Federal and state governments need to do more to ensure patients’ access to physicians under the Affordable Care Act’s new health plans, according to a report from the American College of Physicians.
In its Annual Report on the State of the Nation’s Health Care, issued on Feb. 11, ACP officials said that, even though the Affordable Care Act sets a standard for the adequacy of provider networks, consumers are already complaining that networks are too narrow.
For instance, one California insurer included 204 San Diego–area primary care physicians in its ACA exchange plan network, but its network for employer-sponsored plans in the area is three times larger. In New Hampshire, a hospital was excluded from an exchange-plan contract negotiation despite having lower charges than its competitors and high grades for quality of care, according to the ACP report.
Mr. Robert B. Doherty
On Feb. 4, the Centers for Medicare & Medicaid Services (CMS) sent a letter to insurers outlining its plans to ensure "reasonable access" to provider networks in 2015 by checking that consumers could access physicians without unreasonable delay. The CMS plans to look specifically at access to hospitals, mental health providers, oncologists, and primary care physicians.
The ACP said that the agency and state regulators should strengthen those requirements in several ways:
• Analyze local patient-to-physician ratios as well as current use of out-of-network clinicians and hospitals.
• Publish network monitoring data.
• Require health plans to provide physicians and patients with advance notice of network changes and the opportunity to appeal.
• Provide real-time access to network directories.
• Allow physicians to apply to any health plan and have their application judged on objective, transparent criteria.
• Bar health plans from excluding clinicians because their practices include patients with expensive medical conditions.
• Provide an additional enrollment period if patients are given an outdated or incorrect network directory.
Dr. Molly Cooke
"The college is not advocating that health plans provide unfettered access to every physician, hospital, or medication. We recognize that some physicians and hospitals have higher and possibly unjustifiably higher utilization rates, poorer outcomes, and higher admission and readmission rates," said Robert Doherty, ACP’s senior vice president of governmental affairs and public policy.
"Rather, we are offering constructive and balanced safeguards that emphasize consideration of additional elements in addressing network adequacy, transparency in network selection criteria and physician performance measures, consumer access to real-time network directories, improvements in the health plan selections shopping experience, and exceptions to ensure continuity of care," he added.
The ACP wants Medicare Advantage plans to be subject to similar requirements.
The ACP also called on federal and state regulators to more closely monitor health plan formularies to ensure that they do not exclude medications to treat complex chronic conditions, including cancer, transplants, mental health conditions, HIV/AIDS, and hepatitis C.
"We call for a balanced, constructive, and transparent approach allowing patients to make informed choices, promoting continuity of care, and ensuring fairness and due process for clinicians and patients, including strengthened federal and state regulatory oversight of qualified health plans," said Dr. Molly Cooke, ACP president.
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