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The NetMinder Blog

Laura McMullen

Recent Posts

Expanding Your Vision Network With Online Retailers

Posted by Laura McMullen on Wed, Mar 28, 2018

glasses.jpgAs of October 2017, there were roughly 52,000 vision care locations that participate in at least one PPO network, in the NetMinder database. According to the Vision Council of America, 3 out of 4 Americans need glasses or contact lenses. If the population and the vision care locations were evenly spread out across the country, each location would serve about 4,800 people. Of course, they aren’t which makes the rise of online eyeglass and contact lens purveyors inevitable.

Buying glasses and contact lenses online has become simpler.

Wherever you decide to purchase your glasses and/or contact lenses, you need a prescription and an eye exam from an optometrist or ophthalmologist to get started. To buy online, you upload your prescription and other pertinent information and then move on to shopping.

When you shop online for glasses, like anything else, you can get a lot of information without going anywhere or talking to anyone. There are many more style, color, and other option choices than you’ll find in a brick-and-mortar store. And you can save money: Consumer Reports estimated savings of up to 40%. On the flip side, you could get the wrong prescription or glasses that don’t fit correctly since you might need to measure your own pupil distance. It might also be hard to return the glasses. And you might not be able to use your insurance. WebMD summarized the pros and cons of shopping for glasses online here.

Shopping for contact lenses has similar pros and cons although since disposable contact lenses have been widely available for a long time, mail order retailers, such as 1-800-contacts, have been part of the marketplace longer. Demand for lenses that change eye color and other fashionable products has grown the market further. There are more factors to consider when purchasing contact lenses in general that require the assistance of an optometrist or ophthalmologist. WebMD summarizes them here.

Can you use vision insurance when you shop for glasses or contact lenses online?

Sometimes. You can always use the funds in your FSA or HSA. Some accounts have debit cards to pay directly while other plans require reimbursement. Some online vision retailers are in-network with vision PPOs and will accept benefits while others are out-of-network and will provide a detailed receipt to support reimbursement.

We looked at some online retailers to learn about their policies. Here’s what we found:

  • A few retailers are In-network with some carriers. Members can access benefits online.
Warby Parker – glasses only
Glasses.com - glasses only
Contactsdirect - contact lenses only
  • Most online sources for glasses and contact lenses are out-of-network with all carriers.

Glasses

Felix + Iris
Eyebuydirect
Coastal - glasses and contact lenses
Classicspecs

Contact Lenses

1800contacts
Walgreens
Walmartcontacts.com

Vision insurance doesn’t get as much airtime as medical and dental insurance in general. However, a significant percentage of people with insurance have coverage. In fact, the Centers for Disease Control estimate 58% of people with private insurance have optional vision coverage and 44% of people with public insurance have optional vision coverage.

Online retailers have made inroads into the market. How do they fit with your vision network? How do you compete with other networks that include online retailers if yours doesn’t?

Tags: Vision insurance, vision networks, vision market, eyeglasses, optical retail, contact lenses

Healthcare Mergers On the Rise in 2018

Posted by Laura McMullen on Thu, Feb 22, 2018

A trend that got a lot of attention at the end of 2017 was insurers moving further into healthcare delivery. These three high-profile transactions are just the latest examples:

  • Humana purchased 40% of Kindred Healthcare, a group of long-term acute care and inpatient rehabilitation hospitals.
  • United Health Group purchased DaVita Medical Group, nearly 300 clinics and six outpatient clinics in Florida, California, Colorado, Nevada, New Mexico, and Washington, from DaVita Inc., one of the largest kidney care companies in the U.S.
  • CVS is buying Aetna, combining CVS’ retail presence, pharmacy solutions, infusion services, and nursing professionals providing in-clinic and home-based care across the nation with Aetna’s national, regional, and state insurance offerings.

mergers and acquisitions.jpgIn Pennsylvania, the line between providers and insurers has been blurred for a long time. Highmark Health and the University of Pittsburgh Medical Center are realigning their networks as they compete for market share in central Pennsylvania. Most UPMC hospitals are leaving the Highmark network in June 2019. Highmark’s Allegheny Health Network announced a partnership with Penn State Health in December 2017 and a joint venture with Geisinger in May 2017. UPMC formed a joint venture with Reading Health System in late 2016 to offer health insurance in southeastern Pennsylvania and completed a merger with PinnacleHealth in September 2017. Additionally, both systems are investing in specific service lines in Pittsburgh. This Modern Healthcare article details the rivalry between the two companies.

