Hours. 1. 5 and at the university of pittsburgh. Us, there following is a hashtag. Us can email questions to them. Eet we have heard everything about networks. Why are we having so much trouble naming them . What are they . Consumer plans offer networks that do not include other medical providers and some are saying that the Smaller Networks cause problems for providers and many are saying that, if they are done the right way, it can help create competition and control costs. Questionsare a lot of and there is trouble naming them. Do they save money . Is the quality of care as good . Do consumers need choice . Be inould the governments setting the requirements for the networks. . Hat is the Consumer Experience so, we are fortunate to have are goingth us and we to start with the wisconsin insurance commissioner who plays a leadership role at the National Association of Insurance Commissioners as a point person on this subject and heading up efforts on regulation. Joe, to my left, is the managing director and the first director of the office of Health Insurance exchanges. He has been the pennsylvania insurance commissioner and the oregon insurance commissioner. Ted, aother side of professor at Harvard Medical School and a member of the congressional budget office. Institute of national statistics. Chair of aormer vice medicare advisory commission. When the have given presentations, we will open up to questions and answers. Holder, and the manager of the Blue Cross Blue Shield of qchigan will join us for a and a. We will go ahead and start will stop thank you for having me here today. We will go ahead and start. Hereank you for having me today and this conversation will continue into the future. We really want to focus on the issue of Network Adequacy. I want to provide background and update from the regulator perspective. It is really important to know and realize and remember that there are a lot of conflicting issues surrounding Network Adequacy. For the consumer, the issue is hospital being in the Insurance Plan and whether or not they can receive the care they are looking for. Whether or not they can afford the care and keep their health care at costs down, as well as their Health Insurance costs. The greater the reimbursement rate the wider the network. It increases patient numbers and obviouslyare negotiating with insurers for higher reimbursement rates. Networks aew wide little bit differently. Theyld they would would see them as increasing costs and decreasing the ability to manage care. And narrowgotiate networks to increase and better manage the care of patients and consumers. All this is to a point. ,he network must be sufficient or the insurer may have to pay in Network Benefits to outofNetwork Providers. Interests, how do we, as regulators, referee . It is a mixed regulatory approach. Networks are subject to different reviews. First, a state review. The network must meet state standards and then, there are a me, ofof of excuse insurers who may try to and become accredited by national firms. This is optional and it is often used as a sign of quality and a Good Housekeeping seal of approval. Orling on the exchange opting for a qualified health plan doesnt nation, they must also follow federal standards. ,rom a regulatory perspective who do we regulate . We have to ensure adequacy in for the folks in the network. Plan, it isinsured simple. Regulatorsce regulate the insurers and should regulate the plans through that process. For a selfinsured plan, it is not as clear and some states have looked at regulating thirdparty administrators to get to the issues. Most states will only be able to regulate Network Issues through oversight function. It is important to note that there may be different standards for different products. In wisconsin, and hmo panel may be required to allow direct access to certain providers, such as an ob gyn. They move might also have certain processes in place. Have lesser requirements because consumers have an option to choose from any provider. Is attached to that with a higher copay. . O we look at these how do we look at these . Should the smaller tier be regulated and should they have to be a full network . Typically, it does not include specialists. All of this gets to the next point. Me, in cases, excuse many cases, the passage of this law has resulted in the accelerated usage on networks across the country. Pointback to the earlier about more control lowering costs for insurers, wider benefits under the aca have increased the cost of insurance and insurers, to keep insurance lower, look to network designed to slow the anticipated increase in rates. The renewed focus on network aequacy also caused reexamination an update of the law. Usually, environmental factors update. E the current model has not been look that or updated since the late 1990s. But, states are still able to make changes and have adopted the model. Adopted in 1996 and is very flexible. It is still very good. It reflects a diversity between states, in terms of market differences, large versus urban. Large and urban versus rural oh versus close panel. Keeping the same standards. S. Requires a different type provider distances and wait times should reflect the norms of the area and further require insurers to file a plan to ensure that they are meeting the standards in that area. Wisconsin shares the group and it is charged with revising the model as chair. We have gotten input from all the parties affected by the law. Received 26 comments so far and letters from interested parties. When we review those, we will work on revising the model. The goal is to add in all of those changes and look at all of the changes. Take a fresh look at the model one more time. A great deal of important questions to ask in and around Network Adequacy. In some cases, we will not be able to come up with the answer. Issues that we will grapple with include narrowing a network and what if no Wide Networks is offered in a market. How narrow is too narrow . What does it matter doesnt matter . What happens when a doctor and hospital leaves a network . Of course, consumer notice requirements, as well. The