Managed Care - January 2009 - (Page 7)

LEGISLATION & REGULATION “I think all of those health plans in some form or fashion allow access to their networks by other payers,” he adds. “You may be a large employer in Ohio and have employees that travel or work in Michigan and Indiana, so they want to have their insurer or third-partyadministrator have a network of doctors in those states where the employees may be.” Transparency needed “We resolved that insurers could get as much downstream rental as they wanted as long as there was transparency,” Nolan said. “So a physician could see who had gained access to discounts, and affiliates and subsidiaries should be part of the scope. Physicians should be able to refuse the rate if they can’t tell who the contracting agents are. We felt the original contracting entity had to maintain a Web site or 800 number so doctors could find out who was granted access. “We really tried to develop a bill that balanced the need for the physicians to know what they’re going to be reimbursed for with the desire by insurers or contracting entities to be able to downstream that rental network to provide more access to folks to insurance plans,” adds Nolan. “The model we ended up with was our best attempt to provide that balance.” Maglione, who attended the latest round of negotiations hosted by NCOIL, observes that “we don’t object to a health plan leasing their network. But if they do it, they have to follow rules. They have to be more transparent about whom they lease their networks to. There also has to be an assurance that all terms and conditions apply to the plan that leased the network. The contract flows to the new entity.” That’s only fair, he adds. Doctors are trading discounts on their services for access to more patients as well as things like better payment terms. If someone leases the provider network a doctor is in, they have to provide the benefits — like fast payment terms, for example — as well. Individual doctors should also know about leasing arrangements so they can negotiate on that point with their insurers and perhaps gain better terms in return. The compromise bill, though, punted on the ERISA debate. State legislators, says Nolan, will have to make that decision and work out the legalities involved. Even without a resolution to the ERISA debate, reaching an agreement was no simple task, says Karen Greenrose, president and CEO of the American Association of Preferred Provider Organizations, which negotiated the compromise bill along with America’s Health Insurance Plans and other insurance representatives. “We really hit some stumbling blocks,” she notes. Originally, the physicians wanted a bill that would allow individual physicians the chance to opt out every time a new customer was added to the network agreement. Now the bill simply provides the kind of transparency the doctors have wanted, so that every time someone walks through their practice doors, they can find out which contract covers them. “I think it’s not everything you’d want from an industry perspective,” says Greenrose. “But perhaps it’s not everything the AMA wanted either. It’s something we can work with in each state individually, to make it more effective state by state.” Health plans should expect physicians to bring up the issue of silent PPOs, says Jeremy Lazarus, MD, an AMA trustee. ERISA One of those issues, she readily concedes, is likely to be the ERISA preemption. “ERISA preemption is a federal law that the states cannot ignore,” she says. “That’s what I keep going back to. Whether you like it or not, it’s there.” Any state that decides otherwise is going to have to factor in a likely legal challenge in a field with a long history of court decisions. “We’re going to work very hard to make sure that language is in every state law.” “Anthem can have its fully insured hat on and state law applies. But when they put on their third-party-administrator hat, some question if state laws can apply because of ERISA, even though they’re doing the exact same thing,” says Maglione. Says Lazarus: “If third party administrators are not covered [by the legislation], then 40 percent to 50 percent of a physician’s contracts aren’t covered. Doctors are going to have to be even more aware of what they’re signing.” MC JANUARY 2009 / MANAGED CARE 7

Table of Contents Feed for the Digital Edition of Managed Care - January 2009

Managed Care - January 2009 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor Health Care's Disruptive Innovations Q&A With Clayton Christensen 'Disruption' May Be Plans' Best Bet Avoid the PBM Rebate Trap HealthPartners Puts Diabetes on Notice Formulary Files Plan Watch Tomorrow's Medicine Ad Index Outlook Unmet Needs in the Management of Plaque Psoriasis Impact of RSV: Implications for Managed Care

Managed Care - January 2009

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