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. Signific