plan of our own. and then finally, we participate in the non far ynarrow market, offerings described by other providers in those markets. i would generalize that overall in most of our markets, we're in some form of exchange product because generally, it fits with our mission to serve the low income and the vulnerable since that's who's accessing these products on the exchange. so i do want to meant about these narrow networks and then how they can benefit payers, patients, and providers. we do believe there is benefit in narrow networks. and it can be done through the offering of what we call clinically integrated care. and that's especially helpful for those with chronic diseases. and so some of these benefits that you can outline when you have this tighter integration is

that providers can communicate more openly and easily sharing information between them about patients. that's 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 other's, 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 i'll 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 we've seen 7 57% did not have insurance before, so i'm glad we're talking about this question today. so starting with consumer protection and education. we've invested as ascension health in 200 individuals to become certified application counselors. they've received federal training and they are there to help patients access the networks and understand the website, healthcare.gov.

what we've 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. that's hardly the time to learn that's 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 that's what the patient and the family wanted, but neither the family nor us knew what that patient's 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 we'll be left with the uncompensated care, again, because of the confusion of which provider is in the network. it's 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 co-pays and co-insurance. and possibly the provider's 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 who's in the networks, but education on the related deductibles, co-pays, co-insurance, 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. we've found that the online directories are often incomplete. they're outdated. sometimes inaccurate information. hard copies are not existent. it's 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 individual's 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. we're 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 america's health insurance plan, ahip, made this recommendation last spring in a document that was published, partnership for sustainable health care. defined set of outcome-based 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, they're 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 it's 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 what's driving them? while we have our time figuring it out, it's much more difficult for physicians to understand how they've been graded as far as quality and, frankly, it's 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 i'm 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 low-income 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. we've 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, i'd 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 it's 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 that's 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. they're subject to a $12,000 potential out of pocket maximum. working through the numbers, if one of this couple needed a joint replacement, let's 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. it's well documented that when people will display seeking their care, or they'll have difficulty adhering to their treatment plans when they're faced with large out of pocket costs. so moving forward, it's tempting to develop policies based on anecdotal information, but the reality is we need more rigorous information. we need to know what is working, what's 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 they'll 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 it's more important also to remain flexible and to respond to any particular egregious situation that may come up. which is what we've don't 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. let's turn to brian. brian webb from naic. >> thank you very much. good afternoon, everybody. my name is brian webb. i'm 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. we're 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 you're 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 we're 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 there's a reasonable assurance that somebody can get to an in-network provider in sufficient numbers and types in a reasonable amount of time. we leave it up to the carriers to determine how they're 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, there's 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 they're 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 there's 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 can't get their care. you want to make sure they're

not basically giving inducements to providers to make sure they're not providing certain medically necessary care or there's some kind of gag rules, they can't 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. there's a section of free materials you can get including a all aftof our models. we have a white paper. it looks at the issues we're 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. they're 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 4-year-old man in his mother's basement, but i don't 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. we've gone through a series of calls now where we've had all the stakeholders, the carriers, providers, the -- who else? consumers, of course. others that have come in and brought us their ideas. and we're 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. that's not something that we were really looking at before. are those now inlecluded in you networks? there's 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? we're 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 we're 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 call-in 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 don't want a one-size-fits-all federal government comes in and says this is exactly the time and distance for each type of provider. we don't think that will work. i don't 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. there's 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 we're 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. they're kind of tiered up.

