Network So Small!

Listeners, how many times has this happened to you? You find a great doctor, you make an appointment, and you think everything is fine… until you get the dreaded call from the insurance company that your sweet new doc is “Out of Network.” Well, you aren’t alone – just in the past few months, limited provider networks have been making news, as Johns Hopkins, one of the most prestigious hospitals in the country, is leaving the CareFirst Blue Cross Blue Shield network, which could impact nearly 300,000 patients in the Baltimore area. In this episode, we’re going to demystify what these networks are and how they’re screwing us all and uncover the depressing history of how limited provider networks came out of the longstanding American tradition of screwing immigrants. https://youtu.be/EkDSdUpAZ_o Show Notes So what are "limited networks" or "narrow networks" in your health insurance? Gillian breaks it down: When your health insurance has a limited network, it means you can only get care from a small number of physicians or hospitals that have contracted with your insurance company, and agreed to accept lower rates to treat you. If you receive care “out of network,” it will either be completely uncovered by your health insurance, or you’ll have to pay a huge portion of your bill. Health plans with “broad networks” usually cover around 70% of all providers in the local area - but “narrow networks” generally cover less than 25% of available providers, some even less than 10%. It’s VERY common for the largest hospital chains to be excluded - like the recent example of John Hopkins in Baltimore. The result is that you generally pay a lower premium for a limited network plan: one study found that premiums were 16% lower for narrow network plans, which honestly isn't much of a savings for the impact on patients' lives! Insurers LOVE limited network plans, because in addition to paying lower rates to providers, they also have the affect of “cherry picking” - since healthier individuals tend to opt into limited network plans, if they have a choice. Ben is currently in a limited network plan, because under the Affordable Care Act (ACA) small employers like Healthcare-NOW get subsidies for health insurance they offer to their workers, but ONLY if they offer insurance through the ACA's state exchanges. And as we'll discuss about, limited networks plans have absolutely overrun the state exchanges. The impact on Ben has been difficulty finding specialists, having long waits for specialists, and his primary care doctor basically can't coordinate his care at all, since the specialists she knows, trusts, and works with, are almost all "out of network" under his plan. Ben saw a sports medicine doctor who diagnosed his sciatica, who was in-network for him, but all of the physical therapists at the same sports medicine center - whose offices are right next to his - were out-of-network! How did this all come about? Managed care plans in the 1990s first ushered in the idea of limited networks. These were when the insurer owned their own provider network (like Kaiser Health Plan), so if you had that insurance, you could only see the providers that they “owned.” Today, there aren’t a TON of traditional managed care plans like this - usually your insurance plan creates limited networks by negotiating with physicians and hospitals, and only accepting those willing to accept the lowest rates. So who is most impacted by this new incarnation of limited networks? Ben says there are THREE groups of people most impacted by limited networks today: ACA plans sold on the state exchanges - really, anyone on the “individual market,” buying health insurance on their own. Includes virtually all self-employed people, contractors, artists, without a traditional employer; Medicare Advantage plans; and Student health plans. While slightly different from the above, we're gonna add a DIS-honorable mention here for Medicaid...