MLTSS AND NETWORK NARROWING: A New and Concerning Trend?

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In a recent article on Media Health News, Will Physicians be Dropped from Managed Care Networks?, Greg Freeman, January 22, 2014, Freeman indicated that one of the largest health insurance providers, UnitedHealth Group, recently sent letters to physicians in ten states confirming they were being dropped from participation in their managed care networks.  Additional managed care companies are considering similar action in response to trying to contain health care costs, including the costs of new care requirements under the Affordable Care Act, such as the new provision requiring coverage for pre-existing conditions.

According to Freeman, the company issued a statement indicating, for example, that it “expected its Medicare Advantage network, which covers about 27% of people on Medicare, to remain at about 85% of its 2013 size through the rest of 2014. “

Freeman’s says that, despite new requirements for successful outcomes in the health care we receive, not all of these physician dismissals are because the doctors were not achieving healthy results in their patients either.  Physicians who charge fees at the higher end of the “usual and customary” range had their contracts terminated as well, whether they had good results or not.  He said “The result sometimes is that the networks will drop physicians or groups that are providing high-quality care because that care skews too heavily in the expense consideration…” 

That’s a concern for families in states looking to managed care as the answer for individuals with disabilities and the elderly for health related and long-term services.  People with disabilities, particularly those with special health care needs, complex needs and dually-eligible individuals (Medicaid and Medicare) are the very ones who need high-quality care from highly specialized doctors.  Just because there is an urologist in the network, that doesn’t mean he/she provides or specializes in urology services to children with spina bifida.  Anyone with a child with special health care needs that has transitioned to adult care understands that not all specialists specialize in special needs. 

But according to Freeman, the managed care companies are looking to a more “targeted” network of doctors providing “access,” but not necessarily a broad network.  This reduces choice for the consumer.  So, if the latest idea in “cost savings” is to reduce costs by reducing choice it is inevitable that for some people with special needs, this could translate into losing trusted long-time medical providers and reduced access to care.

This new trend has to be a high priority consideration in any discussion around managed care and special needs populations.

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