especially in form layularies w we're looking at more and more now than in the past for prescription drugs. how are those set up? narrow networks, one issue in particular we're 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. it's not even like a higher cost sharing. it's just we will pay nothing not covered. we're going to have to look at that. we're 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 can't have a free market when people cannot get access to information. we had that this year. i'm 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. but we've got to do better in 2015 open enrollment period. consumers need to know that if they purchase that plan, is their provider in the network or

not? they have to have clear access to the website to make sure they can know which ones are in, which is out. to tell you the truth, providers do, too. i had so many provider groups calling us and saying, i had no idea. i got the call from the consumer. they were doing their due diligence. i said, i'm in, i have a contact with that company. then i find out i don't have a contract for that particular plan. so we need to make sure everybody has the information they need and if there are updates that those notifications are going out so the consumer is well aware what their options are. and we do want options. there are many plans, we're going to have more plans on the exchanges next year. across the country. are some of them narrow? some of them not narrow. and do people know the difference and do they have the options available to them? so the directories are the accurate, updates accurate, consumer information, education, do they have the right choices before them? and then another issue we're going it to be looking at is th

surprise bills. how many like surprises? i like surprises, but not when it's a bill. this is where you go into the -- for a procedure, your doctor is in the network, your hospital is in the network, and your anesthesiologist is not. that's called surprise. you're going to be charged higher for that. making sure everybody's educated. states have been doing things on this. federal government's even looked at this. it's something we're going to be looking at to see if we can make sure, again, everybody is educated. it's okay if he's not or she's not. what's not okay is nobody knows. and really no choice was given. i'll leave you with this last slide. if you have any questions, please hold jolie. she was supposed to be here and i ain't taking the questions. she is the staffer in charge. she's the one writing and updating the model. if you have any questions, please call her. she'd be able to help you out. if you are interested in this, please, swrojoin the calls. we hope to be done by november

of this year with a brand new model that states can use to update their procedures, and if you want to be part of that or know what's going on, jump on the calls. we love to have you. thanks. >> terrific. thank you so much, brian. brian has agreed in the course of the q & a session to channel his inner jolie. so, you now have a chance to join the conversation, and i'm going to exercise a little bit of prerogative just to clarify some things. at the appropriate time, you can fill out a question card that's in your packet. you can also repair to one of the microphones that are in the room, and you can tweet a question using #networkadequacy. so you've got all sorts of channels. and the first thing i to do is sort of a factual clarification. we've heard a lot of talk about

in network and out of network. how many people don't know the difference between in network and out network for purposes of this discussion? we've got a very sophisticated audience here. so the question is, is there a typical pricing pattern? in other words, what's the penalty, maybe not out of state being zero, but in a typical plan, if you are in a narrow network and have to go out for some reason, or think you do, is there a substantial differential? or is it fairly nominal? so how important is this is what i'm asking. dan, you have any sense of that? >> sure. again, i think it's critical from the point of view providing value to consumers that we allow these high-value networks to be a choice.

as many of you heard from a number of the speakers today, many consumers are buying based on premiums. and to get that premium point down to an affordable level, plans are offering narrow networks. it's not the only option. you have broad networks as you can see in the mackenzie poll available to over 90% of the population. and so it's a choice there. but if you're in a plan that does have a specific network, then there are certain requirements to go outside that network. plans don't say you can't do that, but they'll work with the individual on their specific needs. so if there's a particular type of specialist that simply is not in the network, then the plan has an obligation to work with that customer to find someone out of network that can provide that medically necessary service. >> if i can add something, you know, part of it depends on the type of plan you have. if you have -- are in an hmo

does not have out of network coverage, then, you know, it's far more restrictive that you won't get anything out of the network than if you're in an hmo with point of service coverage or preferred provider organization. i would say the differences are substantial. i think they have to be for the narrow network approach to work. because it's not just that you'll pay a higher, say, co-insurance rates with the out of network, but that you won't be benefiting from the insurers' negotiating able to have negotiated a network price so that you'll be liable for the amount beyond what the insurer allows for out of network care, in addition to the extra co-insurance. >> and, paul, is it typical that if that happens, whatever the out of pocket expense incurred is doesn't count toward the out of pocket limits or the deductible in the plan or not? >> yes, the co-insurance counts,

