Narrowing Networks. Are You In or Out? Brett Coldiron, MD, FAAD President, American Academy of Dermatology Association

Transcription

1 Narrowing Networks Are You In or Out? Brett Coldiron, MD, FAAD President, American Academy of Dermatology Association

2 Background The Affordable Care Act Cut Medicare Advantage payments from 114% of Medicare to 104% Humana Medicare Advantage began limited terminations two years ago and throughout 2013 and 2014 Humana and UnitedHealthcare Medicare Advantage began narrowing their networks throughout the country AADA is primarily concerned about Patient Access No new enrollment in some plans including Indiana, Mississippi, and New York 2

3 How Narrow Networks Impact Patient Access Appointment Wait Times Mid-Year Terminations Provider Directory Accuracy Criteria Used to Terminate Physician Termination Appeal Process 3

4 Inadequate Access to Care Ongoing physician terminations jeopardizes patients access to an adequate network AADA evaluated five UnitedHealthcare Medicare Advantage networks to determine wait time Hartford, CT Boca Raton, FL St. Louis, MO Cincinnati, OH Providence, RI Survey Date Approx. 4-Jun-14 4-Jun-14 9-Jul-14 4-Jun-14 4-Jun-14 Mole Wait Time (Weeks) Rash Wait Time (Weeks)

5 Merritt Hawkins Study Specialty Wait Times Average Wait Time (Days) Average Wait Time by Specialty Year Cardiology Dermatology Ob-Gyn Orthopedic Surgery 5

6 Merritt Hawkins Study Dermatology Wait Times Average Wait In Days by City (including Saturday and Sunday) Boston, MA Minneapolis, MN Philadelphia, PA Denver, CO Seattle, WA Portland, OR New York, NY Detroit, MI Houston, TX Dallas, TX Washington, DC Miami, FL Atlanta, GA Los Angeles, CA San Diego, CA Average Wait Time 28.8 Days 9 of the 15 cities have waittimes in excess of 3 weeks Increase in wait time since 2009 survey No Change, or decrease since 2009 survey 6

7 Inaccurate and Misleading Directories Hartford, CT Boca Raton, FL St. Louis, MO Cincinnati, OH Providence, RI Survey Date Approx. 18-Dec Dec-13 9-July Dec Dec-13 Dermatologists Listed in Network Unique Dermatologists Mid-Level Staff Unavailable Listings (Deceased, No New Patients, Incorrect Listing, etc.) Available Dermatologists Unavailable or Duplicate Listings 39% 54% 46% 69% 65% 7

8 Inaccurate and Misleading Directories (Continued) 8

9 UnitedHealthcare Appeal Process Physicians report to AADA that appeal hearings are restricted to one question: Did UnitedHealthcare act in accordance with provisions in contract? 9

10 Our Appeal Asks Ideal termination appeal process would: Provide meaningful appeal process Disclose criteria evaluated to determine network status Give sufficient notification to providers and patients to transition care 10

11 Practice Profiling Impact on Sub-Specialties Wrong Comparison Group Severity Adjustment Cost Dilution Episode of Care Analysis 11

12 WHAT AADA IS DOING FOR YOU 12

13 Overview of AADA Actions and Meetings Met with UnitedHealthcare on November 22, 2013 to discuss initial concerns Conducted network directory study in four markets to assess accuracy of rosters calls competed by January 15, 2014 Met with White House and Members of Congress on February 3, 2014 Wrote letter to CMS on April 2, 2014 to summarize findings and express ongoing concerns Provided feedback and assisted in the drafting of legislation the Medicare Advantage Participant Bill Of Rights Act (HR 4998/S 2552) October 10,

14 Overview of AADA Actions and Meetings (continued) Conducted wait time study in same four markets to determine wait times for two different dermatologic emergencies Met with CMS on June 6, 2014 to discuss findings and concerns Conducted wait time study in St. Louis market after terminations were announced on June 15, 2014 calls completed July 8, 2014 Met with UnitedHealthcare to express ongoing concerns on August 29,

15 AADA Resources Step-by-Step Appeal Guide 15

16 Dermatology World How to Fight a Termination Notice 16

17 SKIN CANCER EPIDEMIC 17

18 Increase in NMSC diagnosis 4.0 NMSC Diagnosis (in Millions) NMSC Cases Source: No end in sight, the skin cancer epidemic continues, Donaldson M, Coldiron, B. Seminars Cutan med surg 2011, March 30:3-5. Medicare data for showed that the number of procedures used to treat NMSCs in the Medicare population increased by 16.0% during that period 18

19 Treatment Cost of Skin Cancer Treatment in U.S. Cost of Skin Cancer Per Year (in Billions) Melanoma $3.3 NMSC $4.8 Excludes: Lost productivity due to treatment ($106.2 M) Lost productivity due to early death ($4.5 B) Cost of topical treatments (Unknown) Source: Centers for Disease Control and Prevention 19

