Safeguard Provider Network Adequacy, AAFP Tells CMS

Academy Tackles Narrow Networks Issue at Federal, State Levels

January 14, 2015 06:28 pm News Staff

As CMS prepares to instruct health insurers( about policies for operating on the federally facilitated exchanges in 2016, the AAFP has again alerted the agency(2 page PDF) to its ongoing concerns about patient access to care in the provider networks these insurers' health plans offer.

[Health Insurance Claim Form and stethoscope]

First, a little background: In the past two years, several insurers have chosen to reduce the number of physicians included in some of their plans' provider networks without explaining why the physicians were dropped. The result? Patients in several areas of the country have had to scramble to find new physicians on very short notice.

According to the letter from AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., to the agency, this practice disrupts the continuity of patients' health care and can impede their timely access to primary care.

"We recognize that insurers have a responsibility to align networks of physicians and hospitals to maintain affordable premiums while ensuring quality and efficiency," says Blackwelder in the letter. "However, we feel that disruptions to the patient-primary care physician relationship are contrary to both of these goals."

Story highlights
  • The AAFP has again alerted CMS officials to its ongoing concerns about how provider network inadequacy hinders patient access to care.
  • The agency is preparing to outline policies for health insurers that plan to participate in the federal health care marketplace in 2016.
  • The Academy also commented on model legislation on network adequacy created by the National Association of Insurance Commissioners.

Insurers participating in the federal exchanges are required to submit detailed reports on the physicians, health care facilities and pharmacies included in their health plans for a particular coverage area. In its draft letter to insurers, CMS explains that it will review each health plan's provider network, focusing primarily on areas with a history of concerns about provider adequacy. If the agency determines that an insurer's provider network is inadequate, it will ask the insurer to include more providers in that area or present an explanation regarding how it will offer "reasonable access" to patients.

CMS further notes that it plans to assess the adequacy of insurance networks for 2016 using processes similar to those the agency used in 2015, including applying a reasonable access standard "to identify networks that fail to provide access without unreasonable delay."

"While the AAFP encourages CMS to assess network adequacies, the AAFP believes more should be done to verify that plans operating in the federally facilitated marketplaces ensure timely access to primary care," says Blackwelder.

This most recent letter is certainly not the first time the Academy has voiced this message. Last September, (then) AAFP Board Chair Jeff Cain, M.D., of Denver, met with CMS officials to outline the Academy's concerns about the so-called narrow networks issue and its effect on patient care. The meeting took place in the wake of reports that patients in Connecticut and Tennessee had received letters informing them that their physician would no longer be in their plan's network and they needed to select another physician in a short time frame.

A subsequent survey of AAFP members showed the problem was even more widespread, a fact that Cain stressed in the meeting with CMS Administrator Marilyn Tavenner, M.A., Deputy Administrator Cindy Mann and other CMS officials.

Meanwhile, on the state level, the National Association of Insurance Commissioners (NAIC) recently released a draft version of model legislation( that focuses on network adequacy. The NAIC asked the AAFP to provide feedback on the document, and the Academy issued a statement detailing those comments(3 page PDF) just this week.

Transparency in provider network changes and ensuring provider directories are regularly updated are among issues the Academy addresses in its comments. In particular, plan changes such as reductions in services or the number of available physicians should be prohibited during the middle of a contract year.

"Overall, the model legislation will place an emphasis on ensuring covered persons have access to primary care medical homes that can coordinate care, behavioral health services, and hospital-based care to meet specific needs," says the Academy.

"Strong network adequacy standards will have the ancillary effect of promoting the primary care medical home model as a way to deliver higher quality, lower costs, and a stronger patient-physician relationship."

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