but not the, what we call the balance billing. >> okay. yes, sir? you want to identify yourself? >> sure. my name is daniel davis. i'm with the administration for community living in hhs. and one of the considerations that we're looking at white a bit right now is the access to providers for people with disabilities in narrow networks. specifically there are considerations where there's been a number of studies on subspecialties where there's 20 20% or 40% of providers according to secret shopper tests in certain subspecialties that don't serve patients with mobility disabilities. and to what extent are naic and the private insurance industry taking that into consideration

and making sure that there isn't inadvertent health status discrimination? >> brian? >> with the naic, yes, that is something that has been raised as an issue and something we need to look at. something that state regulators need to look at when they're reviewing the various plans. not just that, but especially with mental health, things coming on, new requirements on behavioral health, et cetera, there's a lot of issues there that we need to make sure everybody is taking into consideration, so we would agree. >> i'll just add that health plans work very hard to comply with all the federal laws, state laws, rules and regulations. and they submit their plans for review and they're approved in the state and if they're a qualified health plan, also by a federal government and they're certified. so they have to meet the

standards set in statute and in regulation to be able to compete in the marketplace. and we take that very seriously. and if you don't make those requirements, you're now certified to be in the market. >> and having the gentleman from the administration asking that question reminds me of a question that was submitted in advance that is related. and it makes reference to the fact that the administration had communicated with plans not so long ago that they were going to focus on areas that have -- and the questioner actually quotes -- historically raised network adequacy concerns including among others mental health providers. and i wonder if we have any other elaboration of how the current discussions, or the current controversies, for that matter, deal with behavioral held issues.

katherine, do you have anything to add on that? >> i will just add that clearly that's a consideration. we focus so much on, first, what are the physicians and the hospitals in those networks, and that becomes the bulk, and as b brian pointed out, you have the anesthesiologists in. mental health, home health. all of the care continuum for clinically integrated network to be successful has to be considered. and that entire network has to be considered. i don't have any specific examples for you, but i absolutely agree with your point. >> all right. ca carolyn? >> i'm dr. carolyn. i have two questions for the gentleman. one in the satisfaction surveys i think you presented, did they

break out, people with chronic illness illnesses, or people who have had a serious illness in the last year versus healthy people? because most people are healthy most of the time, and if they don't use their network, they'll be satisfied with it. my second question has to do with choice. each -- it sounds like each insurance company in an exchange will present a variety of plans. i guess maybe they're required to present bronze, silver, gold, platinum. and the experience with part "d" has shown that people get very confused when they have too many choices, when they have five insurance companies offering 50 plans. that's hard to deal with. especially if you have to do it every year. and in part "d," i think there was a study that showed, in fact, most people didn't change their primary plan. they just kept the same plan year after year, even though it wasn't the best plan for them.

so, two questions. >> thank you for those. first, on the poll. the commonwealth fund survey that i mentioned in my slides was very comprehensive. i don't have the actual sample data in front of me to answer your specific question, but if you go to their website, they provide a very thorough explanation of where their sample is drawn from, so you could find whether or not it covered the specific populations that you mentioned. >> or whether it's separated, the specific populations, because you're going to get a different answer from the people who have to use the plan versus people who just think it's going to be great because they don't really know. they've never had to use it. >> right. and that survey also included those that actually have used their plan, too, and there's data on that as well. so, again, i encourage you to go to their website and pull up their survey. it is very comprehensive and very informative. with regard to your second question, if you could repeat that for me. >> choice.

