Sunday, June 7, 2015

California Network Regulation Musings

Good doings in California on network regulation.  Two quotes jumped out at me. 
The problem this leaves is who's going to eat the excess charge? That's the core of the medical association's problem with the bill. It's asking that the measure be amended to "require an efficient, equitable dispute resolution mechanism that guides parties towards a reasonable rate for services," in the words of an Assembly staff analysis. The California Medical Assn. says it favors the approach of a 2014 New York law, which requires arbitration between providers and insurers, leaving the patient out of it. 
Arbitration in this context sounds like a polite word for "crappy rate setting process with limited input, limited consistency and limited accountability."  Why would anyone want that?  If we know physicians will do these services for these patients why not deal with it upfront by establishing what they will be paid?  That allows the possibility of opening the process and incorporating more of the interests involved.  Someone could argue, "why make a big deal about this when there's essentially no process around in network contracting?" but the difference is control.  If an insurance plan has a too-expensive or too-cheap network one can switch plans.  There's no equivalent remedy with out of network providers, whatever process the state comes up with is what everyone in the state lives with.  It ought to be held to a higher standard.
Here's the background. in the good old days, doctors in those three key specialties[radiology, pathology, and anesthesiology] were employees of hospitals, so if your hospital was in your insurer's network, they were too. Over time, many hospitals have outsourced these specialties to independent doctor groups, which may or may not be in the same network as the hospitals themselves. If they're not in yours, you could suddenly get a bill with an astronomical number at the bottom line.
Organizational structure matters.  Shock bills are stemming in part from hospitals arbitrarily and without any public discussion deciding that radiology, pathology, and anesthesiology are no longer their problem, instead it's the patient's responsibility.  That's a huge change that I don't think we'd accept uncritically in any other industry.  Airlines are getting pushback about baggage fees, imagine the outcry if one day they decided that ticket prices no longer paid for pilots and passengers had to pay that on their own.  Part of the solution here might well be stricter controls on what hospitals are allowed to outsource and what they're required to bundle within their own services.

Food for thought as I look forward to Oregon jumping into network regulation.

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