list goes on and on. We as regulators and people working on this issue keep a couple of things in mind. We need to be mindful of the cost. Need to look at access to medical care and we need to recognize that we do not have all of the answers. We need a model that can address the existing and emerging issues. Thank you. Before we move on, what can you tell us at the moment . I know that you have not finished your work. What can you tell us about where you think we are heading with regulations . Are there any, based on the with where we are heading and the comments you have raised. That is a broad question. Clear, and i was talking ow some of my fell regulators last week, that the businesses statetostate differences needs to be recognized and we have states with significant urban populations. ,ou have states like wisconsin pockets of urban population and cows. It is important to make sure there is a model in place in a get,work in place to ultimately, consumers the type of care and access they need. The keeping in mind the the cost issues. The other issue that we have , in talking with other regulators and some of my staff, the issue of Network Adequacy. While always being something we get complaints about and we have questions about, we have not seen an uptick in the amount of questions. They canceled my network or throughout my doctor. What am i going to do . We keep those in mind as we look to update the model and with an eye towards new products out there and new technology available. There is a lot in the Health Care Marketplace and Health Insurance marketplace that has changed. We are heading in that direction of updating the model with the the environmental factors we have been experiencing and seeing. Ok. Great. One more followup question regarding the comments coming in ,rom stakeholders and others are there any themes or threads that you saw or distinctive disagreements that you think are going to make your job a lot more difficult . I think the issue that is going to be a challenge is excess. There is going to be certain people who want complete and and the other side that pushes back and says that it is a great idea and it is not affordable at that level. Seenre also we have needthere there is a for more managed care and so much more technology out there. Battlere so many ways to better handle care. And it will be addressed at some point this morning. This idea of focusing on the narrowing of networks and of better management of care is becoming a huge part of the landscape and it is really promoting a healthier outcome. So, there is going to be struggle and back and forth. Were the better and narrow the better. That is what we are looking at as we look at updating the model. Ok. Events and itse reminds me of why i love my years. Of knowledgesense and a lot of these issues look into the different perspectives from the different states and representatives to get a window into the issues. I thank you for the comments here and i hope that we keep the issue at a state level. I think it is an issue that differs grammatically in the states. One more thing i want to say is that the last time i was here was for an event that was organized and i was asked to attend. After, i learned of sudden death to i took a moment commemorate him. He was a reporter in the best tradition and had a natural curiosity about the issues. He did a great job covering those issues. With that, i will get into comments and i have three points to make. And setting ofks the exchanges. Competition within the exchanges. What are the broader issues in the aca that relate to the Network Issue . Manage Delivery Systems and so forth. Third, what are some of the consumer concerns here . Ony will be the barometer the issue and if they react like they did in the 1990s to some of these, we are going to have a different outcome than if we see it as one choice in a marketplace. Starting with the first comment, Narrow Networks, i will use both terms. You get in trouble depending on what you call these things, they were intended, when you take at the other variables, particularly risk selection, which is gone as a form of. Election you have to look at ways to compete. The aca was set up so that insurers would compete against each other by asking questions about networks and managed price around how they set up networks. It was envisioned that part of how that would work, and a distinction to the 1990s, was offering a multitude of choices and it would not be like a an employer going with an hmo. Situation where people i think that is very important. I would want to make sure that were managedoducts and that means the consumer has to be educated and know the difference. The first point is that this is not a surprise to the people who put the aca together. This was intended and it is healthy to have in the marketplace. Fear one are if i thing more than anything else, it is events happening that cause people to think about a onesizefitsall solution that takes away from the competition around the different approaches to networks. That is the first point. If you look to the rest of the exchanges,side the you see the types of things talked about with the Affordable Care organizations and the Accountable Care organizations. They could be Affordable Care organizations. The a. C. L. O. A. C. L. You could call it a kaiserlike approach to the issue. We were setting up network rules thesome people opposed stringent standards apply to everybody. We were kicking around ideas and i would ask about what you would situationiser in that and they would say, they are different. Say, what are other people going to say . You cannot just say they are different. You have to let everybody have a chance to do it or you cannot do it at all. I think the integrated Delivery Systems are important and we saw the calls last week. They talked about the importance of having flexibility with networks and how they work to create things in conjunction with insurance activities and these are examples of products. Create plansg to. Nd local areas rector, i interest want these on the exchange. Sometimes, you had to be pushed. In massachusetts, the