do people -- do you worry about the fact people are going to get confused by having too many choices? >> it depends on -- >> each one has a lot of information. the part "d" experience hasn't been all that reassuring on the question of whether people can make a good choice. >> that's a very good question. it really depends on the individual. some are very savvy and sophisticated about, you know, looking through the websites and finding what's best for them. others need a lot of help. and that's why the aca provides for navigators, assisters, we have brokers as well. and others that can help. the individual review plans and make the choice that's best for them and their families. but, and health plans are doing a lot, too, in terms of basic education and putting as much information as they can on their websites to help individuals make the best choice. including things like cost

calculators so you know you're going to have a specific procedure, what your out of pocket cost would be for that. >> yeah, if i could add something to proliferation of choices, i think the structure of the offerings by, you know, being grouped into tiers, defined by actuarial value, probably helps consumers a lot with going through this, because i suspect that most consumers first decide what tier, you know, what medal they want to get, so the numbers of plans aren't as great. >> thank you. >> oh, go ahead. >> no, no. >> no, i actually wanted to follow up just a little bit because one of the questions that has been raised at least in the materials that our staff has assembled is the question of how --

things, there is a blend, there is a range of narrowness, if you will. are there some standard formulations that are being used either on the marketplace websites or among the plans that can help people who don't deal with this kind of terminology every day to understand which of the choices they're making along that spectrum? >> i can answer that. in reading the mackenzie study, i'm presuming there is nothing out there like what you're saying. since they had -- they came up with their own definitions of, you know, whether it was ultra narrow or just narrow. and it was clearly based on what proportion of the hospitals were in the network. and it probably would be a good idea going forward in that we

have tiers of plans. they'll be arbitrary. a plan that has below a certain threshold of providers is called a narrow network plan. so in a sense consumers can put some aside and then, you know, there won't be standard station like like actuarial values. >> any talk about that in the revisions the naic group is considering? >> no, not at this time as far as in our model. it is something that as far as choices and information, i think states would like to look at, i mean, we don't, in the past, carriers really try to hide the things like that, they want the information. they want to distinguish between one plan and the other. so how that's done and how clear it is will work toward that. probably not something to be on a model, specifically, trying to standardize it, anyway. >> i will add that plans do

provide a summary of benefit and coverage on healthcare.gov and so that provides important information to shop around. there's other information on healthcare.gov. new information will be coming in the future, specifically with regard to quality and consumer satisfaction. they're currently building that in and working to produce that. so, you know, i think just with part "d," it will take a while for the website, healthcare.gov, to get where it needs to be to provide all the information that consumers want. but you have to walk before you can run, so we're still in the first year, and i think we find from the experience and state-based exchanges, those states that try to do too much on their websites ran into some real challenges. and, you know, lesson learned there. but health plans are committed to providing the necessary information so consumers can

make the best choice for their families. >> okay. yes, ma'am? >> hi. lauren kennedy with the national partnership for women and families. and my question follows nicely your last comment which is i was wondering if any of the panelists could speak to what have been successful strategies for ensuring consumer access to this type of information, specifically with regard to quality and performance data? i think it was in everybody's sort of presentation that this is a key criteria not just for provider selection, performance on quality, and value metrics, but also the consumers' ability to access that information, understand it, and use it to make informed choices. and specifically with regards to exchanges, how do we support consumer access not just to plan performance on quality metrics, so being able to rate plans by quality data, but also consumer access to how providers, themselves, are performing on

quality metrics? we would make the case that if we're looking at narrow choice through narrow networks or high-value networks, however they're referred to, that consumers have a distinct interest in understanding how individual providers in the network or facilities are performing on quality metrics in a way that's consumer friendly and understandable to them. >> no one disagrees, apparently. >> it's not an argument. i was wondering if you're able to share some strategies that you've seen successful or that you might be sort of contem contemptating or policies that might be necessary to compel this type of consumer access to provider facility level performance data. >> can you do it directly or do you have to do it by, in effect, requiring the plans to collect the information in some way? >> yeah. i think this is a direction we want to go, and i think the

first thing is to get more meaningful quality data on providers. i did notice that two of our panelists' organizations together were, you know, promoting the idea of standardizing quality measurements. and i think that as we get better at measuring quality, and as we get some consistency, then it's going to be far more possible for plans to really advertise or inform about the quality of the providers in their network. because ultimately, as you said, you know, i think what matters most to many people is the quality of the providers. >> paul, is it a fair assessment of the state of the art that the people who measure quality aren't very happy with the state of quality measurement? at this point? >> yes. yes. i think there's a consensus on the direction of, you know,

