Not only may you not get to keep your plan under Obamacare, you might not be able to keep your doctor; there are reasons

By Molly Burchett
Kentucky Health News

Part of the sales pitch for the federal health-care reform law was that people could keep their doctors, but many Americans and some Kentuckians won't because insurers are excluding some hospitals and doctors from policies in an effort to make the new, standardized plans on the insurance exchanges more affordable.

Eleven Kentucky hospitals have filed complaints with the state Department of Insurance, saying Anthem's policies on the state's exchange include only a narrow network of providers, excluding them. Limiting the number of providers on the exchanges is one seldom-mentioned way insurers are trying to reduce premiums for new policies.

The department upheld three of the complaints because the hospitals said they would be able to serve at least four of the state's eight Medicaid regions, a concern that led to their original exclusion. The department has since ordered Anthem to accept applications from those hospitals- UK Healthcare, Our Lady of Bellefonte in Ashland and Highlands Regional Medical Center in Prestonsburg, reports Mike Wynn of The Courier-Journal.

Insurance-company research shows that consumers’ highest priority when shopping for insurance is price. To compete on price, insurers contract with doctors and hospitals who charge them the lowest fees. Some prestigious and well-known academic medical schools that charge higher prices are being excluded from exchange plans, Forbes magazine reports.

These same market forces may also limit the ability for small hospitals and providers to provide care through exchange plans if their health systems lack economies of scale that enhance their negotiating power. UK has already negotiated a deal with Anthem, and the company's negotiations with Highlands and Bellefonte are ongoing.

Anthem is not the only insurance company with narrow networks. Stephen Miller, vice president of finance for the Kentucky Hospital Association, said other Kentucky insurers are also using network restrictions to "steer patients to hospitals with the best rates for the insurer," Wynn reports. Around the country, many plans have more narrow networks than previous plans in order to limit premiums, Politico reports.

This tactic lowers expenses for the insurers by bypassing higher-priced health systems but means that some patients may have to change doctors or hospitals, report Sandhya Somashekhar and Ariana Eunjung Cha in The Washington Post: "The result, some argue, is a two-tiered system of health care: Many of the people who buy health plans on the exchanges have fewer hospitals and doctors to choose from than those with coverage through their employers."

Consumer advocates say tighter networks will disrupt care and limit access for middle-and lower-income consumers, who may be sicker than the average consumer, reports Kaiser Health News: "Narrow networks present the opportunity for lower costs via discounts from select hospitals and doctors in return for patient volume. But smaller networks can require members to travel farther for care or make it hard to get appointments."

Anthem says limiting networks helps insurers save money, which is passed on to patients through reduced premiums. Critics say healthy people must pay more than their fair share to help provide coverage for sicker people. Health-reform advocates say the law's trade-offs are acceptable costs in exchange for getting health coverage to more needy people, but some wonder about that if they have to drive 30 miles to get it.

What is a narrow network?

An insurance company's health-care network is a group of physicians, hospitals and other providers that agree to provide medical services at pre-negotiated rates. The wider the insurance company's network, the more doctors and hospitals from which you can choose without paying more to see an out-of-network provider.

Anthem spokesman Tony Felts said the smaller networks are an attempt to keep exchange plans affordable and that the company worked hard to design products that would attract consumers to them. Four other companies are offering policies on Kynect, the state exchange: Humana, United Healthcare, Bluegrass Family Health and the Kentucky Health Cooperative. Anthem and the cooperative are the only two insurers offering individual plans statewide.

"Many companies have selectively entered the exchanges because they are concerned that they will be dominated by risky, high-using populations who wanted insurance and couldn't afford it" before the law took effect, Gail Wilsensky, a UnitedHealth director, told U.S. News. "They are pressed to narrow their networks to stay within the premiums."

The reform law requires insurers to provide enough doctors and hospitals to ensure quality care, but the federal government offers little guidance on how this is defined. The Kentucky Heath Benefit Exchange says at least 20 percent of available essential community providers in an exchange service area must be in its network, and insurers must contract with at least one of these providers in each county in the service area. However, these regulations don't specify a penalty for not adhering to the recommendation, and there is no guarantee that the network includes your doctor.

Consider a plan's network, premiums and out-of-pocket amounts

Patients may not realize whether or not their doctor is in a plan's network until January, when the new policies take effect. Therefore, consumers should be careful to check the details about an exchange plan's network. Consumers should also be aware of the plan's out-of-pocket costs; the cheapest exchange plans have high deductibles.

On Kynect, insurance shoppers can filter plans to see if a specific provider is included. Insurance Department spokeswoman Gwenda Bond said the agency relies on insurance companies to provide network information to be posted on the exchange. She said the department has experienced some minor issues with this process due to insurers using different names for the same provider.

To address this problem, Kynect also provides a link to each issuer’s web site for their provider directory, said Bond. "The issuer’s provider directory web site should contain the most current list of providers available in the issuer’s network. We continue to work with insurance companies to improve the lists," she said.

"Under Obamacare’s exchanges, people who really want to keep their doctor, at any price, will often have to pay higher premiums for the privilege. And people who prefer lower premiums, above all, might need to choose a different doctor," writes Avik Roy of Forbes.

As Medicaid enrollment grows, fewer providers accept it

At the same time some providers are being excluded by insurance companies or are choosing to exclude themselves, some providers are opting out of the exchanges and are not accepting Medicaid patients. A recent survey by the Medical Group Management Association found that 40 percent of its members are still deciding if they are going to accept insurance offered on the Obamacare marketplaces, CNN reports.

About 56,000 Kentuckians have enrolled in Kynect plans as of Nov. 22, and 82 percent of those are Medicaid plans. According to the Centers for Medicare and Medicaid Services, which administers the Medicaid program, three times more doctors are refusing Medicare patients than three years ago.

Doctors cite Medicare's increasing rules and lowered payment rates as reasons for not accepting Medicaid, and those who will see some Medicaid patients are limiting the number, reports The Wall Street Journal. Doctors also say administrative hassles and delays in getting paid also discourage them from accepting Medicaid, says the Center for Studying Health System Change.

Hospitals across the state have expressed concern about delayed payments from Kentucky's managed care companies as a result of the state's quick transition to a managed care model, and state officials are working to address this problem. Still, Kentucky's Medicaid payment rates are about 72 percent of Medicare rates. The reform law raised Medicaid fees to match what Medicare pays primary-care doctors, but only for two years and after much administrative hassle.
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