legislature had to say that they wanted them to offer a product with a lower price point with a narrower network. They wanted that choice available. I think that all of that is important here. It is g2 managed care and improving the quality at the same time that you are reducing whichand the way in networks are managed is critical to that. I think a number of developments are happening around the country and will show up as products on the exchanges. That gets into the most important point. I think that the consumer is the ultimate barometer here. Everybody that is part of the theem, depending on what consumer says and how they vote, they will react to that and the rules will differ. Two issues are important to make to a vibrant competitor. Knowonsumer does need to who is in what network and which kind of networks you are likely to see. Gettingw what they are and they know the system. Thing that hasnt a reputation and advertises itself. Networks and so forth. Somebody buys that product and says, there is a small print over here and you do not have that. You should be able to do that. It has to be can transparent and the consumer has to understand what theyre buying. We see that around those issues. Finally, there has to be a safety valve here. It is a line around the Network People to get big penalties if they go out of network or no reimbursement stop you have to have rules no reimbursement. You have to have rules. A billnot want to get later that says, unbeknownst to me, the anesthesiologist is not a network. Kind of thing is regulated. If you do not know ahead of time, you get the innetwork price. There are a lot of issues here to make sure that consumers are educated around the issues and that there is full transparency. That, i suspect that states will have wide latitude to regulate in response to the local market conditions. Lets turn. Kreis. Thank you. I am thrilled to be here. Sometimes, at these events, there are a lot of speakers and it is exciting. For the viewers who wanted a jerry springerlike event, we are not when you have one tonight. Lets talk about value. Value and narrow are not synonymous. Narrow networks may be a highvalue. Value implies something about cost and quality. That is not simply equated with being narrow. You could have a highvalue Narrow Network and you might not. What to docussion is when you have a Narrow Network that is not highvalue. Let me lay out a general conception of why these things are good. What i find is frustrating is reading articles and the topic is one area and then, they moved to another area and forget everything they have read in the last week. So there is a lot about the prices that we have that are high and those are issues. When i say the price, i do not premiums. An the narrower network strengthen the negotiating hand of those who are purchasing. I had a person who is buying and they said, i do not care what we do, we have to get the car today. In thenot useful negotiation process. If you negotiate and the other person knows that they have to in, you lose the ability to negotiate price. Another thing that is interesting is geographic variation. It is known that there are variations in Practice Patterns across providers. There are providers that are more efficient than others and a lot has been written about that. Wouldnt it make sense to have a network that focuses on those providers that you think are more efficient . Has an advantage. There are other reasons why Narrower Networks are good. You can concentrate on enrollment and facilitate engagement of the insurer. I think i can make a strong case for why there are these types of things. Now realize i you am an economist because i am about to say, on the other hand. Suspect. Reasons to be we want to have people have that opportunity. The problem is, in general, you choose a plan before you get ill and it is not clear you know who your doctor is. I am a reasonably healthy guy and i have a lot of body parts. All of them to break. I do not know which dr. I would want to go to in that eventuality. I do not want to research the best neurologist before i make the choice. Consumer information and awareness is important and there are limits to how much we can inform consumers because, at the time they choose their plan because the time they choose their plan is different from the time they need to care. It may be difficult to get the doctors you need inside of a plan. Know if my mother have lymphoma, she could been put in a situation where she would to choose between her primary care physician and oncologist. People are serious and meaningful relationships with their positions and it is difficult to say certain people that they have to choose. We had to figure out how to balance concerns with other advantages that were mentioned before. Transparency is important and it will not be a full solution. Regulation of Network Changes matters. There is a concern about a bait and switch. You join a plan and the Network Changes. It may not be something that the plan did. All of a sudden, your doctor is not in it. The other speakers said, and i think it is important, that dealing with this problem involves reducing the consequences as a physician if a physician or hospital is out of network. Ifuce the harm that occurs there is a mismatch between the dr. You want and what your network looks like. Concern and itr is related to selection. It is true that i can make a compelling case about efficiency and wanting insurers to pick physicians that are efficient. Certainbe able to pick patients by picking certain doctors. We have to worry. Significant a advance. I can show you academic evidence that suggests that now might be more appealing for plants, as opposed to people with tried disease who are out because of risk adjustment. We are at the beginning and not the end of this process. I think it matters. A few final points. I hate to say this because we are going out to the and i believe this. Fairness to providers is important will stop it is not the goal of the Health Care System. There is an undercarriage we need to bethat fair to providers. At the end of the day, the ability of providers