And more mergers appear to be on the way in 2018. The results of a Capital One Healthcare survey in Modern Healthcare found that about half of the respondents in its middle-market sample plan to buy or merge with existing businesses this year. In addition, 20% said they plan to revitalize and update existing offerings while 21% said they plan to launch new segments or sectors. The primary reasons cited for these actions are pricing pressure, availability of private equity, and filling in service gaps. The uncertainty around the Affordable Care Act is inhibiting the desire to add new businesses somewhat, particularly in segments dominated by government-sponsored insurance.  

How are provider mergers affecting your network? What about provider-insurer combinations?

Tags: healthcare mergers, healthcare networks, healthcare providers, healthcare insurers, health insurance mergers, insurance networks, healthcare system

Do We Count Access Points or Unique Providers?

Posted by Laura McMullen on Thu, Feb 08, 2018

This question has been around since the first time someone decided to compare two provider networks. In fact, NetMinder wouldn’t be here without it! One of our founding principles is a commitment to comparing apples to apples. This thread runs through all our processes starting with the way we collect data and ending with selecting report criteria. We’re focused on this idea because we know that how you count network providers can make a big difference in calculating network strength. Read our whitepaper about counting providers.

Choosing The Best Counting Method For Your Analysis

Each counting method has strengths and weaknesses. Access points is the broadest count with the highest numbers. It’s great for showing consumers where they’ll be able to access care. Unique providers (sometimes called “belly buttons”) is often the cleanest count and preferred by benefits decision-makers. It’s not so good for consumers since it doesn’t show all locations. Unique locations (sometimes called “doorbells”) is the narrowest count with the smallest numbers for obvious reasons.

One Report To Show Them All

Dental_Dashboard.jpegMaking sense of these options is why we added a new Dental Dashboard to our suite of snapshot reports. It shows all three counting methods plus validated counts and percentages for a single geographic area in the same report. The six bar charts bring access points, unique providers, and unique locations together for up to five networks. Watch this video to learn more.

Each counting method is important at different points in the sales and renewal process and the Dental Dashboard makes it easier to look at them all. For example, access points are important to consumers when they are making appointments while HR teams rely on unique providers to compare networks. This report helps you prepare for questions about both scenarios and encourages a broader view of the reliability, convenience, and strength of your network.

How are you counting and comparing the providers in your network?

Tags: access points, unique providers, counting method, compare networks, provider network, network strength, network providers, unique locations

How Does the Narrow Network Trend Play Out in Behavioral Health Networks?

Posted by Laura McMullen on Thu, Jan 11, 2018

A recent article from Kaiser Health News discussed a study from researchers at the University of Pennsylvania about narrow behavioral health networks. The researchers compared mental health provider participation in marketplace networks to primary care physician participation in the same networks using 2016 data from the Robert Wood Johnson Foundation for 531 provider networks offered by 281 insurance carriers in the marketplaces in every state plus the District of Columbia. 

Here’s what they found:mental healthcare.jpg

  • The average provider network includes 11% of all the mental health care providers in a given market while 24% of PCPs participate.
  • An average marketplace plan’s network includes just under 25% of all psychiatrists and 10% of all non-physician mental health care providers. Non-physician mental health care providers included psychologists, nurse practitioners and physician assistants, and behavioral specialists, counselors and therapists with master’s or doctoral degrees.

How do these counts compare to commercial behavioral networks? We looked at unique provider counts in the 5 largest behavioral health networks in NetMinder and here’s what we learned:

  • Total mental health care provider participation ranges from 18% - 27%. Total PCP participation ranges from 27% - 41% in medical networks from the same companies.
  • Commercial networks include 12% - 34% of psychiatrists and 16% - 42% of psychologists who participate in at least one network.

While more behavioral health providers participate in commercial networks, the trend is similar. The study went on to consider reasons for the gap:

  • Low levels of network participation among mental health care providers. Among physician specialties, psychiatrists are least likely to join networks, according to a 2014 study in JAMA Psychiatry. While this research was limited to psychiatrists, other private-practice mental health providers have similar participation levels.
  • Reimbursements drive behavior. Many plans don’t reimburse providers for case management and other non-physician services. Psychiatrists prescribe medication which is reimbursed at a higher rate than therapy and often covered in medical plans leading them to participate in those networks instead of behavioral health networks.
  • Shortage of mental health providers. While psychology is consistently one of the top 10 college majors, there is a shortage of psychiatrists and psychologists, as we noted in a 2016 post. In 2017, psychiatrists are ranked #17 and psychologists are ranked #30 in US News and World Reports list of 100 Best Jobs based on demand, salary, job satisfaction, and other factors.

