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The Big Squeeze: More Enrollees and Smaller Networks Plague Some ACA Plans

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by Julie Appleby, Kaiser News
Thu, 06 Apr 2023 09:00:00 +0000

The Affordable Care Act may be struggling with its own success.

Record enrollment over the last two years brought more consumers into the market. At the same time, many insurers began offering smaller networks of doctors and hospitals, partly to be price-competitive.

That combination left some patients scrambling to find an available in-network physician or medical facility. That can be a challenge, especially when enrollees must rely on inaccurate provider lists from their insurance company.

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Take what happened to a central Pennsylvania policyholder, who in January fell and broke her arm and a bone near her eye.

She was directed by the hospital that provided her emergency care to follow up with an orthopedist, recounted Althouse, the patient's insurance agent, who works near Reading, Pennsylvania. Althouse's client spent hours calling orthopedic doctors listed in the provider directory of her new health plan from insurer Ambetter Health, a national carrier that in 2019 started offering ACA plans in Pennsylvania. Several doctors said they weren't part of the network, despite being listed by the company, Althouse said. It took about 15 tries before her client found an in-network doctor who would see her.

That “was the last thing she needed when she was already feeling terrible,” said Althouse.

It's a story that has been repeated to her multiple times since January, when the new plan year began. Her clients have “bombarded” her with calls, saying a range of physicians and other providers were not accepting the insurance, even if that provider was listed in the plan's own directory. “The thing that shocked me was how many offices told my clients, ‘We have never heard of this company,'” Althouse said.

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For its part, Ambetter said in a written statement to KHN that their network in Pennsylvania “meets or exceeds regulatory standards.”

The size of insurers' networks of contracted doctors and hospitals, particularly in ACA plans, has long drawn concern. In recent years, insurers have trended toward offering smaller networks, in part to cut costs and keep premiums in check.

Problems arise when patients cannot find local in-network providers and must either pay more, for out-of-network care, if that's even an option in their plans, or travel farther for in-network care.

It wasn't supposed to be that way anymore, after new rules kicked in this year to address such issues.

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For one, federal regulators are again checking whether insurers have enough providers. That comes after a 2021 court ruling that reversed a Trump administration move to eliminate such federal oversight.

In addition, new “time and distance” standards went into effect, requiring insurers to make available, within certain driving distances, at least one provider for each of a variety of physician specialties. For example, a large metro area must have enough endocrinologists for at least 90% of enrollees to be able to find one within 15 miles or a 30-minute .

Yet insurance brokers in multiple states told KHN that many clients are having trouble finding in-network providers across a variety of health plans. Even when they do, patients on some plans face “a four- to five-month wait to see a primary care doctor,” said Tracy McMillan, president of Marketplace Insurance Exchange, an insurance brokerage in the Dallas-Fort Worth area.

Under the Affordable Care Act, insurers must “ensure a sufficient choice of providers.” But there is no single nationwide standard on what to measure to determine network adequacy, and both federal and state regulators have authority to oversee the plans.

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“These exchange networks have never had much rigorous oversight,” said Karen Pollitz, a senior fellow at KFF.

But access is still limited in some and even the standards themselves may not be tough enough, say policy experts and brokers.

We have insurers that don't even have a hospital in some counties,” said Lauren Jenkins, owner of Native Oklahoma Insurance, a brokerage based near Tulsa. “How do they even get approved to be in these counties?”

In a metro area no more than 40 miles across, a plan could theoretically have as few as 10 doctors and three facilities in network and still meet these standards, Pollitz said.

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In Texas, North Carolina, and other parts of the country, new companies, often charging lower premiums, have entered the ACA market. Some have networks “that are very, very tiny,” said Don Hilke, owner of ClearBenefits Group in Durham, North Carolina. Even larger carriers are either squeezing their networks to compete on price or enrolling so many customers that they are stretching their existing networks.