is not to get into the network. Its about patients getting access to care they need because they can afford. We are seeing a big reorganization of the systems and how it plays out. That will be interesting to monitor as providers find themselves in a complicated environments and have to negotiate in different ways with the plans. As was mentioned before, i think when you think about the issues of Network Adequacy. Im glad im not a regulator. I think it matters a lot. We will not get this perfectly correct. It there will be complaints for a variety of reasons. Of we will have to avoid the temptation to move to a system that prevents any type of Creative Network development because we want to avoid there ever been a problem when those networks to get developed. Q a,fore we head into the one question for the panelists. What do we are ready know about cost and quality . A narrowercomparing network to the broader network, do we have any numbers or research that show us our experience already in terms of quest cost and quality . One thing i can jump in on here, with all of the data that is now available for research, what were seeing and what is highereen by insurers is prices for services does not necessarily indicate that her outcomes. Providers that are doing knees, the more they do it and the better the outcome. They do so many of them that often times the price of that is lowerr procedure than it is for the guy that does one or week. If they are doing one or two a among,opposed to one what we are seeing is the lower cost procedure is producing a better outcome. I think on price we know that Narrow Networks are cheaper. I think we also know that were seeing on a Narrow Networks and the exchanges. Prices are a little lower in general in terms of what people expect going into the exchanges on quality. It is anecdotal still. We really dont know how to measure quality. There are things that we do know. If you look at who scores well , if you lookystem at who comes highest on the achievement under that system, it tends to be the achp companies. The groups that have integrated Delivery Systems do perform better on that medicare system. In, youbefore you jump mentioned medicare and Medicare Advantage, the federal government is looking at new standards that will be similar. It that where we should be going . The federal government didnt. Old up the quality initiatives there are several different initiatives there. One of the reasons is they want to make sure that there was alignment across these different federal programs. The last thing we want is one method for quality in one and a different one in the other. Part of it is if you look at consumers, they dont pay a lot of attention to those ratings. I think it is common sense. I dont think they know how to measure quality very well yet. I think we have lot a lot of work to do. Analogy to this discussion is if you look at the managed care in the past. It was not a resounding success. The evidence at the time suggest that those plans were able to have a lower cost and perform well on the stateoftheart quality measures at the time. Right, the quality measures were not that good. The narrowing of the networks was not the defining features of those plans. Enabled them to do a series of other things in those organizations. I think it will be a mistake given where we are in the process now to try and generalize about these plans. There will be exceptional ones that provide low cost and high quality care regardless of how you define it. I am sure though we some that will be as good. The challenge is to try and set up a system that both identifies and informs and monitors those that are falling on the part of the spectrum that we dont like. That is going to be very challenging to try and generalize about anything. They are going to be local and run by different organizations with different abilities to manage them well. They will have a series of other tools on top that will very. You are not just talking about the network. It is our topic today. There are other things that will happen today. They will define the outcomes. It we will have a. If in which we trust consumers. Choose. T we shouldnt limit their choices for various reasons. Those thato remind are listening on the phone line 2, youching on cspan can email questions. I also want to remind everyone that we have two experts with us. We have diane holder. She is with the university of pittsburgh medical center. She can give us in on the ground perspective. The blue cross and blue shield of michigan. We have on the ground experts and they will join in on the conversation. You can direct questions to anyone on the panel. When you ask a question, please identify yourself. I guess my general concern regarding centers of excellence. If i were diagnosed with cancer to goample, i would want to a National Cancer institute designated center. Those should not be excluded. Is willmy question these networks provide access to designated centers for various diseases . Want to talk about what just happened in pittsburgh. They settled a case between two companies are were arguing about networks. It does need to be a network for both insurers were going to have separate networks over time. I think the point is well taken. You might want have a shared pricing approach. There might be some pricing difference depending on where People Choose to go. Cutting off access completely for certain facilities is not going to work very well with the consumer. If the initial treatment choice if you have that to have that treatment it might prevent more treatment down the road. Thingsink one of the that is a part of this debate is what really is adequate. When the the outcomes people want to achieve, they want an improvement over what we have in many regions. We suffer from some deficits in our quality. The struggle that people have is a network is not a network is not a network. Itis really about what is that the people need in a region and how to get access to the right combination of cost and quality. There are certain level standards that need to be met. Boths to be balanced with refiner and insurance competition. What