Are Narrow Networks Bad or Are There Bad Narrow Networks?

This is a guest post from Tom Barrett of BBG, a highly-regarded employee benefits consulting firm with deep expertise in flexible spending programs and medical management.

The title above plays off of an old adage wisely employed by a very sharp and highly respected colleague.

Here’s one take on narrow provider networks as seen from the trenches.  While it’s mostly informal and unscientific it is cast with an experienced eye when it comes to networks:

Many of the narrow networks offered prior to 2014 placed a more discerning emphasis on contracting with higher performing providers.  We think these networks at least leaned more toward striking the combination of higher quality and lower cost.

Some (“some” emphasized) of the new narrow networks, especially those created primarily for the exchanges, appear almost exclusively aimed at low cost.  In fact, during the run-up to 2014 some carriers indicated that on the exchanges especially, low cost would win. Period. They indicated that network contracts comprised of low fee schedules was the way to get there.  New networks were developed with the key goal of being on the “first page” (lowest cost, think airfare searches, rental cars, hotels, etc.,) when plans were shopped.

Describing how carriers built these new networks, one highly respected industry insider indicated that contracts containing these low fee-schedules were mailed out to the provider community.  Carriers then waited to see which of the providers would accept the low fee schedules and sign-up.  The new networks were then built accordingly.

Probably not surprisingly, some of these new narrow nets bear a striking resemblance to Medicaid networks and are comprised mainly of providers willing to accept Medicaid-like fee-schedules.  We think that it’s safe to say that the quality and outcome side of the equation did not rule the day in the development of these networks.

So what’s the “net” for all of us?

Caveat emptor.  We’re not suggesting it’s necessary or even wise to shy away from all the narrow nets.

Rather, make darn sure you do your homework before building or selecting a plan that’s associated with one.

We don’t expect this to go away and expect provider and network evaluation to continue to grow in importance for everyone going forward, most especially for individuals and small and mid-size businesses ……….


The real cost of rejecting Obamacare

“When one person suffers it is a tragedy, when millions do, it is a statistic.”

As abhorrent as quoting Josef Stalin might be, the monster was right.

Opponents of Obamacare love to cite specific examples of people “harmed” by PPACA. As we’ve seen, while their “examples” are false, wildly distorted, and/or fake, they are also powerful as few bother to read the follow-up debunking stories.

Amidst all the complaints about Obamacare from individuals “suffering” under their new policies, it is easy to miss out on the big picture..

From a reader (thank you JR) came this – 4 million people with mental health issues will not gain coverage under Obamacare.  They will not have access to Medicaid, because the state legislators and/or governors don’t want to accept federal dollars to expand Medicaid.

These are real people – boys, girls, moms, dads, grandparents, friends, neighbors, sisters, brothers, wives, husbands, classmates.

They are suffering from bi-polar disorders, deep depression, addiction, autism, severe anxiety and panic disorders.  We are talking about seriously ill people, some with disorders similar to the perpetrators of the Newtown Connecticut and Navy Yard shootings; others who, without treatment, will never become productive, fulfilled, tax-paying members of society.  Instead they will be a burden on us all.

There are 11 southern states that have, for reasons of their own have refused to expand Medicaid as of now.  According to the piece in Insurance Broadcasting, “More than 1.1 million uninsured people who have serious mental health and substance abuse conditions live in just two states — Texas (625,000) and Florida (535,000).”

What does this mean for you?

The next time someone tells you what a great country we live in, ask them if this is how great countries treat their most vulnerable citizens.

When state politicians cut their own social support budgets while refusing to help those desperate for help, we become a smaller, meaner, and less-civilized society.

The full report is here.



Exchange enrollment – the big picture

Looks like the glitches, gremlins, and guffaws are just about over; CMS reported today that enrollment via the exchanges is up to 4 million, an increase of some 700,000 over the last few weeks. That despite the ongoing efforts in some states to hinder enrollment, efforts which include outlawing “Navigators”, refusing to expand Medicaid, and prohibiting or barring various forms of consumer education.

Of course, there have been many, many stories of citizens disappointed/angered/furious with their new health plans.

