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The NetMinder Blog

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

Extending Your Reach with Telehealth Services

Posted by Laura McMullen on Mon, Dec 12, 2016

Medicare seems to be proceeding cautiously with telemedicine. Traditional Medicare reimburses healthcare providers for 37 services in specific circumstances when they are delivered using telemedicine, which is defined by the Medicare Learning Network as “an interactive audio and video telecommunications system that permits real-time communication between you … and the beneficiary.” These services range from consultations to education and training sessions to psychotherapy and smoking cessation programs.

Employer groups, on the other hand, are embracing telehealth benefits. Typical telehealth services are accessible 24/7 via smart phone, tablet, computer, or telephone. A recent article in CFO Magazine discusses the results of the latest Mercer National Survey of Employer-Sponsored Health Plans. Here are the highlights:

  • Nearly 60% of employers offered telehealth benefits in 2016. Nearly four times as many as (16%) offered them in 2014 and double the percentage (30%) that offered them in 2015.
  • Three-quarters of employers that offer telehealth share in the cost of each visit by offering plans with visit copays of $25 vs. the retail cost of a telehealth visit of $40.
  • More than one-quarter (28%) of large employers that offer telehealth also offer cost transparency tools to help employees make cost-effective choices.

This strong interest in telehealth is another method to help employees better manage their healthcare costs. As more and more workers (29% in 2016 vs. 25% in 2015) have high-deductible health plans, they are looking for lower-cost alternatives to access care.

cost of care.jpg

Source: Smart Business News, Debt.org

Retail Clinics and Telehealth Services Stretch Networks

Narrow networks are more common each year. Members report longer appointment wait times in HMO networks and other networks that have gatekeepers. And in open access narrow networks there are fewer available providers requiring many members to change doctors when they first join the plan and change again as doctors move in and out of the networks.

Employee Benefit News (registration required) noted that “82% of respondents [to the Mercer survey] cover visits to a retail clinic as another lower-cost and convenient option for their health plan members. Such a visit typically costs about $60 before the annual deductible is met.” With lower costs and convenient hours, many people find that these clinics, like telehealth services, are a good option to supplement plans with narrow networks.

Telehealth services also enable faster communication with a primary care doctor, shorter wait times, and no travel time when compared to an ER or urgent care center visit.

Has telehealth become a viable substitute for in-office care for your members? How are you using telehealth services to expand your network?

Tags: telehealth services, narrow networks, HMO networks, healthcare benefits, healthcare providers

Claims Data Makes Provider Directories More Accurate

Posted by Laura McMullen on Thu, Jan 21, 2016

“About 70% of plans sold on the exchanges in 2014 featured a limited network, and their premiums were up to 17% cheaper than plans with broader networks, according to a study by consulting firm McKinsey & Co.”, reported Modern Healthcare in March 2015. In response to consumer complaints about narrow networks, network adequacy regulations set criteria for distance to providers; the quantity of providers in a network; and the inclusion of essential community providers in a geographic area and, beginning January 2016, fines for inaccurate data.

Accurate provider directories are a problem for all networks. Providers retire, sell their practices, change jobs, and die, just like everyone else. It’s difficult to stay on top of this information, especially if you have several networks and/or network partners. The credentialing process, where provider credentials are reviewed at least once every three years to evaluate their practice histories and qualifications, and self-reporting are the primary methods network managers use to update their records. A 2014 study published in the Journal of the American Medical Association Dermatology found that these methods aren’t working:

  • Among 4,754 total dermatologist listings in Medicare Advantage networks in 12 US metropolitan areas, 45.5% were duplicates in the same plan directory.
  • Less than half (48.9%) of the unique physician listings were reachable, accepted the listed plan, and offered an appointment.

The Department of Health and Human Services’ Office of the Inspector General found similar results when looking at Medicaid networks in 2014. When they surveyed 1,800 primary care providers and specialists, “35 percent could not be found at the location listed by the plan, another 8 percent were at the location but said that they were not participating in the plan, and an additional 8 percent were not accepting new patients.”