weot going to get need if we stand in the way of doing things differently than we have in the past. That my mother had lymphoma. She was treated in pittsburgh. Cancer as well as complicated areas because of this notion that you are not going to know beforehand where you want to go for your care. It is unrealistic to expect someone choosing a plan to be sure that they are picking one that has the Cancer Center that they want. That may vary by the type of cancer. I am very wary of a situation in which we force organizations to include a particular providers and them because of what that does the pricing. That would beng, on the road toward some sort of price regulation. You want to say that everybody pays the same price. I dont know how appealing that would be. I dont know if that would or should happen. The concern is if we think there is a monopoly type provider, we have to think the way of dealing with that beyond the rule which is every network has to include this particular provider. In areas where there are competing areas of excellence, there might be fewer types of those providers. It will be a challenge in this Network Development regulation. People need to have access to good cancer care but in a way that does not give a blank check to the organizations and say you can charge whatever you want and do whatever you want. Money, itn fact make is yet to be shown that they really do for a variety of reasons. That is more of an academic discussion. I want to make the point that in and around the work that we when there is a situation that arises and you havent predecided where you want to go if something bad happens, there are formal and informal appeals processes built into the system. I can think of one in wisconsin where there was an informal process where someone called and said i cant get this treatment here. I need to go somewhere else. I need a way to get there. Is weng and short of it made it happen to that person is still alive today because of that. That is the role of the regulator. As long as we play it straight down the line when the situations turn up. In terms of the rewriting of the model, that is going to be contemplated. The ability to file quick appeals for emergencies or specialized care through formal , consumers means have an avenue to pursue. I am jim landers of the dallas morning news. This seems like an opportunity that should insurers have not had a dime to compel hospitals to do more to align their prices with a market response. We get a lot of hospitals in that are like a four star hotel. We dont see anything reflected gives the insurers a way to say wait a minute. If you want that you can buy that. Adequacy does not necessarily include a four star hotel experience. Insurers could of heading error narrower network. People thought they would. They actually voted generally speaking with their feet not to. We could argue the intent. I am not sure that my panelists was comment on it, there demand for these things on the exchanges. I dont mean to say this facetiously. It is a question as to what level of quality of separation we would want and when we would want the consumers to have to make that choice. Create markets that work in a world where information is imperfect . We care about the outcomes in a way that we dont for other things. If you buy a third rate cell sorry. Im if you get bad cancer care i feel differently about that in a variety of ways. See consumerswill making choices to different types of facilities in the network. We have to have a lower bound that is acceptable. Regulate the process. Some of the more egregious things that might happen in that type of world are minimized. I want to say eliminated, but i will stick with minimize. I do vaguely will a limit the problem. Dallas is an ideal place to have this conversation because we have multiple systems. There can be good competition in the way that you describe. Is somer side of this parts of the country there is just one hospital. There is not the same type of leverage to drive price and quality. One thing has become a hot is sometimes on the pages of the press. These are issues of antitrust. If you see this competition and mergers, in combination with this discussion there will be aspects of network consolidation. We can have another press briefing on how we want consolidation to allow integration where we think there have been inefficiencies. We want to maintain Competition Among providers. Many of the issues that are in the forefront of policy makers and the overlapping. One of the themes that transcends all of those is the extent to which we can end up with a system where competition works between insurers and providers. To have regulatory barriers to that competition. I have a question for ted. It was going to put in place more strict Network Guidelines that are offered on the federal marketplace. Specifict look at standards around time and distance requirements. Should they be in the business of doing that . I love my friends of the federal government. And wary of concern that they focus this and come up with a floor. I know i have regulators who would like a floor. Given the diversity of marketplaces them throughout the country marketplaces throughout the country, i dont want a push by the federal government to get into the something that states do very well. They know their markets and their marketplaces in and in of the geography of the distances. They know their urban versus rural areas. They do a good job there. What we dont want to have is our friends around here in d. C. Putting something in place that will mess up strategies that are already working very well the states. They should give us a wide berth of the state level to make these decisions and better manage the marketplaces. We are right there. Ask if thelike to other panelists want to weigh in on this question about federal versus state or is there some combination of oath that would work. Where are we headed . What is going to happen with federal . Is the federal government moving forward with some aspect . We would want the ability to do for our own communities. In michigan we have cases where we dont