That providers can communicate more openly and easily sharing information between them about patients. Thats especially important and helpful with Electronic Health platforms when the providers are on the same platform. This can reduce duplicate testing and even conflicting treatment. Payers and providers can share more Meaningful Health care data, Work Together on Health Care Analytics to determine what is the right improvement we can make to quality and cost . The providers within a clinically integrated network can be more familiar with each others, not just their medical practice protocols but their administrative practices. Allowing handoffs to be much smoother with less error. Then also these tighter relationships allow these providers to comment with the payers back to them where there are Service Needs and things that need to be improved. So ill go on to what we also want to talk about, though, and that is there needs to be adequate Consumer Protection and education. Especially for these families who are accessing these products offered through the exchanges. According to hhs, 85 of individuals that are purchasing products on the exchanges qualify for an insurance subsidy. So i think, therefore, we can conclude a couple things. One, we tend to be at the lower end of the income scale. And two, a good number of them did not have insurance previously. In fact, one study weve seen 7 57 did not have insurance before, so im glad were talking about this question today. So starting with Consumer Protection and education. Weve invested as Ascension Health in 200 individuals to become certified application counselors. Theyve received federal training and they are there to help patients access the networks and understand the website, healthcare. Gov. What weve learned is this counseling takes a lot of time. Not just for those patients who arrive asking for this counseling and this help, but many times when they arrive with the need of medical care. Thats hardly the time to learn thats when your provider of choice is not in your network. This leads to confusion, it leads to frustration and sometimes anger. And i will tell you in one example, in wisconsin, a patient arrived at our emergency room in Critical Condition and needing immediate intensive care. Unfortunately, he had just signed up with a health plan that did not include us in his network. We admitted the patient because thats what the patient and the family wanted, but neither the family nor us knew what that patients liability or financial obligation would be for that bill when it was completed. But we were fairly confident as Ascension Health knowing we had had admitted that if this patient is lower income, which likely they are, they will qualify for charity and well be left with the uncompensated care, again, because of the confusion of which provider is in the network. Its obviously important for patients and families to understand their networks when they sign up for the plans. They need to know they may face higher deductibles, higher copays and coinsurance. And possibly the providers not covered at all. We would advocate to you today that the sinsurers need to be more accountability on educating their customers on their products. That includes ascension, when we offer a product on the exchange. The education should focus not just on networks and whos in the networks, but education on the related deductibles, copays, coinsurance, and even education on tradeoffs to be made when choosing a low coverage, low premium product versus a higher coverage, higher premium product. And this is especially important with these folks who to not have experience with insurance and have cultural and language barriers as well. Weve found that the online directories are often incomplete. Theyre outdated. Sometimes inaccurate information. Hard copies are not existent. Its also not unusual in a community for several practices or providers to have very similar names and that can add to confusion. And finally, the access hours and the capacity for those new patients to access those providers is also important. When an individuals enrolling on healthcare. Gov, they have to leave that website and go to the various insurers websites to determine more about providers and, of course, we believe that information should be accessible through the healthcare. Gov website. So i want to move on to the quality standards. Ascension health has been a leader in patient safety. Over the past decade. Were very proud of our quality record. Our work in the last decade on pressure ulcer has resulted in our pressure ulcer rate 94 below national noorms. Systemwide work in birth trauma made ascension hospitals among the safest places to deliver a baby. We believe we should streamline the existing quality programs into a uniform National Core measurement set used by both private and Public Sectors. Ascension health and Americas Health insurance plan, ahip, made this recommendation last spring in a document that was published, partnership for Sustainable Health care. Defined set of outcomebased measurements can provide the consumers with more understandable and meaningful information to be able to compare providers within their communities. Current practice allows an insurance to develop their own Quality Metrics of their choosing. Sometimes these measures are similar or the same as medicare, but not always. And a recent milliman studty released by ahip which i believe is in your packets found that the primary measure used in evaluating Narrow Network providers are quality measures. And the study goes on to describe how these quality measures can be used. There are seven different types described in the document, and each has dozens or even hundreds of different measures and metrics. I can tell you in one of our health systems, theyre evaluated by three insurance plans, same services, one grades them as a three star, another is a four star, and another is a fifth star. Even though its all reportedly based on the same metrics. And that causes us back and forth