In Texas, two smaller insurance companies left the market, leaving the remaining insurers without enough doctors to absorb the policyholders who had to find other coverage, said Ronnell Nolan, president and CEO of Health Agents for America, a membership association for independent brokers. “It left everyone in a pickle.”

Federal regulators propose more changes for next year, requiring insurers to meet appointment wait-time standards.

More has been done this year too, including reviewing insurer networks, said Ellen Montz, deputy administrator and director of the federal Center for Consumer Information and Insurance Oversight, part of the Centers for Medicare & Medicaid Services.

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Insurers pegged as having a shortfall in their networks must now monthly to CMS their “good faith efforts to fill those gaps” and how many complaints they get from consumers about access, she wrote.

Montz did not say how many insurers have fallen short, but a December report from the U.S. Government Accountability Office noted that CMS found 243 out of 375 insurance companies whose medical or dental plans were reviewed by federal regulators in August failed to meet network adequacy standards. CMS told the GAO that all plans eventually satisfied the requirements or provided “an acceptable justification as to why they were unable to meet the standards.”

Creating networks and keeping lists of participating providers up to date pose ongoing challenges, said Jeanette Thornton, executive vice president of policy and strategy at AHIP, the health insurance industry's leading lobbying group. Those include the need to rely on providers to inform insurers when they move, retire, or stop accepting new patients.

Questions about the accuracy of provider directories persist. Dr. Neel Butala, an assistant professor at the of Colorado School of Medicine, found that fewer than 20% of more than 449,000 physician listings had consistent address and specialty area information across five large insurers' directories, according to a research letter published in the Journal of the American Medical Association on March 14.

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A lawsuit filed in August 2022 in the U.S. District Court for the Northern District of Illinois alleges the provider networks for Centene's Ambetter plans “are simply false and are often just copies of physician directories from other sources.”

Without accurate directories, the lawsuit alleges, patients face “delays in treatment, inability to get treatment, traveling to see an in-network provider who is hundreds of miles away, and paying out-of-pocket for out-of-network providers.” Similar allegations are included in ongoing lawsuits first filed in 2021 by the San Diego Attorney against three California insurers.

The No Surprises Act, which went into effect more than a year ago, requires insurers to update their provider directories every 90 days. No insurers have yet been penalized for failing to update theirs, said CMS' Montz. The also stipulates that if patients get hit with an out-of-network charge because they relied on inaccurate information, the insurer can charge the patient only the in-network rate.

In October, CMS published an official query asking for comment on whether the federal government should create its own national database of in-network medical providers, an inquiry that drew hundreds of responses, both for and against.

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There has been no indication whether such a plan will move forward.

By: Julie Appleby, Kaiser Health News
Title: The Big Squeeze: More Enrollees and Smaller Networks Plague Some ACA Plans
Sourced From: khn.org/news/article/aca-record-enrollment-smaller-networks-health-insurance/
Published Date: Thu, 06 Apr 2023 09:00:00 +0000

Kaiser Health News

KFF Health News’ ‘What the Health?’: The Supreme Court and the Abortion Pill

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Thu, 28 Mar 2024 19:45:14 +0000

The Host

Julie Rovner
KFF


@jrovner


Read Julie's stories.

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Julie Rovner is chief Washington correspondent and host of KFF Health News' weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care and Policy A to Z,” now in its third edition.

In its first abortion case since the overturning of Roe v. Wade in 2022, the Supreme Court this looked unlikely to uphold an appeals court ruling that would dramatically restrict the availability of the abortion pill mifepristone. But the court already has another abortion-related case teed up for April, and abortion opponents have several more challenges in mind to limit the procedure in states where it remains legal.

Meanwhile, , including former , continue to take aim at popular health programs like Medicare, , and the Affordable Care Act on the campaign trail — much to the delight of Democrats, who feel they have an advantage on the issue.

This week's panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post.

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Panelists

Sarah Karlin-Smith
Pink Sheet


@SarahKarlin


Read Sarah's stories.