getting rid of a lot of, you know, the process measures of quality and replacing them, because now we have the ability to do more in the way of outcome measures. >> katherine? >> i do believe we would advocate for collaboration and to make it more universal, as i stated earlier. that having each -- so many different ways of measuring quality -- and that's where we are today in our health care delivery, but with so many different ways, you get completely contradictory conclusions. you know, you read magazine coverages of who's the best hospitals and they're in, they're out. you don't get any real conclusion as to who's providing the best quality. so i think this area has to be -- has to be improved. needs to be universal. and we advocate working with insurers, employers, and patients to come up with the right quality metrics. >> can i ask just one follow up? do you feel that that's best on the private sector, in the public sector or in sort of

collaboration with both if we're sort of aiming toward better alignment and standardization? >> with as far as we have to go, it's certainly going to start in multiple areas, public and private. i think our point is that the ultimate goal would be single. it should be something universal that we're all accustom to and understand. i think in the interim, though, we'll work with insurers, we'll work with hhs. we're interested in pursuing this to help not narrow the number of quality indicators, but make them more understandable and comprehensive. >> let me just digress for 30 seconds and tell you jim who's on the alliance board and runs the united hospital fund of new york city once observed that because of all these various rating systems, new york city contained 40 of the top 25 hospitals in the united states. >> that's right. >> yes, gary? >> stewart gordon with the national association of state

mental health program directors. in the mental health field, a lot of services are provided through peer support, both in mental health and in substance use. brian's -- in an aligned area, i know a lot of services despite scope of practice laws in the states can be provided by nurse practitioners and physician assista assistants. is that something -- i fwes it's two facets of the same issue. is that something naic is looking at in its revised model? >> it's not currently on the table as an issue we're going to look at. we've tended in the past not to get much involved in who provides the care and those certifications, but if it's something you'd like us to look at, you know the number, so, bullbut it's not something in the past we've dealt much with. >> and i should say that we've received several questions on cards asking about the role of nurse practitioners and other

nonphysician providers in these -- in these circumstances. and i wonder, are there states that have taken steps to define adequacy to include some of these nonphysician providers? anybody know? there's a crowd source question for you, if anybody knows the answer to that question, and we'll send it to us all at health.org. we'll put it on the website. >> thank you. i'm a consumer and caregiver, and katherine york, you come ac conveying caring for the consumer, and let lamenting that your narrow network lacked an outpatient laboratory that the narrow network included a hospital laboratory, but it

didn't seem easy for the consumer related to parking issues which i totally understand. but it would seem that they have all of their information, that that little parking ticket can be validated at the lab. so it would not necessitate hiring or contracting with an outside lab. just a simple thought bubble i had. >> appreciate the thought. and i would, if you allow me, just add, we would be happy to serve all outpatients for their lab testing and make the access into that garage or that parking lot as easy as possible, whether it's getting a ticket validated, but even just getting them from the garage in, you know, if we can give -- some folks have trouble walking from that parking lot up to the entry. and i'm saying folks may not want to come to that big

hospital campus, they may want to go to the accessible quest lab that's sitting there, you know, a half a mile from their home. >> most of the parking lots that i've been in for hospitals, they have a button as you enter the parking if you need assistance. >> sure. >> oh, sure. and, again, we'd be happy to provide that. >> okay. yes, mary? >> hi, i'm mary tyranny, i'm a pediatrician my background, i worked in the office of child health, working for a man by the name of leonard schaffer. so obviously my question is going to be on pediatrics. what are you doing -- what are we really doing for kids that absolutely must have tershiary care, children's hospitals and so on? i just talked to a man the other day who had -- talked to him

