Insurers seek limited insurance exchange plan networks

By Jennifer Lubell
American Medical News, August 19, 2013

Health plans are focused on being ready “and doing what we need to do” as states set up their respective marketplaces, said Karen Ignagni, president and CEO of America’s Health Insurance Plans.

But some policy concerns remain. Many states, for example, “still have restrictions on our ability to actually provide high-performing networks for individuals to be able to access high-performing doctors and hospitals to make sure again we’re stretching those dollars. That will have to be looked at,” she said.

Ignagni was referring to the “any willing provider” clause, a mandate in some states that requires health plans to allow health care professionals to participate in a health plan’s network if the professional agrees to a plan’s contract terms, limits and conditions.

She also encouraged giving nurses a broader role, joining them with other professionals as part of health care teams, “so that we can try to customize health care and make it very patient-centered, and again stretch those dollars.”

Insurer opposition to “any willing provider” clauses is yet one more example of why we should question leaving coverage decisions in the hands of the private insurance industry.

Any willing provider clauses allow care provided by any qualified physician to be covered even if that physician is not contracted by the insurer but is still willing to accept payment based on contracted rates. The advantage of such clauses is that patients may choose to continue to see their own physician as long as the physician agrees to the insurer’s rates.

Why would insurers want to prohibit patients from having that right? It has to do with their current strategy of switching to narrow network plans – plans that have fewer choices of health care professionals. They say that they can extract even greater discounts from physicians who believe that they will have more patients referred to them by the insurer. Although it is questionable as to just how much further the insurers can ratchet down rates, these limited network plans have the advantage for the insurer of further impairing accessibility, thereby resulting in savings from forgone care, no matter how important that care might be.

Besides reducing the number of physicians in their networks, they also want to increase the number of nurse practitioners, presumably because they can negotiate even lower rates with them than they can with primary care physicians. That assumes that the current movement by nurse practitioners to gain equal pay for equal work will fizzle when the insurers offer the bait.

When they say this isn’t about the money, but it’s about quality… No, wait, they do say that this is about “stretching those dollars.” But how should those dollars be stretched? Should we take away choices of physicians and substitute nurses unwillingly, or should we consider eliminating this egregiously wasteful industry with its unwelcome intrusions? The latter would not only produce immensely more savings, it would also be much more beneficial for patients.