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Obamacare Narrow Networks: How they affect doctor specialties

Dromaius's picture
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As we venture into the world of narrow health care provider networks, I thought I would take some time to study what they really mean, in terms of how the new networks might affect patients' access to specialty care services. To do this, I compared the current landscape of provider networks with those that will be available on the Exchanges. I used Washington State as a case study. Your mileage may vary, but you will very likely find similar information by querying insurance providers in your state, given that the narrow networks on the Exchange plans are a nationwide paradigm change.

I used Premera Blue Cross in my case study. I did so for a couple of reasons:

  1. They are the only state-wide insurance provider offered on the Washington State Exchange.
  2. They are the only Blue Cross Affiliate on the Washington State Exchange. Thus they have the best search engine for accumulating this information and for finding direct comparisons between networks.

I visited the Premera Find a Doctor site. For each doctor specialty listed in my graph below, I queried the site for "specialty name" (such as oncology) within 500 miles of 98109 (the Space Needle zip code). Theoretically, this broad search would give all of the doctors in Washington State.

Here is a graph of my findings. Posted at the bottom of this page are general instructions on how to reproduce my data. I have proof-read my data but if you find any errors or discrepancies, please let me know immediately and I will update my graph, especially if you find errors that materially affect the trends seen in my graph.

The blue bars represent the numbers of in-network doctors for each specialty in the Premera Blue Cross “Heritage” provider network, the network that Premera historically felt compelled to support for its subscribers. The red bars represent the numbers of in-network doctors on the Premera WAPlanFinder Exchange plans' provider network, called "Heritage Signature". I’ve sorted my data from left to right according to which doctor specialty has the LOWEST representation on Exchange plans.
[Update] I updated my graph today and have seen a slight drift toward more providers in the Exchange network. The change was very small and did not materially affect the trend I'm seeing, which matches the national trends. I have archived my previous chart here. I will revisit my data every week or two and will keep archives of all charts.

Bending the "cost curve" in this way appears to also bend "the care curve"
As you can see from my results, the most under-represented specialties (on the left) are the ones that typically provide services to truly sick patients, such as oncology, cardiology, internal medicine, neurology. And no doctor specialty has more than about 75% representation on the Exchange provider networks. Hospitals are also included on the right of the graph. Their numbers are diminished in the Premera Exchange plan network via excluding specialty hospitals that are crucial to good care in this region, such as Children's Hospital and the Seattle Cancer Care Alliance.

Quasi-Medicaid
What we're seeing has been described as a quasi-Medicaid level of doctor access. I would have little problem with plans that “streamline care”. But using Premera as a case in point along with reading about left-out doctors and hospitals all over the nation, I see a pattern of drastically reducing access to care for the sickest patients. This is a method for insurers to subvert the mandated yearly patient out of pocket maximums, (as well as the loss of insurers' ability to cap lifetime maximum payouts) by making access to expensive care difficult or impractical, especially for the poorest and sickest patients. And by limiting tax subsidies to Exchange plans only, I believe the Democrats wrote their law deliberately to let insurers do this.

Action, Action, Action
Come on A-list blogosphere. Is your party so important to you that you don’t care anymore about the principles that led you to join it? Don't you think you need to fight this? Maybe you should do so for the sake of your party? I would love to spend 24-hours-a-day, 7 days a week in action on this myself. However, besides the fact that I feel powerless, I'm finding that the Exchange plans create in me an urgent need to leave self-employment and venture back into the world of employer provided health insurance. So those of you with a national audience, maybe those who are getting paid to do this, how about stepping up!

To reproduce my data
Visit Premera Blue Cross Find a Doctor search engine
For each specialty you would like to search,

  1. Click Search by specialty.
  2. Enter , search within 500 miles of zip code 98109, the Space Needle zip code (Click go)
  3. In the next dialog box, choose ‘All’ in the first pulldown, ‘Bluecard PPO’ in the second pull-down. Click search.
  4. Pull down the “Plans” list. It gives the provider networks.

You’ll see a dialog that looks like this.

Heritage/Heritage Plus is the provider network used for the blue bars
Heritage Signature is for the Exchange plans, and is the network used for my red bars.
As for Foundations and Foundations Plus, it is the network that seems to have been traditionally used for the “slumming” plans.
The other networks are either in Alaska or are part of the Blue Cross nation-wide network. They don’t apply particularly to Washington.
If you need more details about this, message me and I'll send them to you.

