CMS Successful in Advocacy

When frustrated physicians heard from their patients that the state’s largest health insurance company—Blue Cross and Blue Shield of Illinois—was restricting doctor choices by ending a popular statewide PPO plan, your Chicago Medical Society set in motion a plan to help. And after a year of debate with legislators in a deeply divided political climate in Springfield, physicians can lay claim to bipartisan legislative achievement following the Illinois legislature’s passage of the Network Adequacy and Transparency Act (NAT Act). The bill, expected to soon be signed into law by Gov. Bruce Rauner, comes after a year of collaboration and cooperation on advocacy from physicians to help their patients have adequate provider choices.

But the NAT Act is perhaps more so a victory for physicians as new models from government and private insurers attempt to take not only control of provider networks that limit choices, but threaten physician compensation and the practice of medicine. When private insurers gain more control of your patients’ benefits, that means the likelihood is greater that performance measures will increase and there is potential for winners and losers among physicians. As one example, physicians should be leery of Medicare Advantage because it hands off administration of benefits for seniors to private insurers that control choice of providers and how physician compensation will be measured against quality, health outcomes and performance measures.

Through advocacy on issues like network adequacy, we at CMS are helping physicians because insurers are setting up tiers in their networks based on quality and performance data. The NAT Act ensures, among other things, adequate lists of physicians so patients know who is in the network and who is not. Often directories are unreliable so the NAT Act helps protect patients from charges that are incurred if the insurer claims the provider isn’t in-network and the patient is hit with a higher charge. The legislation helps give the patient better information.

Already, we know that insurance companies that have survived losses and remain on public marketplaces under the Affordable Care Act have done so by restricting patient choice as Illinois Blue Cross has done with a more restrictive plan that has replaced the PPO. In some cases, these plans say they will remain offered under the ACA because they’ve scaled back choice of PPOs in favor of narrow network plans like HMOs and exclusive provider organizations, or “EPOs.” And this narrow network strategy is also poised to gain momentum beyond states and commercial insurance under ACA and into Medicare. Nationally, there is more talk of privatizing Medicare under the Republican-led Congress and that will put even more provider networks at risk for change.

All of this means our work at CMS is only beginning. But what started with physicians bringing the Illinois Blue Cross PPO issue to our attention shouldn’t end there. We found success.

We will continue to advocate in Springfield and Washington for provisions and legislation that protect patients and their physicians. At the end of the day, it’s about the outcomes and providing the best care. Please share your thoughts so we can pursue these shared goals and better represent you.