AAFP Helps Improve Proposed Rule on 2017 Marketplace Plans

December 23, 2015 11:03 am News Staff

The AAFP recently responded to a proposed rule(www.gpo.gov) published in the in Dec. 2 Federal Register that aims, in part, to establish payment policies for the federally facilitated marketplace health plans operating in 2017.

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In a Dec. 16 letter(4 page PDF) addressed to both HHS Secretary Sylvia Burwell and CMS Acting Administrator Andy Slavitt, the AAFP noted its intent to continue supporting efforts to improve patient access to affordable health insurance coverage.

AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., focused his attention on sections of the proposal that most heavily impact family physicians and their patients.

For instance, he said the Academy supported the standardization of health plans offered in the Marketplace arena because doing so would alleviate consumer confusion.

"Displaying standardized plans would enable consumers to compare costs and benefits" and help them to choose a health plan that would work best for their family, said Wergin.

He also approved of CMS' proposal to include primary care visits, generic drugs and some other services as covered benefits before the application of a deductible.

Story Highlights
  • The AAFP recently responded to a proposed HHS/CMS rule that aims, in part, to establish payment policies for federally facilitated marketplace health plans.
  • AAFP Board Chair Robert Wergin, M.D., focused his attention on sections of the rule that most affect family physicians and their patients.
  • The AAFP comments covered issues such as standardizing health plans, the inclusion of primary care visits and other services as covered benefits before application of a deductible, ensuring current provider directories, and minimizing disruptive "network optimization."

"We believe this insurance design feature to be extremely important for patients with long-neglected ailments who are gaining health insurance for the first time," said Wergin.

He noted that covering some essential services with no out-of-pocket cost to patients likely would serve as an incentive for them to seek preventive care and chronic care management from their primary care physicians.

Wergin encouraged CMS to make standardized health plans mandatory and called on the agency to seek input from physicians and other health care providers, payers, patients and purchasers who are "boldly developing and deploying novel and innovative health care delivery models under programs of value-based care and payment."

The AAFP focused a good deal of its attention in the letter on issues surrounding the adequacy of health plan networks and the importance of provider directories.

"In the case of family medicine, accurate and up-to-date physician directories ensure that this entry point for health care coverage stays open and accessible for patients," said Wergin. Provider directories also help family physicians "make appropriate referrals when further specialized treatment is warranted," he added.

He encouraged CMS to automate the method by which physicians and other providers update their directory information. "Entering provider information should be web-based, allowing the provider to log into a secure website to make changes," said Wergin.

He also recommended that CMS "immediately establish and enforce a provider network adequacy standard," and pointed to a 2014 study(oig.hhs.gov) released by HHS' Office of Inspector General that found only about half of physicians listed in official plan directories were, in fact, taking new Medicaid managed care patients.

Furthermore, among those physicians who were taking new patients, about 25 percent disclosed a one-month wait time for a new-patient appointment.

The AAFP also took advantage of the opportunity to again highlight its concerns with private insurers dropping physicians from their networks seemingly without cause. In 2014, the issue took center stage in a letter(2 page PDF) from the Academy to (then) CMS Administrator Marilyn Tavenner.

Some 18 months later, Wergin brought the issue back to the table. "While the proposed rule provides various consumer assistance programs and protections, there is no mention of protections for providers if they are unfairly terminated from networks," he said.

Wergin pushed for an appeals process for physicians similar to what currently is in place for consumers. "It should be fair, timely, transparent and rarely needed," he added.

"Primary care is the most cost-effective access point for care," and reducing access is shortsighted, said Wergin. "Properly constructed narrow/high-value networks can save money for patients when family physicians have wider leeway to coordinate a patient's care with specialists, other providers and hospitals."

Wergin said so-called "network optimization" was disruptive to patients and physicians, and he called on both CMS and health plans to minimize such actions.

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