There’s the one about the Michigan woman with cancer who has to pay more.  Oh, wait, she actually doesn’t; her new plan through Blue Cross Blue Shield cut her monthly premiums almost in half, from $1,100 to $571; that plus the annual-max-out-of-pocket pretty much assures her she’s fine after all.


Well, then there’s the woman who claimed “Obamacare raped her future”!  Wow, such inflammatory language!  Especially for one so…uninformed.  Ashley Dionne said her costs would go up by a factor of four, but she didn’t realize she’d likely qualify for Medicaid, which would have cut her monthly premium to, well, nothing.

And who could forget Bette from Spokane! She was socked with a $700-a-month increase!  Uh, well, not…exactly.

Oops.  Turns out Bette never checked the exchange, could have got a much lower price, and the price she was quoted was for a waaaay better plan than the cheap one she had – and that’s why it was more costly.

Huh.  Well, what about those folks in Texas?  You know the one Maggie Mahar wrote about, the poor woman (why are they always women?  why don’t we men get to be victims?) with MS who had her policy canceled and the new one cost – gasp – $1000 a month! The couple with a $20,000 deductible! OUTRAGEOUS!!!

Well, that was not true.  First, no policy for a 27 year old will cost that much.  Next, there are NO $20,000 deductibles.  Finally, the paper that printed this crap never fact-checked the piece, and didn’t print a correction, and the reporter assigned the story was told to “To find people who [had insurance policies that] were cancelled – and having some difficulty.”

There are more horror stories.  But please, before you read and repeat, think.  Does it make sense?  Is it objective?  Who printed/produced it?

What does this mean for you?

Yes, there will be horror stories.

But none as horrible as 50 million of our fellow Americans not covered by insurance.

None as horrible as a loved one with breast cancer who can’t get care.

Now that’s horrible.



So what’s really happening with Obamacare?

Amongst all the noise about the exchanges and enrollment, it is all-but-impossible to separate the BS from the RS  (real scoop).  So, here are a few factoids.

What’s the net?

Too early to tell.  Looks like things are going much better than late last year – but things were such a horror show that may be “damning with faint praise.”

We will have a much clearer picture in May, after the penalty period comes in to play, premium payment issues are straightened out, and most of the rest of the computer messes are cleaned up.


The GOP’s Alternative to Obamacare

Three republican senators have proposed a bill – the Patient CARE Act – to replace PPACA aka Obamacare.

Kudos to Senators Burr Coburn and Hatch for their efforts – and for staying away from the useless ideas of selling insurance across state lines, high-risk pools which are never adequately funded, and that favorite non-solution, tort reform.

In a nutshell, the GOP bill does away with most PPACA regulations including the mandate, reduces the tax break on employer-sponsored insurance, does away with Medicaid expansion, and gives low income folks tax credits to buy insurance.  There’s not a lot of detail, and it’s clear this is a work in progress.  I would note the GOP’s claim that their bill expands coverage without increasing taxes is sophistry;  according to many in their party, eliminating a tax break IS raising taxes.

There is no mechanism or approach or tools that would reduce health care costs, no assurance that those with pre-existing conditions will get coverage (unless they constantly maintain insurance, something that many folks don’t do), no control over benefit design (which is skillfully employed by insurers to discourage the unhealthy from signing up)

While a home-team analysis indicates the GOP bill will reduce uninsurance by about the same amount as Obamacare, the analysis isn’t credible.  For one thing, the “coverage” provided under the GOP bill would be a LOT thinner than that provided under Obamacare – they’d have to be, as the maximum credit for young singles would be $1,560, hardly enough to pay for anything but the skimpiest of catastrophic coverage.  This may be “insurance” but it certainly isn’t “coverage” .  In addition, doing away with the Medicaid expansion would dump millions of just-covered folks back on the safety net, aka emergency rooms, charity care, and community health centers that have been hammered by budget cutbacks.


Finally, the provider, payer, information technology, supplier and health system communities have all been working feverishly to prepare for and implement Obamacare.  This train left the station four years ago, and Burr, Coburn, and Hatch are just now showing up trackside with a revised itinerary.

