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Insurer-Run Medicare Plans Pressured to Guarantee Doctor Supply

By Kerry Young, CQ Roll Call

September 28, 2015 -- Connecticut Democrat Rosa DeLauro said she will introduce a bill that would make it tougher for Medicare plans to drop doctors and other health providers from their networks, adding to pressure on insurers to maintain more robust offerings for their customers. 

DeLauro also on Monday released a Government Accountability Office (GAO) report she and other lawmakers requested, which found that federal officials have been "largely reactive" in their monitoring of the adequacy of the networks of health professionals offered by these plans.

So-called Medicare Advantage plans have boomed in recent years, bringing more urgency to questions about whether the customers in this roughly $160 billion market have adequate access to doctors and other health workers. Enrollment stands at more than 16 million people, or more than 30 percent of the elderly and disabled people covered by Medicare.

UnitedHealth Group, Humana Inc., and other firms that sell Medicare Advantage plans must do a balancing act in creating networks of doctors and other health professionals for their customers. The ability to exclude some medical professionals is one of the key cost-savings tools for these plans, which were designed to allow Medicare to benefit from strategies used in the private sector.

But the Centers for Medicare and Medicaid Services (CMS) also has regulations determining the minimum number of providers of different medical specialties that a network should include. These are set on a county-level basis, factoring in population. Advantage plans in Muscogee County, Ga., for example, would be required to have six primary care doctors to serve about 3,300 eligible beneficiaries, according to an example provided by CMS in a guidance document.

To check on whether these standards are met, CMS relies heavily on reports from the insurers about their networks and complaints from doctors who may have been shut out of Advantage plans, according to GAO. The investigative arm of Congress also said CMS doesn't look closely at whether doctors listed as participating in a plan may work only part-time or may not be taking new patients.

"As a result, provider networks may appear to regulators and beneficiaries as more robust than they actually are if not all providers are open for business," GAO said in the report, which is dated August 2015, but was not posted until Monday.

There have been complaints for several years about how Advantage plans create their networks and how they inform their customers about which doctors are included, with many protests coming from specialty medical groups.

GAO noted in its report the results of a 2014 study, which looked at listings for about 4,700 dermatology professionals listed in directories of large Medicare Advantage plans.  About 46 percent of the listings were duplicates and 8.5 percent of the individual providers had died, retired, or moved out of the area, GAO said in summarizing the study results.

CMS in April said it was considering whether to require the Advantage plans to provide, and regularly update, network information in a standardized, electronic format for eventual inclusion in a nationwide provider database. 

In Connecticut, UnitedHealth's termination of more than 1,440 providers last year affected about 18,700 beneficiaries, or 13 percent of the state's participants in Medicare Advantage, GAO said. UnitedHealth mailed letters to customers in mid-November 2013 about changes effective Feb. 1, 2014. CMS began weekly calls with UnitedHealth about the terminations after "these network cuts drew media attention and widespread provider complaints," GAO said.

DeLauro will soon reintroduce a bill for which she drew 10 Democratic cosponsors in the 113th Congress, according to a spokeswoman. That measure would have allowed Medicare Advantage plans to drop doctors and other health professionals from networks due to medical negligence and violations of contractual requirements. But the cost of a doctor or another health professional for an Advantage plan "does not constitute cause for the [Medicare Advantage] organization to remove such provider or supplier from the network, and such cost may not be considered as a factor in favor of a determination," the 2014 version of DeLauro's bill said.

In a statement Monday, DeLauro said that the GAO report on provider networks reinforced her concerns about the program. "Medicare Advantage patients have no recourse to stop bad behavior like we saw in Connecticut with UnitedHealth," she said.

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