Fwd: qotd: CMS's shocking rules on QHP networks and ECPs

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-------- Original Message --------
Subject: qotd: CMS's shocking rules on QHP networks and ECPs
Date: Thu, 6 Feb 2014 13:11:58 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Centers for Medicare & Medicaid Services
February 4, 2014
Draft 2015 Letter to Issuers in the Federally-facilitated Marketplaces

This Letter provides issuers seeking to offer Qualified Health Plans
(QHPs), including stand-alone dental plans (SADPs), in a Federally-
facilitated Marketplace (FFM) and/or Federally-facilitated Small
Business Health Options Program (FF-SHOP), with operational and
technical guidance to help them successfully participate in the
Marketplaces.

Chapter 2

Section 3. Network Adequacy

Pursuant to 45 C.F.R. 156.230(a)(2), an issuer of a QHP that has a
provider network must maintain a network that is sufficient in number
and types of providers, including providers that specialize in mental
health and substance use disorder services, to assure that all services
will be accessible to enrollees without unreasonable delay.

For the 2015 benefit year, issuers will be required to submit a provider
list that includes all in-network providers and facilities for all plans
for which a QHP certification application is submitted. CMS will review
the collected provider list to evaluate provider networks using a
"reasonable access" review standard, and will identify networks that
fail to provide access without unreasonable delay. In order to determine
whether an issuer meets the "reasonable access" standard, CMS will focus
most closely on those areas which have historically raised network
adequacy concerns. These areas may include the following:

• Hospital systems,
• Mental health providers,
• Oncology providers, and
• Primary care providers.

If CMS determines that an issuer's network is inadequate under the
reasonable access review standard, CMS will notify the issuer of the
identified problem area(s) and will consider the issuer's response in
assessing whether the issuer has met the regulatory requirement and
prior to making the certification or recertification determination.

Section 4. Essential Community Providers

Essential community providers (ECPs) include providers that serve
predominantly low-income and medically underserved individuals (includes
federally qualified health centers, Ryan White HIV/AIDS Providers, Title
X Family Planning Clinics, Tribal and Urban Indian Organization
Providers, Disproportionate Share Hospital (DSH) and DSH-eligible
Hospitals, Children's Hospitals, Rural Referral Centers, Sole Community
Hospitals, Free-standing Cancer Centers, Critical Access Hospitals, STD
Clinics, TB Clinics, Hemophilia Treatment Centers, Black Lung Clinics,
and other entities that serve predominantly low-income, medically
underserved individuals).

i. Evaluation of Network Adequacy with respect to ECP

Because the number and types of ECPs available vary significantly by
location, CMS intends to propose in rulemaking an approach to evaluating
QHP Applications for sufficient inclusion of ECPs for the 2015 benefit year.

If finalized, we intend for certification year 2015 to utilize a general
ECP standard whereby the application would first have to demonstrate
that at least 30 percent of available ECPs in each plan's service area
participate in the provider network.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/draft-issuer-letter-2-4-2014.pdf


Comment: In an effort to improve the function of health plans being
offered through the Federally-facilitated Marketplaces (insurance
exchanges), CMS has issued a Draft Letter providing guidance to
Qualified Health Plans (QHPs) as they apply for certification or
recertification of their plans. From CMS's 51 page letter, two of the
issues presented warrant our special attention: 1) network adequacy for
the QHPs, and 2) network inclusion of Essential Community Providers (ECPs).

The Affordable Care Act (ACA) very intentionally included limited
provider networks as a tool to reduce health care spending. QHPs could
negotiate lower payment rates by offering physicians and hospitals
exclusivity - exchanging lower fees for higher volume, while excluding
the other physicians and hospitals in the community. The insurers seemed
to think that they were given carte blanche and trimmed these back to
narrow networks or even ultra-narrow networks. The insurers' bargaining
leverage with the few providers that sign on is even greater, plus these
narrow networks further reduce spending since patients have greater
difficulties accessing care because of transportation problems and
difficulties obtaining appointments with overbooked providers. Patients
losing their established health care providers not only have the right
to be angry, but that can also be disruptive to the care of those in
ongoing treatment programs for more serious problems. Disruption of
care, impairing access, and depriving patients of choice of their care
are opposite of the policies that reform should bring us.

The CMS Letter states that "a provider network must maintain a network
that is sufficient in number and types of providers," and that "issuers
will be required to submit a provider list that includes all in-network
providers and facilities" so that CMS can "evaluate provider networks
using a 'reasonable access' review standard."

Well, that's a nice process. Sufficient providers? Reasonable access
standard? Every community is different. How many hospitals and
physicians would be needed in each network, and, furthermore, how do you
choose which ones are to be anointed? Is this another one of those
public-private partnerships burying corruption under the banner of
market efficiency? Further, what about the next year when it turns out
that the selected providers were not so hot after all? Do you then turn
to the providers who were rejected? Not if they closed shop and left
town. Disrupting the community health care infrastructure is the
opposite of the policies that reform should bring us.

Since tens of millions will remain uninsured it is essential that ECPs
be supported. The uninsured will have to rely largely on federally
qualified health centers, disproportionate share hospitals, critical
access hospitals, rural referral centers and other institutions that
have traditionally provided care to the poor and uninsured. In many
communities, these institutions also provide services to insured
individuals, including especially those with Medicaid. Sometimes these
sites are chosen by patients because of impaired access to mainstream
providers, sometimes for convenience, and sometimes because of patient
preference, especially when these sites have always been the
individual's source of care.

So what is the new proposed CMS rule on ECPs? For 2015, CMS would
require that "at least 30 percent of available ECPs in each plan's
service area participate in the provider network." The reciprocal? The
health plans can exclude up to 70 percent of essential community
providers from its networks! ACA reduced the funding for safety-net
institutions since "everybody would be insured" so their care could be
paid for through the plans. Yet when the beneficiaries use these
essential community providers, the insurers do not have to pay for care
provided by 70 percent of these ESSENTIAL institutions. Defunding
essential community providers is the opposite of the policies that
reform should bring us.

The few good polices contained in ACA do not begin to offset all of the
terrible policies that already characterize our dysfunctional health
care system - policies that were left in place because of the highly
flawed design of ACA.

There is something we can do about it. First, it is essential that
everyone has a solid foundation in knowledge about social insurance.
Once we have that, it will be so obvious that we need a universal,
publicly financed and publicly administered program of social insurance
for health care, something like an improved Medicare that covers
everyone. For those who missed yesterday's Quote of the Day on "Social
Insurance" by Marmor et al, click on the link below, read the message,
and then buy the book.

http://www.pnhp.org/news/2014/february/social-insurance-what-you-need-to-know