Health Access California reviews the issues of access to care, argues for the patient protections needed to ensure timely access to care, adequate provider networks, and accurate directories. March 2015

1. Networks: What Do Consumers
Care About?
Anthony Wright
Health Access California
www.health-access.org
www.facebook.com/healthaccess
www.twitter.com/healthaccess

2. Health Access California
• California’s statewide healthcare consumer
advocacy coalition
• Created in late 1980s over patient dumping
• Fought for:
– 1990s: HMO Reform, Patient Bill of Rights
– Hospital Overcharging; Prescription Drug Prices
– State Budget Battles
– Health Reform & Coverage Expansions: Children’s,
Medicaid, Employer, Comprehensive, Etc.
– The Affordable Care Act & CA’s implementation

3. BFD
Biggest Congressional Action for Consumer Protections; Coverage Expansion; Cost Containment

4. CALIFORNIA IMPLEMENTS
Millions with new consumer protections; financial assistance
4+ million Californians with new coverage already
Uninsured cut in half; Average rate hike 4.2%
CALIFORNIA IMPROVES
EARLY:
Low-Income Health Programs
Children with pre-existing conditions
Maternity coverage
BETTER:
Exchange that negotiates & standardizes
Medi-Cal express lane enrollment options
Coverage of legal & DACA immigrants
LGBT inclusion

5. Network Issues
• Headlines in the News
• “Narrow Networks”
• New Access Concerns
• Consumers and Providers
• “Mad As Hell And Not Going To Take It
Anymore.”
• New Scrutiny Under the Affordable Care Act
and Covered California
• Centrally Important: Need to Get Right
5

6. The Policy Response
• Regulation (DMHC, CDI)
• Investigation (DMHC Survey)
• Negotiation (Covered CA)
• Litigation (Courts)
• Legislation (SB964 in 2014)
(SB137 in 2015)
6

7. With ACA, Networks Matter More
• More Californians covered, more impacted
• Standardized benefits means consumers now
need to shop on price and network. Need
tools to do this.
• Not just more people, but more diverse: more
education about the network and using it.
• Lower-income families now in the market:
Going out-of-network is expensive for many;
for lower-income families it is prohibitive.
7

8. Insurers’ New Constituency
Median income in California is just below 400%FPL;
new subsidies and enrollees under 400%FPL.
What does an annual out-of-pocket limit of $6,600
mean for one living on less than $47,000 a year? 8
2015 U.S. HHS Poverty Guidelines
Family
Unit
100% 138% 200% 300% 400%
1 $11,770 $16,243 $23,540 $35,310 $47,080
2 $15,930 $21,983 $31,860 $47,790 $63,720
3 $20,090 $27,724 $40,180 $60,270 $80,360
4 $24,250 $33,465 $48,500 $72,750 $97,000

9. Out-of-Network Costs Not An Option
9

10. The Basic Promise of Managed Care
• The core principle and premise of managed care:
insurers must provide networks so that consumers can
get the care they need when they need it
• Consumer agree to a limited network—insurers
promise that the network is adequate and appropriate.
Otherwise it is consumer fraud.
• Managed Care, Limited Networks, ACOs work only if
the consumer is guaranteed:
The Care You Need, When You Need It,
at In-Network Cost Sharing
10

11. Health Access’ Perspective
• Not advocating for “any willing provider.”
• Not against “narrow networks.”
• Support an active purchaser Exchange that
bargains with health plans for lower premiums
and higher quality
• Covered California: a large group purchaser for
the individual and small group markets
• Supports health plan bargaining with providers
for lower costs and improving quality
• The ability to bargain and say “no” to providers–
balanced with need to ensure access for patients.
11

12. Confusing the Consumer
• Consumers need reliable, up to date information—
including provider directories--about who is in and who
is out of a network:
– For shopping for a plan before purchase
– For using the plan after purchase
• Medical groups, IPAs, Preferred Provider Groups:
complicate networks for consumers:
– Many of the complaints about CCI are about the delegated
model: consumers do not know that when they pick one
doctor, they are locked into a medical group
• Different networks for different products: confusing! 12

13. Covered California
• Provider directory and provider search tool
essential to consumer choice
• Some consumers will prefer and even pay
more for wider networks (MA experience), all
are price sensitive
• Californians expect limited networks but also
count on adequate networks
13

14. Network Adequacy Goal
A health plan should have:
- The right kinds of providers
- In the right places
- Available at the right times
- In sufficient quantity to meet enrollee
needs in a timely manner