20 Who Treats Melanoma? Melanoma Visits (%) 60% 50% 40% 30% 20% 10% 0% Melanoma Treatment Trend (By Specialty) Year Dermatology Plastic and General Surgery Internal and Family Medicine Other Specialties Dermatologists have responded to the epidemic Experts at diagnosis and surgical treatment of most melanoma Source: Ambulatory Melanoma Care Patterns in the United States; Ji, Andrew L., Baze, Michael R., Davis, Scott A., Feldman, Steven R., Fleischer, Alan B., Journal of Skin Cancer, 2013 July. 20

21 Melanoma Third most common cancer in adolescents and young adults (ages years) More than 63,000 people diagnosed per year between Fifth most common cancer in men (25.4 cases per 100,000) Seventh most common cancer for women (15.7 per 100,000) Found on parts of skin that get more intermittent, high frequency exposure to UV radiation (torso and legs) Nearly 9,000 deaths each year Adults 65 or older, melanoma treatment costs total about $249 million annually. About 40% annual spend for melanoma is treating stage IV cancers - only 3% of melanomas. 44% of Melanomas occur in age groups over 65 Source: National Cancer Institute 21

22 NARROW NETWORKS 22

23 Impact of Access on Cost Primary Care Physician Treats Patient Notes Possible Skin Cancer a Medical Emergency Refers Patient to in-network Dermatologist Dermatologist Patient requests appointment Wait Time is 5 Weeks General Surgeon Wait Time under one week Performs Biopsy and Excision in outpatient surgery Care through General Surgeon increases costs up to $4,000 or more 23

24 Public Press on Wait Times 24

25 Delay in Care Could Prove Fatal LAWYER: VA DELAY KILLED WASHINGTON STATE MAN By GENE JOHNSON May. 21, :27 PM EDT SEATTLE (AP) Donald Douglass had a small spot on his forehead when he went to the Seattle Veterans Affairs hospital in A biopsy confirmed it was cancerous. But it was four months before he was able to schedule an appointment to have it removed and by then, it had spread, wrapping around a facial nerve and eventually getting into his blood. The delay proved fatal, his lawyer said and it mirrors concerns being raised about the VA system nationally. "There was no reason for this procedure to be delayed," said the attorney, Jessica Holman of Tacoma. "Had he had his surgery timely, he'd be alive today." 25

26 Blocking Access to Care Will save money short term but result in bigger cancers and more deaths (more expensive) in long term. Medicare advantage patients are a long term proposition. Only a matter of time until there is a disaster. Metastatic Melanoma now treatable disease, at $150,000 per year Better to catch early 26

27 HOW TO GET THE MESSAGE OUT 27

28 Engage Local Media UnitedHealthcare drops more doctors June 19, 2014 Casey Nolen, KSDK ST. LOUIS - One of the largest insurance companies in the country is dropping some St. Louis area specialists from its coverage. And, that could leave seniors looking for new doctors.. UnitedHealthcare cuts Missouri physicians from Medicare Advantage June 18, :27 pm By Tara Kulash UnitedHealthcare has notified more physicians in Missouri that they will be removed from the company s Medicare Advantage plan on Sept

29 Engage Stakeholders Activate Letter Writing Campaign Contact Member of Congress Who: Patients who lose access to their physician through termination How: AADA Sample Letter What: Urge key decision makers to restore access Who: Physicians at AADA Legislative Conference Physicians through in-district meetings What: Ask Members of Congress to co-sponsor the Medicare Advantage Patient Bill of Rights Act (HR 4998 or S 2552) 29

30 Letter Writing Campaign CMS needs to hear from affected patients that Narrowed Networks negatively impact quality of life, and that they can t get appointments for months. Members of Congress needs to demand CMS investigate adequacy of Medicare Advantage network UnitedHealthcare and Humana need to hear from concerned patients that termination impedes access to and continuity of quality care 30

31 Where to Write Centers for Medicare and Medicaid Services (CMS) Medicare Beneficiary Contact Center Attn: Plan Complaints PO Box 39 Lawrence, KS Send a copy to: Members of Congress State Insurance Commissioner Your physician Insurance Company CSD Organization AADA 31

32 Key Talking Points for Hill & District Visits Transparency: Patients should be provided reasonable and adequate notice if their physician is being terminated from a plan prior to Open Enrollment periods. Fair Appeals Process: Physicians should be provided a fair, meaningful, and timely appeal whenever a physician is terminated from a network, regardless of how the plan characterizes the termination. Appeal process should consider whether the removal of the physician from the network would result in network inadequacy. 32

33 Key Talking Points for Hill and District Visits Access to Care: Physicians rosters given to patients should be accurate and updated monthly. Insurer should ensure that physicians on list see new patients. Insurers should demonstrate that their physician roster is adequate by geographic region on provider availability and provider subspecialty. No one should have to wait more than 30 days to see a dermatologist. 33

34 Contact Information Brett Coldiron, MD, FAAD President Leslie Stein Lloyd Director Regulatory and Payment Policy David W. Brewster Assistant Director Practice Advocacy Direct: Direct: October 10,