Academy Leader Meets With CMS Officials

Member Feedback Drives AAFP Advocacy on Narrow Networks

September 30, 2014 10:06 am Michael Laff Washington –

Patients and physicians in several states have spoken out against recent moves by insurance plans to reduce their physician networks, disrupting patients' health care and giving them short notice to find another physician.

[Colorized map of the U.S., reading

Last week, AAFP Board Chair Jeff Cain, M.D., of Denver, met with CMS Administrator Marilyn Tavenner, M.A., Deputy Administrator Cindy Mann and other CMS officials to discuss how the narrowing of insurance networks in Medicare Advantage and Medicaid managed care plans is preventing many patients from continuing to receive care from family physicians with whom they have longstanding relationships. The same issue is also a concern for plans being offered through the health insurance marketplaces.

Within the past year, patients in a number of states -- notably, Connecticut and Tennessee -- received letters from UnitedHealthcare that their physicians would be dropped from their insurance plan. Patients in those states were told to select another physician on a short timeline with no explanation for why their physician was being dropped.

Insurers in other states, including Humana in Texas and Cigna in Wisconsin, are following suit by reducing the number of physicians in their coverage networks.

Story highlights
  • AAFP Board Chair Jeff Cain, M.D., recently met with CMS leaders to discuss how patient care is in danger of being compromised by insurers' narrow provider networks.
  • The Academy urged CMS to require health plans to maintain the same list of physicians for an entire year and to provide physicians with cost and quality information on which network eligibility decisions are based.
  • CMS officials said AAFP was the first organization to present detailed research on the spread of narrow insurance networks.

"All of a sudden, patients can no longer see their doctor because the insurance company changed the contract after it was signed," Cain said in an interview after the meeting. "It's unfair to both patients and doctors."

Cain presented information that included new feedback from an AAFP member survey about members' experience with narrow networks. Within two weeks, a total of 253 members from 38 states responded. More physicians reported being let go by UnitedHealthcare and Humana plans than by any other insurance plan.

"Doctors were being dropped without being provided any cost or quality data, and they were not even given a reason," Cain said.

Cain urged CMS officials to examine the issue during the upcoming rule-making process for 2016, the earliest point at which the agency will be able to finalize adjustments. He asked for two specific policy changes. The first request seeks guarantees to ensure that when patients sign up for an insurance plan, they have access to the same list of physicians in that plan for an entire year.

He also asked CMS to consider a rule that would require insurance companies to share with physicians the cost and quality data they use to determine network eligibility and allow physicians a fair opportunity to respond.

"The cost and quality data should be more transparent," he said.

CMS officials pledged to use the feedback collected from family physicians in discussions with the insurance plans but did not make specific promises about pending policy changes.

"They said this is the first data they had seen on the topic, and they really valued the information about the effect of insurance companies dropping doctors who are part of the Medicaid and Medicare Advantage programs," said Cain.

It's important to realize that narrow networks do not have to carry negative outcomes for patients, Cain noted. He also shared with CMS leaders a recent National Bureau of Economic Research working paper( on narrow/high-value networks. Researchers studied the insurance plan for state employees in Massachusetts, which recently introduced major financial incentives for enrollees to choose limited network plans.

The study revealed that insurance companies employing a narrow network plan were able to reduce overall costs primarily by relying more on primary care.

For patients who moved into narrow networks, payment for primary care office visits actually increased and spending rose by 28 percent. However, visits to subspecialists fell significantly, with a 45-percent reduction in spending on subspecialty care, according to the study. But the narrow network proved effective only if patients were able to keep their primary care physician.

"(Accountable care organizations) and the ACA (Patient Protection and Affordable Care Act) were built upon the idea that patients would have the same primary care physician over time, which adds value to the system," Cain said.

CMS officials acknowledged during the meeting that the trend toward narrow networks is likely to continue, but they also recognized the need to maintain an adequate number of primary care physicians in an insurance network to preserve continuity of care.

"It was more than just one or two anecdotal stories from members," Cain said. "We had communication from hundreds of our members. We were able to demonstrate that this is a problem not just in Connecticut and Tennessee, it is even a problem in my home state of Colorado and throughout the country."

Related AAFP News Coverage
Members Invited to Respond to AAFP Survey on Narrow Networks

AAFP Denounces 'Arbitrary Elimination' of Physicians from Insurers' Networks
Academy Calls on CMS to Protect Patient Access, Care Quality