American College of Physicians: Internal Medicine — Doctors for Adults ®

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Transparency needed for successful health care reform

From the March ACP Internist, copyright © 2014 by the American College of Physicians

By Robert B. Doherty

Health care reform is mostly about creating access through affordable health insurance. This breaks down the financial barriers that formerly prevented people from getting needed care from physicians, hospitals and other health care providers. And health care reform is also about controlling costs, because unlimited access with no financial barriers would be more than the country can afford.

What happens, though, when the objective of providing access collides with the objective of controlling costs? This is the question being asked not only of the Affordable Care Act (ACA), but also the Medicare Advantage program and, for that matter, employer-based health plans.

The ACA tries to break down financial barriers to needed care by providing tens of millions of Americans with coverage they otherwise could not obtain or afford, while improving benefits and consumer protections for hundreds of millions more. The Medicare Advantage program tries to break down barriers to needed care by providing tens of millions of seniors with coverage that typically offers better benefits than traditional Medicare. Employers offer health insurance out of a belief that it is good for business to reduce barriers to their workers getting needed care so they can stay healthy and productive.

Yet, concern is growing that the coverage options the government and employers offer to consumers increasingly try to control costs by limiting access to clinicians.

The cost-control limitations on access can come in several forms. One is for the insurer to directly limit patient choice of physicians and hospitals by establishing “narrow networks.” Another is for the insurer to limit access to expensive drugs that a physician prescribes for a patient by establishing restrictive formularies. Another is to pay physicians or hospitals so little that many choose not to participate in the plans. Another is to shift costs to consumers by offering them plans with higher cost-sharing through deductibles and co-pays. Legions of Obamacare critics are quick to point the finger at the health reform law, conveniently forgetting that the trend toward offering plans with narrow networks, restrictive formularies and high cost-sharing has been going on for years.

Access is more than having health insurance. It is also about having the ability to see a physician you trust, to be able to get care from the hospital or cancer center that is close to home and/or has the facilities and reputation you need, to get the prescriptions that are most effective for your medical condition, and to avoid paying so much out of pocket that you can’t afford it.

At the same time, it is not reasonable to argue for unfettered access to everyone and everything at no cost to the patient. That would be a prescription for runaway health care spending, which in turn would cause the government and employers to cut benefits and shift even more costs to the patient or stop offering coverage altogether—a different kind of “death spiral.” Runaway health care spending also would harm U.S. economic competitiveness in a global economy, add to the public deficit and debt, and result in lower wages, higher taxes and reduced public spending on everything else we, as a country, need and value.

It also isn’t reasonable, in my view, to argue for “any willing provider” laws, which would require health insurers to include in their network any clinician who wants to be in the plan’s network, no matter the quality and cost of care associated with the clinician or whether the demand for health care services is sufficient to justify adding more clinicians to the plan’s network.

We need to acknowledge that some physicians and hospitals have unjustifiably high utilization rates, poorer outcomes, and high admission and readmission rates. Do we really want to argue that health plans must be required to include them in their networks? Patients may decide to choose a less expensive health plan that excludes their own physicians and preferred hospitals or has a higher deductible. Do we want to take that choice away from them by requiring that they buy a more costly plan that includes everyone with no out-of-pocket costs?

It isn’t reasonable to argue that health plans should be required to pay physicians and hospitals whatever they demand to participate in the network. That’s not the way market competition works. At the same time, insurers and government programs shouldn’t pay so little that it drives the best physicians and hospitals out of their programs. It isn’t reasonable to insist that every medication be on a plan’s formulary if there is an equally effective and less expensive alternative. Nor is it reasonable to argue that everyone should have very expensive coverage, with no skin in the game when it comes to the costs associated with care.

What is reasonable is to insist on balance, transparency, fairness and real choice. Consumers should have access to real-time and accurate clinician directories when they select a plan, so they know at the time they make their selection if their physician and hospital are in the network, rather than being surprised later to find they are not.

Health plans should be required to be transparent in the criteria they use to determine which physicians and hospitals are allowed in their networks—no black-box secret selection criteria!—and they should not be allowed to make such determinations based only on cost.

Also, quality and resource-use measures used to evaluate physician performance as a basis for making network selection decisions should also be transparent, risk-adjusted and open to challenge. And there should be a transparent and fair appeals process for a physician who is dropped from a plan to be reinstated or for patients undergoing care to continue to see the physician of their choice or to continue to get a preferred prescription that is not on the plan’s formulary.

Cost-sharing requirements need to be reasonable and income-adjusted to give people incentive to consider the costs of their own care, but not so high as to make care unaffordable. And the ACA’s network adequacy standards need to be enforced.

It is possible to have access to good coverage that reduces barriers to care and also the ability to see a trusted physician who can prescribe effective prescriptions with affordable out-of-pocket costs. It is just a matter of balance, transparency and real choice.

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