Here is a screen capture of the best of the Premera Exchange plans. Looking at the table headings on the right, you will see that "Exchange Signature" is the provider network.

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oncol.JPG167.72 KB
signature.JPG46.65 KB
In-network provider graph 10112013.jpg232.84 KB
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Comments

Submitted by marym on

The connector is funded through federal grants, with plans to become self-sufficient by 2015 by charging customers a 2 percent fee on plans sold through the exchange, Andrews said.

This is news to me. Anyone know if this is true for all the exchanges?

Dromaius's picture
Submitted by Dromaius on

I'm pretty sure they were talking about an ...$85?... sir charge on plans sold in the Exchanges.

Rainbow Girl's picture
Submitted by Rainbow Girl on

I'm sorry -- so on top of (1) premium, (2) deductible, (3) copays, (4) co-insurance, (5) not covered (6) out of network (it's way past bankruptcy time by this point), we now have to pay a FEE to buy into this???

Please tell me this is not what it seems. And please help me find anywhere that Obama or Sebelius mentioned this "FEE" we'll be paying for the privilege of buying a bankruptcy-inducing sub-Medicaid "policy."

Dromaius's picture
Submitted by Dromaius on

The marketplace fees are likely included in the premiums.

Link to ALL the fees

Ayup, adding fees to mandated insurance is a great way to lower the cost of health care...LOL.

Splashoil's picture
Submitted by Splashoil on

A follow up call to WA Insurance Comissioner Kreidler's office neted some different information than what I reported earlier. This time I was told both plans were approved by the Insurance Commissioner as presented. IOW there was no over ride by an Administrative Law Judge.
I was not satisfied with the answer given about credit information. The spokesman told me credit information is not one of the "listed criteria." When you call down there and ask you are in deep water. It's very hard to know if your question gets a real answer.

Submitted by lambert on

This is the first study I've seen that could show how "bending the cost curve is bending the care curve."

Even more importantly, you've given a way to duplicate (or disprove) your results. If we can nail this issue in one state systematically, we can roll out the study and the technique to other states. Readers? Volunteers?

Who knew ObamaCare would be so complicate you'd need to use the scientific method to figure it out!

First they ignore you, then they ridicule you, then they fight you, then you win. -- Mahatma Gandhi

Submitted by lambert on

Here:

As you can see from my results, the most under-represented specialties (on the left) are the ones that typically provide services to truly sick patients, such as oncology, cardiology, internal medicine, neurology. And no specialty has more than about 75% representation on the Exchange provider networks. Hospitals are also included on the right of the graph. Their numbers are diminished in the Exchange plan network via excluding specialty hospitals that are crucial to good care in this region, such as Children's Hospital and the Seattle Cancer Care Alliance.

Can we translate that into a number of those who need that care that won't be able to get it? I don't even know where to begin.

First they ignore you, then they ridicule you, then they fight you, then you win. -- Mahatma Gandhi

Submitted by lambert on

I confess I am baffled and bewildered by the sheer weight of horrible problems at the nuts and bolts level.

And therefore I do not remember the key question: Those key specialties will require people to go out-of-network. Have we nailed that those expenses are not capped?

First they ignore you, then they ridicule you, then they fight you, then you win. -- Mahatma Gandhi

Dromaius's picture
Submitted by Dromaius on

Those expenses can sometimes be capped at the insurer level. However, the balance billing is never capped.

Take for instance our Bridgespan plan in WA State. They cap the premiums for an INDIVIDUAL's out of network provider usage at $12,500 (family is unlimited). However, the balance bill is NEVER capped, since it is billed by the health care provider. And remember the payouts in general on these plans is lower than the typical payouts, so the individual will be responsible for a higher balance bill amount.

And the insurance plan summaries in my state at least, always list the following at the very bottom in the finest print:

People have the option to use in-network providers, where the yearly out of pocket max is capped, but the competition will be high when they are so limited.

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Submitted by lambert on

I know you posted on this before, but I'm drawing a blank on the concept. An example would help, especially a horrible one :-)

If there's a cap, how does balance billing bite me?

