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Tuesday Jul 29, 2014

We're Not Gonna Take It: Network Optimization Disrupts Continuity of Care

Hundreds of family physicians recently have been informed that they are no longer eligible to provide care to patients covered by certain insurance policies. Sadly, most of these physicians were not notified directly by insurers. Instead, patients told the affected physicians that they received a letter stating that their family physician is no longer covered by their insurance plan. These patients and their family physicians were not given any justification why these actions are being taken. They were only given a date on which their relationship would be terminated. These patients are rightfully upset, their family physicians are mad, and the AAFP is taking aggressive action.

To quote the 1980’s rock band Twisted Sister, “We’re not gonna take it.” Last week, the AAFP wrote letters to America’s Health Insurance Plans (AHIP) and United Healthcare notifying them of our concerns and urging them to take a more responsible approach to the formation of their provider networks – especially with respect to primary care physicians.

We also wrote a letter to CMS Administrator Marilyn Tavenner, M.A., expressing concern with actions taken in Tennessee with respect to TennCare, the state’s Medicaid program. TennCare, operated by UnitedHealthcare Community Plan, recently informed hundreds of individuals that they would need to change primary care physicians or face higher out-of-pocket expenses for their health care.

In addition to these letters, we are meeting with representatives from the insurance industry as well as individual plans to identify ways to curb the negative impact of these decisions. We also are working closely with state chapters to draft letters to governors and state insurance commissioners questioning the legality and purpose of such actions.

Our recent actions are in addition to the "friend of the court" brief the AAFP joined, along with several other medical societies, in support of two Connecticut medical associations that sued United Healthcare in 2013, challenging its actions to summarily “dump” more than 2,000 physicians from its Medicare Advantage network in the state of Connecticut.

Although the practice of “network optimization” is not new, the disruptive manner in which it is being executed is troubling to the patients, their family physicians and the AAFP. Fearing that insurance companies may tighten networks -- similar to health maintenance organizations in the 1980s and 1990s -- Congress included in the Affordable Care Act provisions that require insurance plans participating in the Health Insurance Marketplaces to provide an “adequate” network of physicians and hospitals. The compelling criteria are that insurance plans include a “choice of providers” and that networks include “essential community providers.” The National Association of Insurance Commissioners (NAIC) has a great paper(www.naic.org) on network adequacy that provides an excellent overview of the issue.

The AAFP is deeply concerned with actions being taken by insurance companies. Decades of peer-reviewed studies have shown that there are two factors that contribute to better health outcomes for individuals – health care coverage and a usual source of care. We also know from research that patients that have a continuous and longitudinal relationship with a primary care physician have better health care outcomes at lower costs than those who do not have a continuous relationship with a primary care physician.

The AAFP has evidence that thousands of patients, in multiple states, are being told that they must identify a new family physician in the next few months as a result of their family physicians being dropped from certain insurance products as a result of insurers optimizing their provider networks to better align resources. Many of these patients will have years' long relationships with their family physicians terminated in the name of efficiency. These actions are tremendously disruptive to a physician practice, but we are most concerned with the disruption patients face as they are told to change primary care physicians without any input in the decision – not to mention the lack of an appeals process in many cases. These patients face intrusive disruptions in their care and an uncertain future as a result of these actions.

We recognize that insurers have a responsibility to align networks of physicians and hospitals to maintain affordable premiums while ensuring quality and efficiency, but we feel that disruptions to the patient-physician relationship at the primary care level are contrary to both of these goals. Primary care is relatively inexpensive as compared to specialty or hospital care. It also benefits from continuity and trusting relationships. We are baffled by the language used by insurers who say they support patients having a continuous relationship with a primary care physician and then act in a way that make this impossible. In short, we are no longer flattered by insurers’ language that speaks to our policy goals but are demanding action that aligns their public comments with their actions in the health care market place.

If you have received a letter from an insurance company notifying you that you or your practice is being dumped -- oh, excuse me, “optimized out of network” -- please notify your AAFP chapter. We are in close contact with the chapters on this issue, and it benefits our efforts to organize actions by states and regions.

Wonk Hard

The Congressional Budget Office (CBO) has released its 2014 Long-Term Budget Outlook(www.cbo.gov) and predicts that the Independent Payment Advisory Board (or IPAB) created under the Affordable Care Act will not go into effect for the next 10 years due to a slowing in overall Medicare spending. IPAB, in concept, is a 15-member panel tasked with achieving specified savings in Medicare if spending growth exceeds a set target. They are not allowed to negatively impact benefits, coverage or quality – meaning they can only cut payments. The controversial panel has yet to have any members appointed to it, and its funding was cut by $10 million in the most recently enacted spending bill.

Jonathan Easley at Morning Consult wrote a great explanation(themorningconsult.com) on the politics of IPAB.

Posted at 09:00AM Jul 29, 2014 by Shawn Martin

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ABOUT THE AUTHOR



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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