01/22/2014
http://www.cnbc.com/id/101354183
(2) Marketplace Plans’ Networks Are Very Small, Study Finds. Kaiser Health News, 12/12/2013
http://capsules.kaiserhealthnews.org/index.php/2013/12/marketplace-plans-networks-are-very-small-study-finds/?referrer=search
(3) Authorization Use and Disclosure FAQs
http://www.hhs.gov/hipaafaq/use/index.html
(4) HIPAA Release Form
http://www.healthcare-information-guide.com/HIPAA.html
(5) HIPPA Release Authorization Form
http://www.healthcare-information-guide.com/support-files/hipaa-release-form.pdf
'After overcoming website glitches and long waits to get Obamacare, some patients are now running into frustrating new roadblocks at the doctor's office.
A month into the most sweeping changes to healthcare in half a century, people are having trouble finding doctors at all, getting faulty information on which ones are covered and receiving little help from insurers swamped by new business.
Experts have warned for months that the logjam was inevitable. But the extent of the problems is taking by surprise many patients — and even doctors — as frustrations mount.
Aliso Viejo resident Danielle Nelson said Anthem Blue Cross promised half a dozen times that her oncologists would be covered under her new policy. She was diagnosed last year with non-Hodgkin's lymphoma and discovered a suspicious lump near her jaw in early January.
But when she went to her oncologist's office, she promptly encountered a bright orange sign saying that Covered California plans are not accepted.
"I'm a complete fan of the Affordable Care Act, but now I can't sleep at night," Nelson said. "I can't imagine this is how President Obama wanted it to happen."
To hold down premiums under the healthcare law, major insurers have sharply cut the number of doctors and hospitals available to patients in the state's new health insurance market.
Now those limited options are becoming clearer, and California officials say they are receiving more consumer complaints about access to medical providers. State lawmakers are also moving swiftly to ease some of the problems that have arisen.
"It's a little early for anyone to know how widespread and deep this problem is," said California Insurance Commissioner Dave Jones. "There are a lot of economic incentives for health insurers to narrow their networks, but if they go too far, people won't have access to care. Network adequacy will be a big issue in 2014."‘ - Obamacare enrollees hit snags at doctor's offices, Los Angeles Times, 02/04/2014
Link to the entire article appears below:
http://www.latimes.com/business/la-fi-obamacare-patients-20140205,0,1675336,full.story#axzz2sgbPiNeG
“To keep premium prices down for individuals and small businesses buying coverage through new online marketplaces, insurers have created smaller networks of hospitals. But consumers and policy experts have wondered, just how small?
Turns out, many are very small.
“About two-thirds of hospital networks on the exchanges are narrow or ultra-narrow,” said Paul Mango, a director at the consulting firm McKinsey & Co., at a conference of insurance industry leaders in Washington Thursday.
Based on research he says it took his team weeks to develop, Mango said the majority of the lowest-priced insurance plans sold through the new online marketplaces use very small networks of hospitals. The study did not evaluate doctor participation in those networks.
The issue of whether doctors or hospitals are in a network is often of utmost importance to consumers choosing an insurance policy. But prices also are important.
Mango said his research looked at 20 urban areas representing about 25 percent of the uninsured. To develop a definition of broad or narrow, McKinsey identified the biggest 20 hospitals by their number of beds. Insurance plan networks with 15 or more big hospitals were tagged as broad networks. Those with 7 to 14 were considered narrow, and those with 6 or fewer of the top 20 were considered ultra-narrow.” - Marketplace Plans’ Networks Are Very Small, Study Finds. Kaiser Health News, 12/12/2013
Link to the entire article appears below:
http://capsules.kaiserhealthnews.org/index.php/2013/12/marketplace-plans-networks-are-very-small-study-finds/?referrer=search
