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Network Adequacy Tops  Our Agenda

PERHAPS no time in U.S. political history will our efforts to promote education and collaboration in our advocacy for physicians be as tested as in the coming weeks and months with the changing of the guard in Washington and divided government in Springfield. In particular, there is a lot of legislative talk and many moving parts to the potential repeal, replacement or repair of the Affordable Care Act. Much of the political attention has been focused on insurance companies leaving markets and large premium increases by those health plans that stay and continue to offer coverage.

But we must remain focused as we educate lawmakers and advocate for physicians as a solution to any changes to health coverage in this country and improvements to the existing laws. Already, we know that insurance companies that have survived losses and remain on public marketplaces under the Affordable Care Act have done so by restricting patient choice. In some cases, these plans state that they will remain under the ACA because they have scaled back consumers’ choice of PPOs in favor of narrow network plans such as HMOs and exclusive provider organizations, or EPOs.

And this narrow network strategy is also poised to gain momentum beyond states and commercial insurance under the ACA and into Medicare. Nationally, there is increased talk of privatizing Medicare under the Republican-led Congress.

Though it’s unclear how a more privatized Medicare program would take shape, it’s generally interpreted as an expansion of Medicare Advantage. U.S. House Speaker Paul Ryan’s “Better Way” agenda looks to expand the role of Medicare Advantage plans. Even under President Obama, Medicare Advantage grew to 18 million enrollees or almost one-third of beneficiaries in a private managed care plan.

But physicians should be leery of Medicare Advantage because it hands off administration of benefits for seniors to private insurers that will control provider networks. When private insurers gain more control over your patients’ benefits, the likelihood is greater that performance measures will increase and there is the potential for winners and losers among physicians.

At CMS, we remain concerned about increased insurance control of networking strategies and who is determining performance and therefore who is going to determine your compensation. This could be an even more important issue as payment under the Medicare Access and CHIP Reauthorization Act of 2015, also known as “MACRA,” is rolled out over the next few years and physician reimbursement is increasingly based on performance.

We will continue to advocate in Springfield and Washington for network adequacy legislation. Your CMS has already laid out the necessary legislative language for ISMS, by developing many of the provisions contained in the legislation that would allow patients to receive the care they need in a timely manner from physicians in the health plan’s network.

I am going to Washington on February 26 to advocate for our members and will be meeting with members of Congress in leadership and from Illinois’ delegation to Washington. Please reach out to me or to CMS staff if you have points that you want to stress and legislative efforts you want me to bring to their attention.

Clarence W. Brown, Jr., MD
President, Chicago Medical Society

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