TMA RESOURCES
TMA’s white paper, “Network Adequacy and Unfair Discrimination in Insurance,”
www.texmed.org/ networkadequacy
Health plan problems? Contact TMA’s Payment Advocacy Department:
www.texmed.org/ PaymentAdvocacy.
File a complaint with the Texas Department of Insurance : tma.tips/TDIcomplaintform.
nation’s largest health plans, he says any supposed promises of greater savings and better products come at physicians’ and patients’ expense in the form of take-it-or-leave-it payment contracts, high out-of-pocket costs, and less choice. (See “Bigger Isn’t Always Better,” December 2015 Texas Medicine, pages 22–31, or visit
www.texmed.org/HealthPlanMerger.) “The narrower [insurers] make these networks, the more they shift costs onto patients and doctors, and if regulators don’t look at this, we are all in big trouble,” Dr. Valenti said. According to TMA research, only two insurers offer broad preferred pro-
vider organization (PPO) networks in the 2016 Texas ACA marketplace, and both sell only regional coverage. That’s compared with four health plans offer- ing hundreds of PPO plans across the state in the 2015 exchange. Last summer, Blue Cross and Blue Shield of Texas (BCBSTX) dropped the only statewide PPO plan from both the ACA exchange and the private individual market due to high profit losses. Cigna also discontinued its PPO products on and off the exchange, while Humana dropped its PPO exchange plan. And UnitedHealth has indicated it is considering abandoning the ACA marketplace altogether in 2017 after losing an estimated $400 million. (See “2016 Texas ACA Marketplace Health Plans,” page 35.) Texas Department of Insurance (TDI) officials confirmed to Texas Medicine
that over the past few years the agency has received an uptick in plan filings for narrow networks, particularly super-narrow exclusive provider organizations (EPOs) that have no out-of-network benefits, except for emergency services. Even if networks are smaller, however, TDI says they still have to meet the same requirements as any other plan type to show they have enough physicians. It’s not for lack of trying on physicians’ part, TMA leaders say. “We try hard to be in network. The big dilemma is that sometimes being out
of network is not a choice of the practice. It’s a choice of the insurance company gaming the system to their advantage,” Dr. Bourgeois said. “Subspecialists like me are understandably worried because we have the potential to be kept away from some of our patients. With these narrower networks, insurance companies say they only need a few neurosurgeons or retinal surgeons on their panels. And the people who are making those decisions from a thousand miles away may look at a map of the greater Houston-Galveston area and think 50 miles looks close, but it can take patients two or three hours in traffic.” He’s not alone. According to TMA’s 2014 Texas Physician Survey, one-quarter
of physicians approached a plan with which they were not contracted in an at- tempt to join its network. Of those, 29 percent received no response at all. When it does come to negotiating contracts, a number of health plans barely
cover the rent, Dr. Bourgeois adds, with some offers as low as two-thirds of Medicare rates. “That’s unsustainable. We have a business to run. But even if we negotiate in
good faith, if insurance companies give you a low-ball, take-it-or-leave-it offer and you don’t take it, you don’t have much leverage as a two-person practice, and you never hear from them again,” he said. “I just renegotiated my lease, and the building expects a 3-percent rise every year. What’s frustrating is many of the contracts I hold are the same as they were 10 years ago.” Dr. Callas acknowledges there may be some entities with a policy to stay out
of network. But having come to an agreement himself with all but one of Texas’ major payers, he says that’s the exception, not the rule. Most physicians nego- tiate in good faith and charge a reasonable fee for their services when those efforts fail, he says. “I know if I’m in network, it helps my patients, but not if I don’t get paid appropriately and can’t keep the lights on.” Early results from TMA’s 2016 Physician Survey show physicians across
30 TEXAS MEDICINE May 2016
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