Wednesday, June 19, 2013

Fwd: qotd: In-network providers are often not available

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-------- Original Message --------
Subject: qotd: In-network providers are often not available
Date: Wed, 19 Jun 2013 14:13:16 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

June 2013
Out-of-Network Physicians: How Prevalent Are Involuntary Use and Cost
By Kelly A. Kyanko M.D., M.H.S., Leslie A. Curry Ph.D., M.P.H., Susan H.
Busch Ph.D.


To determine the proportion of privately insured adults using an
out-of-network physician, the prevalence of involuntary out-of-network
use, and whether patients experienced problems with cost transparency
using out-of-network physicians.

Data Sources

Nationally representative internet panel survey conducted in February 2011.

Study Design

Screener questions identified a sample of 7,812 individuals in private
health insurance plans with provider networks who utilized health
services within the prior 12 months. Participants reported details of
their inpatient and outpatient contacts with out-of-network physicians.
An inpatient out-of-network contact was defined as involuntary if: (1)
it was due to a medical emergency; (2) the physician's out-of-network
status was unknown at the time of the contact; or (3) an attempt was
made to find an in-network physician in the hospital but none was
available. Outpatient contacts were only defined as involuntary if the
physician's out-of-network status was unknown at the time of the contact.

Principal Findings

Eight percent of respondents used an out-of-network physician.
Approximately 40 percent of individuals using out-of-network physicians
experienced involuntary out-of-network care. Among out-of-network
physician contacts, 58 percent of inpatient contacts and 15 percent of
outpatient contacts were involuntary. The majority of inpatient
involuntary contacts were due to medical emergencies (68 percent). In an
additional 31 percent, the physician's out-of-network status was unknown
at the time of the contact. Half (52 percent) of individuals using
out-of-network services experienced at least one contact with an
out-of-network physician where cost was not transparent at the time of care.


The frequency of involuntary out-of-network care is not inconsequential.
Policy interventions can increase receipt of cost information prior to
using out-of-network physician services, but they may be less helpful
when patients have constrained physician choice due to emergent problems
or limited in-hospital physician networks.

Comment: An important role of private health insurers is to control
prices through provider contracting. The current trend is to narrow
their networks of providers even more. This allows them to further
squeeze payments to the providers, in exchange for reducing the numbers
of their competitors. If that will slow the increase in insurance
premiums, then shouldn't patients be supportive? No, and here's why.

When patients obtain their care outside of provider networks, they are
inflicted with severe financial penalties, sometimes receiving no
coverage at all, plus losing the controlled rates that the insurers have
negotiated. This study shows that using out-of-network providers is
frequently unavoidable. The problem is particularly severe with
in-hospital care, adding to the already burdensome expenditures for
high-deductibles and coinsurance.

This is a direct result of placing private insurers in the role of
financial intermediaries for our health care. They profit by selling us
an inordinate amount of administrative services that we don't want and
shouldn't need, while penalizing us for obtaining care that we need when
we are unable to access providers within their narrow networks.

The model is all wrong. We need to dump the intrusive and wasteful
private insurers who are forcing on us services that we don't want but
have to pay for - like taking away our choice under threat of financial
penalty. We need to replace them with our own public program that is
designed to ensure that we get the care we need, without penalizing us
for doing so.

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