with enough facility-based physicians to achieve an adequate network without “the ability to tell a hospital that if we’re going to list you as a network provider you’ve got to undertake certain efforts to have the physicians you grant privileges to in the network.”
TMA and other medical groups ob- jected when a draft of the TDI rules phased out the existing prohibition against forcing physicians to contract with health plans as a condition of maintaining medical staff privileges. In comments on the draft rules submitted to TDI in February, those groups argued there was no demonstrated need for re- moving the prohibition and that doing so could hurt access to care, particularly in smaller communities with only one hospital where loss of staff privileges could force a physician to relocate to stay in practice.
In addition to TMA, those comments were signed by the Texas Society of Pa-
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In fact, results of a recent TMA survey showed that, in large part, health plans themselves were at fault for their inabil- ity to contract with physicians. That TMA survey found that 44 per- cent of physicians who requested to join a health plan network eventually signed a contract. Twenty-seven percent said they received no response from the plans to their requests, and 29 percent said they received an offer that was un- acceptable.
TDI eventually agreed with the physi-
cian groups and deleted that proposed language.
Dr. Hinchey, who represented TMA on the network adequacy advisory commit- tee, says that action was a big win for physicians.
“If that had happened, all negotiating leverage would have been left with the plan because they knew they could dis- rupt anybody’s practice very quickly by not coming to terms with them,” he said. “It could have ruined a person’s practice.”
Out-of-pocket relief
TMA officials say patients will not only benefit from greater access to in-net- work physicians and more transparency, but also should see lower out-of-pocket costs because of the provision that re- quires plans to credit some expenses to their deductibles or annual out-of-pocket maximums. Lee Spangler, JD, TMA vice president for medical economics, says patients pre- viously never received credit for out-of- pocket expenses even if they were forced to go out of network because in-network care was not available. Now, those expenses will count against deductibles or annual maxi- mums, meaning patients’ out-of-pocket costs will be less, Mr. Spangler says. “The new deductible provisions will cer- tainly benefit people in actually getting an insurance product for their premium dollars.” Mr. Wolfe of TAHP thinks the new rules will be “problematic” for health plans and suggests other interested parties, particularly hospitals and even some physicians, are not enthusiastic about them. “They tried to split the baby about 20 times, and we ended up with a 400-page rule based on three lines in a bill that I think are going to be incredibly difficult to implement and are largely at odds with the reality of how health care is de- livered,” he said. Mr. Wolfe calls the provision creating
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an approved hospital care network des- ignation, which he says encourages hos- pitals to make a good faith effort to use only health plan-contracted physicians, one of the “more absurd” provisions. “That is absolutely something that cannot be regulated,” he said. “What is a good faith effort? If they don’t comply or
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