Alice Miranda Ollstein
Politico

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@AliceOllstein


Read Alice's stories.

Lauren Weber
The Washington Post


@LaurenWeberHP

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Read Lauren's stories.

Among the takeaways from this week's episode:

  • At least two conservative Supreme Court justices joined the three more progressive members of the bench during Tuesday's oral arguments in expressing skepticism about the to the abortion drug mifepristone. Their questions focused primarily on whether the doctors challenging the drug had proven they were harmed by its availability — as well as whether the best remedy was to broadly restrict access to the drug for everyone else.
  • A ruling in favor of the doctors challenging mifepristone would have the potential to reduce the drug's safety and efficacy: In particular, one FDA subject to reversal adjusted dosing, and switching to using only the second drug in the current two-drug abortion pill regimen would also slightly increase the risk of complications.
  • Two conservative justices also raised the applicability of the Comstock Act, a long-dormant, 19th-century that restricts mail distribution of abortion-related items. Their questions are notable as advisers to Trump explore reviving the unenforced law should he win this November.
  • Meanwhile, a Democrat in Alabama flipped a state House seat campaigning on abortion-related issues, as Trump again discusses implementing a national abortion ban. The issue is continuing to prove thorny for Republicans.
  • Even as Republicans try to avoid running on health care issues, the Heritage Foundation and a group of House Republicans have proposed plans that include changes to the health care system. Will the plans do more to rev up their base — or Democrats?
  • This Week in Medical Misinformation: TikTok's algorithm is boosting misleading information about hormonal birth control — and in some cases resulting in more unintended pregnancies.

Also this week, Rovner interviews KFF Health News' Tony Leys, who wrote a KFF Health News-NPR “Bill of the Month” feature about Medicare and a very expensive air-ambulance ride. If you have a baffling or outrageous medical bill you'd like to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:

Julie Rovner: KFF Health News' “Overdosing on Chemo: A Common Gene Test Could Save Hundreds of Lives Each Year,” by Arthur Allen.

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Alice Miranda Ollstein: Stat's “Fetal Tissue Research Gains in Importance as Roadblocks Multiply,” by Olivia Goldhill.

Sarah Karlin-Smith: The Washington Post's “The Confusing, Stressful Ordeal of Flying With a Breast Pump,” by Hannah Sampson and Ben Brasch.

Lauren Weber: Stateline's “Deadly Fires From Phone, Scooter Batteries Leave Lawmakers Playing Catch-Up on Safety,” by Robbie Sequeira.

Also mentioned on this week's podcast:

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Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News' “What the Health?” on SpotifyApple PodcastsPocket Casts, or wherever you listen to podcasts.

——————————
Title: KFF Health News' ‘What the Health?': The Supreme Court and the Abortion Pill
Sourced From: kffhealthnews.org/news/podcast/what-the-health-340-supreme-court-mifepristone-march-28-2024/
Published Date: Thu, 28 Mar 2024 19:45:14 +0000

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California Is Expanding Insurance Access for Teenagers Seeking Therapy on Their Own

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April Dembosky, KQED
Thu, 28 Mar 2024 09:00:00 +0000

When she was in ninth grade, Fiona Lu fell into a depression. She had trouble adjusting to her new high school in Orange County, California, and felt so isolated and exhausted that she cried every morning.

Lu wanted to get help, but her Medi-Cal plan wouldn't cover therapy unless she had permission from a parent or guardian.

Her mother — a single parent and an immigrant from China — worked long hours to for Fiona, her brother, and her grandmother. Finding time to explain to her mom what therapy was, and why she needed it, felt like too much of an obstacle.

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“I wouldn't want her to have to sign all these forms and go to therapy with me,” said Lu, now 18 and a freshman at UCLA. “There's a lot of rhetoric in immigrant cultures that mental concerns and getting treatment for that is a Western phenomenon.”

By her senior year of high school, Lu turned that experience into activism. She campaigned to change state policy to allow children 12 and older living in low-income households to get mental health counseling without their ' consent.