with the insurers, is it the Patient Population looked at, is it the time period, what are these differences in whats driving them . While we have our time figuring it out, its much more difficult for physicians to understand how theyve been graded as far as quality and, frankly, its a mystery for patients. So considering there should be uniform helpful quality information as part of the patients decision on these networks. So what is a sufficient number of providers and services to include in a Narrow Network . I understand the work is in progress and it will continue to evolve, and im glad hhs and naic are working to further define this definition. I want to point out just a couple things. First of all, the individual marketplace includes many, many lowincome families who are also medically vulnerable. So measuring the distance to providers is sometimes not simplistically solved by measuring miles. Ten miles away to a hospital may not seem very far, but if you have no transportation, and you rely solely on public transportation, that can be 100 miles to you. And also, we have folks that are buying on this, on the exhachans that have complex childcare needs. They need Flexible Work hours. Their information regarding providers accessibility within hours, after hours, et cetera, is also important. Weve seen a few holes in the coverage in some of the Narrow Networks. For example, in one market, where we are the named narrow provider, we found one of the Narrow Networks had no access to pet scans. Another glitch we found is that as their narrow exclusive network provider, they had not contracted with any other Outpatient Lab services. Or radiation therapy. And we can provide those services. Are happy to provide them. But frankly, getting Outpatient Lab testing at your hospital may not be as convenient as some of the Outpatient Labs that are available with better parking and better hours. So, finally, id like to emphasize the reality of the marketplace is still that price dominates. Premiums are what consumers are the most likely to look at when they choose their networks. The Accountable Care act established affordability standards for health premiums. But its cautionary, those with low income still leave large out of pocket medical expenses that can be unaffordable in this population. Most households with income below 400 of the federal poverty limit have negative net assets. So as a result, even modest out of pocket costs create affordability problems. And i will give you one example. This is from one of our markets thats worked with some folks. A married couple, both aged 59. With income of 48,000 a year. They those a bronze plan. Their priemium is subsidized. Play 3,600 in annual premium. Have a 3,600 deductible. Theyre subject to a 12,000 potential out of pocket maximum. Working through the numbers, if one of this couple needed a joint replacement, lets say a knee or a hip, their share of this proceprocedure, including proceed wrurs, the premiums, the deductibles, et cetera, would result in an annual expense of roughly 16,000 which is now 34 of their total income. These high deduct bl plans, not only are they unaffordable, but they lead to poor care. Coordinating care for this population is difficult. Its well documented that when people will display seeking their care, or theyll have difficulty adhering to their treatment plans when theyre faced with large out of pocket costs. So moving forward, its tempting to develop policies based on anecdotal information, but the reality is we need more rigorous information. We need to know what is working, whats not working around the nation. What works in one community may not work in another community. The one priority we have for the initial attention in this area is education, providining clari and transparency for the consumer so that they know which and who providers are in their network, how available those providers will be to them, how much cost sharing theyll be accountable for, and the quality that can be provided by those providers. And at the same time, as this more rigorous information is developed, we believe its more important also to remain flexible and to respond to any particular egregious situation that may come up. Which is what weve dont in our Health Care System as we see these specific examples come up responding with compassion to understand what the patients needs are in meeting that as best we can. Thank you. Thanks, katherine. Lets turn to brian. Brian webb from naic. Thank you very much. Good afternoon, everybody. My name is brian webb. Im with the National Association of insurance commissioners. We represent the commissionerses from the 50 states, washington, d. C. , which just became more important to some people in the room, last year. And also the five u. S. And also the five u. S. Territories which as clarified last week are not states for title 1, the Affordable Care act. One of our jobs is to develop model laws, rules and regulations that states can choose to use. We do this with an open process. Were bringing stakeholders from all, various areas. And we try to develop one and one of those that we have is the Network Adequacy model act. Number 74. If youre keeping track at home. Number 74, basically was developed in 1996 and looking around the room, looks like about half of you were in kindergart kindergarten. So it was a long time ago. Now were starting to look at it once again to see if it needs to be updated given the new environment. Looking at the existing model, the basic focus was to make sure that carriers when they set up their networks for managed care do set them up in a way that theres a reasonable assurance that somebody can get to an innetwork provider in sufficient numbers and types in a reasonable amount of time. We leave it up to the carriers to determine how theyre going to set that up. States can look at the networks to make sure that that definition of reasonable is reasonable. That when you look at the time it takes people to get to them, any waiting periods, any distance issues