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Burwell Appears Reluctant to Add New Network Adequacy Standards

By Rebecca Adams, CQ HealthBeat Associate Editor

October 9, 2014 -- Health and Human Services (HHS) Secretary Sylvia Mathews Burwell signaled last week that the federal government is unlikely to step in anytime soon to ensure that health insurers are offering sufficiently broad provider networks or that the lists of providers that plans give to consumers are up-to-date and accurate.

The National Association of Insurance Commissioners (NAIC) is already trying to come up with revisions by December to their state law template addressing the issue. The organization is expected to vote on approving the draft and recommending it to state officials next year. NAIC senior health and life policy counsel Jolie Matthews said two weeks ago that the model state law may add requirements for insurers to update their provider lists on a regular basis.

Burwell referenced that work in a briefing with reporters when she was asked whether HHS officials will tighten their own standards. The wide-ranging briefing also covered the fight against Ebola, electronic medical records, payments to insurers that are not as profitable as expected, the federal health enrollment website and the upcoming marketplace enrollment period.

"The role of the state insurance commissioners in the networks is the place where" changes are likely to emerge, said Burwell. "We want to continue to listen and understand how the marketplace is working."

The health care law (PL 111-148, PL 111-152) requires networks to be adequate and to include a sufficient number of providers that serve low-income, medically underserved patients.

But many consumers have complained that some plans' networks offered in the new marketplaces leave out the largest or most important hospitals or physician groups in their communities.

The law also requires insurers to offer provider directories online, but consumers and research groups examining the issue also have found it hard to figure out which providers are actually in the network because the information often is outdated or confusing.

Burwell said that because HHS officials project that the number of plans offered nationwide will increase by 25 percent this year, "we're hopeful that that's going to increase more competition and diversity of the type of plans that will be in place."

HHS officials will provide "any support we can to efforts of state insurance commissioners if they have questions or need help as they're thinking through how to work on this issue," said Burwell.

Consumer and patient advocacy groups are concerned that some large children's hospitals or cancer treatment centers that are well-regarded in the community are among the providers that are not covered by insurers.

A Robert Wood Johnson Foundation––Urban Institute case study of six states released last month found that in four of them, insurers made significant changes to the providers included in their networks as they designed their marketplace coverage. In the other two states, at least some insurance companies narrowed provider networks in order to exclude more expensive providers and try to keep costs lower than they otherwise would be. Across all six states, insurers and state officials reported confusion from both consumers and providers about which providers were in insurers' networks.

Insurers may drop providers or providers may decide to stop participating in a network at any time during the year, according to insurance industry lobbyists.
Burwell said she believes the adequacy of provider networks and accurate information is "an issue for the entire system," including employer-provided insurance, and "not simply a marketplace-based issue."

She also suggested that some consumers may accept narrower networks if the plans hold down costs.

"One of the things that we saw last year in terms of what many consumers make their decisions on, and you see it in the private employer place, is actually they do make that decision often based on price and so as we continue to move forward we're going to learn––and we want to continue to learn— what consumers are making choices on and have that inform how we try and shape and influence," Burwell said. "But it is a marketplace. It is an open market and that is part of the system we have and that we support and work within."

Asked whether a consumer should have the ability to switch plans during the year if the patient's provider is no longer covered by an insurer, Burwell suggested she would think about it further.

"As we work through this and understand what the consumer actually cares about and wants, those are things that we will incorporate into our thinking," she said.

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