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Tackling Obamacare's Narrow Networks - Health Care Edge

Tackling Obamacare's Narrow Networks 

By Sophie Novack

 

HOW NARROW IS TOO NARROW? Premium rates and coverage are a constant give-and-take, but consumers say that some insurers on the Obamacare exchanges have gone too far in limiting doctors and hospitals included in their plans. The trade off for lower premiums in plans can be fewer provider options -- but some patients say insurance companies didn't make clear just how narrow the networks were, leaving them with unexpected high medical bills.

As a result, the Obama administration is working with state insurance regulators to strengthen coverage requirements in a similar way that they evaluate Medicare Advantage plans. Insurer applications to sell plans on the health exchanges were due at the end of last month, and the administration says it is increasing review of the networks to ensure wider options. We'll see if this comes at the cost of higher premiums.

Top Health Care News

NARROW NETWORKS: "In a recent memorandum to insurers, the Obama administration said it would focus on 'those areas which have historically raised network adequacy concerns, including hospital systems, mental health providers, oncology providers and primary care providers.'

 

Under the new standards, insurers will generally be required to have contracts with at least 30 percent of 'essential community providers' that treat 'low-income, medically underserved individuals' in their area. These providers include community health centers, clinics for people with HIV/AIDS and family planning clinics." (Robert Pear, New York Times)

THE DANGER OF THE RUSH TO ELECTRONIC MEDICAL RECORDS: The administration has funnelled billions of dollars into the push for digitization of health records, to incentivize providers to step up technology to improve care and lower health costs. But the rush to computerize, combined with little oversight and no reporting of errors required has led to new risks for patients. (Christopher Rowland, Boston Globe)

HIV/AIDS

AIDS CONFERENCE HONORS PLANE CRASH VICTIMS: The International AIDS conference began Sunday with a tribute to the six AIDS researchers and activists killed in the Malaysia Airlines plane that was shot down over Ukraine last week. (Associated Press)

STUDY: RATE OF HIV DIAGNOSIS FELL BY ONE THIRD IN A DECADE: Declines were seen in every group except for young gay and bisexual men, which saw an increase in diagnoses, according to a study released in the Journal of the American Medical Association. (Mike Stobbe, Washington Post)

 

Drugs

PHARMA BATTLES OVER HEPATITIS C DRUG DOMINANCE: Hepatitis C drug sales could climb to $20 billion each year by the end of the decade, prompting legal battles as drug companies try to claim patent rights to gain a piece of the lucrative business. Gilead's $84,000 treatment, Sovaldi, is at the center of the fight; sales of the drug made an estimated $5 billion in the first half of 2014, believed to be the best-selling prescription drug launch ever. (Peter Loftus, Wall Street Journal)

WHY OREGON IS LIMITING COVERAGE OF THE NEW HEPATITIS C DRUG: The state advanced recommendations last week to limit Sovaldi to its sickest Medicaid patients, and a state committee will consider them by the end of the month. By targeting the sickest patients, Oregon will spend $40 million on Sovaldi, instead of the $360 million it would cost to cover all 5,600 Medicaid enrollees that the state knows to be infected with hepatitis C. (Jason Millman, Washignton Post)

  • Oregon plans to bargain for a better deal on a new hepatitis C drug when competing treatments come on the market next year. (Joseph Walker, Wall Street Journal)

MISSOURI IS THE ONLY STATE THAT HAS RESISTED A PRESCRIPTION DRUG DATABASE: The other states use them to identify individuals who obtain excess prescriptions for addictive painkillers and tranquilizers, and the physicians who overprescribe them. (Alan Schwarz, New York Times)

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COALITION URGES WHITE HOUSE ACTION ON PRESCRIPTION DRUG ABUSE: The Alliance to Prevent the Abuse of Medicines, a group of health care stakeholders including CVS and the American Medical Association, wrote to the head of the White House Office of National Drug Control Policy to praise its 2014 agenda and offer assistance in implementing the strategy.