Moreover, the passengers on this train – the middle class, health care providers, and older folks – are going to be adamantly opposed to the GOP plan as it:

  • raises taxes on the middle class;
  • undoes Medicaid expansion thereby harming health care providers; and
  • increases insurance costs for older people.

Politically brilliant it’s not.

As Jonathon Cohn notes; “It would have been a lot more productive if these three senators, or any other Republicans, had been similarly constructive back in 2009…”

He also thinks it is better late than never – I disagree.

Obamacare is the law of the land.  It is not going to be repealed.  The triad would have better spent their time working on something more productive; say immigration reform or revamping the tax code.  Alas, this is an election year, and the GOP bill is a political ploy.

But it’s not a very smart one.

What does this mean for you?

Not much.




More states will expand Medicaid

Even those dominated by Republicans.

To understand why, here’s a quote from a conservative GOP legislator from Michigan:

State Rep. Al Pscholka: “When people say Medicaid expansion, I think to a lot of us that meant bigger government, and it meant expanding a program that doesn’t work very well…When I understood how it worked, and what we had done in Michigan in the late ’90s, that was actually pretty smart, we’ve privatized a lot of that already, which I think a lot of folks didn’t understand.”

But it’s more than that.

Hospitals and health care systems will be in dire shape without expansion.  Already the feds are reducing the amount of funds they are transferring to hospitals that provide a lot of uncompensated care and Medicaid services. The federal DISH (disproportionate share) allotments are established, HHS has a formula in place for rolling out those changes but that formula doesn’t account for states that don’t decide to use expansion. States that don’t expand Medicaid will see a reduction in these payments, and no increase in Medicaid, leaving the hospitals in a financial bind.

Without Medicaid expansion, hospitals and health systems will find it increasingly costly to care for the uninsured  – and they will pass that cost along to privately insured patients and workers’ comp payers.  This already happens, and is one of the arguments in favor of universal coverage.

More significantly, the poor uninsured with chronic conditions (diabetes, asthma, hypertension, depression) will become increasingly expensive to care for.   The lack of primary care will mean when they do get care, it will be much more expensive than if they’d been able to effectively manage their health and thus avoid hospitalization.

Unhealthy people find it harder to get and keep a job, don’t do well in school, and thus are less able to contribute meaningfully to society than those of us with insurance.

That’s not to say that Medicaid shouldn’t be modified; for example, some sort of nominal copay or coinsurance so services aren’t just a freebie makes sense to me. That’s happening in some states.

Finally, there’s a bit of history here; when Medicaid was originally introduced, many states opted out.  Within a few years, each one had signed up.

What does this mean for you>

History will repeat itself, and that’s good news indeed.

Thanks to Kaiser Health News for the heads’ up.



That’s the best way to describe health insurance execs’ views on their business these days.  The massively-screwed-up-but-steadily-improving rollout of the federal exchange is the biggest reason for that uncertainty, but there’d be huge uncertainty even if things had gone flawlessly.

Health care providers are consolidating rapidly, increasing their negotiating leverage.  More and more physicians are working for health systems.  Some employers are dropping coverage, while others are moving to narrow-network based plans. All this against a backdrop of an aging population, increasing income inequality, major growth in Medicaid enrollment, reduced Medicare reimbursement for facilities and a possible “fix” to the fatally-flawed physician reimbursement system/mechanism.

And, the metrics they use to measure performance are in flux as well; the old measurements were fine when insurers could underwrite, adjust benefit designs, change deductibles and copays, and negotiate with providers from a position of strength.

Add to that the uncertainty over who is going to enroll via the exchanges – will there be enough “young immortals” to balance the older, sicker folks who sign up?  More importantly, how will that play out for individual health plans; Plan A isn’t concerned about the overall picture, but is very, very concerned about the demographics of their member group.

It’s no wonder senior management – and other stakeholders – are “uncertain” about the short-term, much less the longer-term.

Amongst all this confusion, there’s one thing that is clear – there isn’t going to be an “Obamacare death spiral”, at least not for three years.  The scaremongering about death spirals and adverse selection that might result from too many old folks and not enough young folks signing up is mis-informed.