Some experts suggest improving the accuracy of provider directories by including only providers to whom you’ve paid claims within 12 months. “Since 2013, New Jersey health plans must attempt to contact any provider who hasn't filed a claim in 12 months. If a provider fails to respond in 30 days, the insurers must remove that listing. Since then, ‘the number of complaints has gone down,’ says Larry Downs, CEO of the Medical Society of New Jersey,” in “Insurers Race to Avoid New Fines” on nasdaq.com.

Overstated access has been a problem in dental PPO provider directories for several years; access points are growing twice as fast as unique providers and unique locations.

top_15_dental.jpg

We’ve seen success using claims to verify locations where providers are practicing in our dental network analyses. In general, we find that about 75% of dental access points can be validated through claims analysis. Demonstrating clean data vs. your competitors is a definite advantage when selling your network to clients and brokers and also helps focus recruiting efforts, saving time and money. Learn more about our approach in our whitepaper Are Dental Provider Directories Overstated?

What steps are you taking to ensure accurate provider directories? How do you figure out which providers are really available in your competitors’ directories?

Tags: narrow networks, provider networks, dental PPO networks, medicare advantage, provider directories, claims data

The impact of integrated health care delivery systems is growing

Posted by Laura McMullen on Thu, May 28, 2015

Hospitals have always had informal networks of nearby physicians with admitting privileges as well as staff physicians. And some hospitals and health systems, particularly those that self-insure, have long required employees to access care within their organization to help control costs. With a new set of incentives in the Affordable Care Act that encourage providers to focus on outcomes instead of activity, these practices came together to reduce the barriers to entry in the health insurance industry and create new entities that compete for premium dollars.

Cutting Out the Middlemen

hospitalLarge hospitals and local or regional health systems have formed insurance companies that sell plans to employer groups and individuals, i.e. North Shore – Long Island Jewish Hospital’s CareConnect or UPMC in western Pennsylvania. Dr. Kenneth L. Davis, CEO and president of Mount Sinai Health System in New York, said, “Inevitably the large systems are going to move to take part of the premium dollar,” in an article in the Fiscal Times after the 2014 Health Care Forum in Washington, DC, sponsored by The Atlantic. He went on to discuss the importance of “retaining more and more of the health care premiums paid by consumers is essential to providing a full spectrum of care.” For example, St. Luke’s Hospital, part of the Mount Sinai Health System, lost $14 million in its psychiatric program in 2013 and needs to be subsidized by revenue from other parts of the system. Offering insurance coverage is another way to do that.

Partnering to Compete

Some insurance companies own hospitals, other facilities, and physician groups which are included in their networks, for example Kaiser Permanente or Willamette Dental Group. Others choose to create new companies such as the joint venture between Anthem and seven Southern California hospitals when they formed Vivity Health Plan. Vivity is priced below Anthem’s standard HMO plan and includes the big academic medical centers consumers want access to, according to the LA Times. This new market entrant could take business away from Kaiser Permanente in the large Southern California market.

Too Big to Fail?

Another approach is for hospitals to merge. There were 95 hospital mergers and acquisitions in 2014, according to The ObamaCare Effect: Hospital Monopolies in the Wall Street Journal. Two acquisitions are being challenged in state court:

How does this trend play out in your network? Does hospital consolidation make it easier to set up a narrow network? Or is this an opportunity to add more locations and providers through the physician groups that are included in integrated health care delivery systems?

Tags: health insurance, narrow networks, Affordable Care Act, health reform, consumer choice, insurance companies

CO-OPs: a new twist on traditional insurance?