that you make sure that everybody can get to somebody in a sufficient way. And if not, what the model does, theres an insufficient network, that the carrier makes sure the person can go to another doctor, another hospital, another provider. And that they would be not charged more for going to them. There is an alternative mechanism set up. And to regulate it, what they do is require the carriers to file an access plan with the commissioner prior to offering the new managed care plan. And what goes into that is, of course, a description of the network. They need to also say how theyre going to monitor that network on an ongoing basis. What the grievance procedures are going to be if somebody has a problem or a question about the network. Notification. How are they going to notify the consumer if theres a change in that network . Either the provider decided to cancel, or they are terminated by the company and also, this is very critical, the continuity of care. If somebody is dropped, how are you going to make sure that person continues to get the care they need, from that provider at no additional cost, or through a separate provider . It also goes into the contracts. You want to make sure the contracts being set up are not done in a discriminatory way. Not only with certain kinds of providers so certain consumers cant get their care. You want to make sure theyre not basically giving inducements to providers to make sure theyre not providing certain medically necessary care or theres some kind of gag rules, they cant discuss certain kinds of care. All those are all rolled together into our model act. About ten states have taken and adopted our model verbatim. Taken it just as it is. Another ten have some kind of similar, and i just want to point out, even on those 20, states through guidance and through other regulatory have adopted these concepts. They work with the carriers. The carriers do use a lot of these standards in developing their networks. Copy of it, go t the naic model, go to store, and free. Theres a section of free materials you can get including a all aftof our models. We have a white paper. It looks at the issues were now going to be looking at as we look to revise our model. We have set up a subgroup which is currently doing regular phone calls. Theyre open phone calls. Anybody, anybody in this room, can sit in them if you have nothing else better to do with your life. I always picture a 4yearold man in his mothers basement, but i dont know why. Just sitting down there, calling in. You an do that. You can provide comments. Anybody and everybody can provide comments, suggested changes, however uyou want to d it. Weve gone through a series of calls now where weve had all the stakeholders, the carriers, providers, the who else . Consumers, of course. Others that have come in and brought us their ideas. And were going to soon start the process of updating it. And there are a couple of areas we are clear we need to update. One is the concept of an essential community providers. Thats not something that we were really looking at before. Are those now inlecluded in you networks . Theres also just issues in the new environment of are we applying it to all manner of managed care . Some states only did what you would call your old managed care, closed network type of plans. Now do you go out to ppos, do you go out to others as well to make sure everybody is doing what they need to do . Were having weekly calls. In fact, our next one is thursday, july 24th, at 1 30 p. M. Mark it on your calendars. Be there. As we start looking at amendments. We received comments from about 30 different groups so far. And were going to start going through those and seeing where we need to update our model. If you want information, the website is there. You can go and get the exact callin information. What are the issues . One is just a flexibility to reflect state needs. This is always going to be our number one point. We dont want a onesizefitsall federal government comes in and says this is exactly the time and distance for each type of provider. We dont think that will work. I dont know about you, but wyoming is just a tad different than los angeles. So what are the standards . How do people get there . There were some good examples brought up as well. What about certain populations and certain maybe very populous areas but maybe some transportation issues . States have been looking at these issues and are best to address these issues given on their needs. But then we do, as has been brought up, we need to balance. Theres no sense in going here and saying we need to get rid of all of these. No Narrow Networks. Because we need to balance quality, we need to balance affordabili affordability, then we need to balance access. And how do you do that and how you do that in the model and make sure everybody is protected is our number one concern. Some of the key issues were going to be looking at, tiered networks and far ynarrow networ. Tiered networks are basically if you go to this group, you have to pay this much. If you go to this group, this much. This group, that much. Theyre kind of tiered up. Especially in form layularies w were looking at more and more now than in the past for prescription drugs. How are those set up . Narrow networks, one issue in particular were going to be looking at is in a couple of states, carriers said if you purchase in the state, we will cover you either as in network or out of network. If you go to any provider outside the state, we will pay nothing. Its not even like a higher cost sharing. Its just we will pay nothing not covered. Were going to have to look at that. Were also going to have to look at provider directories and updates, and i think that was there are addressed here, and this is probably the most critical issue. You cant have a free market when people cannot get access to information. We had that this year. Im not placing blame on anybody. It was a rough year. Just trying to get plans on, getting things up and running, and get it out there. B