There is a financial back-stop in the form of reinsurance that protects insurers from high cost claims for the next three years.  Bob Laszewski has an excellent description of the program and implications thereof here.  Funded by a tax on each insured, the program provides coverage for insurers “selling coverage on the state and federal health insurance exchanges as well as in the small group (less than 50 workers) market…”

By then, things will have settled down, insurers will have figured out what works, what doesn’t, and what they need to do to operate profitably.  Some will drop out of the exchange(s), while others will expand their service offerings and coverage areas.

What does this mean for you?

Lots of uncertainty means lots of opportunity for those aware, nimble, and stalwart enough to take advantage.  Not that there are many in this business that fit that description!


Obamacare is NOT just the Federal Exchange

Okay, deep breath here folks.

There’s no question the Federal Exchange is a mess.  And that’s the polite characterization.

But let’s not get too carried away, because the Federal Exchange is just a small part of PPACA/Obamacare.  In fact, the Exchange impacts just 7% – seven percent! – of the US population.  Thus, it is:

  1. Irrelevant for most Americans – specifically the 80% who get their insurance from their employer or are covered by Medicare or already covered by Medicaid.
  2. Not operating in 16 states plus DC, and that includes a couple of big ones – California and New York specifically.  In general, those exchanges are doing pretty well. Yes there are significant problems in Hawaii, Maryland and a couple other states, but overall they’re doing fine.
  3. Operating in states where 59% of today’s uninsured live.  Sure that’s a lot, but it isn’t everyone, not even close. And, a big chunk of that 59% are not eligible for coverage for various reasons (undocumented, state refused to expand Medicaid, etc.)

And, the Federal Exchange is just one part of Obamacare.

It is a means to an end, and that “end” is covering as many eligible people as possible, while fundamentally changing the competitive marketplace to force insurers to compete based on delivering the best outcomes at the lowest price.

Key components of Obamacare already implemented include:

  • Medicaid and CHIP expansion, providing coverage to the growing population of people who don’t make enough money to buy their own coverage, or who work for small companies that don’t provide insurance.  
  • Credits to help small businesses buy coverage
  • Elimination of medical underwriting, lifetime caps, and coverage of dependents to 26
  • Allocation of funds to Comparative Effectiveness Research to promote treatments that actually work.
  • Policy changes and funding for new delivery systems and reimbursement arrangements, funding which has generated explosive growth in Accountable Care Organizations and Medical Home-based models.

What does this mean for you?

Eventually, the federal exchange will be fixed.  Meanwhile, our health care “system” is going thru drastic change, change that will, over the long term, improve the health care we get and reduce the cost of that care.  

Of course, there’s going to be some well-deserved political fallout in the interim.



5 – shut it down till it is ready to go

It is increasingly clear that is not working, and is not getting appreciably better. If it doesn’t get fixed – and I mean REALLY fixed – by the drop-dead date of December 1, the implementation will have to be delayed until it is.

And that may not happen until late next year.

There are two problems – the front end enrollment process, and the back end information distribution process. On the front end, a handful of people are successfully enrolling in health insurance on but a handful is nowhere near enough to get the program up and running successfully.  However, that’s just as well, and may actually be intentional.

If tens of thousands of people were successfully enrolling every day, the back end – where all the things happen that make health insurance actually work – would not be able to handle the volume.  That is a very polite way of saying it would be an unmitigated disaster.

Once you’re signed up, (among other things) your bank account has to be debited, subsidy calculated and applied (if there is one) and enrollment and eligibility information catalogued and prepared for distribution.  This process relies heavily on an EDI  process using an industry standard known as the “834”.