again -- who had a child born with tetrology aflow, a complex heart disease. want to send his child to a surgeon who hadn't done any heart surgery on kids in about ten years. and we luckily got him into a children's hospital. so how are you addressing these things, especially with kids with very complex needs? >> well, i think that's where choice comes in. in this current marketplace, there's a lot of choice. you know, whether you want to choose a very broad network, or a very narrow network or something in between. and so it's important that consumers have the right information so they can make the best choice for their families to get the care they need. >> i have an answer to the question, this sounded like a case of a need for a very speedy appeals process to provide

access for very specialized care. to those providers who really are experienced in it. you know, in the various work identify do i've done over the years in health care markets, you know, one of the observations is that often the pediatric hospitals are by far the highest priced hospitals in the area. so the inclination to create a network without some of them i can fully understand that, but, you know, if you're going to do that, comes the obligation of providing access for those that cannot be served in the general academic medical centers that are in the network. >> i'd just add consumer education and involvement. >> and if i could just add to that, because often the departments of insurance, the commissioners, do get involved in these kind of cases. they work very closely with the insurance companies as well as with the consumers to try to make sure if it's determined to be insufficient, to just resolve

the issue instead of just saying, you got to cover everybody, let's deal with it situation-by-situation. that's why the grievance procedure is there. that's why there is regulation just to make sure everybody can resolve the issue, and it most often does. >> okay. if i can ask you to forebear for just a second, i wanted to follow up on something with a question on a card. and i should say that we have enough cards to carry us through tuesday of next week. so you might want to use the microphones if you absolutely positively have to get your question answered, or at least addressed. this one actually is also, excuse me, directed to you, brian. what's the naic position, if there is one, on mid-year network removals as we are seeing with the medicare advantage plans? and i want to come back to the medical advantage part. but what happens when you sign

up for a plan that has the physician you want, and then she or he drops out halfway through? >> our current model l deals with that by making sure everybody is changes. and then also makes sure if there is an issue of continuity of care, that is taken care of. it is something we're looking at. especially since e again, there's been a drastic change in the marketplace. i specially individual market. where we do have a policy and we really didn't have that before. so we are going year after year and looking at how that can be resolved if something needs to be done there. it is something we're looking at gibb the new environment. >> do you want to comment? there is a general industry practice for that kind of situation? >> you mentioned medicare advantage and their plans are unextraordinary pressures. the aca produced payments by

over 200 billion dollars for ten years in the plan. and the aca has added additional cost through the regulatory process. so plans have to find a way to provide value to consumers and some is by taking a closer look at the networks and to see if there are ways they can, you know, tailor their networks to provide more value to consumers. and a lot of discussion with administration to adequate for the consumers and we're working to the goal. >> i'm not sure how we get there but to the degree limited narrow networks are going to be an important part of the landscape for a long time we should start thinking about how to move the system so all network agreements between plans and providers conform to the plan so they were on a calendar year.

so this issue of provider dropping out of the network would be very limited to a provider that got out of practice or something like that. >> and i'll just add too, which i think is an important part of this debate there have been numerous studies that show tremendous price variation with little or no correlation to quality. and so that is something that we have to take a close look at and plans are trying to deal with that it saying let's focus on those providers that provide value, given the tremendous price variation in this country you can provide good quality service by finding the providers that provide valuable services, high quality services at a lower price. and that is the premise behind doing networks in a way that is focused on value. and if we don't, if we just open it up to everyone, including,

you know, we're stuck back in this fee-for-volume type system which we all agree we have to move away from. and this is one of the ways plans are helping move us towards a value-based system. >> okay. yes, sir, thank you. >> that was actually my tweet and you have answered my follow-up questions now. soo i'll just sit down. >> let the records show we respond to tweeted questions. yes, go right ahead. >> i'm with truevin health analytics. this question is for brian but anyone who feels like chiming in. brian, going back when you mentioned stepping in the pediatric champ when a network was determined to be inadequate. what other tools do you have at disposal when networks are determine to be inadequate? are there fines on plans that don't offer enough coverage? are there bans on them offering continuing to sell insurance in the state? or do they have to promise to get better and improve the