have Network Providers because the Doctors Office does not exist in that area. I think it becomes complex for in ruralwho do live areas if they go to access care and how expensive it is in that geography. There is also a way to work with providers in a partnership and develop measures and programs where you have a team between the plan the provider to develop height quality and low cost highquality and lowcost care. Say we have this set up in the original regulations. We have qualitative standards that are not qualitative quantitative standards. There are always wrinkles. One is the exchanges have more low income people come into the commercial marketplace than has been the case traditionally. The second part of Network Adequacy are people that serve that population. We start with quantitative regulations. We wanted to make sure the providers would be represented. Of where thaty exactly goes. It illustrates that all generalizations are a good motto to keep in mind when you thinking about these issues. I am from the new york times. I would like to followup with a question. Have the Medicare Advantage problems . Created there are five Different Levels based on diversity of a community population. Recognize failed to diversity among states . That is not a question i am well versed on. It does not occur to me that ive heard much in terms of complaints of an issue. That when i would have to get back to on. Do you have something to say about Medicare Advantage . The standards are set for a particular population, the elderly. To import them directly into the broader marketplace would not be the best solution. I would look at some of the principles that are there. Road, shoulds the there be a quantification . Everybody starts with times and distance. Going to be in the standards. Do we need those or a National Forum . I would be skeptical of doing that at this point. That is where the rubber will meet the road in the discussion. Advantageicare example has one distinction from a lot of the discussion were having about the exchanges. That is the existence of medicare. You have this market backdrop in care advantagehe world. Some people stay in the traditional Medicare Program rather than the exchanges. You dont have the same broad plan that you can automatically pick. The worry in the exchange much that is not so there is a plan that might be narrower than you would like as opposed to a marketplace where there is a lot of choice of something that you would want. In the Medicare Advantage situation, medicare leaves relieves the pressure. This, the National Committee has just recently come out with something of an accreditation of plans. How is that going to work . Well . T going to work how does that fit in with the other parties . I think it is a welcome development. Those kinds of programs can be helpful and there is a level regulation. I think you have to worry about once a regulation is put into effect, it is hard to change. The states tend to be more nimble about finding something and then undoing it. That was not my experience working the federal government. Looking at things through is to betion commended. I think in general the standards look to be more process oriented. They work great process of working asking the right questions and not so much strict bottomline. That was my impression that it was more of a process oriented, which it think is good. I think you need to interpret the activity. This is a subset of enormous movements to inform people and provide information about these plans. There is an enormous amount of Venture Capital. They are trying to find ways to inform people about different plans and the different providers within the plans. Arerm them when they choosing a physician. There is a lot of Venture Capital in rabbit and private effort to make these work. We are just beginning to understand how well these new tools that take advantage of enormous amounts of data and dont know how well we will be able to translate all of that knowledge into things that consumers must choose. Will they be able to process all that information . Organizations are important. You will see a lot of stuff being done by different organizations. Comments,ople make people dont think they can handle the information. How will they handle more . The answer is you could not have done any of this without the internet. People will win the race in this when they create algorithms that give consumers the answers that they trust. You have to where look through 38 pace of data. There will be people who do double clicks on a webpage and get on the thousand pages of data. Most people will say on the surface page and want a recommendation based on the information. Im going to start typing and you give me what you think would be my match of a Health Plan Area of let me give you a little bit more information. Most peopleor two, will get the answers they want because there is an algorithm. You upload last years information. It is not going to be a consumer looking at all of that data. It is going to be an intermediary figuring out how to process. The ones that win will be the one that gives you the results that you want. That is what the Venture Capitalists are thinking about. One thing that may have slipped by, new information is often personal. It is not risk management. It is what plan is best for me. Stuffre not just spitting out. They are combined in ways that would be useful to individuals. Involvesevolves a lot of information, there are some value judgments that need to be made. It remains to be seen how successful they will be. That is the vision that these people will have. I am with med page today. I am going to ask a provider related question. There have been some reports about providers not finding which networks they are in or thinking they were in a network that they were not. Are there efforts being made in the model to make sure that providers are adequately informed . Your question is more about providers not being informed than consumers buying a plan and figuring that the provider is not there . Model spends ae lot of time on that aspect. Be lookinggoing to at it from the perspective