Am J Manag Care. 2021;27(3):In Press
The coronavirus illness 2019 pandemic may have 3 essential results on supplier networks and their regulation: enrollment adjustments, adjustments to the supplier panorama, and adjustments to care supply.
- Plans might want to regulate their community dimension to accommodate elevated enrollment or elevated utilization attributable to forgone care.
- Regulators may even require up to date monitoring information and plan community information that mirror postpandemic supplier availability.
- Telehealth may have a bigger position in care supply than within the prepandemic interval, and regulators might want to adapt community requirements to accommodate in-person and digital care supply.
In public medical insurance applications, regulators use community adequacy requirements to make sure that well being plans present enrollees with ample entry to care. Requirements are based mostly on supplier availability, anticipated enrollment, and patterns of care supply, all of that are affected by the continuing coronavirus illness 2019 (COVID-19) pandemic. COVID-19 impacts how people in public medical insurance applications entry, pay for, and make the most of well being care past the pandemic. Regulators may have to switch community adequacy requirements and monitoring processes to make sure beneficiary entry on this altering well being care panorama, notably in gentle of prior work exhibiting that many plans have slim networks1-3 and that community design impacts beneficiary entry to care.4-8 We offer an outline of federal and state community adequacy requirements and focus on how regulators could adapt these requirements and accompanying monitoring processes in response to COVID-19.
Overview of Community Adequacy Requirements
Community adequacy may be measured in a number of methods: the variety of suppliers contracted by a well being plan for a set of essential specialties, supplier capability (eg, variety of beds, wait occasions to see a supplier), and/or geographic protection of the community (eg, most journey time/distance to a supplier). Inside this framework, regulators have developed community adequacy requirements to observe supplier networks for Medicaid managed care, certified well being plans (ie, trade or Market plans), and Medicare Benefit (MA) plans.
The 2016 Medicaid Managed Care Last Rule required that states suggest time/distance requirements for a minimal set of supplier specialties.9 Moreover, a number of states embrace quantitative measures of supplier capability, reminiscent of appointment availability and wait occasions.
States are tasked with main oversight of community adequacy for certified well being plans.10 Though just a few states, reminiscent of Colorado,11 Delaware,12 Idaho,13 and South Dakota,14 have established quantitative community adequacy requirements for certified well being plans, many states merely depend on their standards for business well being plans. Standards range by state, however typical business standards embrace a subset of requirements for supplier and facility specialties, minimal variety of suppliers, geographic entry requirements, and appointment wait occasions.
MA community adequacy standards comprise essentially the most complete set of requirements in contrast with these for state Medicaid or certified well being plans. CMS measures (1) the minimal variety of suppliers required in a county based mostly on the penetration of MA plans in counties with related inhabitants and density and (2) a enough variety of suppliers to make sure that no less than a specified share of beneficiaries have entry to no less than 1 of every supplier and facility sort inside a most time/distance traveled based mostly on the urbanicity of the market. Traditionally, plans have been required to cowl 90% of beneficiaries for these 2 requirements.
As a part of the ultimate rule revealed June 2, 2020, making technical adjustments to the MA program, CMS lowered to 85% the proportion of beneficiaries in nonurban counties that ought to have entry to a supplier throughout the most time/distance.15 Additional, MA plans are eligible for a 10-percentage-point credit score towards the proportion of beneficiaries residing inside required time/distance requirements after they contract with chosen telehealth suppliers. The next supplier specialties are amongst those who MA plans can contract with for telehealth companies and procure a credit score towards their community dedication: dermatology, psychiatry, cardiology, otolaryngology, neurology, ophthalmology, allergy and immunology, nephrology, main care, gynecology/obstetrics, endocrinology, and infectious illnesses. Lastly, MA plans are eligible for a further 10-percentage-point credit score for every facility sort or medical specialty included in MA community adequacy standards that’s topic to state-level Certificates of Want necessities (Determine15).
Results of COVID-19 on Creating and Monitoring Supplier Networks
We have now recognized 3 main concerns for monitoring supplier networks in response to the COVID-19 pandemic: (1) insurer and regulator concerns for enrollment surges, (2) the altering panorama of obtainable suppliers because of COVID-19, and (3) how COVID-19 has systemically modified the supply of well being care.
Enrollment surges. The financial downturn from COVID-19 will enhance enrollment in essential public medical insurance applications. When people lose employer-sponsored insurance coverage, they could select to enroll in a certified well being plan or, in the event that they meet the eligibility standards, they could enroll in Medicaid protection. Financial downturns additionally enhance the variety of people who apply for and obtain Social Safety Incapacity Insurance coverage (SSDI).16,17 After 24 months of eligibility for SSDI, people could enroll in Medicare protection. Will increase in enrollment would require plans to extend the breadth of their supplier networks or enhance the capability of their current networks. Job loss–pushed enrollment will increase in Medicaid, certified well being plans, and ultimately MA plans will imply that public payers can not depend on historic enrollment projections to find out the minimal variety of suppliers. Coverage makers might want to guarantee that their current minimal supplier thresholds guarantee enough capability for elevated enrollment or replace these thresholds to safe ample entry to care for extra enrollees. In cases wherein it’s not possible to rapidly change minimal quantity requirements, regulators could depend on elevated monitoring actions, reminiscent of “secret shopper” calls to observe wait occasions.