The decade-long push for mental health parity in insurance coverage has provided incentives to fill this gap. Primary care physicians, physician assistants, and other non-physicians are providing mental health services. In fact, NPR and Kaiser Health News reported that a recent Milliman study found that “insurers paid primary care providers 20 percent more for the same types of care than they paid addiction and mental health care specialists, including psychiatrists.”

How is your network adapting to the changing market?

Tags: behavioral health, mental health care, narrow networks, behavioral health networks, healthcare providers, healthcare benefits

Four Ways to Improve Your Provider Directory’s Accuracy

Posted by Laura McMullen on Fri, Dec 15, 2017

Initiatives to Improve accuracy in provider directories are gathering steam in companies that offer Medicare Advantage plans. Because the federal government pays for these plans, it’s no surprise that regulations and the vendor approval process are driving the improvements. CMS audits online directories and if inaccurate data is found, it can affect the plan’s star ratings. Regulations allow for civil monetary penalties, notices of noncompliance, and warning letters for deficiencies – which affects Past Performance Analysis results that could lead to denied applications.

provider data.jpgThere’s also a promotional impact. Star ratings are used by beneficiaries to choose between Medicare Advantage plans, so a drop there could discourage enrollment in favor of a plan with a higher rating. And the enrollee “grapevine” is sure to spread the word about how difficult it is to make appointments because the provider directory is inaccurate which can also affect enrollments.

Perhaps more important than the downside of inaccurate data is the upside of better business results. “Plans need accurate, complete provider data to run their business, especially with value-based care arrangements and things like that,” Lucia Giudice, Deloitte Consulting’s managing director and government programs practice leader told AIS Health for an October article in Medicare Advantage News (registration required). For ACOs and other organizations better data translates directly into better revenues.

AIS Health/Medicare Advantage News interviewed Kenneth Wrzos, senior director for operational excellence at EmblemHealth, about their provider directory information. Here are some tactics they find useful that can be applied to any provider directory for any line of business or type of plan:

  • Use a “front-end validation team” to assess the quality of provider data from delegated entities before adding it to the network. This team calls a sample of providers and then a network management team works with the providers to correct any inaccurate data.
  • Audit internal directory data periodically. This proved so helpful EmblemHealth increased the frequency from quarterly to monthly.
  • Analyze claims data to target records for cleaning. Locations that haven’t been paid at least one claim in 12 months get special attention. This has proven helpful in reducing dental directory inflation.
  • Reconcile rosters with large groups regularly. Staff at large group practices change frequently which can have a big impact on your network. Getting ahead of these changes by periodically comparing the provider’s office roster to your provider directory makes things easier for everyone.

Clean provider information in your directory is a competitive advantage. What are you doing to make it easier for current and prospective members to find what they are looking for?

Tags: provider directories, medicare advantage, healthcare providers, healthcare networks

The Fine Line Between Differentiation and Disruption

Posted by Laura McMullen on Thu, Nov 16, 2017

Switching networks can be rough, as the Texas Employees Retirement System found out when they switched to a Blue Cross Blue Shield of Texas HMO plan after using United Healthcare for several years. The Texas Blues plan uses the HealthSelect network which was designed for large groups offering ample coverage in Dallas, Houston, and other big cities. In rural areas, the Blue Advantage network, designed for small groups and individual plans, would have been a better fit, according to local experts. Blue Cross Blue Shield of Texas has moved quickly to address the network gaps. Members who are more than 30 miles from an in-network PCP or more than 75 miles from an in-network specialist can request network gap exceptions. Click here to read the Health Business Daily story that has more details from November 6, 2017. (registration required)

This type of situation happens all the time in the employee benefits industry. A network looks like it matches a group’s locations but when members start making appointments there are gaps. Minimizing network disruption to avoid employee dissatisfaction is often a big factor in making changes to the overall benefits package. Estimating disruption is one of the most common uses of NetMinder.

disruption.jpgCarriers have taken different approaches to managing the inevitable disruption that comes with changing benefit plans and networks.

