Fwd: qotd: Got cancer? Don't buy a plan in our network.

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-------- Original Message --------
Subject: qotd: Got cancer? Don't buy a plan in our network.
Date: Thu, 20 Mar 2014 14:14:06 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Associated Press
March 19,2014
Health Law Concerns for Cancer Centers
By Ricardo Alonso-Zaldivar

Cancer patients relieved that they can get insurance coverage because of
the new health care law may be disappointed to learn that some the
nation's best cancer hospitals are off-limits.

An Associated Press survey found examples coast to coast. Seattle Cancer
Care Alliance is excluded by five out of eight insurers in Washington
state's insurance exchange. MD Anderson Cancer Center says it's in less
than half of the plans in the Houston area. Memorial Sloan-Kettering is
included by two of nine insurers in New York City and has out-of-network
agreements with two more.

In all, only four of 19 nationally recognized comprehensive cancer
centers that responded to AP's survey (members of the National
Comprehensive Cancer Network) said patients have access through all the
insurance companies in their state exchange.

Not too long ago, insurance companies would have been vying to offer
access to renowned cancer centers, said Dan Mendelson, CEO of the market
research firm Avalere Health. Now the focus is on costs.

"This is a marked deterioration of access to the premier cancer centers
for people who are signing up for these plans," Mendelson said.

Those patients may not be able get the most advanced treatment,
including clinical trials of new medications.

And there's another problem: It's not easy for consumers shopping online
in the new insurance markets to tell whether top-level institutions are
included in a plan. That takes additional digging by the people applying.

To keep premiums low, insurers have designed narrow networks of
hospitals and doctors. The government-subsidized private plans on the
exchanges typically offer less choice than Medicare or employer plans.

By not including a top cancer center an insurer can cut costs. It may
also shield itself from risk, delivering an implicit message to cancer
survivors or people with a strong family history of the disease that
they should look elsewhere.

For now, the issue seems to be limited to the new insurance exchanges.
But it could become a concern for Americans with job-based coverage too
if employers turn to narrow networks.

In a statement, Anthem said its network was based on research involving
thousands of consumers and businesses. "What we learned was that people
are willing to make trade-offs in order to have access to affordable
health care," the company said. "Our provider networks reflect this."

http://hosted.ap.org/dynamic/stories/U/US_HEALTH_OVERHAUL_TOP_CANCER_CENTERS

Members of the National Comprehensive Cancer Network
(http://www.nccn.org/members/network.asp)

****

CMS
March 14, 2014
2015 Letter to Issuers in the Federally-facilitated Marketplaces

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… to assure that all services will be accessible
to enrollees without unreasonable delay. All issuers applying for QHP
certification will need to attest that they meet this standard as part
of the certification/recertification process.

CMS will assess provider networks using a "reasonable access" standard,
and will identify networks that fail to provide access without
unreasonable delay as required by 45 C.F.R. 156.230(a)(2).

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.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2015-final-issuer-letter-3-14-2014.pdf

****

KFF.org
February 26, 2014
Kaiser Health Tracking Poll: February 2014
By Liz Hamel, Jamie Firth and Mollyann Brodie

The latest Kaiser Health Tracking Poll finds that, in general, the
public leans towards more expensive plans with broader networks. About
half (51 percent) say they would rather have a plan that costs more
money but allows them to see a broader range of doctors and hospitals,
while just under four in ten (37 percent) prefer a plan that is less
expensive but allows them to visit a more limited range of providers.
While older individuals and those with higher incomes exhibit a clearer
preference for more expensive plans with broader networks, younger
adults and those with lower incomes are more evenly divided in their
preferences. But those who are either uninsured or currently purchase
their own coverage – a group that is most likely to be in a position to
take advantage of new coverage options under the ACA – are more likely
to prefer less costly narrow network plans over more expensive plans
with broader networks (54 percent versus 35 percent). Those who
currently get their insurance through an employer (and are more
protected from the cost of coverage) have the opposite preference: 55
percent prefer a more expensive plan with a broader network, while 34
percent would rather have a cheaper narrow network plan.

Those who prefer narrow network plans may be less likely to prefer them
if it means they can't see their usual providers. When those who prefer
a less costly narrow network plan are presented with the possibility
that they would not be able to visit the doctors and hospitals they
normally use, the share who continue to prefer this option drops from 37
percent to 23 percent among the public overall, and from 54 percent to
35 percent among the uninsured and those who buy their own insurance.

On the other hand, when those who initially prefer a more expensive plan
with a broader network are told that they could save up to 25 percent on
their health care costs, the share continuing to prefer the more
expensive option drops from 51 percent to 37 percent among the public
overall, and from 35 percent to 22 percent among those the uninsured and
those with non-group coverage.

http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-february-2014/

****


Comment by Don McCanne

For decades we have been hearing heartrending stories of children and
adults under 65 who develop cancer but were uninsured. For those of us
striving for a comprehensive health care program for everyone, there
could not be a greater motivating force than the desire to eliminate
forever the twin tragedies of impaired access to care and personal
financial ruin for these unfortunate cancer victims.

The Affordable Care Act brought us expanded access to private insurance
plans with incentives for the insurers to provide plan innovations to
help slow spending on health care. Although plans already were using
limited networks to leverage lower prices from the providers, the degree
to which they would further narrow networks was not expected, except
perhaps by the cynics amongst us.

But the insurers have no shame. Cancer management is expensive. What
better place to restrict access could there be than to remove most
members of the National Comprehensive Cancer Network from many of their
insurance networks. Only four of nineteen of these centers are included
in all exchange plan networks within their respective states.

CMS tells us that they will use a "reasonable access" standard when the
plans are recertified for the federal exchanges next year. This is a
relative rather than an absolute standard. They have no intention of
opening up insurer networks to all comers. That would defeat the
insurance innovation of controlling costs by blocking access to
out-of-network providers, especially the expensive ones such as the
members of the National Comprehensive Cancer Network.

The latest Kaiser tracking poll is of concern since it shows that
lower-income and uninsured people will select the plans with more
restricted networks simply because the premiums are lower. No
centers-of-excellence cancer care for them.

Although insurers are prohibited from denying coverage, just think of
the advantage they would have in avoiding adverse selection by being
able to tell those patients who have cancer that they really don't want
to buy the plans they offer since the nation's noted cancer institutions
are not covered. They can do the cancer victim a favor by sending her to
a competitor. Then they can retreat into their headquarters to devise
yet more insurance innovations that work this well.

A single payer national health program would not have networks. Patients
could go anywhere. With an improved primary care infrastructure, they
would receive assistance in obtaining the best care for their medical
condition. For those with cancer, there would be no private insurers
profiting off of discount cancer care, though the single payer system
would take care to see that the services are priced right for the
benefit of us taxpayers who would be financing our health care system.