of insurance regulators. We are looking at it from th regulating the insurers and making sure that their plans are adequate. Were looking at it from that perspective. We not reach net providers and saying you may it will not be in our wheelhouse to be going that far. In any of the comments he received from providers, did you hear about this . Is this something they were talking about . That is not one i have seen yet. I did not mean to apply that imply that i am a supporter of being unfair to providers. I do believe the system needs to be fair to providers. One way in which consumers could a lot of information is from their providers. If the providers are not wellinformed about the networks, referral patterns, if youre providers cannot figure out what other providers are in the network, it is hard for them to make referrals in a way you would want. It is important for the well fortioning of a market providers to be informed, treated fairly, have the information consumers have. Importantare an portion of the information flow. Knowas consumers need to which hospitals are in a network, the providers need to know what hospitals are network. The per ryder system is fragmented provider system is fragmented. Provider site issues that important require important attention. At the end of the day, we care about those because the whole system will depend on the providers being treated fairly. Provider being in versus out of the network is not the ultimate goal. Knowing who is in and out, eating treated fairly in that process being treated fairly in that process. I think the regulators will take heed if we see abuses. I have had the misfortune of having to deal with hospital bills for one of my boys, Customer Service is atrocious. System,oyer based everybody the system knows i am not making the choice. There is not and accountability. Believe the individual will be making their choices. When the insurers are responding to the individual on a retail level to sell the product, Customer Service will get much much better. There is no other profession, no other system in which the supply chain, the doctors, have as many ultimate with the payer in the system. Not customer friendly. The winners will be the ones to figure out how to treat the individual right. I think if you look at what actually makes Health Care Work better, it is the ability for all the important components to be wellinformed and to understand what is happening. If you say, who are the important parts in the system, the consumer and the transparency, the provider has to be wellinformed and they have to understand not just networks, but the complexity with which benefit designs are increasing. It is really important because the average patient is going to the average doctor saying, what do i do . Who is the better dr. For me to see . Patients have trusted their doctors more than anyone when it comes to health care. They continue to seek advice. We owe it to make sure the provider systems are as well as formed as they can be because they are the agents of care. If you are a primary care we inform about quality and cost across the sector. Where is the best place to refer you . What Systems Practice judicious use of resource . How do you define parameters around what is a good Referral Network interspecific area . How do you share that information with primary care . Thatst cases, we found pcps are interested in their own performance. It is a complicated issue for us. For theis a question professor. When you say we should be fair to the providers, do you mean we should shield them from economic distress question mark why is that economic distress . I do not mean we should shield them from economic distress. Our providers need to be solvent and provide care. I do not mean we need to protect them from fiscal distress. Most of this discussion is about how to instill competition. What i mean by that is you should be transparent in your dealings. Hold them to standards they simply cannot meet in a variety of ways. The provider and i believe in the marketplace being fair to providers being a winning strategy. I believe the provider system are the ultimate place in which consumers experience the Health Care System and a need to be able to function in a reasonable way. I do think pressure through competition is something these networks will generate. To that, butsed there are stories you hear about people believing they were in contracts and then them not being in contracts. Broad contract law dealings with folks. Meant. What i they need to be the need to know what theyre getting into when they join a network. I am a person who is relatively flexible. Set, you should knows the provider what you are getting into it. That is what i meant by being fair. Should i do believe it will be competition and that will lead to lower prices. That is probably the good thing generally speaking. We have been talking about providers and their level of knowledge. About the consumers . Mckinsey,eport from based on april consumer survey, indicated that 26 of respondents indicated they had enrolled in a plan and they were unaware of the network type they selected. Twice that were aware. About doestions consumers know what they are signing up for when they are signing up for it . Once they are in, are they informationright about who is in and he was not in and who they should go see. This is a broad question, but can we talk about the consumer and . End . Nsumer the difference between your decision, where most consumers will assume they will stay healthy and tend to buy down on product. That is what we are learning from the exchanges. And then there is a different attitude if they do get sick. The people who are most cynical about whether there would , just wait a change until people actually need the care. Then they will say, no one explained this very well do me and i demand very well to me and i demand x. It is hard to educate people at the front end about all of the different eventualities. Transparency, transparency, transparency. You need these brokers of information to make it work because you will never get the average consumer to understand the