The Ohio Department of Insurance (ODI) took the next step toward finalizing a rule that will help Ohio consumers get better and more timely information about provider networks. Without access to their insurers’ provider networks, consumers can get hit with high costs for using out-of-network providers.

On July 19, 2015 ODI held a public hearing on proposed Rule 3901-8-16, which will require insurance companies to regularly update their network lists, make them more available to enrollees and prospective enrollees, and provide information about the cost of out-of-network services.

Ohio Consumers for Health Coverage provided written and oral testimony in support of the rule, but with some strong caveats about the rule’s limitations and need to go further. Also testifying was Janet Shaw, Executive Director of the Ohio Psychiatric Physicians Association (OPPA), who supported the rule but urged that more data be collected and made available pertaining to the number of in-network and out-of-network claims that insurers handle. Wendy McVicker of Athens shared her story of being stuck with $11,000 in bills from an emergency life flight to a Columbus hospital from Athens following a serious bike accident. The air ambulance company was not in her network, and her insurance and a provider discount covered about $14,000 of the $25,000 bill. She urged ODI to strengthen the rule to address the issue of “balance billing” – which occurs when the insured person is expected to pay the balance due after the insurance company only pays a portion of the bill for an out-of-network provider. As Wendy noted, she had no choice in the life and-death situation but to go with the air ambulance offered. Tim Maloney, Vice President of Payer Contracting for the University of Cincinnati Medical Center, also offered support for the rule and especially noted that it is important that their staff can access updated patient directories so that they can link UC patients to providers in the patient’s network.

Here is what OCHC would like to see ODI do:

• Hold consumers harmless from balance billing when the consumer did not select the out of network provider;
• Require insurance companies to offer an adequate selection of providers;
• Require an in-network hospital or other facility to assign to a patient only providers who are in the patient’s network when available, and take steps to assure that there are available at the facility providers of all specialties affiliated with each health plan in the service area.

OCHC also commended the Department for proposing that insurance companies must provide consumers with co-pay, co-insurance, and deductible information pertaining to an out-of-network provider when requested, but argued that the information provided should be binding on the insurance company. Under the rule, the information provided is not binding.

OCHC also urged ODI to require the provider directory to list all staff of its in-network facilities who are NOT in the health plan’s network. The rule in its current form simply requires “a general statement notifying enrollees that there may be providers of services at the facility, such as anesthesiologists, radiologists, and laboratories that are not in-network, and a method for contacting the issuer [insurance company] to obtain more detailed information.”

Kathleen Gmeiner, who provided the OCHC comments, stated: “Simply saying that ‘there may be providers who are not in-network’ provides the consumer no information to make an informed decision. It is also pointless to simply tell the consumer how to contact the issuer for more information, because in the plan selection process it is not realistic and often not possible to obtain the information of what providers are not in the network. OCHC strenuously urges that the rule be revised to require the issuer to provide a listing of all providers affiliated with the facility; and a listing of any providers providing services at the facility who are not in-network.”

Under the proposed rule, the insurance company’s obligation to update the directory is triggered if the physician or hospital tells the insurance company of a change that impacts their participation in the network, OR, if in the course of business, such as claims processing, it becomes apparent to the insurance company that there is a change in status. OCHC and OPPA both urged that the insurance companies should be required to take stronger action to confirm that a provider is still in the network. OCHC urged that the insurance companies be required to routinely communicate with network members to confirm that they remain in the network. OPPA proposed that the insurance companies be required to review the claims history of each psychiatrist listed and remove from the directory any psychiatrist who is not actively submitting claims.

Finally, OCHC supported requirements in the rule to make sure that provider directories take into account the needs of persons with disabilities and limited English proficiency. OCHC also supports a requirement that a health plan give a consumer notice when his/her provider drops out of the network.

Next step: ODI finalizes the rule, taking into consideration the comments made, and takes the rule to the legislature’s Joint Committee on Administrative Rules (JCAR). The Ohio Department of Insurance expects the rule to be generally effective 1/1/16, but a few provisions will not go into effect until the following year.

Many people have theories about what makes health care cost so much in the US. The truth is that many factors contribute to excessive spending, but experts have identified 4 major reasons why: (1) Per-Unit Price of Health Care; (2) Administrative Waste; (3) Quality; and (4) Population Health.