  • Dental benefits companies frequently “stack” multiple lease partners on top of their direct contract network. Since many lease partners are working with multiple carriers, these networks are very similar which reduces disruption.
  • Vision benefits companies are starting to work with multiple lease partners which reduces disruption when moving between networks as well. Additionally, vision networks rely heavily on retail chains such as Target, Wal-Mart, and JCPenney which also reduces disruption.

Broad medical networks are alike due to the nature of employer-sponsored medical insurance: very few people decline it when offered and virtually all doctors accept insurance because costs are high and utilization is virtually guaranteed over a lifetime. Narrow networks, however, have introduced a new element of disruption into the medical network marketplace. As they continue to evolve, it will be interesting to see what tools and strategies are developed to minimize disruption and dissatisfaction caused by changing plans and doctors while keeping costs down.

How are your networks different from your competition? How do you measure and track the differences?

Tags: medical networks, disruption reporting, network disruption, employee benefits, dental benefits, Vision insurance, healthcare benefits

Kaiser Permanente Hires Harvard Professor to Lead Medical School

Posted by Laura McMullen on Thu, Nov 02, 2017

medical school students.jpgThe lines of communication between doctors and insurance companies are key elements to make sure that patients get the treatment they need. Kaiser Permanente established a medical school affiliated with its hospital system with a vision “to provide a unique medical education embedded in a physician-led health care delivery system, that ignites a passion for learning, a desire to serve, and an unwavering commitment to improve the health and well-being of patients and communities.” The school broke ground in September 2017 and will enroll its first class of students in the fall of 2019.

Carey Goldberg, CommonHealth blog editor at WBUR, interviewed Dr. Mark Schuster about his plans for the Kaiser Permanente School of Medicine. Here are some highlights:

  • Students will have experience in clinical settings from the very beginning. Schuster says, “our students will be in clinical settings from the start, doing work that’s appropriate to their level of experience. They might be interviewing patients or serving as navigators for them. We want our students to understand what it's like to be a patient who is intimidated by the health care system, fearful of potential diagnoses, confused by the jargon.”
  • Courses will use a variety of teaching and learning methods. Classes will be small-group and case study-based. Spiral learning techniques will be used – introducing concepts early and returning to them regularly as students progress. Some classes will be ‘flipped’; where students watch videos, complete exercises, and read ahead of class so that class time can be spent in more interactive pursuits.
  • Graduates will contribute to a wide variety of communities. Schuster wants “students to be able to choose their field and where they practice without the constraints of the high debt that so many medical students have.” And Kaiser Permanente is providing the school with significant financial aid. Additionally, students will not be obligated to work for Kaiser Permanente after graduation. “The goal is to teach students who will spread out around the country and beyond, and take their skills everywhere and teach others around them,” said Dr. Schuster.

The Kaiser Permanente system is unique in that it is an integrated delivery system that also offers insurance. Their goal of preparing doctors who are lifelong learners, focused on health instead of disease, go beyond the clinical setting to understand patients’ needs, and use data to find gaps and solve problems who can share that knowledge throughout the healthcare system is admirable. The first class of prospective doctors will have 48 students and subsequent classes will grow to 96 students.

Is this a strategy that other public and private health insurers would benefit from? Are there opportunities for collaboration in areas like evidence-based medicine and establishing coverage in health professional shortage areas?

Tags: medical school, hospital system, health insurance, healthcare system, health insurers, healthcare providers

Superior Vision and Davis Vision to Merge

Posted by Laura McMullen on Thu, Oct 05, 2017

Centerbridge Partners, Superior Vision’s parent company, and HVHC, a wholly owned subsidiary of Highmark and the parent company of Davis Vision, announced two transactions in August:

  • vision.jpgCenterbridge will purchase Davis Vision, HVHC’s managed vision care subsidiary. Davis Vision will be combined with Centerbridge’s existing managed vision care portfolio company, Superior Vision. Highmark will acquire a minority ownership interest in the combined Davis Vision-Superior Vision company.
  • Centerbridge will acquire a minority equity stake in Visionworks, HVHC’s optical retail subsidiary. Highmark will retain a controlling ownership interest in Visionworks.

In 2013, Superior Vision merged with Block Vision, covering more than 8.5 million members nationwide, with a provider network surpassing 55,000 access points. Vision Monday reports that Superior Vision currently has more than 11 million members. Davis Vision reports more than 22 million members and more than 68,000 points of access including optometrists, ophthalmologists, and retailers in private practice and retail settings. 

