Tuesday, November 11, 2014
November 10, 2014
New policy calls for adequate networks for patient access, choice
The new AMA policy, which is part of a new report by the AMA Council on
Medical Service, calls for health insurers to make changes to their
provider networks before the open enrollment period gets underway each
year. Implementing changes to provider networks at this time will help
prevent patients from being stuck with plans that drop their physicians
after they already have enrolled.
The policy also reiterates the need for health insurers to provide
patients with an accurate, complete directory of participating
physicians through multiple media outlets. These lists also should
identify physicians who are not accepting new patients.
Other provisions of the new policy include:
* Promoting state regulators as the primary enforcers of network
adequacy requirements. These regulators can ensure compliance with state
network adequacy laws and regulations that are intended to make sure
patients have access to adequate provider networks throughout the plan year.
* Calling for insurers to submit quarterly reports to state regulators.
These reports should provide data on several measures of network
adequacy, including the number and type of physicians who have joined or
left the network, the provision of essential health benefits, and
consumer complaints received.
* Calling on insurers to treat patient visits to out-of-network
physicians the same as in-network visits if the plan's provider network
is deemed inadequate.
* Supporting regulation and legislation that require out-of-network
expenses to count toward a patient's annual deductibles and
out-of-pocket maximums when a patient is enrolled in a plan with
out-of-network benefits or is forced to go out of network as a result of
Comment by Don McCanne
If any organization should be able to devise policies that would correct
the deficiencies of narrow provider networks, it is the AMA. When you
read their new recommendations, clearly they leave in place the
fundamentally flawed policy of restricting patient choices of
physicians. Tweaking a policy that needs to be eliminated is not an
They speak of ensuring network adequacy, but networks are not adequate
if they eliminate your primary care provider, if they require greater
distances to travel in seeking care, if they limit access to
specialists, if they exclude physicians at centers of excellence, or if
they include any of the other restrictions that result from not having
freedom to choose from all available physicians in the community and in
Keeping provider lists current is almost impossible. Physicians often do
not notify the insurers when they close their practices to new patients
or when they move their offices. List changes of physician attrition
(retirement, license revocation, death, etc.) or of new physicians
entering the community can be difficult to keep current.
Requiring prior authorization for out-of-network services is a barrier
to care, if it is even allowed at all.
One of the more important AMA recommendations is to allow the cost of
out-of-network care to be applied to the deductibles and to the
out-of-pocket maximums. But then there would be little reason for
patients to stay in network unless they had catastrophic expenses that
could expose them to large balance-billing costs. Regardless, the
patient is still exposed at least to the high deductibles and high
out-of-pocket maximums, creating financial hardships for many of the
The AMA recently again rejected recommending single payer proposals.
That's too bad. Single payer would have taken care of not only the
narrow network problem, but also the thousands of other deficiencies
that are unique in our highly dysfunctional, market-oriented non-system
of health care financing.
at 1:03 PM