In October of last year, Gov. Gavin Newsom signed a new law expanding access to young patients covered by Medicaid, which is called Medi-Cal in California.

Teenagers with commercial insurance have had this privilege in the state for more than a decade. Yet parents of children who already had the ability to access care on their own were among the most vocal in opposing the expansion of that coverage by Medi-Cal.

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Many parents seized on the bill to grievances about how much control they believe the state has over their children, especially around gender identity and care.

One mother appeared on Fox News last spring calling school therapists “indoctrinators” and saying the bill them to fill children's heads with ideas about “transgenderism” without their parents knowing.

Those arguments were then repeated on social media and at protests held across California and in other parts of the country in late October.

At the California Capitol, several Republican lawmakers voted against the bill, AB 665. One of them was Assembly member James Gallagher of Sutter County.

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“If my child is dealing with a mental health crisis, I want to know about it,” Gallagher said while discussing the bill on the Assembly floor last spring. “This misguided, and I think wrongful, trend in our policy now that is continuing to exclude parents from that equation and say they don't need to be informed is wrong.”

State lawmaker salaries are too high for them or their families to qualify for Medi-Cal. Instead, they are offered a choice of 15 commercial health insurance plans, meaning children like Gallagher's already have the privileges that he objected to in his speech.

To Lu, this was frustrating and hypocritical. She said she felt that the opponents lining up against AB 665 at legislative hearings were mostly middle-class parents to hijack the narrative.

“It's inauthentic that they were advocating against a policy that won't directly affect them,” Lu said. “They don't realize that this is a policy that will affect hundreds of thousands of other families.”

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Sponsors of AB 665 presented the bill as a commonsense to an existing law. In 2010, California lawmakers had made it easier for young people to access outpatient mental health treatment and emergency shelters without their parents' consent by removing a requirement that they be in immediate crisis.

But at the last minute, lawmakers in 2010 removed the expansion of coverage for teenagers by Medi-Cal for cost reasons. More than a decade later, AB 665 is meant to close the disparity between public and private insurance and level the playing field.

“This is about equity,” said Assembly member Wendy Carrillo, a Los Angeles Democrat and the bill's author.

The original law, which regulated private insurance plans, passed with bipartisan and had little meaningful opposition in the legislature, she said. The law was signed by a Republican governor, Arnold Schwarzenegger.

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“Since then, the extremes on both sides have gotten so extreme that we have a hard time actually talking about the need for mental health,” she said.

After Carrillo introduced the bill last year, her office faced death threats. She said the goal of the law is not to divide families but to encourage communication between parents and children through counseling.

More than 20 other states allow young people to consent to outpatient mental health treatment without their parents' permission, Colorado, Ohio, Tennessee, and Alabama, according to a 2015 paper by researchers at Rowan University.

To opponents of the new law, like Erin Friday, a San Francisco Bay Area attorney, AB 665 is part of a broader campaign to take parents' rights away in California, something she opposes regardless of what kind of health insurance children have.

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Friday is a self-described lifelong Democrat. But then she discovered her teenager had come out as transgender at school and for months had been referred to by a different name and different pronouns by teachers, without Friday's knowledge. She devoted herself to fighting bills that she saw as promoting “transgender ideology.” She said she plans to sue to try to overturn the new California law before it takes effect this summer.

“We're giving children autonomy they should never have,” Friday said.

Under the new law, young people will be able to talk to a therapist about gender identity without their parents' consent. But they cannot get residential treatment, medication, or gender-affirming surgery without their parents' OK, as some opponents have suggested.

Nor can minors run away from home or emancipate themselves under the law, as opponents have also suggested.

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“This law is not about inpatient psychiatric facilities. This law is not about changing child custody laws,” said Rachel Velcoff Hults, an attorney and the director of health of the National Center for Youth Law, which supported AB 665.

