Increasingly, changes that health insurance companies are making to their products in markets across the country -- including eliminating primary care physicians from plan networks -- are sparking frustration among patients and physicians. Nationwide, patients who have long-established relationships with their physicians are learning that they must select another physician within only a few months.
Adding insult to injury is the fact that patients -- like their physicians -- are not aware of the reasons behind the changes and, in most cases, are unable to appeal the decision.
In response, the AAFP sent a number of letters last week outlining its growing concern regarding the practice of limiting physician networks. In a letter to CMS Administrator Marilyn Tavenner,(2 page PDF) M.A., AAFP Board Chair Jeff Cain, M.D., of Denver, specifically asked the agency to step in to protect the interests of Medicaid beneficiaries in Tennessee.
At issue is the fact that many of the state's Medicaid patients who are insured by UnitedHealthcare (UHC) Community Plan recently received a letter stating that their primary care physician would no longer be included in the plan's network. UHC Community Plan is one of three managed care organizations authorized to provide benefits to Tennessee Medicaid recipients.
- The AAFP is strongly protesting the continuing practice of insurers limiting patient choice and access to primary care.
- Among other actions, the Academy specifically asked CMS to intervene in Tennessee where a large insurance carrier is seeking to drop physicians from Medicare Advantage.
- Patients who seek low-cost insurance plans are often unaware of how narrow their insurance network is in terms of available physicians.
"As the agency overseeing the integrity of the Medicaid program, we feel compelled to alert you to our concerns with these practices and solicit your immediate intervention on behalf of Tennessee Medicaid beneficiaries," said Cain in the letter.
"While these actions are tremendously disruptive to a physician practice," Cain added, "we are most concerned with the disruption patients face as they are told to change primary care physicians without any input into 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."
It's not the first time UHC has run afoul of the Academy and other groups because of its decision to drop family physicians and others from its rolls. Last year, thousands of physicians in multiple specialties and multiple states, including Connecticut, Florida, Ohio and Rhode Island, found themselves caught up in UHC's efforts to downsize its Medicare Advantage physician networks.
Last December, a U.S. district judge issued an injunction against UHC in Connecticut, preventing the insurer from dropping 2,000 physicians in Hartford and Fairfield counties from the Medicare Advantage program. Earlier this year, a judge rejected the insurer's request to drop the injunction. Both sides are headed to arbitration to settle the dispute.
In last week's letter to UHC(2 page PDF), the AAFP chided the insurer for its recent actions. Physicians under contract with the company were dropped from its Medicare plan but not from other commercial plans, the letter pointed out, indicating that quality of care was likely not a factor in the policy change.
"This so-called 'network optimization' is disruptive to patients and their physicians and, in our opinion, a violation of the core tenets of quality primary care," said the letter.
Sizing Up the Problem
Insurance networks are classified based on the proportion of large hospitals in a community or region that participate in a given plan. Thus,
- a broad network is classified by consultant McKinsey & Co. as one in which 70 percent or more of the 20 largest area hospitals participate in the plan,
- a narrow network includes 31 to 70 percent of area hospitals, and
- an ultra-narrow network includes no more than 30 percent of area hospitals.
Narrow networks make up 48 percent of all exchange networks nationally and 60 percent of networks in the largest city of each state, according to McKinsey.
"If patients go to a new physician, they lose the trusting relationship established with their physician. The value of those physicians rests on their familiarity and unique experiences with each of their patients to create and manage an appropriate treatment plan."
In a third letter sent to Karen Ignagni(3 page PDF), president and CEO of America's Health Insurance Plans (AHIP), the AAFP laid out its overall apprehensions regarding the policy steps insurers are taking to cut plan costs, saying that in all likelihood, such actions will prove counterproductive.
"We recognize that insurers have a responsibility to align networks of physicians and hospitals to maintain affordable premiums while ensuring quality and efficiency," said the Academy. "However, we feel that disruptions to the patient-primary care physician relationship such as those being implemented by UHC Community Care are contrary to both those goals."
The Alliance for Health Reform hosted a recent discussion on narrow insurance networks, during which panelists discussed how the range of choices is often sacrificed as both insurers and patients place a priority on keeping costs low.
Panelist Paul Ginsburg, Ph.D., Norman Topping Chair in Medicine and Public Policy at the University of Southern California, Los Angeles, contended that a smaller network of physicians and hospitals can offer long-term cost savings.
"Limited networks have the potential to lower costs," Ginsburg said. "They are steering volume to lower-cost providers. When enough plans do this, it can lower costs."
Still, patients have said they would pay more for a plan that allows them a greater range of choices. According to the results of a Kaiser Family Foundation survey(kff.org) conducted in February, 51 percent of respondents overall said they would prefer a plan that costs more but provides more choice in terms of doctors and hospitals. Thirty-seven percent said they would prefer a plan that costs less even if it included a narrow network.
Of the 51 percent who favored a broader plan, however, when told they could save as much as 25 percent off their health care costs by settling for a narrower network of providers, only 37 percent of the same group preferred the costlier plan with greater access.
"Broad provider choice is a luxury that few people can afford," Ginsburg said. “A (narrow) network plan can be successful in the exchanges (established under the Patient Protection and Affordable Care Act [ACA]) if 50 percent of the people sign up. In an employer-based plan, that would be a disaster."
Paul Ginsburg, Ph.D., left, a professor of health policy at the University of Southern California, and Daniel Durham, vice president of Policy and Regulatory Affairs for America's Health Insurance Plans, discuss insurance networks during a recent policy meeting in Washington.
Among those Kaiser surveyed who were uninsured or purchased their own insurance, 54 percent said they preferred less costly plans. However, when individuals who favored lower-cost narrow networks were presented with a plan that did not include their regular physician and hospital, support for narrow networks dropped by 15 percent to 20 percent.
"The reality of the marketplace is that price dominates," said Katherine Arbuckle, chief financial officer of Ascension Health, who also participated in the panel. "Premiums are what consumers are most likely to look at as the reason people choose a network. Even modest out-of-pocket costs can create affordability issues. High-deductible plans are not only unaffordable, but they can lead to poor care."
Milack Talia, senior strategist for practice environment for the AAFP, suspects that many individuals, especially younger, healthier people, are purchasing insurance plans but have no intention of using them -- even though an annual physical, for example, is covered.
"When you buy a car, you want to know about the car's gas mileage, its reliability and the consumer reviews," said Talia. "Why don't people do the same thing with health plans?"
Indeed, consumers' awareness about what their plan includes is relatively low. According to McKinsey, 26 percent of individuals who obtained an ACA health care plan were unaware that their plan included a narrow provider network.
Granted, information available to patients -- and physicians -- is often limited. In some cases, online physician directories are outdated, or a physician may think he or she is part of an insurance provider's entire network but actually only be under contract for a particular plan. Arbuckle acknowledged that carriers have to inform patients about how their plan operates and what their share of the costs will be.
"Insurers need to be more accountable in educating customers on their products," she said.
One way to reduce confusion would be to require that insurers identify their narrow network plans, Ginsburg suggested. But Brian Webb, manager of health policy and legislation for the National Association of Insurance Commissioners, said his group is not considering that option as it continues to revise managed care model legislation.
Still, Webb noted, "Consumers need to know if their physician is in their particular plan or not."
He said the group developed the Managed Care Plan Network Adequacy Model Act, which includes elements to protect patients. Ten states have adopted the model act, and another 10 states have adopted a similar model. One section of the act includes a provision requiring insurance carriers to maintain a network with both a sufficient number and type of physicians to assure access without an unreasonable delay.