MEMO - Mnmed

2y ago
17 Views
2 Downloads
695.43 KB
14 Pages
Last View : 1m ago
Last Download : 2m ago
Upload by : Aarya Seiber
Transcription

MEMOTo:MMA Policy CouncilFrom:Janet Silversmith, MMA Director of Health PolicyRe:Narrow NetworksDate:May 15, 2015IntroductionThe issue of narrow networks (both insurance-created network products and providerdefined/ACO networks) was considered at the MMA Health Policy Conference on April 25,2015. The various issues associated with narrow networks were identified during a facilitateddebate between two advocates supportive of narrow networks (Daniel Trajano, MD, vicepresident for population health, Medica; Sue Hoel, senior benefits analyst, Hennepin CountyHuman Resources) and two opposed to narrow networks (Stephen Eckrich, MD, South Dakotaand Sue Abderholden, Executive Director of the National Alliance on Mental IllnessMinnesota).This memo provides background information on the issues associated with narrow networks,identifies some of the policy options that the MMA might wish to consider, and summarizes theinput captured from attendees at the April conference.Background: Network Adequacy StandardsPrior to passage of the Affordable Care Act (ACA), regulation of insurance provider networksin Minnesota was limited to health maintenance organization (HMO) products. Preferredprovider organizations (PPO) also use provider networks, but their composition and structurewere not regulated. Whereas PPOs generally provide higher benefits for services delivered byin-network providers and lower benefits for services delivered by out-of-network providers,HMOs generally exclude care provided by any out-of-network provider from coverage.Among the ACA’s requirements for insurance products to be sold on health insuranceexchanges, known as qualified health plans (QHPs), is that they must maintain a providernetwork: a) sufficient in number and types of providers, including those who specialize inmental health and substance abuse services, to ensure that all services will be available withoutunreasonable delay; and b) include a sufficient number and geographic distribution of essentialcommunity providers1 to ensure reasonable and timely access to care for low-income, medicallyIn Minnesota, essential community providers are designated by the MN Department of Health and are generallyorganizations that are nonprofit; use a sliding fee schedule to charge for services; and, have a demonstrated ability toserve high-risk and special needs populations, and the underserved. (MS § 62Q.19, Subd. 1)1

underserved individuals in a QHP's service area.2 With no further federal guidance offered,states were left to implement the QHP network standards and to ensure compliance.As part of the 2013 Minnesota Legislature's authorization of MNsure, it established explicitpolicy intended to "ensure fair competition for all health carriers in Minnesota, to minimizeadverse selection, and to ensure that health plans are offered in a manner that protectsconsumers and promotes the provision of high-quality affordable health care, and improvedhealth outcomes.”3 This policy created a common set of rules for all individual and small-groupinsurance products, whether or not they were sold on MNsure. Among those rules was aprovider network adequacy provision that would apply beyond HMOs to include “all healthcarriers that either require an enrollee to use or that create incentives, including financialincentives, for an enrollee to use providers that are managed, owned, under contract with, oremployed by the health carrier.”4Borrowing from the previous network requirements for HMOs, the Legislature createdgeographic standards for health plan networks. These required that the network be able toensure enrollee access to care as follow: The lesser of 30 miles or 30 minutes to the nearest provider of primary care services,mental health services and general hospital services;5The lesser of 60 miles or 60 minutes to the nearest provider of specialty physicianservices, ancillary services, specialized hospital services and all other health services.6In addition, the networks must have enough providers, including those who specialize inmental health and substance use disorders, to ensure that covered services are available to allenrollees without unreasonable delay.7The Minnesota Department of Health is responsible for enforcing the network adequacystandards. To further guide the department’s review of network adequacy, the Legislaturenoted the following: Primary care physician services must be available and accessible 24 hours per day, sevendays per week, within the network area;45 CFR 156.230(a).MS § 62K.02, Subd. 1.4 MS § 62K.10, Subd. 15 MS § 62K.10, Subd. 2.6 MS § 62K.10, Subd. 3.7 MS § 62K.10, Subd 4.23

