Colorado Medical Society

The final word: Senate Bill 17-088: Colorado General Assembly addresses network adequacy

Saturday, July 01, 2017 01:02 PM

My experience with network adequacy or, more accurately, inadequacy, began in October 2016. At age 55, I had not yet received my first colonoscopy and my wife made it clear that I would get one – prior to the opening of the 2017 legislative session on Wednesday, Jan. 11, 2017.

Because I am in reasonably good health, rarely see a doctor and take no prescriptions, I needed a primary care physician. I had never visited the doctor whose name was listed on my insurance card and I discovered that he no longer practiced at the clinic listed on my card. So I explored my insurance company’s website to find a primary care physician, schedule a physical examination and obtain a colonoscopy referral.

The website listed dozens of doctors in my network who were located in the Parker and Lone Tree area where I live. Many were listed as accepting new patients…so far, so good! However, after calling several offices to inquire about the dozens of doctors listed, I discovered that the earliest available appointment for a physical was in late January 2017: four months out.

That seemed more an indication of the inadequacy of my network. That judgment was not about doctors – but against the insurance company. Its promotion described a large number of excellent providers who were willing and ready to see me – all within a predetermined network that would offer quality, convenience and pre-negotiated pricing.

What I found was limited availability. With no appointments available, the cost exposure of my insurance company was zero – at least for that four-month period prior to the first available appointment with a doctor. Such limited access might be more common in rural communities where few doctors are located. However, in north central Douglas County between Sky Ridge Medical Center and Parker Adventist Hospital, we have a thriving and growing medical community.

My own experience came on the heels of meetings with the Colorado Medical Society during the summer and fall of 2016. I listened to the growing frustration with network adequacy decisions. Some of those very doctors with whom I met have offices within a mile of my home. I heard from many doctors who had been deselected from one or more networks with no explanation as to why, but were left having to explain to their patients that they could no longer treat them due to an unexplained decision by an insurance company.

Knowing that there were doctors near my home who were not only seeking new patients but who were literally having patients taken away while I could not find a physician was frustrating.

In the end (no pun intended), I was able to schedule an appointment with a physician’s assistant within a few weeks and received a referral for a colonoscopy before the start of the legislative session. PA, yes; doctor, no.

My experience proved that the perspectives shared by many doctors were accurate: Insurance companies and doctors may agree on prices and services, which play a role in controlling costs. But insurance companies also control costs by limiting the supply of doctors in relation to patient demand. When that occurs, the value of insurance to the policyholder plummets.

It was a pleasure to work with the Colorado Medical Society – particularly Susan Koontz, JD, CMS general counsel and senior director of government relations; Marilyn Rissmiller, CMS senior director, division of health care financing; and Jerry Johnson, contract lobbyist for CMS – to craft Senate Bill 17-088, which I carried in the Senate with my friend, Sen. Angela Williams. Most important, the bill requires health insurance companies to develop and use standards for selecting and tiering participating providers. Insurers are now required to make their standards publicly available. Insurers must also provide written notice to a provider at least 60 days in advance of a deselection or tiering action, and allow providers to request reconsideration of such a decision. Read more about what the bill does on pages 9-10 of this issue.

After much discussion and negotiation with insurers, SB 17-088 passed the state Senate on a vote of 30 Yes and 5 No, with 14 co-sponsors. It then passed the House with strong bipartisan support and was signed into law by Gov. Hickenlooper on Tuesday, April 18.

Thank you to all the doctors who took the time to meet and brief legislators and candidates last year, sharing both your frustration and personal experience with network adequacy. Thank you for taking the time to contact legislators to advocate for the bill. Thank you to all the CMS members and staff who testified in committee and worked on amendments.

Congratulations, CMS. It is an honor and privilege to work with you.