Insurers seek limited insurance exchange plan networks

AHIP chief says health plans want to create high-performing networks through the new marketplaces with the ability to reward high-performing physicians.

By — Posted Aug. 19, 2013

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As the Oct. 1 deadline approaches for states to launch new marketplaces for buying health insurance, a leader in the insurance community is encouraging the use of plan networks that have participation limits, health care teams and incentives for high-quality physicians.

Health plans are focused on being ready “and doing what we need to do” as states set up their respective marketplaces, said Karen Ignagni, president and CEO of America's Health Insurance Plans, who joined other health care observers at an Alliance for Health Reform briefing in Washington on Aug. 9. Plans have been readying their enrollee call centers; training their brokers and agents; and engaging in outreach, education and technical infrastructure support. They want to make sure they're meeting state and federal accreditation standards for the exchanges, she said.

“We're focused on portability and workability and making sure this experience is a positive one,” Ignagni said.

But some policy concerns remain. Many states, for example, “still have restrictions on our ability to actually provide high-performing networks for individuals to be able to access high-performing doctors and hospitals to make sure again we're stretching those dollars. That will have to be looked at,” she said.

Ignagni was referring to the “any willing provider” clause, a mandate in some states that requires health plans to allow health care professionals to participate in a health plan's network if the professional agrees to a plan's contract terms, limits and conditions. The mandate would apply even in instances in which the network includes enough physicians and other professionals to meet patient needs and comply with the state's network adequacy requirements.

Ignagni suggested rewarding physicians who are meeting the latest professional society standards in an effort to encourage high care quality in the exchange plans. She also encouraged giving nurses a broader role, joining them with other professionals as part of health care teams, “so that we can try to customize health care and make it very patient-centered, and again stretch those dollars.”

Arkansas, which chose to partner with the federal government in developing an exchange, has been moving toward team-based care in reorganizing its health care practice system, said Joseph Thompson, MD, MPH, the state's surgeon general. Physicians assume a leading role in such teams but aren't necessarily the only “touch point” for patients, he said.

The American Medical Association House of Delegates addressed the issue of health care teams at its 2012 Interim Meeting, adopting policy to help guide doctors in leading such teams amid projected work force shortages and increasing demands for health care services.

In general, AMA policy has encouraged a proactive role for physicians in the development of the exchanges. The Association has supported an “open marketplace model for any health insurance exchange, with strong patient and physician protections in place, to increase competition and maximize patient choice of health plans.”

Tactics to attract plans

States have taken a variety of approaches to encourage insurers to offer plans on the states' exchanges, said Sarah Dash, a member of the research faculty at Georgetown University's Health Policy Institute in Washington, during the Alliance briefing. Discussing the results of a recent Commonwealth Fund study that focused just on state-run health insurance exchanges, Dash said some states assumed a hands-off approach to regulating the plans, assuming this would encourage interest. Any state that does not run a marketplace will default to a federally operated exchange.

Other states issued requirements for regional insurers to participate. In several instances, states decided to close the nonexchange market, “which is a de facto way of getting insurers into the exchange market,” Dash told participants of the Alliance briefing.

States also varied in how they approved plans for their respective exchanges, she said. Some took the “clearinghouse approach,” which effectively means they OK'd any plan that met minimum criteria for qualified health plans. A smaller number of states acted as active purchasers or selective contractors, which required having an additional layer of review once the plans were selected.

There also was a category called the “market organizer,” which adopted some structure around the plans that could be offered, “such as limiting the number of plans offered, but then not applying an additional layer of review once they were submitted,” Dash said.

State-based exchanges took a number of steps that hadn't been required of them to make it easier for consumers to choose plans, she noted. They also accomplished a great deal in terms of quality reporting. Although not required to report quality metrics for plans until 2016, nine states chose to do so starting in 2014, “an indication that states feel consumers should know more about the value proposition of exchanges,” Dash said.

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Options for state insurance exchanges

States have adopted a variety of models to establish health insurance exchanges, with many of them either deciding to run their own exchanges or have the federal government operate their exchanges entirely. But at least 15 states are adopting one of three hybrids of the two main approaches. According to the Congressional Budget Office, at least 7 million people are expected to enroll in the exchanges in 2014, a number that's projected to increase to 25 million by 2018.

Exchange model States
State-run exchange 16 plus the District of Columbia
State-federal partnership exchange 7
State-run small-business exchange/federally run individual exchange 1
Federally run exchange with state-run plan management 7
Federally run exchange 19

Source: “State Health Insurance Marketplaces on the Eve of Open Enrollment: Key Implementation Issues,” presentation of Sara R. Collins, vice president for affordable health insurance with the Commonwealth Fund, Alliance for Health Reform Briefing, Aug. 9 (link)

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External links

“Implementing the Affordable Care Act: Key Design Decisions for State-Based Exchanges,” the Commonwealth Fund, July 11 (link)

“State Health Insurance Marketplaces on the Eve of Open Enrollment: Key Implementation Issues,” presentation of Sara R. Collins, vice president for affordable health insurance with the Commonwealth Fund, Alliance for Health Reform Briefing, Aug. 9 (link)

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