The network must have a sufficient number of primary care physicians who havehospital admitting privileges at one or more participating hospitals within the networkarea so that necessary admissions are made on a timely basis;Specialty physician service must be available through the network or contractarrangement;Mental health and substance use disorder treatment providers must be available andaccessible through the network or contract arrangement;Non-physician primary care providers must be available and accessible, to the extentpermitted under state scope of practice law;The network must have available (or through arrangements) appropriate and sufficientpersonnel, physical resources and equipment to meet the projected needs of enrolleesfor covered health care services.8Networks are also required to offer a contract to any essential community providers within theservice area.9The Legislature's standards for network adequacy include a provision allowing insurers toapply for a waiver of the geographic standards. A waiver for up to four years can be granted ifcomplying with the 30 minutes/miles and 60 minutes/miles standards is not feasible in aparticular service area.10 According to the Department of Health, it is not uncommon toauthorize waivers, often due to limited availability of specialty physicians in certain geographicareas.11Background: Role of Narrow NetworksPrior to passage of the ACA, insurers had a variety of ways of designing price-competitivepolicies, from limiting or excluding certain benefits to employing complex cost-sharingoptions. In a move aimed at improving coverage and making it easier to compare products, theACA eliminated some of those options by establishing new standards for cost sharing (bronze,silver, gold and platinum benefit levels) and creating a set of essential health benefits that mustbe included in all non-grandfathered plans.12 As a result, many insurers have moved towardlimiting or narrowing their provider networks as a way to create less expensive products.MS § 62K.10, Subd 4 (1-6).MS § 62K.10, Subd. 7.10 MS § 62K, Subd 5.11 Personal communication with Tom Major and Diane Konecny, Minnesota Department of Health, November 18,2014.12 Under the ACA grandfathered plans are exempt from several provision of the law (e.g., preventive visit coveragewithout cost sharing, essential benefits, out-of-pocket maximums) if the plan covered a worker at the time of ACApassage and the plan has not had significant changes that reduce benefits or increase employee costs. Approximately26% of insured workers were enrolled in grandfathered plans in 2014 (Kaiser Family Foundation/Health ResearchEducational Trust. Employer Health Benefits: 2014 Summary of Findings, 2014 Annual Survey).89

There is significant price competition among insurance products on insurance exchanges. In itsfirst year (2014), MNsure boasted insurance products with the lowest average premiumscompared to other states and the federal exchange, although it also had among the highestaverage deductibles ( 4,061 in MN, compared to 2,762 average of all others for silver plandeductibles).13A general review of qualified health plans (QHPs) sold on MNsure in 2014 suggested variationin network breadth among the five health plans offering products (BCBS, PreferredOne,HealthPartners, Medica, UCare). Some of the networks’ names offered insight with the trend toward greater transparency in health carecosts and quality, is to strive for greater transparency regarding network composition. Forexample, MNsure has not yet accomplished the functionality that would allow individualspurchasing coverage to search for products based on available physicians, hospitals or otherproviders. Network directories/lists have also been found to be inaccurate. There is also someconcern that network participants may not all be taking new patients, further challenging thelevel of access associated with some networks.Transparency may also be applicable to provider/ACO networks. For example, it is not clear towhat extent patients are fully informed of policies/practices to limit referrals outside of thesystem/ACO network. It is also not clear to what extent physicians within systems/ACOnetworks are being compelled to limit referrals against their preferences.Policy Conference InputAttendees at the policy conference were polled on their opinions on several narrow networkrelated topics.

The following summarizes the pre-debate responses to the debate thesis question:“Limited insurance networks and closed ACO networks undermine the physician-patientrelationship by limiting continuity of care and patient choice.”Strongly agreeAgreeDisagreeStrongly disagreeDon’t know50.0%19.2%11.5%11.5%7.7%N26The following summarizes the post-debate responses to the debate thesis question. Mostattendees continued to agree with the statement, but the level of support softened.“Limited insurance networks and closed ACO networks undermine the physician-patientrelationship by limiting continuity of care and patient choice.”Strongly agreeAgreeDisagreeStrongly disagreeDon’t knowN30.8%26.9%11.5%23.1%7.7%26Other responses from attendees included:How big of a threat do narrow insuranceprovider networks pose to doctorpatient relationships?No threatSlight threatModerate threatSignificant threat4.0%32.0%48.0%16.0%N25

How big of a threat do narrowACO/system networks pose to doctorpatient relationships?No threatSlight threatModerate threatSignificant threat13.0%34.8%21.7%30.4%N23Responses to preferred policy options were as follows:What policy position would you like tosee MMA pursue regarding narrowprovider networks?Work to prohibit their use0.0%Seek greater transparency about networklimits for patientsSupport more stringent definition of network“adequacy”Support “freedom of choice” lawSupport “any willing provider” lawAllow market to determine their valueN34.6%7.7%11.5%23.1%23.1%26

