Health Care Reform

Last week I started a twitter argument about narrow networks with Yevgeniy Feyman a (very nice) fellow at the Manhattan Institute.
He wrote that we don’t know whether narrow networks negatively impact patients.
I responded: BS.  Plenty of evidence.
Feynman asked me to show him the data.
So, after lobbing a couple of snarky comments (that YG swatted away) I realized I had engaged in a Twitter tantrum instead of responding to his request.  
I needed to become more mature and substantive to improve on my original response.  Thank you Yevgeniy for a second chance to act like an adult!
So here goes.
By narrow networks, I meant and mean excluding or restricting access to hospitals, doctors and other services based on price or cost considerations. That includes the VA, Medicaid and now many exchange plans under the ACA.  (Doug Badger doesn’t call these exchange plans “Medicaid lite” for no good reason.)
To be sure, consumer surveys suggest that most people are willing to forgo more choice of providers, hospitals, and medicines in exchange for lower premiums.  People have picked narrow network plans over broader options with increasing frequency and surveys show they tend to be satisfied with their choices.
Moreover, while research examining the quality of care provided by plans with limited networks is relatively sparse, there is some evidence to suggest that these plans have performed just as well as those that offer access to a broader range of providers. 
At the same time, “according to a Consumer Reports survey, 44 percent of those who bought an Affordable Care Act (ACA) plan for the first time in 2015 reported that they did not know the network configuration associated with their plan. 
For the clear majority of consumers, a narrow network can be a good choice and provide good care.
For the 5-10 percent of Americans with chronic, fatal or rate conditions narrow networks, evidence suggests, not only fail to deliver the care people are paying premiums (and deductibles) for.  They can also increase the cost and seriousness of the condition.
It should also be noted that restrictions go beyond access to doctors and hospitals.  Health plans restrict access to medicines in many ways such as formulary exclusions, prior authorization, high cost sharing and step therapy.  In addition, if someone receives care from a doctor outside of a network than the drug prescribed is also not covered.
For example, a recent examination by Harvard researchers of the network composition of health plans offered on the federal Marketplace during 2015 found that nearly 15 percent of the sampled plans lacked in- network physicians for at least one specialty
Narrower provider networks are more likely to exclude oncologists affiliated with NCI-Designated or NCCN Cancer Centers. Health insurers, state regulators, and federal lawmakers should offer ways for consumers to learn whether providers of cancer care with affiliations are in or out of narrow provider networks.
There are dozens of studies demonstrating that narrow prescription drug formularies and narrow pharmacy networks hurts patients.  (I link to those articles that review a number of these studies as well as the most impactful citations.)
While the ACA bars discrimination in proving coverage, health plans, and PBMs narrow choices because by doing so they can discriminate against the chronically ill.  Offering high priced drugs, hospitals and specialists will attract sicker enrollees into the plan

If plans and PBMs narrow networks to avoid adverse selection once someone is enrolled, it is hard to make a convincing case that they do not shift the burden of disease to patients in one way or another.  And the results of studies examining the impact of narrowing on patient well-being (as well as out of pocket costs) strongly suggest that for chronically ill people, such skinny choices can be sickly as well.  
But what if networks were limited to hospitals and medicines that provided the best overall quality and access customized to the specific needs of patients?
This quality and patient-focused approach to network development has guided Horizon Blue Cross Blue Shield of New Jersey’s the development of its network of providers, called the OMNIA plan.  Unlike many top-down efforts that require doctors to follow a cookbook or force people into narrow networks, Horizon Omnia has been collaborating with doctors, hospitals and health professionals to encourage wellness and patient-centered care.  About 750,000 of its members are now receiving this type of care from more than 6,500 physicians.
Horizon has provided the tools but it’s the doctors that are leading the change.  Primary care doctors now see their patients 3-4 times a year because keeping in touch and engaging in some coaching keeps people healthy.   Orthopedists have partnered to reduce lengthy hospital stays and replaced them with teams of physical therapists and home health aides to get people back home and on their feet more quickly.  And important, Horizon, while making these design changes have made this new arrangement one of many choices available to patients. And so far, that has translated into lower premiums and out of pocket costs.
In addition, HBCBS is partnering with GNS Healthcare, a precision medicine company that applies causal machine learning technology to match health interventions to individual patients, to further refine and personalize the Omnia offerings.   As Colin Hill, the CEO of GNS, notes: HBCBS and his company will analyze claims and medical records to predict the disease risks of patients and customize the best treatments.   The goal is to “know the value and efficacy of an intervention for a specific individual, as well as an entire population.”
So, the moral of the story is: The quality of a network is not about who you know, but what you know about who you are treating.   That's the difference between most narrow networks and the Omnia approach. 

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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