First they ignore you, then they ridicule you, then they fight you, then you win. -- Mahatma Gandhi

Dromaius's picture
Submitted by Dromaius on

In-network doctors are doctors who have formulated contract agreements with insurers, wherein the doctors agree to accept discounted reimbursements from the insurance companies. By law, in-network providers are NOT allowed to balance bill.

Out-of-network doctors have not formed these agreements with the insurers. They have not agreed to accept the insurers' discounted reimbursement. Thus, once the insurer has paid out what they will pay the doctor for your care, the doctor can bill you for the difference between that amount and what the total bill is.

A complication of this is that the insurers are already paying out smaller sums to out-of-network providers with Obamacare than they were in the good old days (aka this year), so this payout can be high.

Say, you have a doctor's appointment that costs $100, but it's with an out-of-network doctor.

Your insurer allows 65% TO the provider on these appointments. That's their allowed reimbursement, period. In addition, your co-pay for out of network providers goes up to 50%

So, the insurer allows $65 for this appointment and pays $33.
You are expected to pay the other $33 because of the copay.
In addition, the out of network doctor can bill you for the difference between what the insurer ALLOWS and the actual amount billed, $35.
So the total bill for the services is $68.

Given that every out of network doctor whom you might see also has the right to balance bill you, the costs you can incur are unlimited, even when the insurance company caps your out-of-network, out of pocket max. Say your out of network cap is $12,500 (typical). Your out of network cap is really $12,500 plus whatever your out of network balance bill you.

The little fine print snippet that I linked above warns you about this a little. If you open the attached version of it, you can actually read it.

Now, Obamacare put in place some restrictions for ER visits only, that insurers have to pay out the larger of 3 amounts, one of which is the Medicare payout. To get an idea of how wonderful that is just Google how much docs love Medicare. They are dropping Medicare like a rock. The rationale for regulating those payouts was that if the payouts were decent (which Medicare isn't), then the docs would be less likely to go after you for the balance bill.

Doctors DO have the option not to balance bill. But most of them will balance bill. The docs who have refused to contract with Premera are doing so because they want more money than Premera will give. Thus, they are likely to balance bill unless you have a big sob story.

Some states disallow balance billing for emergency care. A few states disallow it for everything. But doctors are going to hang onto it. If they can't balance bill, that means they have to accept insurer payments. That means they cannot set their own rates.

Here's a nice readable, snarky post on the topic, written by a pro-balance bill guy: http://www.kevinmd.com/blog/2010/07/understanding-balance-billing-primer...

Dromaius's picture
Submitted by Dromaius on

For oncology, say....A beginning would involve finding out how many patients a given oncologist treats. Then it would involve observing how the patient loads on these limited #'s of providers increase over 2014. That would be a start.

It would all involve finding an oncologist who is willing to share information. I doubt that would be easy. They would have to volunteer.

Or, given that this is quasi-Medicaid, we already have a comparison platform to normal in Medicaid, but again, it probably would require that treatment providers share some of the information about how slowly their Medicaid patients get in to see them versus their regular patients, something they probably won't do.

Lots of articles exist about Medicaid, but they involve the extremes. It would be interesting to see what everyday is like.

Sooo, anybody know a retired oncologist?

Richard Lyon's picture
Submitted by Richard Lyon on

It seems likely that it would be necessary to wait for the horror story experiences to come out. unfortunately for the people involved, that shouldn't take too long.

Alexa's picture
Submitted by Alexa on

I see a pattern of drastically reducing access to care for the sickest patients.

This is a way for insurers to subvert the mandated yearly caps (and also the loss of the ability to create lifetimes maximums) by making access to expensive care difficult or impractical, especially for the poorest and sickest patients.

And by limiting tax subsidies to Exchange plans only, the Democrats wrote their law deliberately to let insurers do this.

Thank you, teresa!

Alexa

“If a dog won’t come to you after having looked you in the face, you should go home and examine your conscience.” -- Woodrow Wilson

[Avatar Photo Credit: Conflagrate, jurvetson's photostream, flickr]

Richard Lyon's picture
Submitted by Richard Lyon on

That was the game of adverse selection and pre-existing conditions that ObamaCare was supposed to fix. It looks like they have given the insurers a loophole to get around it.