Following last week's highly circulated reports of the disconnect between Affordable Care Act requirements for women's health coverage and what is actually being offered by many insurers, the question now is whether the findings will have any real impact on the health insurance industry.
Two studies by the National Women's Law Center examined more than 100 health plans in 15 states, and reported that more than half of them violated coverage requirements for contraception, maternity care or other women's health services.
Those studies follow a similar one recently released by the Kaiser Family Foundation that examined plans from 20 carriers in five states, and reported that most of them limited certain forms of birth control in some way.
The question of impact boils down to three elements: the credence given to these findings; the issue of what constitutes appropriate medical management; and whether any action will be taken to influence the industry through more specific language or regulation.
Calling for action
The NWLC is among those now calling for action. "We don't need legislation," Sharon Levin, who runs the group's reproductive health policy program, told NPR. "We have that. We need better enforcement."
At the same time, however, at least one insurer group is challenging the findings and aiming to limit their impact.
America's Health Insurance Plans tells Healthcare Dive they have a number of concerns with the findings, which they call accusations without merit and with little context.
For one, the NWLC highlights what AHIP says are numerous "one-off" stories from the CoverHer hotline, which is supported by BayerHealthcare. However, the researchers did not indicate whether there was a methodology in tracking complaints and their resolutions. "As such there is very little context about the degree of the complaints (whether there was confusion about the benefits) or whether they were addressed between the plan and the patient," AHIP says.
Medical management concerns
AHIP also points toward the subject of appropriate medical management, now under vigorous debate throughout the industry.
"While the report acknowledges that federal guidance allows plans to use their medical management tools, the report goes on to condemn plans' efforts to provide access to affordable, effective treatments," AHIP writes. As an example, the report cites plans' imposing cost sharing on "certain covered services" but doesn't include any specifics about whether those treatments or services are provided by an in-network clinician or out-of-network provider, or use generic vs. brand-name medication.
AHIP says the report also fails to acknowledge the role that providers play in informing payers as to why a particular method of birth control may be more medically appropriate for a patient than another, so that the plan can ensure that patient gets access to the right medication and can follow the guidance of the law. "Insinuating that any use of medical management presents barriers to needed medical care ignores the fundamental cost and quality challenges that patients face," AHIP says.
Given that the success of the ACA relies heavily on health plans' efforts to keep coverage affordable, medical management is a necessity that can't be ignored, the group suggests. "That's why the ACA has made very clear where plans may rely on their medical management tools to deliver the best value to patients—whether that is providing access to more affordable generics and prescription drugs, providing access to providers with a track-record of delivering the most effective care, or promoting evidenced-based treatments for patients," the group argues.
As far as regulation of health plans, AHIP notes that qualified health plans must meet state and federal requirements on benefits and coverage to be sold in the marketplace. In addition, they point out, CMS will perform an outlier analysis on cost sharing as part of the QHP certification application process to ensure there is no discrimination in any benefit design. The NWLC reports do not factor in this approval, AHIP argues.
A call for clarification
In addition, consumer surveys appear to be at odds with the complaints noted in the reports. "The fact of the matter is that consumers are consistently reporting high levels of satisfaction with their coverage—see reports from the Commonwealth Fund, and J.D. Power," AHIP says. They suggest that if there was such widespread discrimination, we would not see consumers reporting such high marks for their coverage.
Finally, AHIP argues that the reports lack any examples of exorbitant prescription drugs costs or charges imposed by providers for medical services, and points toward the efforts of health plans in negotiating on behalf of patients to get them the care they need. "Focusing on insurance coverage without highlighting these serious cost challenges ignores the fact that the prices being charged for treatments and care remain the biggest barrier to patients' access to care," AHIP says.
The one clear issue to emerge from the controversy is the confusion over what constitutes appropriate medical management, as insurers seek to balance the ACA's calls for cost control as well as its mandates such as full coverage for all FDA-approved methods of birth control.
"We need better clarification" from the federal government, says the NWLC's Levin, and HHS may be in agreement. "We will continue to provide guidance to help ensure that women have access to recommended preventive benefits and will explore whether additional measures are necessary," spokeswoman Katie Hill told the media last week.