"These gaps really make it so that Georgians can't afford needed health care. If they receive health care, they're left with medical debt, or they have to make really tough…
Tag: network adequacy
Georgia legislative study committees meet during the off-session to take a deeper dive into specific policy issues and develop strategies for the legislature to address them. Each committee produces a report on its findings and recommendations that they want to move forward in the next legislative session. Click here for a complete listing of House and Senate study committees. GHF has been following and participating in the study committees focused on health issues impacting consumers. Below is a run-down of committees that have published their reports, the issues they investigated, and report recommendations.
Senate Study Committee on the Consumer and Provider Protection Act (SR 561)
In light of changing practices and norms in the insurance market Senate Bill 158, the Consumer and Provider Protection Act, was introduced in 2015. This bill outlined provisions for consumer and provider protections regarding health insurance and created the Senate Study Committee on the Consumer and Provider Protection Act. The aim of this committee was to understand how the current insurance environment affects the stability of providers and consumers’ access to care. The committee members included legislators and representatives from the provider, insurer, and consumer communities, including GHF’s Executive Director Cindy Zeldin as the consumer representative.
Committee recommendations include the following:
- Rental networks– When insurers create networks for health plans, they contract with providers who agree to offer services at discounted rates. Rental networks are created when the same insurer “rents out” or sells access to network providers, at a different discounted rate, to other payers (e.g. insurers, third party payers, employers). Oftentimes this is done without provider’s consent, so a provider may unknowingly treat someone who is part of the rental network and have to accept a different payment amount. The committee agreed that transparency for both consumers and providers can be improved by including a more complete definition of “rental networks” in Georgia Code and further defining the Georgia Department of Insurance’s regulatory authority in this area.
- Provider contracting- The committee agreed that more discussions need to take place in two areas surrounding how insurers contract with providers. First, insurers are allowed to change the terms of a contract with a provider, at any point, without the provider’s consent. Second, providers argue that some insurers include all-product clauses in contracts, which means a provider has to participate in all plans offered by the insurer or none.
- Health provider network adequacy- As you may have read in the November Peach Pulse, the National Association of Insurance Commissioners (NAIC) has put together a model act to address network adequacy. The committee recommended convening a multi-stakeholder group to review the Model Act to determine whether Georgia should consider adopting some of the Model Act’s measures and if we need additional legislation and regulation in these areas to protect and provide an appropriate level of access to care for consumers in the future.
GHF has identified network adequacy and the need for more accurate and user-friendly provider directories as important, emerging consumer issues. We support the setting and enforcement of network adequacy standards for all health plans in Georgia. As the multi-stakeholder group looks into these issues further, GHF will continue to add the consumer voice to the dialogue to keep consumer priorities at the forefront of the minds of decision-makers.
Senate Study Committee on Youth Attention Deficit Hyperactivity Disorder and Mental Health Substance Use Disorders (SR 487)
The committee was charged with identifying prevention and screening approaches for youth substance use disorders (SUD) and examining issues around the diagnosis rate of youth attention deficit hyperactivity disorder (ADHD). The committee made recommendations in the following five areas:
- Behavioral therapy- Behavioral therapy should be the first line of treatment for ADHD in young children and be required treatment for any child under six who has a diagnosis and receives medication.
- School workforce- Georgia must increase efforts to reduce student-behavioral health personnel ratios in schools and maximize resources available to students.
- Clubhouse Services Provided by the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD)- The committee supports the clubhouse programs that provide a place for youth to go for substance use recovery support. The committee recommended increasing state funding for them, as well as creating additional clubhouse sites across the state.
- SBIRT: Screening, Brief Intervention, and Referral to Treatment- While the Committee supports SBIRT programs and training in the state, currently Medicaid does not bill for services, so the Committee will continue to monitor states that have recently activated Medicaid codes for SBIRT.
- School-Based Health Clinics- The Committee plans to monitor and share findings with Georgia’s CMOs and the House Study Committee on School-Based Health Centers (see below for committee summary), to potentially convene a joint study on the issue in 2016
GHF appreciates the Committee’s special focus on SBIRT and has been working over the past two years with the Georgia Council on Substance Abuse to raise awareness about the promise of taking a public health approach to substance use disorders that focuses on prevention through screening. GHF will continue to advocate for the activation of Medicaid codes to bill for SBIRT services because it is an effective approach to reducing youth substance use disorders and creating a bright future for our youth.
Senate Study Committee on Women’s Adequate Healthcare (SR 560)
The focus of the Senate Study Committee on Women’s Adequate Healthcare was on the current condition of women’s healthcare in Georgia, areas with existing deficits, and the growing number of women who are at risk of unhealthy outcomes. Here are some of the Committee’s recommendations:
- The Georgia Maternal Mortality Review Committee and the Alzheimer’s Disease and Related Dementia (ADRD) State Registry are important initiatives that the Committee strongly supports.
- Strategies for funding and development (e.g. loan forgiveness, tax credits, increasing GME residency slots, etc) for health care providers that serve women across the state should be increased.
- The Committee will continue to monitor the status of the Rural Hospital Stabilization Pilot Program to inform future opportunities for patient-centered medical homes and increase the use of telemedicine.
- Continue state funding to Elder Abuse Investigations and Prevention under DHS and the Cancer State Aid Program for FY 2016.
House Study Committee on School Based Health Centers (HR 640)
The intent of the committee was to provide recommendations on how to establish school-based health centers in communities to ensure students are healthy and achieve academic success. Committee members looked at the associations between health and education and ways in which school based health centers can be leveraged to increase access, provide affordable care, and produce cost savings. I am giving my children focus supplements and it has really helped a lot with their grades. Key committee recommendations include the following:
- Steps to establish a SBHC should include three stages: planning, implementation, and sustainability.