“This law is about ensuring when a young person needs counseling or needs a temporary roof over their head to ensure their own safety and well-being, that we want to make sure they have a way to access it,” she said.

Removing the parental consent requirement could also expand the number of mental health clinicians in California willing to treat young people on Medi-Cal. Without parental consent, under the old rules, clinicians could not be paid by Medi-Cal for the counseling they provided, either in a private practice or a school counselor's office.

Esther Lau struggled with mental health as a high school student in Fremont. Unlike Lu, she had her parents' support, but she couldn't find a therapist who accepted Medi-Cal. As the only native English speaker in her family, she had to navigate the health care bureaucracy on her own.

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For her, AB 665 will give clinicians incentive to accept more young people from low-income households into their practices.

“For the opposition, it's just about political tactics and furthering their agenda,” Lau said. “The bill was designed to expand access to Medi-Cal youth, period.”

This article is from a partnership that includes KQED, NPR, and KFF Health News.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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By: April Dembosky, KQED
Title: California Is Expanding Insurance Access for Teenagers Seeking Therapy on Their Own
Sourced From: kffhealthnews.org/news/article/california-teen-access-mental-health-care-without-parental-consent/
Published Date: Thu, 28 Mar 2024 09:00:00 +0000

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As AI Eye Exams Prove Their Worth, Lessons for Future Tech Emerge

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Hannah Norman, KFF News
Wed, 27 Mar 2024 09:00:00 +0000

Christian Espinoza, director of a Southern California drug-treatment provider, recently began employing a powerful new assistant: an artificial intelligence algorithm that can perform eye exams with pictures taken by a retinal camera. It makes quick diagnoses, without a doctor present.

His clinics, Tarzana Treatment Centers, are among the early adopters of an AI-based system that promises to dramatically expand screening for diabetic retinopathy, the leading cause of blindness among working-age adults and a threat to many of the estimated 38 million Americans with diabetes.

“It's been a godsend for us,” said Espinoza, the organization's director of clinic operations, citing the of a quick and easy screening that can be administered with little training and delivers immediate results.

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His like it, too. Joseph Smith, who has Type 2 diabetes, recalled the cumbersome task of taking the bus to an eye specialist, getting his eyes dilated, and then waiting a week for results. “It was horrible,” he said. “Now, it takes minutes.”

Amid all the buzz around artificial intelligence in health care, the eye-exam technology is emerging as one of the first proven use cases of AI-based diagnostics in a clinical setting. While the FDA has approved hundreds of AI medical devices, adoption has been slow as vendors navigate the regulatory process, insurance coverage, technical obstacles, equity concerns, and challenges of integrating them into provider systems.

The eye exams show that the AI's ability to provide immediate results, as well as the cost savings and convenience of not needing to make an extra appointment, can have big benefits for both patients and providers. Of about 700 eye exams conducted during the past year at Espinoza's clinics, nearly one-quarter detected retinopathy, and patients were referred to a specialist for further care.

Diabetic retinopathy results when high blood sugar harms blood vessels in the retina. While managing a patient's diabetes can often prevent the disease — and there are treatments for more advanced stages — doctors say regular screenings are crucial for catching symptoms early. An estimated 9.6 million people in the U.S. have the disease.

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The three companies with FDA-approved AI eye exams for diabetic retinopathy — Digital Diagnostics, based in Coralville, Iowa; Eyenuk of Woodland Hills, California; and Israeli software company AEYE Health — have sold systems to hundreds of practices nationwide. A few dozen companies have conducted research in the narrow field, and some have regulatory clearance in other countries, tech giants like Google.

Digital Diagnostics, formerly Idx, received FDA approval for its system in 2018, following decades of research and a clinical trial involving 900 patients diagnosed with diabetes. It was the first fully autonomous AI system in any field of medicine, making its approval “a landmark moment in medical history,” said Aaron Lee, a retina specialist and an associate professor at the of Washington.