"We unequivocally support the position that reducing the incidence of abuse must be done primarily through a public-health approach, rather than through incarceration," the group wrote to Michael Botticelli, acting director of ONDCP. (Elise Viebeck, The Hill)

MEDICARE CHANGES HOSPICE DRUG RULE: Medicare announced that is would amend rules requiring hospice patients or their families to confirm that their prescriptions were not covered by hospice providers before filling them through their Part D drug plans, so that the additional authorization would be only be required for four kinds of medications. (Susan Jaffe, Kaiser Health News)

THE GOVERNMENT IS USING BIG DATA TO FIND DRUG PROBLEMS: The Food and Drug Administration is starting a $116 million government project called Mini-Sentinel to mine databases of medical records for signs that drugs may be linked to problems. (Nell Greenfieldboyce, NPR)

Implementation

WHAT HAPPENED TO OBAMACARE'S 'DEATH PANELS'?: The Independent Payment Advisory Board (IPAB), sometimes referred to as 'death panels' by some conservatives who have argued that it bestows powers to unelected officials that belong to Congress and could lead to rationed care for the elderly, has seen its raison d'etre swept away under an avalanche of good news." (Jonathan Easley, Morning Consult)

Illness

POOR WOMEN ARE HAVING HEALTHIER BABIES: While other economic and health disparities continues to grow, low-income women are narrowing the gap with wealthier women in the health of their newborns. (Zachary A. Goldfarb, Washington Post)

WHAT IF A CHILD HAS A CONDITION THAT'S NEW TO SCIENCE?: Genetic sequencing and sharing of patient information could help doctors find other patients with the same seemingly one-of-a-kind disorder. (Seth Mnookin, New Yorker)

Happening This Week

We're monitoring the U.S. Court of Appeals for the D.C. Circuit for a decision on Halbig v. Sebelius, which could come any day now. The lawsuit challenges the legality of government subsidies for ACA plans on the federal marketplace, and if successful, could have a devastating effect on the health care law. The D.C. court has been known to release decisions on Tuesdays and Fridays between 10 and 11 a.m.

Monday

Alliance for Health Reform briefing on "Network Adequacy: Balancing Cost, Access and Quality" at 12:15 p.m.

Tuesday

Centers for Disease Control Director Tom Frieden will address concerns about a range of health issues as a National Press Club Newsmaker Luncheon at 12:30 p.m.

Senate Veterans' Affairs Committee hearing on the nomination of Robert McDonald as the next VA Secretary at 2 p.m.

House Energy and Commerce Health Subcommittee hearing on "21st Century Cures: Examining Barriers to Ongoing Evidence Development and Communication" at 3 p.m.

House Veterans' Affairs hearing on "VA's Longstanding Information Security Weaknesses are Increasing Patient Wait Times and Allowing Extensive Data Manipulation" at 7:30 p.m.

Wednesday

Democratic Reps. Hank Johnson and G.K. Butterfield will hold a news conference with members of health care advocacy groups to announce the newly created State Medicaid Expansion Caucus at 10 a.m. Both lawmakers represent states -- Georgia and North Carolina, respectively -- that are not currently participating in Medicaid expansion under the ACA.

House Ways and Means Committee hearing on preventing abuse and fraud in the Affordable Care Act's premium subsidies at 10:30 a.m.

Thursday

House Ways and Means Committee hearing on the future of Medicare Advantage plans and the health care law's impact on the program at 10:00 a.m.

House Rules Committee markup of a resolution authorizing Speaker Boehner's lawsuit of Obama over delays to the employer mandate, with the full House expected to vote on the measure next week, ahead of the August recess.

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Don't Miss Today's Top Stories

Health Care Edge is one of my top resources."

Meghan, Associate Specialist

Great news in short form along with much needed humor."

Patrick, President of private healthcare consulting firm

Informative and help[s] me stay on track. "

Director of Scientific Affairs, Non-profit medicial society

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