A Tale of Two Letters (Part 2 of 2): AMA Challenges CMS on Federal HIE Standards

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Editor’s Note: In the second half of March, the Centers for Medicaid and Medicare Services received two letters from influential voices in healthcare directly challenging recently proposed or enacted measures. The first challenge from the American Hospital Association regarding a new patient-experience survey was discussed in our last post. The second challenge from the American Medical Association on federal HIE standards is detailed below.


Although the goals of healthcare reform are grand and admirable, few thought achieving these goals would be easy or orderly. Instead, the roll-out of healthcare reform continues to be messy and at times, confusing, especially in relation to the federally operated health insurance exchanges (HIEs).

Case in point: On March 15, the American Medical Association served up a letter challenging the government’s standards for these HIEs. The standards were originally designed to make sure “that consumers have access to sufficient networks of healthcare professionals on federally operated health insurance exchanges,” Jennifer Lubell of American Medical News reports.

In the letter to CMS Acting Administrator Marilyn Tavenner, James L. Madara, M.D., AMA executive vice president and CEO, said the current standards are actually “too vague,” rendering them inadequate to help consumers and insurance regulators make “informed decisions on whether a plan’s network has an adequate supply of primary-care and specialty physicians.” Furthermore, he added, these standards make “it difficult to gauge whether the qualified plans are meeting [final federal regulations].”

Lubell writes, “Dr. Madara was responding to guidance CMS issued March 1 to insurance companies that will be offering qualified health plans in federally facilitated or partnership health insurance exchanges. These are the companies CMS will be working with, as both the federal and partnership models involve a central administrative role for the federal government. States pursuing partnership exchanges will retain some traditional state insurance roles while receiving federal structural and financial support to run the marketplaces.”

Dr. Madera believes that consumers and regulators “need meaningful measures of network adequacy covering all aspects of the network, including emergency and other hospital-based physicians, taking into account any tiering or other network restrictions.” Without major revisions to the current standards for HIEs, the AMA fears consumers “will end up getting driven out of the system” because poorly staffed networks will prevent consumers from seeking out “preventive services or…needed medical care.” This would be counterproductive, of course, because the health-insurance plans would once again end up “with the least risky patients.”

Lubell writes that the AMA believes health insurance benefits should be available to consumers “‘at the preferred, in-network rate on a timely and geographically accessible basis.’ Insurance regulators and consumers also should have access to certain pieces of information to determine the adequacy of qualified health plans’ networks. An example of this are the requirements health plans must meet for network quality assurance processes, or ‘definitions to ensure that the adequacy of the entire provider network is evaluated.’”

Consumers and regulators, the AMA continues, should also be provided with “objective data on critical-access measures, such as the number of visits made to out-of-network healthcare professionals per 1,000 enrollees, or what percentage of services from in-network physicians and other professionals are making up the percentage of total services enrollees received.”

The AMA states its model for network adequacy should be adopted by the government if it expects HIEs to ever achieve any level of efficiency for the consumer.

As healthcare executives, what are your thoughts on the AMA’s letter to CMS? Do you agree with their take on federal HIE standards? How will HIEs affect your organization, especially if the government isn’t being clear on what constitutes an adequate network?

-by Pete Fernbaugh

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