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Grassroots Pressure Pays Off


The recent passage of HB 311, known as the Network Adequacy and Transparency Act (the NAT Act), marks the culmination of a two-year odyssey launched by the Chicago Medical Society. Passed with bipartisan support, HB 311 creates protections set forth by CMS that will benefit patients who purchase state-regulated health insurance plans, and the physicians who care for them. “We’re very grateful to Illinois lawmakers who helped us advance this critical legislation,” CMS President Clarence Brown, MD, said after the House passed the bill on June 24. “On both sides of the aisle, House and Senate members joined as co-sponsors, to address an issue that we can all agree on—the well-being of patients.”

Dr. Brown praised the leadership of State Rep. Gregory Harris (D-Chicago), Rep. Chad Hays (R-Catlin), State Sen. Linda Holmes (D-Aurora) and State Sen. Sue Rezin (R-Morris), all of whom paved the way for the bill’s passage. Rep. Chad Hays was the leading Republican sponsor of HB 311. “The health insurance issues we face here in East Central Illinois are very real,” Rep. Hays said. “It is not unusual for patients to drive an hour or longer to an appointment, and I hear all too often from constituents who believe they are scheduling appointments with ‘in-network’ physicians and specialists only to learn when they arrive for an appointment that the professional is no longer on their insurance plan. The provisions in HB 311 will go far in establishing new standards to protect consumers.”

An Odyssey Begins

Physicians familiar with Chicago Medicine magazine may recall the origin of this effort under Immediate Past President Kathy Tynus, MD. Dr. Tynus, an internal medicine specialist and educator, took office in June 2015, and throughout her term gave regular updates on the initiative.

CMS was aware early on of worrisome developments in the Affordable Care Act’s (ACA) insurance marketplace. By 2015, Illinois patients who bought marketplace insurance were facing drastic reductions in choice of hospitals and doctors. And the trend was not just limited to the ACA marketplace but also to products sold outside the ACA insurance marketplace.

For patients with highly complex medical needs, where continuity of care is most critical, many physicians worried that these shifts could have catastrophic results. And the process for patient and physician appeals to insurance companies can be complex, inefficient and lacking in transparency, causing delays in care or payment, Dr. Tynus pointed out.

Another worrisome feature—reports of unsuspecting patients, through no fault of their own, getting hit with penalties for out-of-network care. These surprise medical bills, often for emergency care, stoked outrage and controversy.

Not long into Dr. Tynus’ presidency, the state’s largest insurer announced it would be withdrawing its broad PPO plan from the insurance exchange’s individual market as of Jan. 1, 2016. While this was major news, capturing media attention, other narrow network plans were entering the Illinois market. Alarmed physicians brought their concerns to the Chicago Medical Society. It was clear to all that narrowing and tiering of plans in the Chicago area and Illinois could have a profound impact, on physicians and their patients.

Now the Chicago Medical Society had its work cut out.

Under Dr. Tynus, a network adequacy taskforce was appointed to study the shrinkage of health plan networks, as well as the turmoil in the insurance marketplace. The taskforce got reinforcement from CMS’ Healthcare Economics Committee, in addition to stakeholder input from various sectors and specialty societies. By year-end, a multipronged strategy was taking shape at CMS.

Talking to Insurance Companies

Amid dire reports of some insured patients losing access to covered care at the major academic tertiary hospitals, CMS decided to initiate talks with insurance officials. These meetings shed some light on the challenges faced by insurers. According to one insurance executive, many newly ACA insured individuals had gone for years without care because of pre-existing conditions or unaffordability. As a group, these patients were sicker and older, and, as a result, drove up costs far higher than estimated. At the same time, healthy young people who were needed to balance the actuarial pool of insured patients opted to pay a penalty rather than buy marketplace insurance. Last but not least, the loss of risk corridor adjustment payments promised in the ACA dealt a serious blow. These payments were supposed to offset insurer losses in the early years of Obamacare. But Congress removed these payments in omnibus budgets beginning with 2014.

As the Chicago Medical Society studied the marketplace turmoil, something else became clear: the need for better communication. Physicians and patients should be properly notified of upcoming changes in insurance products. “As we draw closer to enacting MACRA and its alternative payment models in 2019, this information will be crucial to physicians and patients alike,” Dr. Tynus said. “Although we cannot force an insurance company to stay in the marketplace, we should expect to be notified of network changes, along with our patients.”

Medical, Legal and Regulatory

Just what constitutes an “adequate network”? That was something else the Chicago Medical Society set out to investigate. In meetings with medical specialty groups and others, CMS found that the American Medical Association and even Medicare and the National Association of Insurance Commissioners had been clamoring for clarification on that point, Dr. Tynus said. CMS’ fact-finding even led to a meeting with the Illinois attorney general.

“We came away with the realization that what was happening with these insurance products is perfectly legal, which underscores the fact that rules and oversight are sorely lacking,” Dr. Tynus said of these discussions. “Narrow network insurance products are being created and sold without transparent rules for geographic and timely access to care, or quantitative standards, and without objective scrutiny prior to their approval by the state insurance board,” she added.