- Telemedicine is an important element, especially in rural areas and is most effective when integrated into a healthcare system that is capable of delivering comprehensive services. State-wide investments should be made to increase use of telemedicine for systems of care and expanding the scope of practice for on-site providers who can be authorized to deliver services.
- Lake Forest Elementary School (Fulton County) and Albany Area Primary Health Care at Turner Elementary are models that have been successfully implemented.
The legislative session begins January 11th and many of these recommendations will be moving forward in the form of bills, policy changes within state agencies and through additional study committees. GHF will continue to follow these issues and keep you posted on progress and advocacy opportunities to get involved. Stay tuned!
The National Association of Insurance Commissioners approved an updated network adequacy model act at its Fall meeting in November. The model act is a framework that states can adopt to help ensure that consumers have meaningful and timely access to the health services in their benefit package. With more insurance companies offering narrow network plans, these basic standards are an important consumer protection, and GHF encourages state policymakers to consider tailoring and adopting the model act in Georgia. We’ll be announcing our legislative priorities for 2016 soon, and this issue will be on the list!
Several health-related study committees met during the summer and fall months, and most of them are wrapping up their work. The Consumer and Provider Protection Act Study Committee held its final open meeting in November with a focus on network adequacy and provider directories. Claire McAndrew from Families USA, a national consumer health advocacy organization, and Georgians for a Healthy Future’s Health Policy Analyst Meredith Gonsahn delivered testimony on the importance of setting network adequacy standards and ensuring provider directory accuracy and usability. Look out for a final report from the committee later in December!
Commentary from Cindy Zeldin, Georgians for a Healthy Future’s Executive Director
The nation’s uninsured rate has plummeted over the past year and a half. Here in Georgia, more than 400,000 people have enrolled in health insurance, bringing our state’s uninsured rate down to 15 percent. While there is still much work to be done to ensure that all Georgians have a pathway to coverage (like expanding Medicaid), it’s also important to make sure that those who are newly covered are able to access needed health care services.
Are newly insured Georgians accessing the care they need? For the most part, the answer seems to be yes. The early evidence shows that most people who signed up for health insurance have been able to find a doctor with relative ease and get an appointment for primary care within a week or two.
This is a development worth celebrating, but there are also some warning signs on the horizon that policymakers should heed: according to a recent study by the University of Pennsylvania, Georgia had the highest percentage of health plans utilizing “narrow networks” of providers. In addition, reports of provider directory inaccuracies and networks too skinny to deliver all of the services in a plan’s benefit package have started to emerge.
Narrow networks offer a limited choice of providers in exchange for a lower premium. While many Georgians are willing to make this trade-off, others need a broader network to meet their health needs. And everyone deserves the tools and information to make that choice and to know that they can access services for all covered benefits.
Health care consumers now have access to standardized information about premiums, benefits, deductibles, and other health plan features that make it easier to pick the right plan. Yet provider network size and composition remain a black box for consumers, holding them back from making the best, most informed decision they can. Combined with a rapid trend toward narrow networks, this could put some consumers at risk of not being able to access all of the providers and services they need (or at risk for high medical bills if they have to go out-of-network).
These trends are being examined as part of the Senate Study Committee on the Consumer and Provider Protection Act (SR 561). I was honored to be appointed to this committee to represent Georgians for a Healthy Future and to bring the consumer perspective to the committee. The committee’s third meeting, slated for the morning of November 9th at the State Capitol, will focus on network adequacy, or whether there are adequate standards in place to ensure that consumers enrolled in a health plan have reasonable access to all covered services in the plan.
As a committee member, it is my goal to make sure the voices and needs of consumers are heard and considered. It is becoming clear that consumers don’t yet have 1) access to all of the information they need to select a health plan that best meets their needs and 2) protections that ensure their health plan will provide timely and meaningful access to all covered services. Fortunately, these are problems we can address.
I will be supporting enhancements to provider directories that give consumers the information they need and deserve (such as enhanced search functionality and a simple way to report inaccuracies) as well as network adequacy standards for Georgia that ensure no insured Georgian has to travel an unreasonably long distance or wait an excessive amount of time to access the care they need. I’ve also learned a great deal about this issue by watching the National Association of Insurance Commissioner’s work in this area, and was happy to sign on in support of the policy recommendations around network adequacy that the NAIC’s consumer representatives issued last year.
I am excited about this opportunity to make our health system work better, and GHF will keep you posted on new developments. If you’re interested in providing testimony to the committee, please let us know and we can forward your request to Senator Burke, who chairs the study committee.
During the 2015 Legislative Session, the State Senate established the Consumer and Provider Protection Act Study Committee. This committee will review and make recommendations around several health insurance practices, including network adequacy. GHF has identified network adequacy, or the sufficiency of the health care providers patients can access when they enroll in a health insurance plan, as an important emerging consumer health issue. Our Executive Director, Cindy Zeldin, is a member of the study committee and looks forward to bringing the consumer perspective to the committee’s work. Cindy also recently appeared on WABE and Top Docs Radio to talk about network adequacy and participated in a panel discussion along with several state legislators at the Medical Association of Georgia’s Summer Legislative Education Seminar to discuss this important issue. Stay tuned for study committee agendas, updates, and opportunities to weigh in!
Study Committee Schedule:
September 14, 9:00 – 12:00
State Capitol, Room 450
October 26, 2:00 – 5:00
Tift Regional Healthy System, Tifton
November 9, 9:00 – 12:00