15. Timely access
Care delayed is care denied.
• Timely access to care is an indicator of
adequate network and financial solvency
• With a narrow network, timely access
monitoring by DMHC is more important for
providers and consumers.
• Based on standards filed by plans since 1975,
but which plans could not demonstrate
compliance with
15

16. Timely Access to Care
• In 1975, law said:
”All services shall be readily available at reasonable times to
each enrollee consistent with good professional practice.”
• In 1997, Health Access sponsored AB497:
– same-day urgent care
– non-urgent care in ten days
– answer the phone in four minutes
• In 2010, regulations impose time-elapsed standards:
– 48 hours for urgent care
– Telephone triage within 30 minutes
– Non-urgent care:
• 10 days for primary care
• 15 for specialty

17. SB964: Adequate Network, Reliable Info
• Consumers need to be able to count on their health
plan to have an adequate network—or to send them to
the necessary out of network provider at in-network
cost sharing
• Covered California products and Medi-Cal managed
care plans should meet the same standards as
commercial health care service plan products
• SB964: if a plan uses a different network for a different
product, then DMHC should determine network
adequacy for each network
17

18. Recent Efforts
• 2014: SB964
– Annual reporting on network adequacy
– Annual reporting on timely access
– All products regulated by DMHC: group,
individual, Medicaid, Exchange
– Separate reports for separate networks
• Many commercial plans use different networks for
Medicaid than for commercial
• Some use different networks for individual market than
for employer market

19. Language Access
• Not either/or with timely access
• Critical in California, especially with the new
constituency under the ACA
• Various ways to meet the demand with
trained personnel: in-person; video medical
interpretation; Language Line as backup; NOT
untrained staff or family members
19

20. After the ACA, we all need to:

21. Networks: The Quadruple Aim
• Networks should be designed to advance the
quadruple aim:
– Better health outcomes
– Better health care
– Lower costs for consumers and purchasers
– Reduced disparities
• Networks that work improve all four, and not
one or two at the expense of the others.
21

22. Networks:
Driving the Quadruple Aim
• Easy to “lower” costs by worsening disparities:
– Dumb: Cost shift to consumers=worsening disparities, worse
care, worse outcomes
– Smart: Safer care=more cost effective care, better care, better
outcomes
• Easy to “lower” costs by advantaging providers that serve
high income populations
– Dumb: Readmissions penalties that fail to take into account
social determinants of health
– Smart: Aligning incentives so plans and providers reduce ER use
and admissions for pediatric asthma by better management
– Smart: Align incentives so plans and providers reduce ER use by
frequent flyers
22

23. Provider Directory
• California’s experience to date: What a mess!
• Nonroutine surveys of Anthem and Blue
Shield in 2014:
– Directories 2-3 years old
– 25% or more of providers not correct!
• Medi-Cal managed care worse!
• Law designed for pre-Internet era and not as
good as the Yellow Pages

24. Quality and narrow networks?
• Low cost should not mean low quality.
• Quality measures for physicians, physician
groups and hospitals as well as health plans
• Quality measures at the regional level and by
line of business (Medi-Cal, CoveredCA,
commercial)
• Quality for CoveredCA products comparable to
large employer plans?
24

25. Ideas for the Future
• How to convey the quality of network to
consumers?
• New constituency & including essential
community providers?
• People don’t live by county or state lines: How to
easily convey the geographic boundaries of a
network?
• Can an insurer design a network to maximize
excellent care for someone with a chronic
condition (AIDS, asthma, diabetes, etc.)? Can we
shift from running from risk to an incentive to
serve them better?
25

27. 2015 Efforts
• Provider Directory: SB137 (Hernandez)
– Standards across plans/insurers
– Allow people to shop for Medi-Cal managed care, exchange, off-
exchange, group coverage: it is a multi-payer world
– Find in-network provider accepting new patients
• Surprise bills at in-network facilities: AB533(Bonta)
– Consumer pays in-network cost sharing unless voluntarily consents to
out of network provider
• Annual out of pocket maximum: limited to individual cap:
AB1305 (Bonta)
• Timely Access monitoring
• California Department of Insurance emergency regulations

28. For more information
Website: http://www.health-access.org
Blog: http://blog.health-access.org
Facebook: www.facebook.com/healthaccess
Twitter: www.twitter.com/healthaccess
Health Access California
1127 11th Street, Suite 234, Sacramento, CA 95814
916-497-0923
414 13th Street, Suite 450, Oakland, CA 95612
510-873-8787
1930 Wilshire Blvd., Suite 916, Los Angeles, CA 90057
213-413-3587