The question, therefore, was how could the Chicago Medical Society help protect patients from unforeseen costs? CMS could do several things, according to Dr. Tynus: “We can provide feedback to insurance companies when there are gaps in coverage. We can also seek to mandate minimum requirements for narrow networks.”

The Search for Model Legislation

Evaluating models upon which to create Illinois legislation, the Chicago Medical Society taskforce studied how other states grappled with the problem. New York’s “Surprise Medical Bill” law, they found, protects patients from out-of-network fees when they receive emergency care; when there are no in-network providers available; or when there are no disclosures made to the patient prior to the service. Providers and insurers also dispute fees through an independent agency. The law also creates network adequacy requirements. Ultimately, New York’s law become one of the models CMS urged ISMS to incorporate into draft legislation.

CMS also looked to the National Association of Insurance Commissioners. Back in 2015, as the NAIC revised its draft Managed Care Plan Network Adequacy Model Act, the AMA and dozens of other groups urged commissioners to incorporate several features above and beyond the draft revisions. In a letter to the commissioners, the groups called for: active approval of networks prior to products going to market; the use of quantitative measures to determine network adequacy; and regulation of tiered networks to prevent discriminatory network design.

“We believe state legislatures and Insurance Commissioners will be better equipped to establish reasonable, meaningful standards for network adequacy, while still allowing for market flexibility and choice,” the letter said. In addition, the AMA’s suite of model legislation directly addresses network issues and improved access to care for patients. CMS opted to include several of the AMA models in its proposal.

To the Illinois State Medical Society

Once the taskforce made its recommendations, the Chicago Medical Society drafted a network adequacy and transparency proposal, and fired it off to the Illinois State Medical Society. Dr. Tynus urged the ISMS Board to give it prompt review. The proposal, presented as a resolution, set forth network adequacy provisions, as developed by the taskforce. The ISMS Board, then chaired by Paul DeHaan, MD, was urged to draft a bill for introduction in the General Assembly in spring 2016. Dr. Tynus stressed she was working outside the usual process. Unlike the typical resolution to the ISMS House of Delegates, there was no time for this one to wind slowly through. “We believe the problem is too critical for delay, and have opted to forgo the traditional path of introducing a resolution to the April House of Delegates,” Dr. Tynus wrote to Dr. DeHaan. Soon, in a matter of days, Dr. Tynus was already giving in-person testimony to ISMS.

Network Adequacy and Surprise Medical Bill Resolution

The CMS proposal recommends adoption of the AMA principles for network adequacy rules along with other model acts developed by the AMA. Here is what the Chicago Medical Society requested of ISMS:

  1. Create network adequacy rules, modeled on those proposed by the American Medical Association.
  2. Mandate adequate network directories, modeled on the AMA Model Bill entitled “Meaningful Access to Accurate Provider Directories.” – This Act requires insurers to provide accurate provider directories that are updated in a timely manner. Such directories are essential to patients when choosing plans, and to helping regulators successfully monitor network adequacy.
  3. Protect patients from out-of-network charges that were incurred due to emergency care or charges that were incurred without prior notification, similar to the “Surprise Medical Bill” law enacted in the State of New York.
  4. Provide adequate out-of-network notification and payment structures, modeled on the AMA Model Bill entitled “Truth in Out of Network Healthcare Benefits Act.”
  5. Provide a transparent and efficient appeals process for coverage and claim disputes with insurers for patients and providers, utilizing a third-party mediator when necessary, modeled by the “Surprise Medical Bill” law enacted in the State of New York.
  6. Mandate that insurers provide 90-day advance notice to current enrollees prior to the open enrollment time period; case management services for transition of care to in-network providers; and a 90-day period of additional coverage for those patients affected by an insurer’s elimination of an insurance product or narrowing of their network within an insurance product.
  7. ISMS adopt as policy and act on these measures in an expedited manner, due to the negative impact of these recent developments on Illinois patients’ health and well-being.

The ISMS-drafted bill was amended slightly as it went through the legislative process. But the substance—protecting patients who purchase stateregulated health insurance plans—remains strong and clear in purpose. For highlights of the final legislation, see “NAT Act Highlights”.

Working for You

The biggest legislative victory of the year, the NAT Act came about because of your Chicago Medical Society working for you and your patients. It was taken up enthusiastically by the Illinois State Medical Society, Dr. Tynus says proudly.

For Dr. Tynus, the NAT Act provides the best possible argument for membership in organized medicine. In fact, she traces her involvement in CMS back to a conversation years ago. “After practicing as an internist for a few years and noticing some policies that were just not right, I would commiserate with colleagues who had similar complaints, and we’d wonder, ‘How did things get like this? Why isn’t anybody doing anything about it?”’ That’s when her colleague and mentor, Dr. Sharad Khandelwal, told me, “Kathy, you should join the Chicago Medical Society. That’s where you can do something about it.” I thought, “Why not? Can’t hurt, maybe they are working on it.”

Well, we’re working on it, I’m proud to say. And it’s a group effort that can’t happen without the support and participation of members like you.

UPDATE: AMA Passes New Network Adequacy Measures

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