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If I had to pick one story that has the potential to dominate news coverage of the second-year enrollment in Healthcare.gov–and warrants the attention–it would be the narrow networks. Restricted provider networks are not new, but their widespread inclusion in policies sold in state and federal insurance exchanges has once again brought a consumer backlash, particularly in California where Los Angeles Times health insurance reporter Chad Terhune has brought a new dimension to the story. On Sept. 28, Terhune wrote that California’s “largest health insurers are sticking with their often-criticized narrow network of doctors” for 2015–if not cutting them further–and “the state’s insurance exchange still has no comprehensive directory to help consumers match doctors with health plans.” Accompanying the piece, Terhune and colleagues on the data team– Doug Smith, Sandra Poindexter, and Ben Welsh–launched a database Californians can use to answer the question: “Can I keep my doctor with Obamacare? Does this physician take Covered California?” The difficulty of getting an answer to this basic, crucial question, Terhune and team wrote, “has been one of the biggest complaints during the rollout of the Affordable Care Act.”
The Times‘ work could serve as a template for other journos looking to do useful coverage of this topic. I recently talked with Terhune about his reporting. What follows is a lightly edited transcript of our conversation.
What prompted the database project?
The biggest complaints have been about the new limited narrow networks, the inability to find a doctor, losing a long-time doctor, and inaccuracy of information. It was often difficult to find good, reliable information.
Besides not finding a doctor, what other complaints do you hear most often?
People stuck with out-of-network providers. I get a fair amount of complaints from very frustrated people who are on the hook for very large bills. These people did their homework. They checked with the plan and were assured their doctors were part of the network. But they weren’t.
Doesn’t Covered California, the state’s exchange, provide this help?
They did for a while. They made a big deal out of their provider directory and promoted it, but it was not ready for launch on October 1 [2013]. Eventually they did launch it, and as people used it they found numerous errors, glitches, and problems. They took it down a few times and eventually scrapped it in February. They’ve set no timetable for relaunching it.
So you jumped in to fill the void?
I thought how could I help people and dig deeper. What could the Times do in a watchdog role and really check what’s going on? There was a lot of attention paid to rates and making insurance affordable and much less to the doctors and hospitals in the network. What’s been missing in all those rate stories is who’s in the networks and what are you getting for your money. This was not getting enough attention and there was not enough good data to back up what was happening. I needed data to write a better story.
How did you get the lists of providers for your database?
I submitted public records requests to the state insurance department and the Department of Managed Health Care. After insurers filed their rates on August 1, I made the request and got it within a couple of weeks. It was a good turn-around time.
Was there any push back from the health plans?
Health Net claimed the information was confidential, according to the state. After I pressed state officials, they ultimately turned over the information I requested.
What did you learn about Health Net?
They eliminated their PPO [preferred-provider organization] and replaced it with an EPO [exclusive-provider organization] with less than half as many doctors. Current PPO members could automatically enroll in the EPO assuming they understood the difference. Not only are there fewer doctors, but Health Net also raised premiums as much as nine percent for these stripped down EPO policies. [FYI, Both HMOs and EPOs restrict coverage to in-network providers, but with an EPO consumers don’t need a primary care physician or referrals. PPO customers can use any doctor they wish.]
What did you have to do to the data once you got it?
It took several weeks to clean it up for accuracy and compare the 2014 networks with 2015 networks. Then it was trying to make the search function and the maps user friendly. The clean-up was tough and took lots of back and forth with the health plans to understand coding and jargon in the files. We needed to know who was in their HMOs, PPOs, and EPOs.
What did this process show?
It gave us a window into how complicated these provider lists have become and whether officials can really scrutinize what insurers are doing and how it affects patient access.
You’ve said the network numbers given to the public don’t always match reality. Can you give an example?
Blue Shield sent Covered California a letter saying they had some 36,000 doctors in their PPO network and have cited that number publicly many times. We found the actual number was closer to 31,000 and about four percent less for 2015—about 30,000 doctors. The company says the higher number included some hospital-based physicians. Both numbers could be technically correct, but I prefer an official government document over what a company chooses to release.
Given the plan’s poor track record keeping directories up to date, how can you be sure your database doesn’t fall into that same trap?
My mind set is let’s figure out these problems now, not three months from now. In a sense, it’s being crowd-sourced by providers, agents, consumers, and regulators. They can go back to the health plan and iron out any discrepancies before people make their final decisions. I felt accuracy was not a reason to hold back. Plans gave information to the regulators and that passed my threshold. People are using our database and checking the information.
Can other journalists construct this kind of database?
I would encourage reporters covering the Affordable Care Act to do this. They need time and patience to sort the files and to make sure the data are accurate. They’ll have to decide if this is a priority for their news outlet.
How can they get the data to begin?
First, they’ll have to see what’s available. It’s great if you can get it from a public records request.
If they can’t, what’s the next step?
You can get some information from the health plans on a smaller scale, but it’s generally better to go through a public records request. If you can’t get it through a public records request, I would put out a blanket request to all insurance plans and use competitive pressure to try to get everyone to respond. The hope is they won’t want to be left out if their competitors are in your database. This is a lesser alternative, but it’s a start. And if a company doesn’t respond, put that in your story.
Anything else they can do?
They can spot check doctors and hospitals in their county or city and see if they are in particular plans. Check what plan websites say and then call the doctors’ offices to see if there is agreement. I can guarantee you’ll get some doctors offices that say ‘what are you talking about.’ When the information doesn’t match, that in itself could be a story.
Considering you found all these problems with networks in a state like California, which has decent regulation, can a state really be expected to stay on top of this issue?
California has stringent rules. Are they being enforced? What I learned from the data is, can you really judge their networks? Narrow networks are not necessarily bad things, but the rollout has been poor in terms of accessing information and disclosing what people can buy.
What did you learn about who’s in and who’s out of a network?
Sometimes a doctor or a hospital is in only one network. This is different from the past. These deals have become much more exclusive, and this marks a departure from the time when a doctor or hospital might have been more broadly available in three or four different networks. This raises the stakes for consumers picking the right plan.
Would it help if journalists examined who gets into these networks and for what reasons? Have you done that?
The next exciting area to explore will be looking at quality of the providers in these narrow networks. We want to take a closer look at who is part of the networks by examining different kinds of quality measurements. We are thinking of bridging other data with our database.
Terhune is on to something here–the missing piece in the narrow network story. Who gets into a network? Are providers chosen because they play ball with insurers on price? Are they chosen because they deliver better care? If so, how good are the measurements they use? How good is the care actually given to patients in these restricted arrangements? If the health system is taking away patient choice, then what is its obligation to make sure patients receive quality care? The insurance companies directing where patients are allowed to get medical treatment is a big story to follow long after open enrollment is over.
Related content:
Wonkblog on the ACA cost-control feature that might make you change your doctor
The Great Cost Shift Comes into focus
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