Sunday, February 08, 2015

Narrow networks: a painful of tourniquet on a bleeding healthcare system

Stories of bad buyer experiences with ACA exchange plans often induce me to push back a bit. I can't do that with Elisabeth Rosenthal's laser strike on patients' troubles with ACA plans' narrow networks and mazes of separate copays and coninsurance for different procedures.  Rosenthal is too nuanced, too thorough with context, and too precise in her accounts of buyers' experiences to quibble with. A sampling:
Alison Chavez, 36, who is self-employed, signed up for a marketplace plan in October 2013 that she hoped would be an improvement on her previous plan. She had recently been given a diagnosis of breast cancer and was just beginning therapy, so she was careful to choose a policy on the Covered California marketplace that included her physicians.

But in March, while in the middle of treatment, she was notified that several of her doctors and the hospital were leaving the plan’s network. She was forced to postpone a surgery as she scrambled to buy a new commercial policy that included her doctors. “I’ve been through hell and back, but I came out alive and kicking (just broke),” she wrote in an email

Dr. Alexis Gersten, a dentist in East Quogue, N.Y., switched her family and 11 employees to a new Blue Cross/Blue Shield plan for 2014, after a previous small-business group plan was canceled. She bought the plan through a broker, and says she was unaware that it was an Affordable Care Act plan. When her son needed an ear, nose and throat specialist, the nearest was in Albany, five hours away. Though her cardiologist was on the network list, he said he did not take the plan. She ended up driving an hour to see a new one. A dispute with the insurer about how to count deductibles left her with a $457 pediatrician’s bill. This year she has chosen a new policy.
Rosenthal provides essential context: the trends toward higher deductibles and out-of-pocket costs predate the ACA, though the ACA probably accelerated them; ACA rules banned various more egregious abuses; the growth of health costs overall and even patient indebtedness has moderated in recent years. I would also add -- though there was no particular reason for Rosenthal to do so -- that Cost Sharing Reduction (CSR) subsidies greatly relieve one of these two ills -- high out-of-pocket costs -- for buyers with incomes under 200% of the Federal Poverty Level. On the other hand, costs are still way too high for buyers with somewhat higher incomes, eligible for weak CSR or none at all. Here in Essex County, NJ (which includes Newark), a single person earning $28k will pay $180 for a silver plan with a deductible of $1500 and an out-of-pocket max of $4,000 That's a lot of OOP.

As for the narrow networks, many health economists hail them (as Austin Frakt does briefly here) as necessary pushback from insurers against the outsize pricing power wielded by American doctors and hospitals. The problem is our every-payer-for-itself chaos of variable rates, in which Medicaid pays too little and private insurers generally pay far too much, and everyone pays more to cover the absurd administrative costs of processing payment through dozens or of different payers.

What the story suggests to me is that the U.S. healthcare system will always be subpar -- more expensive, less efficient and less equitable than that of almost any other wealthy nation -- until we find some way of imposing uniform rates, or at least a narrow rate range, on all payers.  Either the government needs to set rates, or it needs to oversee negotiations in which all payers do so, whether on a state or national level.

Perhaps we'll find ways to pay for quality, or pay per patient rather than per procedure. Perhaps we can make pricing transparent enough that consumers, responsible for a large portion of their medical costs, can exert some leverage. I suspect these measures will prove secondary, though, to uniform pricing, which is the sine qua non of affordable healthcare delivery.

An intermediate stage would be to add a strong public option to the ACA exchanges, as University of Pennsylvania healthcare scholar Janet Weiner tweets in response to Rosenthal:
Getting there, though, is almost unimaginable in our current political landscape.  Maybe in ten years? Twenty?

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