COMPARISON CHART: AWP VS. FOCISSUEDefinitionAny Willing Provider(AWP)AWP laws generally requireinsurers/health plans to allow anyphysician, hospital or other providerinto their networks if they are willingto meet the terms and conditions of theplanFor purposes of the AF&Drecommendation to the MMA Board,network status was dependent on thephysicians’ willingness to accepthealth plans payment and qualityassurance terms and conditions.Freedom of Choice(FOC)FOC laws generally allow health planenrollees to obtain reimbursable health careservices from any qualified provider (e.g.,licensed, able to provide services covered bythe enrollee’s benefit contract) even if theprovider has not signed a contract with thehealth plan (payment is generally at innetwork rates; enrollees may face additionalcosts for charges above in-network amount).ApplicationWould apply to insurance/health planproducts that use a defined network.Could apply to any insurance/healthproduct as well as to other risk managementarrangements, such as ACOs (accountableprovider networks, M.S. § 62T.01).Impact onhealth care costsWhile the impact of AWP laws onhealth care costs is not definitive, thereis some empirical data that theyincrease costs somewhat by limitingthe negotiating clout of payers,Similar cost arguments as AWP – the valueof network status to physicians or otherproviders (and, hence, the negotiating cloutof payers) is more limited if volume is not anexpected return for lower rates. FOC lawsNOTESAWP/FOC laws havedifferent orientations to asimilar problem.AWP laws focus oninsurance network status forphysicians/other health careproviders.FOC laws focus on patients’insurance benefits andprovide for payment atnetwork levels to anyphysician/health careprovider.Theoretically, FOC lawscould be applied morebroadly than AWP laws andcould help address concernsabout “closed” ACO panels.Opponents of AWP/FOCwill certainly use costcontainment as a primaryargument against adoption.

ISSUEQualityAny Willing Provider(AWP)increasing transaction costs, andchallenging utilization management.Freedom of Choice(FOC)make creation of networks morechallenging.AWP laws generally retain for theinsurer/health plan some ability todefine network standards/criteria, suchas quality or efficiency standards.FOC laws could be viewed as undermininghealth plans’ ability to manage quality andefficiency to the extent that health planenrollees could access care from anyphysician or other provider – he/she maynot otherwise meet the plans’ credentialingor other QI criteria.NOTESFTC opposition – thatAWP/FOC is anticompetitive – bolsters thisposition.Under AWP, insurers stillretain other cost-savingtechniques such as priorauthorization with theirnetwork. Under FOC, thereach of insurers to applythese techniques issignificantly limited.The AF&D Committee’soriginal recommendationincluded the ability for thehealth plan to define thequality standards requiredfor network status.Concerns about the impactof FOC laws on quality maybe relevant to the extent thatinsurers/healt

HealthPartners, Medica, UCare). Some of the networks’ names offered insight into their provider make up (e.g., Medica North Memorial Acclaim, UCare Fairview Health, BCBS Sanford). The smallest network identified was the Medica North Memorial Acclaim Network, which included only 22 clinics—all of which were North clinics or Buffalo clinics.

Related Documents:

Past exam papers from June 2019 GRADE 8 1. Afrikaans P2 Exam and Memo 2. Afrikaans P3 Exam 3. Creative Arts - Drama Exam 4. Creative Arts - Visual Arts Exam 5. English P1 Exam 6. English P3 Exam 7. EMS P1 Exam and Memo 8. EMS P2 Exam and Memo 9. Life Orientation Exam 10. Math P1 Exam 11. Social Science P1 Exam and Memo 12.

52 19 12/4/1970 Memo From Harry Dent to John Brown RE: Action Memo P1061. 1pg. Set 2/3. White House Staff 52 19 12/2/1970 Memo From John R. Brown III to Harry Dent RE: Gordon Wade. 1pg. Set 3/3. White House Staff 52 19 12/1/1970 Memo Action Memorandum from Staff Secretary to H. Klein RE: Television plan for Tricia, Julie and David. 1pg. Set 1/3 .

This mode let you start to take a quick memo on the last template you chose. 1. Select MemoPAD mode. 2. Tap Quick Memo icon. Memo Pad Creating a New Memo. 1. From Safari, Mail . * You should have an account of DropBox and Google Docs to upload your files. Create ID

Mémo candidat Motocross 1 . 2017/V2 MEMO CANDIDAT OCS / ODC 1 MOTOCROSS Ce mémo résume dans la première partie, les devoirs de l’organisateur envers les officiels de l’épreuve (en particulier du Directe

Foundations "NSSO develop a National PNT Architecture" "NPCO will initiate an effort with NSSO" "RITA will lead effort on behalf of DOT for the civil community" ASD/NII Memo 23-Jan-2006 ASD/NII Memo 23-Jan-2006 NPEC Action Items 26-Jan-2006 NPEC Action Items 26-Jan-2006 DOT/RITA Memo 14-Mar-2006 DOT/RITA Memo 14-Mar-2006 PNT .

The warnings should be clear and unambiguous. Each warning should be in writing, in the form of a memo or letter. It is a good idea to have the employee sign a copy of the memo or letter acknowledging that the memo has been received and read. In order to terminate an employee for poor performance for just cause, the warning must

past exam paper & memo n4 about the question papers and online instant access: thank you for downloading the past exam paper and its memo, we hope it will be of help to . between 2014-2019. the papers are in pdf form and each pdf has a minimum of seven different papers. the years for the papers you are purchasing are also included on the website.

1.1 Local Hooking API In the following, methods marked with no asterix are available in user- AND kernel-mode, methods marked with one asterix are available in user-mode only and methods marked with two asterix are available in kernel-mode only. In general, if a method is available in both modes, it will behave the same