Posted by Laura McMullen on Fri, May 15, 2015

Health insurance CO-OPs (Consumer Owned and Operated Plans) are part of the Affordable Care Act. More than 400,000 people enrolled in CO-OP plans during the first open enrollment period for Obamacare, and CO-OP managers are taking steps to increase enrollment. Their plans are the lowest-cost silver plans on the exchanges in nine states after cutting rates based on their experience in the first enrollment period, according to the National Alliance of State Health CO-OPs.co-ops

There are 23 non-profit CO-OPs in 26 states and all were started with 5-year loans from the federal government. Once the loan is repaid, the CO-OP is owned jointly by the private investors and members. All of the CO-OPs are members of NASHCO, the National Alliance of State Health CO-OPs. Their purpose is to provide health insurance to individuals and small businesses that have a hard time getting coverage, particularly in markets where a single insurer is dominant. This puts CO-OPs directly in competition with many Blues plans.

Most CO-OPs contract with providers directly and supplement with leased networks that wrap around their proprietary networks while a few lease or direct contract exclusively. This mix of leased and direct-contract networks is very similar to traditional commercial health insurers.

So far, CO-OPs have chosen to differentiate themselves through care management and outreach to members instead of following the narrow network trend. “Our whole strategy has been to invest heavily in medical management because at the end of the day, we can’t make money the way we used to, which is to conservatively underwrite this population,” says Martin Hickey, MD, CEO of New Mexico-based Health Connections and board chairman of the National Alliance of Health Care CO-OPs, in AIS Health Business Daily on Jan. 6, 2015. Typical hospital readmission rates for a commercial population are between 12% and 14%. Hickey says his firm’s readmission rate has held at 6.5%, and dipped to 2.5% over the last three months.

Like all businesses, CO-OPs live and die by their balance sheets. In January 2015, the Iowa Insurance Commissioner found that CoOportunity Health, an Iowa-based health insurance company, was insolvent and requested liquidation in court. Current members were notified and encouraged to enroll with different carriers prior to February 15 to ensure continuous coverage and compliance with federal law.

Are CO-OPs part of the network landscape in your state? Do you compete with them for customers and/or providers?

 

Tags: compare networks, health insurance, narrow networks, Affordable Care Act, insurance companies, health care providers, health insurance co-ops

Network Emerges as Key Differentiator in Health Insurance Purchasing Process

Posted by Laura McMullen on Tue, Jul 08, 2014

As intended, the consumer demand created by the Affordable Care Act is expanding the insurance marketplace, as reported in Inside Health Insurance Exchanges and reprinted in Health Business Daily (free registration required) on June 24, 2014. Some examples of new entrants include:

  • Co-ops in states where Blue Cross Blue Shield plans dominate, like Kentucky Health Cooperative in West Virginia and Montana Health Co-op in Idaho
  • Local plan expansions from nearby states like Harvard Pilgrim and Minuteman Health in Massachusetts moving into New Hampshire
  • Health system-based networks in densely populated areas like North Shore-Long Island Jewish Hospital and Health System in New York

With more plans to choose from that offer the same mandated benefits and guaranteed issue requirements, the provider network is a key decision point for consumers and employers. “Many carriers’ rates ‘look good on paper, but when you pull back the layers,’ consumers are wary. In the end, ‘it really comes down to the network,’ since consumers don’t want to give up existing providers when they switch insurers,” said Kyle Kautzman, GBA, an insurance broker with EBNY Insurance Services, Inc., in a Health Plan Week article reprinted in Health Business Daily on May 12, 2014 (N.Y. Small-Group Market Isn’t Suiting United’s State of Mind (with Table: Top 10 Health Plans in New York's Commercial Risk Market). Mr. Kautzman was commenting on the New York State small-group market but the observation applies to any area in the US.

narrow networks definedEmployer groups and consumers are grappling with the term “narrow networks.” What are they really? McKinsey & Co. define narrow networks as “having at least 30 percent of the 20 largest hospitals in a geographic area not participating in the exchange’s silver plan.” Perhaps a simpler way of looking at it is typical narrow networks include providers who agree to lower prices with the expectation that patient volume will grow. Insurers then pass some of the savings on to consumers. Starting to sound similar to an HMO, right? Carriers have been using network size to reduce rates for quite some time; the ACA rules simply accelerated the trend.