The system, used by Tarzana Treatment Centers, can be operated by someone with a high school degree and a few hours of training, and it takes just a few minutes to produce a diagnosis, without any eye dilation most of the time, said John Bertrand, CEO of Digital Diagnostics.

The setup can be placed in any dimly lit room, and patients place their face on the chin and forehead rests and stare into the camera while a technician takes images of each eye.

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The American Diabetes Association recommends that people with Type 2 diabetes get screened every one to two years, yet only about 60% of people living with diabetes get yearly eye exams, said Robert Gabbay, the ADA's chief scientific and medical officer. The rates can be as low as 35% for people with diabetes age 21 or younger.

In swaths of the U.S., a shortage of optometrists and ophthalmologists can make appointments hard to schedule, sometimes booking for months out. Plus, the barriers of traveling to an additional appointment to get their eyes dilated — which means time off work or school and securing transportation — can be particularly tricky for low-income patients, who also have a higher risk of Type 2 diabetes.

“Ninety percent of our patients are blue-collar,” said Espinoza of his Southern California clinics, which largely serve minority populations. “They don't eat if they don't work.”

One potential downside of not having a doctor do the screening is that the algorithm solely looks for diabetic retinopathy, so it could miss other concerning diseases, like choroidal melanoma, Lee said. The algorithms also generally “err on the side of caution” and over-refer patients.

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But the technology has shown another big benefit: Follow-up after a positive result is three times as likely with the AI system, according to a recent study by Stanford University.

That's because of the “proximity of the message,” said David Myung, an associate professor of ophthalmology at the Byers Eye Institute at Stanford. When it's delivered immediately, rather than weeks or even months later, it's much more likely to be heard by the patient and acted upon.

Myung launched Stanford's automated teleophthalmology program in 2020, originally focusing on telemedicine and then shifting to AI in its Bay Area clinics. That same year, the National Committee for Quality Assurance expanded its screening standard for diabetic retinopathy to include the AI systems.

Myung said it took about a year to sift through the Stanford health system's cybersecurity and IT systems to integrate the new technology. There was also a learning curve, especially for taking quality photos that the AI can decipher, Myung said.

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“Even with hitting our stride, there's always something to improve,” he added.

The AI test has been bolstered by a reimbursement code from the Centers for Medicare & Services, which can be difficult and time-consuming to obtain for breakthrough devices. But health care providers need that approval to get reimbursement.

In 2021, CMS set the national payment rate for AI diabetic retinopathy screenings at $45.36 — quite a bit below the median privately negotiated rate of $127.81, according to a recent New England Journal of Medicine AI study. Each company has a slightly different business model, but they generally charge providers subscription or licensing fees for their software.

The companies declined to share what they charge for their software. The cameras can cost up to $20,000 and are either purchased separately or wrapped into the software subscription as a rental.

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The greater compliance with screening recommendations that the machines make possible, along with a corresponding increase in referrals to specialists, makes it worthwhile, said Lindsie Buchholz, clinical informatics lead at Nebraska Medicine, which in mid-December began using Eyenuk's system.

“It kind of helps the camera pay for itself,” she said.

, Digital Diagnostics' system is in roughly 600 sites nationwide, according to the company. AEYE Health said its eye exam is used by “low hundreds” of U.S. providers. Eyenuk declined to share specifics about its reach.

The technology continues to advance, with clinical studies for additional cameras — including a handheld imager that can screen patients in the field — and looking at other eye diseases, like glaucoma. The innovations put ophthalmology alongside radiology, cardiology, and dermatology as specialties in which AI innovation is fast.

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“They are going to come out in the near future — cameras that you can use in street medicine — and it's going to a lot of people,” said Espinoza.

——————————
By: Hannah Norman, KFF Health News
Title: As AI Eye Exams Prove Their Worth, Lessons for Future Tech Emerge
Sourced From: kffhealthnews.org/news/article/artificial-intelligence-ai-eye-exams-diabetic-retinopathy-innovation/
Published Date: Wed, 27 Mar 2024 09:00:00 +0000

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