Network adequacy

Wednesday, July 01, 2015 12:14 PM
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What's next for out-of-network charges and managed care reform

by Kate Alfano, CMS Communications Coordinator


  • The issues around network adequacy and care by out-of-network providers are some of the hottest health care topics in state legislatures across the country. In Colorado it came up as a result of debate over Senate Bill 15-259, “Out-of-Network Health Care Provider Charges.” The bill was narrowly defeated in committee by a 5-4 vote.
  • CMS formed a Working Group on Managed Care, which held its first meeting in June.
Peter Ricci, MD

Colorado Medicine sat down with Peter Ricci, MD, chair of the CMS Committee on Physician Practice Evolution (CPPE) and a board-certified radiologist and president of Radiology Imaging Associates in Englewood, Colo., to talk about issues of increasing importance in Colorado: network adequacy and care by out-of-network providers. CPPE is the committee of CMS that studies issues related to the evolving health care system and how such changes affect the ability of physicians to deliver accessible, high quality, cost-effective patient care in an economically sustainable manner.

Colorado Medicine (CM): Why is this issue receiving so much attention in Colorado?

Peter Ricci, MD (PR): The issues around network adequacy and care by out-of-network providers are some of the hottest health care topics in state legislatures across the country. In Colorado it came up as a result of debate over Senate Bill 15-259, “Out-of-Network Health Care Provider Charges.” I was one of many physicians who testified in opposition to the bill. Our coalition felt that problems inside of systems with the complexity and magnitude of health care coverage and payment, both in and out of network, are best addressed through the type of collaboration that comes from an interim study. The bill was narrowly defeated in committee by a 5-4 vote.

CM: Why did CMS and, ultimately, legislators pursue an interim study?

PR: We asked for the interim study from the very beginning. There is a lot is at stake and this issue has broad interest among stakeholders, including state officials, physicians, facilities, insurance companies, consumers and business. All parties involved bring a different perspective and we all agree the subject is extremely complex with many interrelated parts. This is particularly true in Colorado because of our highly competitive health insurance market. While developing and gaining consensus on public policy solutions will not be easy, it needs to be done, and I think the legislature was willing to give stakeholders a chance to work it out.

CM: How is CMS preparing for the interim study?

PR: We have outstanding policy, communications and advocacy experts working for CMS and the specialty societies, and we have our most potent weapon – physicians at the grass-roots level. With the committed help of the AMA, we are a formidable force. The CMS board of directors voted on May 1 to make this project one of our highest priorities. We will spend the next eight months gaining a physician consensus on certain policies, and positioning ourselves to be successful in the 2016 legislature and beyond.

CM: How will CMS leverage the opportunities the study presents?

PR: The interim study presents opportunities but it also presents challenges. For instance, we anticipate greater media scrutiny of the issues under discussion. Fortunately CMS has an exciting vision. It is the enthusiastic view of the board of directors that the study can and should be used to open a broad front on the managed care pain points being experienced by all physicians, regardless of specialty, and also to serve to unify the profession. The board referred this issue to the CPPE, and the committee members fully understand the need to be proactive, solution-oriented, and unifying among our peers. We will demonstrate how we can use the power of strategic positioning right now to set the stage to help all of our members, and the patients they serve, over the remainder of the decade.

At our first CPPE meeting on this issue members proposed expanding the committee to include specialty society and component society representatives and convening as the “Working Group on Managed Care.” The working group held its first meeting on June 17. Again, we want to convey to physicians that this project is about all physicians, regardless of specialty, and not just about issues related to out-of-network specialists.

CM: What are your goals for the working group?

PR: At our June 17 meeting we had a starting point discussion on definitions of and potential CMS policy on excessive charges and usual and customary fees, as well as language that non-participating physicians can provide patients on their billing statements to make them aware of the potential protections they may be afforded under existing Colorado statute. It will be imperative for us to develop meaningful policy solutions on these issues. If we can step up as a profession on behalf of our patients, we exponentially increase our chances of getting policymakers to help our profession on a broader array of managed care pain points.

While we are working to develop policy solutions on the major issues relating to out-of-network charges and billings, we will work with longtime partner Kupersmit Research to survey our members on a broader array of pain points with managed care plans, including the impact of narrow networks and provider directories. This research is imperative and CMS will ask all members of all specialties to complete it.

CM: Any final thoughts on this issue or the interim study?

PR: There is a great deal of work ahead of us. We are already in discussions with the Colorado Association of Health Plans (CAHP) about the structure of the interim study. Together we are talking to the governor’s office about an oversight role. These discussions, which will be assisted by a professional facilitator, will be about new public policy and, as such, consumers, facilities and public officials will be involved including Sen. Irene Aguilar, MD, and Sen. David Balmer, chair of the Senate Committee on Business, Labor and Technology.

CMS will work to determine who will best represent physicians. Our chances of success are greater if medicine is unified from a policy perspective, we know our bottom line and hang together. Gaining this consensus will be a big part of our job.

Posted in: Colorado Medicine | Health System Reform


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