The problem is that each insurer has their own slightly-different version of the 834, so each health plan’s 834 has to be programmed, tested, and then tested each month to ensure the right data in the right format is getting to the right computer databases.  The best discussion of the issue was on Bob Laszewski’s interview with Daryl Chapman last week. Here’s an excerpt:

 There are lots of data elements and a lot of field variables. Because of this complexity, no one takes a file straight into a production system––too risky. There are variations on the process but every company has some type of validation process. Generally, the 834 goes through an acceptance process, which scans the file and checks for errors. If it passes the data check it uploads to some kind of “model office” where it is tested again and then, if it passes, it goes to production. Although most of that is automatic there are several chances for the file to “error out.” Once in production, the file drives the payment system, claim system, and is the source for the list of doctors and hospitals they need to confirm the person is eligible for benefits.

Files still have lots of opportunity to trigger false reports in each of these systems if they aren’t accurate.

For example, member data is not the same as payment or cash data (member payments in this case come from two sources; the subscriber and the government). Poor quality data can lead to lots of problems trying to reconcile who the health plan was paid for and who they have on their eligibility system. Very few systems ever connect cash to belly-buttons and even fewer have debit and credit carry forward accounting capability making reconciliation on the fly very difficult.

If the member data is a mess then the cash becomes a mess. When the subsidy cash goes to the carrier from the federal government, the carrier doesn’t just get you; they get thousands of member cash files. If there isn’t a match, the claim paying process has to be suspended until people with green eyeshades figure it out.

And out in the world where doctors and hospitals live if the data isn’t clean doctors and hospitals may not treat you if the carrier file doesn’t say you are covered. They may demand payment upfront from the patient until things are straightened out or balance bill if claims aren’t reimbursed. That is a particular problem here because so many of these people will presumably be low-income.

This is where the biggest problem lies, and the hinge on which the success or failure of Obamacare rests.  I do not understand why the Administration doesn’t bite the proverbial bullet and shut down the Exchanges until they are absolutely ready to go.  Sure, there’d be a lot of political fallout, but that would last for a few news cycles, and then they’d be off to some new celebrity scandal.

Instead, the President and his proxies are telling people to get on to the site and sign up.  A site that isn’t working, and is much harder to fix because the White House appears to want to avoid some political damage. That is unconscionable.

What we need now is Lyndon Johnson.  He’d get the right people in the room, beat them mercilessly, make the tough decision and move on.  Instead we have millions of people who desperately want and need health insurance spending hours trying fruitlessly to enroll on a site that is fundamentally broken.

 What does this mean for you?

An aphorism is appropriate – If you don’t have time to do it right in the first place, what makes you think you’ll have time to fix it?



The time to fix the federal Exchange is now

The rollout of the federal Exchanges has been a disaster.

There’s no way to sugar coat it; whether it’s a design, technology, or communications problem (more likely all three), they are NOT working. And yes, there’s a clear management/leadership failure here; the Obama Administration failed twice;

  • first – designing the right development process (it appears that among other things, political decisions caused them to hold back on issuing detailed guidance to key stakeholders, i.e. health insurers)
  • second – encouraging Americans to use the Exchanges on day One, when they should have known they were not ready.

While the feds and their contractors are working feverishly to fix things on the fly, I’m hearing from my tech expert colleagues that they’d be far better off taking the Exchange off line, fixing the problems, then re-starting it.

Among the issues/problems, there’s:

  • a requirement that enrollees enter all their personal info before they can look at and compare plans
  • a lack of server capacity to handle the traffic volume
  • a lack of communication between the Exchange and the various health plans (this may be the most critical problem over the next few months as folks get cancellation notices from their current insurers and are required to sign up via the Exchanges)
  • erstwhile enrollees can’t find out if their doctors are in any of the plans available to them.

HHS bears a lot of responsibility for this, and perhaps Sec. Sibelius should be fired.  However, that would require the President to nominate a new Secretary, and given the hyper-partisan approval process, any new Secretary would face uncertain-at best-chances of approval by the Senate. And yes, President Obama is ultimately responsible, and therefore it is incumbent upon him that this gets fixed now, and gets fixed correctly.

Better to shut down the Exchanges now, get them fixed, test the heck out of them using feedback from early users, and get them back up when they are really ready..

If that requires delaying the mandate for a few months, so be it.

What does this mean for you?

A very big, and very painful, lesson on how not to do big IT projects, and an equally big and painful lesson on the perils of allowing politics to trump common sense.