With so many mergers taking place in the healthcare industry overall. We decided to also look at the evolution of selling dental and vision insurance as a key part of the total benefits package employers use to attract and retain top talent. Download our whitepaper, Exploring How Dental and Vision Work Together to learn more about the favorable trends as well as the synergies that help the dental and vision insurance markets work together. 

How does this new vision combination change the landscape in your territory?

Tags: Vision, vision networks, Vision insurance, optical retail

Studying the Accuracy of Provider Directories

Posted by Laura McMullen on Thu, Jul 27, 2017

Many people have had this experience – you’re looking for a new healthcare provider in your insurance plan’s directory and when you call, that doctor (or dentist or optometrist) doesn’t work at that location any more or the office isn’t accepting new patients. So you move on to the next name on the list and keep calling. As market forces, government regulations, and rising costs combine to focus more attention on every aspect of the health insurance industry, two recent initiatives examine provider directory accuracy.

provider-directory-4.jpg

CMS Online Provider Directory Review

In a previous post, we shared the preliminary findings from a CMS project designed to assess provider directory accuracy. CMS released the final report which confirmed that 47% of the 5,832 provider records reviewed in Medicare Advantage networks had at least one deficiency and listed the names and results of the 54 health plans involved in the audit along with the compliance actions taken. Fierce Healthcare summarized the results here.

AHIP Provider Directory Initiative

Between April and September 2016, AHIP executed a large-scale project to evaluate a variety of ways to update directory information. This issue brief summarizes the project including background on the vendors, methodology, and results of an independent evaluation by NORC at the University of Chicago. A blog post from March 2017, What It Takes to Improve Provider Directories, discussed the findings and offered potential solutions in actions that could be taken by providers and networks:

  • Provider side: enforce contractual requirements and offer incentives to providers
  • Network side: use multiple channels and media to connect with providers such as email, phone, mail, fax, and provider one source to update data for multiple plans

The prevalence of inaccurate data that CMS found and the low response rates plus lack of information about the importance of updating directory information underscore the complexity of maintaining this information. “The root cause of the problem isn’t the directories themselves; it’s the underlying data. Capturing, storing, and retrieving provider data has always been a complex process,” writes Mark Martin, Availity’s director of payer solutions, provider data management, and Dianne Wagner, senior director, provider engagement and enablement at Guidewell, in Managed Healthcare Executive.

The importance of accurate provider directories to the whole healthcare industry – consumers find providers and make appointments easily, providers earn the advertising and publicity benefits of inclusion in provider directories, and networks improve customer satisfaction, compare provider directories, and avoid compliance actions – make fixing this problem a chronic priority.

What steps are you taking to improve the accuracy of your provider directory?

Tags: provider directories, healthcare providers, healthcare system, provider networks, health insurance

The Best Solutions to High Healthcare Costs Are Local

Posted by Laura McMullen on Tue, Jul 11, 2017

A new interactive mapping tool and issue brief released by the Health Care Cost Institute with support from the Robert Wood Johnson Foundation shows wide variation in prices for different categories of medical services within communities and across the country between 2012 and 2014.

map of US.png

The Healthy Marketplace Index: Medical Service Price Category Index uses annual health care claims data from over 40 million Americans under age 65 with employer-sponsored insurance which accounts for more than 25% of the commercially insured population in the US. Aetna, Humana, Kaiser Permanente, and UnitedHealthcare contribute data to this project. The information is organized by CBSA, Core Based Statistical Areas, which are commonly used geographic regions of economic integration comprised of counties.

Users can look at costs in three categories: inpatient, outpatient, and physician services. Costs rose in all three categories although not at the same rate. “Prices for outpatient services rose fastest, while physician price increases were minimal. The most consistent growth was seen in inpatient prices which increased, on average, five percent each year,” the report notes.

Other highlights are:

  • There’s a link between inpatient and outpatient price levels. The report hypothesizes that “some aspects of the drivers underlying inpatient and outpatient prices may be related, such as commonalities in labor supply or population health.” HCCI found only a minimal relationship between physician services and the other two categories.
  • Some markets are consistent in pricing across categories. For example, prices in Cincinnati are consistently below average, prices in Nashville are consistently average, and prices are consistently high in Dallas. Other markets, such as Trenton, New Jersey had average inpatient and physician prices, but high outpatient prices compared to the national averages.

Download the issue brief or try out the mapping tool to see what your key markets look like.

Tags: healthcare cost, claims data, health insurance, inpatient services, outpatient services

 

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