A basic premise of the insurance business is that denying patients access to low-value providers or services (for example, through establishing narrow networks or refusing payment for things that aren’t “medically necessary”) will save money. With respect to providers and limited networks, most of that discussion is predicated on the assumption that “low value” equals “high cost.”
On paper, this makes some sense. But in practice, it’s clear to those who have taken a closer look that there are a few more factors to consider. These factors become especially important in pediatrics, generally, and for children with special health needs, in particular. …Read More
Statistically speaking, sick children need more of everything than the average sick adult: more nursing care and support services, a wider range of smaller sizes in specialized equipment (because they grow) and “customized” medication dosages to adjust for their size. Children also respond differently than adults in a medical crisis and need experts trained to help them.
All these needs increase exponentially when we’re talking about children with special health care challenges.
Despite these distinctions, children and their families are often forced to make do with hospitals, systems and products not principally designed with their needs in mind—and health plans are no different. Stripped-down, “high-deductible” plans that are designed for adults (nearly all of them)—and plans with limited networks—are simply not created for children. …Read More
Narrow networks—health insurance plans that sharply limit the providers a patient can see—have been winning the popularity contest among consumers, especially on the Affordable Care Act’s (ACA) insurance exchanges. Limited choices can equal cheaper premiums, which is why about 70 percent of plans sold on the exchanges last year featured a limited network, with premiums that were up to 17 percent cheaper than less restrictive plans (according to McKinsey & Company).
A telling new study examining physician networks for plans sold on the ACA’s online insurance exchanges revealed that 11 percent of plans are “extra small,” covering fewer than 10 percent of physicians in a plan’s region. Another 30 percent were “small,” covering between 10 and 25 percent of physicians. Just 11 percent earned “extra large” status by covering at least 60 percent of physicians in the area.
While limiting consumer choice in order to control costs rightly continues to be a hot-button topic, there’s a piece of the conversation that’s rarely voiced: how this affects children, and in particular, children who are extremely sick and require specialized care. …Read More