Centene is facing a lawsuit that its networks are too narrow and that not all of the docs that it says are in network actually accept their Ambetter individual market insurance.
Centene’s Coordinated Care subsidiary faced a fine and regulatory action by Washington State regulators in December. They failed to have an adequate network.
Coordinated Care Corp. has agreed to a consent order detailing steps it must take to fix its provider network deficiencies and other ongoing issues. The company was fined $1.5 million with $1 million suspended, pending no further violations over the next two years…
In particular, Coordinated Care admitted to not having enough anesthesiologists in King, Snohomish, Pierce and Spokane counties. According to the company’s own data, its provider network is also seriously deficient in other categories of providers, including immunology, dermatology, and rheumatology. [my emphasis]
The ROAD specialties are Radiology, ophthalmology, anesthesiology and dermatology. These specialties tend to be high cost and comparatively speaking conducive to good work-life balance for the docs. Centene’s own data shows an issue with two of these specialties. There are two stories that can be told.
The company friendly story is that they are trying to recruit for these specialties and at some point they had an adequate network but someone had the nerve to die or retire on them. Every network manager had that happen to them at least once. They’re trying and if someone really needs a dermatologist, an out of network service will be authorized for in-network cost sharing. That is their story to tell.
The other story is a bit more cynical. We know that Centene’s business strategy in multiple insurer regions is built on cherry picking the healthiest chunk of the population by offering very low cost, narrow network products and spamming the Silver subsidy point. This strategy leads to very large risk adjustment outflows as comparatively few people with high cost or complex medical needs sticks with Centene. They are explicit about this strategy by their pricing, their networks and benefit designs.
The more cynical story is that the lack of ROAD specialists is part and parcel with this story. Dermatology, rheumatology and immunology are specialties that are capable of generating large claims for both the specialist and then follow-up inpatient and pharmaceutical claims. If there are either no one in those specialties or if those specialties can only be accessed after the patient fills in fourteen forms in triplicate in Number 7 pencil, those claims can be averted as the patients who need those types of providers will have decided that the hassle is not worth it. Instead, those patients with their higher than typical risk scores are covered by someone else and Centene pays some risk adjustment money out to partially compensate for the risk transfer.
That is the story that the plaintiffs will try to tell.
rikyrah
Hope that the plaintiffs win
Crusty Dem
Hmmm. Here in NC there are plenty of derms available on our network and you have free reign to schedule appointments with them at their earliest availability in mid- to late-2019. I thought this was just becoming standard.
Proudgradofcatladyacademy
And these games being played is what makes people hate insurance companies. Maaaybee there was a targeted virus that triggered a retirement mutant gene only in immunologists in that network, but maybe Centene is just being manipulative jerks.
What color is my cynical pen again because I need to coordinate an outfit after I am colored with it.
Mary G
An HMO once sent me to a specialist who didn’t exist. The address they gave me was the driveway for an apartment complex.
WereBear
The thing that annoyed me the most about my out-of-network experience is that they TOLD me to go ahead and set everything up, and only after it was all over did they shrug and say they didn’t have to cover any of it.
I don’t know if I could have juggled anything differently, but at least I would have planned differently.
Typical Trumpian business style; pretend you are providing something, then keep the money.
?BillinGlendaleCA
@Proudgradofcatladyacademy: If they keep at it, folk will warm to single payer, I’m getting there myself.
Caracal
I really like reading you posts. Healthcare is hard, I learn something new every time! I like that. Sometimes I get discouraged and think we need single payer to stop all the bad-actor shenanigans. But I realize single payer has it own issues too (sigh). Please keep writing these, I’ll keep reading them :-)
WereBear
@Caracal: I think however we do it, the idea that health care needs to make oodles of money is the real, core, problem. That’s more of the “privatization” scam that took us down a lot of bad roads.
Government does such things far far better than private enterprise; you have people running it who are secure in their jobs and get benefits, and profit does not lead to the kind of abuses that are so common now.
ThresherK
@WereBear:
Pun intended?
Feathers
Question: I understand the other two, but why is dermatology a budget buster? Very short answer OK. Just curious.
David Anderson
@Feathers: The prescription drugs that Derms prescribe can be very expensive very quickly
Proudgradofcatladyacademy
@WereBear:
In my experience, because the insurance company has to negotiate the cost shaing and rate for OON doctor they are letting you see at INN rates or close to INN rates, a pre authorization number is generated and required to be on all subsquent claims. It also helps to have that number in case the insurance company “reneges” on their agreement for when you need to file a complaint with the Department of Insurance after exhausting your appeals.
Not helpful now or maybe you did that and they still said SOL, but it might help in the future.
ThresherK
@David Anderson: Spousal Ms ThresherK’s Humira is a good example.
WereBear
@ThresherK: Must be… I don’t get it :)
Feathers
@David Anderson: as I walked into work, I remembered my Dad’s psoriasis and went, duh. And those people undoubtedly chose plans with care. My Dad was in several medical studies when I was growing up. He was a federal employee, so access wasn’t even a concern. He also got the time off to go to Bethesda or NIH. Incredible privilege to have grown up barely noticing that.
sheila in nc
@WereBear: Humira is a good example. It’s an anti-TNF monoclonal antibody (mab)-type medication that is targeted at a wide range of autoimmune diseases. I took it for several years for Crohn’s but I’ve also seen it advertised a lot for rheumatoid arthritis. I believe that my dosage cost BCBS multiple thousands of dollars per month and would have been more if I weren’t on the federal employees’ health plan. The mabs are a really powerful, targeted class of drugs which are being used more and more widely in medicine, with a lot of clinical success, but they are horrendously expensive.
WhatsMyNym
I looked at their original network in my county and had a good laugh. It was basically “a we’ll take your money now and get used to driving when you want a Dr on our Network”.
Stan Dorn
How do risk-adjustment payments factor into this strategy? My impression is that carriers make a lot of money enrolling people with chronic conditions, like diabetes, that are fully compensated through CCIIO’s risk-adjustment methodology. Some research suggests that risk adjustment undercompensates carriers for members who do not suffer from conditions included on the so-called “Hierarchical Condition Category” list. If so, why would Centene benefit financially from deterring enrollment by people with chronic conditions?
Of course, deterring claims by creating hassles is an age-old strategy. See “Health care rationing through inconvenience,” http://www.nejm.org/doi/full/10.1056/NEJM198908313210909