detail. People who have health conditions, they can run that through the system and see exactly how their situation will play out. We will have a lot of data broker type people able to help consumers. People would choose these things on the front end. We do not know so much what about happens what happens when the rubber meets the road. Seen complaints had this thing i and i did not have the saying we are not hearing much of that yet. This is all new to many folks. This is the first time there has been a mandate to purchase Health Insurance. , are is a certain percentage lot of folks said, they bought something and i just went to the website or they went through an agent or a navigator and purchased that Health Insurance helping they got what they needed. Bought it because it was the cheapest thing and they knew they had to have something. There might be some of that. And of course you had all the problems last year, open enrollment that seemed to last forever. Hopefully, they sure, things are little more squared away and after a year of consumers purchasing Health Insurance, maybe they start Getting Better about it, maybe they start asking questions. Understandbetter what benefits are available. Something me if how will it treat me of something should happen . Im optimistic that consumers ultimately will become more informed as they play a greater role. That optimistic view, there will be a subset of people not going to be able to make the choice. That is been true in every walk of life in every dimension. Challenge isof the to try to figure out how we balance what i think is an , having consumers take some responsibility to be engaged. System inmanage a which we try to minimize the chance that someone ends up in a really bad situation. Some of these fallback processes to make sure the worstcase it is going to be. Mpossible how we feel a 10 of consumers are making bad choices . It is not going to be that most people are able to make the Perfect Choice for them anything. That will certainly be true in health care. We have to minimize the downside. Give them the opportunity to change over time. Learn to will have to take more responsibility. I realize that many of them will not. [indiscernible] there is an rs amount of work on an enormous amount of work on how to help people make better choices. I am an economist and i believe in markets, but in health care, i think there is a lot of limitations to choice and a lot that can be learned. Ou see this in 401 k we can help people make choices that are for themselves while still giving them the opportunity if they want. Omething different to do it to go into this with an understanding of econ 101 will give us now, that will have more people and situations they dont like that i would be comfortable with. I do want to remind you and folks that for number of years , there was an allowance for medical savings accounts. Individuals were in charge of the good portion of their health care. You have more of a catastrophic plan. Really put consumers in charge and made them make that her choices and cause them curiouslittle more about where the money was going. Lets not forget that that is out there as well. There is a certain percentage of the population that will not have that Information Available to them. It is up to regulators to step in when those problems occur. Or promote as much transparency and communication as we can. Are Insurance Commissioners already stepping in . Sense as to us a how many of your colleagues in other states are already being being active. Commissioners and regulators really do care about their market. When they see disturbances or disruptions or things they have the authority to step in and do something about, they will. In this very issue of networks, and some of the more rural , there are serious distances between you anything. You cannot just have, will you have to be within 60 miles. You drive 60 miles to get a loaf of bread in some states. In andioners will step have conversations and say look, this is unreasonable. Lets work through these things. Whether it is that situation or , very often,ation the commissioners will be talking directly with or through to work these things out and get the market disruptions taking care of. Up onssue is very high many commissioners list. Daytoday, over the years, it is something that they deal with regularly. Look at the three west coast states. The commissioner had to figure out new regulations this year. He settled on a transparency strategy. Think there ist enough. That is where he settled. California, the exchange guy, a very active commissioner, all of whom have some stake in this. If you wanted to look at or some of the more is those were all people who are active. As the other side to the prairie states. That is the other side to the prairie states. Many states are doing a lot more. Issues is to make sure the strategy related to the product fits into the broader strategy. Up. Ets wrap i will give each of you a 30 seconds to tell you what is the one thing they ought to be looking for . It can be what you hope is going to have an or youre worried about happening. The one thing everyone in this room should keep their ion moving forward . Should really be clear to differentiate value versus the other terminology. We should not stand in the way or create unnecessary burdens. My two things remember the tradeoffs. Do not get stuck on one aspect of the story, but not the other. Anecdotes well prove the rule wont prove the rule. I will second what you said. This is an important issue. It is accelerating at a rate which we did that anticipate. On isrking group we work taking comments and considerations and letters from all parties to better a dress a better model for states to adopt and implement. The issues are complex and there are tradeoffs. I hope we let the states be the laboratories of democracy and experiment. Look at the different states and what they are doing. I would be wary of a premature federal intervention that would limit the kind of experimentation when he to have on these issues. I think finding ways to report on quality and cost across the spectrum are goin