Adjustments to supplier panorama. To gradual the unfold of COVID-19, localities issued emergency public well being orders, together with bodily distancing guidelines and prohibitions on elective procedures. Moreover, many people selected to forgo medical care to scale back their danger of publicity to COVID-19.18
Many outpatient practices quickly closed in response to COVID-19; some could shut completely as a result of monetary pressure, and others could also be bought by a bigger group.19,20 Small and rural hospitals, which had been already financially weak earlier than COVID-19, may shut.21,22 It will change the quantity and site of suppliers and hospitals accessible to take part in supplier networks. Follow acquisitions may consolidate negotiating energy amongst a extra restricted variety of supplier practices. Insurers and regulators might want to be certain that shuttered practices and hospitals are usually not included in supplier directories or submitted to regulators in plan oversight supplies (such because the MA Well being Service Supply [HSD] tables).23
Regulators usually examine contracted networks of suppliers to the panorama of suppliers serving a market.23 Regulators might want to replace their information information documenting supplier availability to seize put up–COVID-19 adjustments. Knowledge lag for information reminiscent of Doctor Examine and the Nationwide Plan and Supplier Enumeration System (NPPES) signifies that these information sources will probably be an inaccurate supply of supplier workplace location data put up pandemic. Though plans are anticipated to take care of present supplier listing and community data, audits present that plan information are sometimes inaccurate.24 Because of this, claims information from after the pandemic would be the most correct and well timed supply of supplier follow location data. Claims information from the interval previous to the pandemic can present a dependable supply of details about supplier specialties. Counting on information from the peak of the pandemic, which is able to mirror disruptions in supply patterns, together with quickly closed practices and first care or office-based specialists quickly serving within the inpatient setting, might result in insufficient or much less accessible networks, or inaccurate assumptions about supplier companies and places.
Adjustments to care supply. In response to the COVID-19 pandemic, suppliers have transitioned to delivering many nonemergency/outpatient bodily and psychological well being visits by means of telehealth.25 From the week of March 2, 2020, to the week of April 13, 2020, telehealth utilization for Medicare enrollees elevated by greater than 11,000%, from 11,000 beneficiaries to greater than 1.3 million beneficiaries receiving care by means of telehealth.26 Insurers have supported this transition by quickly transferring to extend reimbursement for telehealth companies and by loosening cost guidelines for the kinds of care that may be delivered by way of telehealth.27,28 States have additionally loosened licensing legal guidelines, e-prescribing legal guidelines, and written consent legal guidelines to permit well being professionals to ship further companies by means of telehealth.29 It’s unlikely that telehealth utilization will return to pre–COVID-19 ranges, and plans are more likely to search a higher position for telehealth of their networks.30 Plans could desire to partially substitute in-person care with telehealth visits and slim in-person networks accordingly. To take care of beneficiary entry, coverage makers might want to be certain that networks retain enough capability by means of each telehealth and in-person visits. The federal authorities and states could think about making everlasting the short-term waivers that enabled broader care supply by means of telehealth.27 Within the June 2020 closing rule,15 CMS loosened in-person community requirements for MA plans that supply telehealth. State regulators could need to comply with an analogous strategy for Medicaid managed care and certified well being plans.
Many people forwent care throughout the preliminary months of the pandemic.18,31,32 Because the pandemic subsides, the elective surgical procedures, screening procedures, and routine care that people delay throughout the pandemic will resume. There may be a rise in utilization because of problems from forgone take care of power circumstances. Slim networks with restricted supplier capability could also be inadequate to deal with the surge in enrollee demand for care. As described earlier, regulators may have to extend minimal quantity necessities or enhance monitoring.
COVID-19 has dramatically modified well being care supply and can affect entry to, and utilization of, well being care companies past the pandemic. Regulators that oversee supplier networks for public insurance policy could have to take a extra lively position in adapting and utilizing community adequacy monitoring instruments for the subsequent a number of years.
Writer Affiliations: Division of Well being Coverage and Administration, Johns Hopkins Bloomberg College of Public Well being (KEA), Baltimore, MD; The Lewin Group (LRS, KD), Falls Church, VA.
Supply of Funding: This work was supported partially by grant quantity T32HS000029 from the Company for Healthcare Analysis and High quality. The content material is solely the duty of the authors and doesn’t essentially signify the official views of the Company for Healthcare Analysis and High quality.
Writer Disclosures: As a former worker of The Lewin Group, Ms Anderson carried out contract analysis for CMS on supplier community adequacy requirements. As workers of The Lewin Group, Dr Shugarman and Ms Davenport conduct contract analysis for CMS on supplier community adequacy requirements.
Authorship Data: Idea and design (KEA, LRS, KD); evaluation and interpretation of information (KEA); drafting of the manuscript (KEA, LRS, KD); essential revision of the manuscript for essential mental content material (KEA, LRS, KD); administrative, technical, or logistic assist (LRS).
Handle Correspondence to: Kelly E. Anderson, MPP, Division of Well being Coverage and Administration, Johns Hopkins Bloomberg College of Public Well being, 624 N Broadway, Rm 428, Baltimore, MD 21205. E-mail: firstname.lastname@example.org.
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