Understanding the real reasons why health care costs so much is vital, for two reasons: (1) without understanding the cause, we won’t be able to fix the problem; and (2) so-called “solutions” that don’t address the real causes tend to harm consumer access to the right care at the right price. Examples of this are cuts in Medicaid eligibility or benefits, higher deductibles and cost sharing, narrower provider networks and drug formularies, and other policies that hurt consumers.

Extensive research into cost drivers have identified the FOUR major reasons why health care costs so much:

1. Per-Unit Price of Health Care: That means the price charged for each unit of care (such as an MRI, a pill, a procedure). NY Times reporter Elizabeth Rosenthal has a long series, “Paying Till It Hurts,” that’s a must-read on unjustifiably high health care costs. Prices that different providers charge for different procedures vary tremendously, both within and among regions, but it’s hard for consumers to comparison-shop, and it’s important to note that numerous studies have found no relationship between higher price and higher quality. Never assume more expensive care means better care.
2. Administrative Waste: Hospitals, doctors’ offices, and insurance companies all have large staffs to process all the paper and electronic forms and documents. Each payer has different forms, benefits, and reporting requirements, multiplying bureaucracy. We spend a lot on marketing competing prescription drugs, hospitals, and health plans. It goes on and on.
3. Quality: The Institute of Medicine estimates that over 30% of health care spending provides either no value or “negative” value – meaning harm to the patient. In 2013, an article in the Journal of Patient Safety estimated that 400,000 Americans die each year from medical errors, costing $1 trillion per year.. Ten times more suffer complications. In 2002, an estimated 1.7 million Americans died of infections acquired in hospitals (mostly preventable). 18% of Medicare patients who are hospitalized get readmitted to the hospital for potentially preventable reasons.
4. Population Health: Chronic health conditions, brought on by poor diet, inadequate exercise, stress, air pollution, and other environmental factors, are the leading cause of death in the US. Heart disease and cancer together account for 47% of deaths. Total costs of treating people with diabetes in 2012 were $245 billion. These diseases are largely preventable with more investment in preventing disease, through population health initiatives that address health behaviors contributing to these diseases: poor nutrition, lack of exercise, tobacco use, and drinking too much alcohol. The CDC list fails to mention other behavioral health conditions, including chronic stress, which is more common in people struggling to survive because of poverty, racial bias, and other pressures. We must improve the quality of life and standard of living for people living in unhealthy communities so that they can live healthier lives.

 Those are the four biggest reasons why we spend so much on health care. If you want to know more, go to the Consumers Union Health Care Value Hub and have a field day.

This article, with the exception of the quote at the end from the Health Affairs Blog, is an abbreviated version of an e-mail sent on September 14, 2015 by Kellan E. Baker , MPH, MA, Senior Fellow of the LGBT Research and Communications Project of the Center for American Progress to the LGBTQ State Exchange List-serve.

A new rule proposed by the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services will implement Section 1557 of the Affordable Care Act. This section includes non-discrimination protections that prohibit any health program or facility that receives federal funds, including insurance companies in the state and federal marketplace, from discriminating on the basis of race, color, national origin, age, disability, or sex. The deadline for comments on the proposed rule is November 9, 2015. In this article we will focus primarily on the provisions related to gender identity and access to services for gender non-conforming people.  In our next newsletter we will address the impact of this proposed rule on race, color, national origin, age, disability and sex (other than gender identity issues).

In the proposed rule, OCR confirmed that the sex nondiscrimination protections in Section 1557 prohibit discrimination on the basis of gender identity and sex stereotyping. This rule applies to many “covered entities,” including private health insurers, state Medicaid programs, health facilities that accept federal funding (such as hospitals or clinics that accept Medicare or Medicaid patients), and the Health Insurance Marketplaces. It also applies all of these protections to programs run by HHS itself. 

The proposed rule does the following: 

• Prohibits many private health insurance plans as well as state Medicaid programs from categorically excluding coverage for gender transition.  This new rule—once finalized—will require insurers to provide access to health care services that transgender people need, whether related to gender transition or not. The rule applies to any health insurance carrier that sells plans through a Health Insurance Marketplace, regardless of whether the plan in question was bought on the Marketplace, including the coverage they sell to or administer for small and large employers.