Narrow networks seem to be most successful in areas where providers are plentiful so that carriers can choose providers with lower rates and better outcomes. For example, Health Net is seeing success in California. They offer narrow, or tailored, networks in five southern California counties and use their existing PPO network everywhere else. According to Health Net spokesperson Brad Kiefler, in an AIS’s Health Reform Week article reprinted in Health Business Daily on May 5, 2014, entitled Calif. MD Supply Concerns May Boost Networks, Reimbursements, enrollment in tailored networks is 38% of the commercial total enrollment reflecting demand from employer groups as well as consumers from Covered California, the state exchange.

Kiefler went on to say, “So in Southern California, where there is significantly more competition among providers – there are 80 hospitals in LA County – insurers have been able to create these narrow networks and demand relatively lower reimbursements from providers. In the parts of the state that are dominated by a particular provider system, the rates are consequently higher.” In densely populated places with many providers, like Los Angeles, market forces drive costs and rates down so even though networks are narrow by choice, consumers still see reduced costs. In sparsely populated areas with fewer providers, like central California, networks are naturally narrow and competition doesn’t exert pressure on costs or rates.

What do narrow networks mean for you and your customers? How will you monitor changes in the network landscape on the exchanges and off?  

Tags: healthcare reform, health reform, healthcare benefits, ACA, Affordable Care Act, narrow networks, healthcare exchanges, provider networks

Narrow Networks Add Complexity to the Health Insurance Business

Posted by Laura McMullen on Thu, Apr 24, 2014

narrow networksThere’s been a lot of buzz in the media lately about narrow networks in health insurance plans on the federal and state health insurance exchanges. This has prompted a larger discussion about network adequacy and the trade-offs between cost control and choice. Carriers Defend Use of Narrow Networks as Fair, Market-Driven Options for Consumers, an article from Health Plan Week reprinted in AIS Health Reform Week on April 4, 2014, sums the situation up well, discussing network adequacy, consumerism, and transparency.

Here are some questions to think about when you are comparing provider networks, whether you are managing a network, selling insurance plans to employers, or purchasing a plan for your company or family.

1. Are the right types of providers in the network? When provider networks get narrower, the definition of network adequacy shifts from the size of the network to the types of providers that participate. Employers and other group benefit sponsors are asking questions like: Are there enough PCPs or optometrists? What about cardiologists or oral surgeons? How many radiologists or ER doctors are near my members? (Download our whitepaper All Provider Networks Are Not Created Equal for more.)

2. Is the carrier financially and administratively reliable? Narrow networks reduced one of the barriers to entering the health insurance market, namely the need to have a large provider network. Many new entrants to the market raise questions about financial solvency and claim payment speed. 

    • In the dental insurance industry, we’ve seen established brands like Prudential come back to the market with a leased network and outsourced back office only to exit after a few years. (See our blog post Prudential Exits Dental Benefits Market; Others to Follow? for more.) 
    • In the health insurance industry, more than 50% of hospitals and health systems responding to a June 2013 Advisory Board Co. survey said that they planned to launch a health insurance plan by 2018 or they already had one. (See our blog post More Health Systems Becoming Payers for more.)

3. Are the right providers in the network? From the consumer perspective, all networks are narrow – they only include the providers they use! Many people are accustomed to the large PPO networks that have been popular in employer-sponsored plans over the last several years, so they may be surprised by narrow networks that don’t include popular providers and academic medical centers. Communicating early and often, like B2C companies do, could make a big difference here. For more about how consumers look for health care information online, see our blog post Consumers Seek Real Data Online for Health Decisions.

Key questions for the Department of Health and Human Services in the coming weeks and months will be which types of providers are essential and how large is an adequate network. As they work on the answers for plans on the exchanges, carriers will be watching closely to see what the impacts are for plans off the exchanges.

How will you assess your network and your competitors’ networks?

Tags: healthcare reform, health insurance, health reform, network providers, Affordable Care Act, market comparison, compare networks, narrow networks, healthcare exchanges

 

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