The state insurance department is looking at possible ways to strengthen a Georgia law that requires health insurers’ networks to give consumers adequate access...

The state insurance department is looking at possible ways to strengthen a Georgia law that requires health insurers’ networks to give consumers adequate access to doctors and hospitals.

“Georgia is not alone: The feds and all the states are looking at the issue,’’ Trey Sivley, director of the Division of Insurance and Financial Oversight for the Georgia agency, told GHN recently.

Healthcare CostThe National Association of Insurance Commissioners is working on a redraft of its model for a network adequacy law. Georgia is studying the NAIC proposals, Sivley said. But he added that the state’s interest in the details “doesn’t mean that we’re going to adopt” the national group’s plan.

Such regulatory changes, if enacted, would coincide with an accelerating trend of health insurers offering consumers more limited choices of medical providers. The resulting health plans have become known generally as “narrow networks.”

Complaints about limited choice of doctors and hospitals in health plans — in Georgia and nationally — erupted during the rollout of the Affordable Care Act exchanges a year ago.

Some consumers complained that they had either lost a longtime physician or a trusted hospital by enrolling in an exchange plan, or had not found enough physicians in their network.

Georgia law currently requires “reasonable access” for a consumer in a PPO or HMO plan, Sivley said. A rural area “will be different than one that has a glut of providers,” he added.

Limited-choice plans aren’t confined to the insurance exchanges.

Three Surgeons Operating On A Patient

Recently in Georgia, UnitedHealthcare wrote to consumers that it was dropping some physicians in Atlanta, Augusta and Columbus from its Medicare Advantage doctor network.

United said that only about 10 percent of doctors in its Medicare network were dropped, and it denied that the resulting network was “narrow.” (Here’s a GHN article on the issue.)

The state insurance department has no jurisdiction over Medicare plans, because that program is run by the federal government.

Industry officials say network changes are partly about holding down costs, a major consideration for consumers who are concerned about the price of insurance premiums.

“We’re trying to build networks that balance quality and cost,’’ Graham Thompson, executive director of the Georgia Association of Health Plans, an industry group, told GHN. Employers emphasize the need for affordable plans, he said.

On the question of possible insurance department action, Thompson added:

“Issues around access and affordability are one of several issues under review, particularly for exchange plans, and formal regulations are one of the tools in the commissioner’s toolbox, as the industry and department strive to strike the right balance.”

Aside from the ACA, Sivley said, “in the [private] market now, I’m sure there are narrow networks out there, but the people buying them are more aware of it. There’s a difference in pricing.”

“Networks change all the time,” he added.

Whether the agency goes forward with a proposal, Sivley said, is “ultimately the commissioner’s decision, but he has made sure to devote resources to the issue.”

 

Open enrollment season

 

Health plan networks, meanwhile, are currently being scrutinized as open enrollment for private employers, Medicare, the exchanges, and the state employees’ plan has just begun or will debut shortly.

“Networks are being formed now for next year,” said John Crew of Strategic Healthcare Partners, which consults for more than 30 hospitals, 600 physicians, and 26 behavioral health centers in Georgia. “There is a lot of uncertainty about what the [network] composition of those health plans will be.”

Cindy Zeldin of the consumer group Georgians for a Healthy Future, which has supported the ACA, said “it’s a positive sign that the department is looking into’’ possible regulations on insurance networks.

“It’s important that the state has some standards and that consumers have some input,” she said..

If limited networks are done right, Zeldin said recently, “they’re not necessarily harmful to consumers.” And they have the potential to provide more coordinated care, she added.

Georgia’s largest physician organization, though, said recently that narrow networks “threaten the individual and trust-based relationship that physicians have with their patients.”

“Narrow networks also undermine the economic viability of the medical profession, which employs a lot of Georgians and which makes a significant contribution to the state’s economy,’’ said Donald J. Palmisano Jr., executive director of the Medical Association of Georgia.


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Andy Miller

Andy Miller is editor and CEO of Georgia Health News

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