problem? >> it depend on the state and whether it is in the law or regulation as to the standards. they are going to file their plan at the beginning of the year when they are saying we want this plan. they will file their access plan. they will -- the state will look at that. if they don't approve it, then they will ask the company to refile it. so you have to get that proufd first. then if during the year there are a lot of grievances and issues, then of course the state as the regulator, can step in, can talk to the company, can ask them to make changes to fix issues. and then, you know, a market conduct review. eventually you could fine them, eventually you could withdraw the license. you have all those on your disposal. we are not going to get there on this kind of issue. but yeah, talk to the company and usually you can resolve it that way. but you are the regulator. you have said that company can sell that product. if they are not fulfilling their

access plan can they filed with you, then you can take action against them to fix it. >> thank you. >> bob? >> bob grisss with the institute of social medicine and community health. two issues i haven't heard addressed so far and yet they are trends in a sense in the healthcare marketplace. one is concierge medicine. how will this focus on network adequacy deal with doctors who want to collect a special fee just for the privilege of going them? secondarily, the subject of conscientious clauses, since we have a representative of the catholic hospital systems, when providers choose not to provide certain fda approved medical

services, what obligations does the health plan or provider have to ensure that that patient is able to get the medically necessary treatment they want? >> not sure that the provider has the sole responsibility here. there is a matter of disclosure up front about what providers are providing what services. and people do sign agreements and waivers. and i may be wrong on this and i'd be you aren't in dan's comment about this. but if your plan, presumably you have the responsibility for making sure that the services are available through one or another of the providers. >> it really depends on the state. there is just at lot of variation in state law in this particular issue.

>> i'll comment generally that, of course, being our mission base we would not provide deathically -- death ical -- ethically. we follow ethical religious directives. but as patients are wanting other services it is expected through the plan to get them the access they need. so it is determined at the plan level. >> how do you do that? let's say you are a hospital. in fact let's say you are the only hospital in a geographical area and a provider. and you decide that something is not consistent with your religious -- with the provider ears or owners religious believes. how does the patient get the medically necessary treatment? >> i can't comment on all. i can tell you in our markets we are not the sole provider, in our markets. >> and i don't want to belabor it. but we are getting a little bit

off the question of adequate networks at the plan level. and i want to make sure that we don't miss out on the opportunity to get to these questions. and that means calling on you at the moment. >> thank you. i'm with summit healthcare consulting and represent a number of provider organizations. thank you this has been a really terrific panel discussion. i'm kblad the topic of network adequacy has been brought up with respect to medicare advantage plans. because i think of the is same issues regarding transparence to patients about whose in their network at any given time due to mid year contract terminations at no cause are very concerning. and then whether subsequently there is adequate networks of providers. i'll add that senator brown and

congresswoman deloro have introduced legislation pertaining to those med year terminations. but on the top of the network adequacy, a question was raised what do you do in a network is inadequate. but what are the tools been used to ascertain whether or not a network is adequate? and mr. ginsberg you raised an important point at the beginning of this conversation. so i would welcome a response from either mr. durham or mr. web. but if a plan looks at its network and says we have 30 ophthalmologists in our network and they are looking at the specialty designation but not looking aing aing a at subspec. should they be doing a little

bit more of a deeper dive. if for example someone needs to see a retina specialist but that ophthalmologist doesn't provide a lot of retina services. should they be taking it down to the cpt level to find out? do we have, you know, an adequate number of retina specialists in our network to be caring for patients with very specific needs? so i think that is really important point. and you know i've heard of health plans using the geo access reports to help determine network adequacy. that doesn't go to the subspecialty level. so i'd welcome any thoughts that mr. web or mr. durham have or even mr. ginsberg on ascertaining whether truly there is network adequacy. >> let me say something quickly about the subspecialties and move onto the other questions. i would say, you know, we are on a learning process