Thursday, July 10, 2014

qotd: Exclusive Provider Organization (EPO) is an irreparably flawed concept

Los Angeles Times
July 9, 2014
Anthem Blue Cross faces another suit over Obamacare doctor networks
By Chad Terhune

Amid growing scrutiny statewide, insurance giant Anthem Blue Cross faces
another consumer lawsuit over its use of narrow networks in Obamacare

A group of Anthem policyholders sued California's largest for-profit
health insurer Tuesday in state court, accusing the company of
misrepresenting the size of its physician networks and the insurance
benefits provided.

A similar suit seeking class-action status was filed June 20 against
Anthem, a unit of WellPoint Inc., The Times has reported.

In response to the two lawsuits, Anthem said "materials at the time of
enrollment and in members' explanation of benefits have clearly stated
that the plan was an EPO plan which may not have out of network benefits."

The company added that Blue Cross Blue Shield Assn. rules required the
PPO designation on EPO member cards because coverage for emergencies is
available in other states.

In May, two San Francisco residents sued Blue Shield in state court,
accusing the company of misrepresenting that their policies would cover
the full network.

Separately, California regulators are investigating whether Anthem and
Blue Shield of California violated state law in connection with
inaccurate provider lists and making it difficult for patients to obtain
timely care.

To hold down premiums under the health law, Anthem and Blue Shield cut
the number of doctors and hospitals available to patients in the state's
new health insurance market.

These exclusive-provider organization, or EPO, health plans have been
particularly troublesome for some consumers who were accustomed to
having more conventional preferred-provider organization, or PPO, policies.

One of the major differences is that patients with an EPO plan typically
have little or no coverage if they see an out-of-network medical
provider and they are often responsible for the full charges.

"EPOs will continue to play a role," said exchange spokeswoman Anne
Gonzales. "But we're going to have to do a better job educating people
about how these networks work. We recognize the EPO model can be confusing."

Some supporters of the Affordable Care Act say the smaller size of the
provider networks isn't the problem so much as clear information about
what doctors and hospitals are available.

"The problem has been the transparency and reliability of the networks,"
said Micah Weinberg, a health-policy analyst at the Bay Area Council, an
employer-backed group.

"That's the problem that we need to fix. If we focus on narrowness we
will be focusing on the wrong thing," Weinberg added.


Comment by Don McCanne

Micah Weinberg, a health-policy analyst at the Bay Area Council, an
employer-backed group, says, "The problem (with exclusive provider
organizations - EPOs) has been the transparency and reliability of the
networks. That's the problem that we need to fix. If we focus on
narrowness we will be focusing on the wrong thing." Really? Narrow
networks are not the problem?

There is a general rule that when you are confronted with a problem you
should provide a solution that corrects the problem at its origin rather
than providing a solution that requires compliance by everyone else
involved. In the case of EPOs it would have been far better to simply
eliminate them and address cost issues by more effective policies rather
than to try to get each individual to understand EPOs and comply with
the restrictions on which health care providers will be covered -
compliance which is sometimes impossible to achieve.

Once private insurers began using networks of contracted physicians and
hospitals, compliance has been a problem for many reasons. The network
lists are difficult to access. They undergo continual revisions.
Frequently not all physicians providing coordinated health care services
are contracted with the insurer. EPOs tend to use narrower networks to
leverage more favorable contracts with those who do participate which
further limits patients' access and coverage. The individual's selection
of health plans often changes for a variety of reasons, and the networks
change accordingly. This often disrupts continuity of care.

The only rationale for EPOs is for the insurer to negotiate lower
prices. It is a terribly inefficient and disruptive way to do that. A
far more effective way of pricing health care services appropriately
would be to establish a single payer system. There would be no networks

Much the same applies to PPOs. They differ from EPOs primarily in that
they may cover a very modest portion of the charges outside of their
networks, but they do not protect the patient from prices that are
higher than the insurers' usual contracted rates. By the rule that a
problem should be corrected at its source, PPOs should be eliminated as

In fact, single payer advocates know that this applies to all private
insurance plans. They should be eliminated and replaced with a single,
publicly-financed and publicly-administered health program. You have
eliminated the problem at its origin - the private insurers - and have
replaced it with a program in which patient compliance is totally
automatic - a single payer national health program.

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