Skinny networks – Are they in your patient’s best interest?

Skinny networks – Are they in your patient’s best interest?

The Advocacy Council of ACCAI (formerly JCAAI) knows that you are concerned about skinny (or narrow) provider networks. The Affordable Care Act (ACA) (“Obamacare”) created the first federal standard for network adequacy in the commercial insurance market. The ACA regulations require that insurance plans must maintain “a network that is sufficient in number and types of providers” so that “all services will be accessible without unreasonable delay,” and are required to disclose their provider directories to the marketplace for online publication.

The Commonwealth Fund has addressed this issue with an excellent analysis. A summary of the article follows, or you can read the article in its entirety.

Attempts to limit access to specialists through the use of “skinny networks” is viewed by many as a means health plans use to avoid high-risk patients. Because plans can no longer risk-rate patients, the financial exposure of having a high-cost patient choose a plan becomes problematic. For example, parents of a child with a high-risk medical condition may decide to avoid a particular health plan based upon the availability of well-qualified specialists in that child’s condition. The plan, by virtue of how they have constructed their network, is able to avoid the financial risk of having that high-risk child in their plan.

This is particularly troubling for A/I physicians because chronic disease patients, such as people suffering from asthma, are the types of patients that plans will try to avoid. The best way to avoid a high-cost asthma patient is to keep the allergist who is treating that patient out of their network. For this reason, the Advocacy Council included information about the adverse consequences of “skinny networks” as part of the Advocacy Council’s Allergy Strike Force meetings earlier this year.

Are there enough specialists and specialties? The answer was left to the discretion of individual states and is a concern for many allergists. In 2014, it was estimated that about 50 percent of all network plans offered included narrow networks.

This concept is not new. A fair number of carriers have, before the passage of the ACA, offered “narrow” or “skinny” networks under the concept that they could offer an attractive premium with a more restricted choice of providers. This concept allowed the carriers to compete based on price, knowing that fewer numbers of specialists in the relatively high-cost specialties would be limited and hold overall costs down.

Last year was the first year that most carriers restricted specialists under the ACA. The Advocacy Council heard that many of you have been excluded from plans in which you had previously been an approved provider. In 2014, the new ACA compliance rules set a standard to assess the adequacy of specialists’ availability. The states “standard” ranged from a requirement that carriers maintain a panel of in-network providers that is “sufficient in numbers and types of available providers to meet the healthcare needs of the enrollees,” to some states where network-based plans were required to satisfy one or more quantitative measures by specifying a maximum amount of time and/or distance an enrollee must travel to access covered services. 

These rules seemed to put an excessive limitation on defining how many specialists in a specialty are sufficient. The federal rules on network adequacy seem to delegate most of the rulemaking (in this area) to the states. However, as a result of “feedback and ongoing public discussion about the benefits and risks of narrow networks, federal regulators (have) sought to increase oversight for (this) the second year of coverage.”

Federal officials are now evaluating plans on the basis of a “reasonable access” standard, which could require a widening of the “narrow access” plans. The Department of Health and Human Services is looking more carefully at how often a provider directory is updated and they have adopted a new rule to require directory updates every month. As a result of federal involvement, many state policymakers are considering whether to revisit the state’s standards.  

Finally, “as the process of refining regulatory approaches to narrow networks moves forward on multiple tracks – in individual states…and at the federal level – it is possible that…more states will enhance network transparency…allowing both physicians and consumers to address network efficiency.” 

In the meantime, let us know if you think narrow networks in your state have significantly limited patient access to needed allergy care. We believe that if there is enough evidence of risk to your patients – because too few allergists are in certain plans – we can advocate for you on this issue. We will collect these reports and see if we can open a dialogue with decision makers to obtain reasonably “wider” networks.