Bill could add primary-care doctors to every health-insurance network

Bill could add primary-care doctors to every health-insurance network

By Ed Sealover (Jan 18, 2024) 

A top Colorado House leader has introduced a bill intended to allow state residents to maintain their primary-care providers even if they switch insurers — a proposal that insurance-industry leaders warn could carry significant costs with it.

House Bill 1005, sponsored by Democratic Reps. Chris deGruy Kennedy of Lakewood and David Ortiz of Centennial, would require all state-regulated health-insurance plans to include primary-care physicians who meet a set of newly created standards. Insurers who can’t agree with qualified providers on contracts would have to reimburse them at a rate determined by the Colorado Division of Insurance, according to the introduced bill.

Speaking Thursday to the Colorado Chamber of Commerce’s Health Care Council, deGruy Kennedy emphasized that he’s open to changes on a variety of aspects to the proposal, including backstop payment rates and the definition of primary-care providers. He said he’s not opposed to most narrow physician networks that insurers create to keep costs down through reimbursement negotiations, but he believes that primary care must be treated differently than specialty care because of its key role in improving public health, he said.

What bothers deGruy Kennedy, who has authored some of the most significant health-care bills of the past six years, is the churn he sees as people change jobs and insurers and then must find new primary-care providers with whom they haven’t built a relationship. Allowing residents to maintain their primary doctors could improve health, avert the more expensive costs of emergency care from conditions that could have been treated earlier and boost the spread of value-based healthcare, he said.

“I do think that there is something lost when you don’t have a longer-term relationship between the patient and the doctor,” deGruy Kennedy said. “If Colorado is a state where we change the way we do primary care, including making investments in primary care, I believe we can have a healthier population and a better health-care system.”

Insurers determine which doctors are in their networks through negotiations with practices that aim to produce a pool of primary-care providers that is big enough to treat customers without delay but that also is small enough where insurers can set limits on reimbursement rates. Requiring that they permit any qualified primary-care physician to be in their network not only takes control of network determination away from insurers who pay for the doctors’ services but gives far greater leverage in contract negotiations to physicians.

Under HB 1005, primary-care doctors would have to be included even in the narrowest networks if they are licensed to practice in Colorado, accredited by a national association of primary-care providers, credentialed to take Medicaid patients and enrolled in a value-based alternative-payment model. DeGruy Kennedy said he’s trying to determine through conversations with insurers how much this would expand typical networks but hasn’t been able to ascertain that yet.

Setting rates for primary-care doctors

The bill would require that the Colorado insurance commissioner contract with an actuary to determine a minimum reimbursement schedule for alternative payment models, and it requires reimbursement at rates that are at least 135% of Medicare payments. DeGruy Kennedy argued the bill must have teeth if insurers can’t agree on payment terms with physicians now outside their networks, though he acknowledged that serves as a stick for insurers even as providers are given more carrots and aren’t required to join networks.

It is that requirement in particular that’s led many health insurers to oppose the bill, arguing that it permits unprecedented government intervention into contract negotiations and destroys the makeup of networks that are a main way that insurers keep down costs. Removing insurers’ control over network makeups and reimbursements in turn could boost insurance-premium costs for Coloradans covered by small-group and individual insurance plans if the bill were to go into effect by 2027 as proposed, several officials said.

Dr. Grace Holub of OB/GYN Affiliates acknowledged that physicians need to be able to spend more time with their patients — a step that, like deGruy Kennedy’s goal of boosting value-based payment models, would improve general health. But Holub, whose practice offers primary-care services to patients who need them, said that as a small employer, she fears the cost impact of a bill that would expand networks so much, leading her to judge that the bill could make healthcare more unaffordable and offset its aims of boosting primary-care services.

“In an ideal world where money is not a factor, it’s great,” Holub said. “But it is going to be very expensive. And as a small business, providing medical coverage to my employees is very important to me.”

Bigger health-care changes

HB 1005 is one of several insurance-mandate bills introduced in the first eight days of the 2024 legislative session, including proposals to require greater fertility coverage, mandate coverage of weight-loss drugs and bar insurers from requiring patients with rare or chronic conditions from having to use only certain pharmacies. Many health-insurance leaders argued, though, that deGruy Kennedy’s effort would have the furthest-reaching effects.

Term-limited after this session, deGruy Kennedy, the House speaker pro tempore, acknowledged HB 1005 is not the request of a particular interest group but is his effort to leave what he believes would be long-lasting improvements on the state’s health system. He continues to negotiate with business groups, patient advocates and others, and he said he doesn’t plan to bring the bill up for a committee hearing before mid-February, so that he has time to consider various concerns and see how he can work them into the bill.

But it’s clear that his biggest obstacle will be convincing insurers, who have been subject to a host of new regulations in recent years, that HB 1005, isn’t just an attack on the networks they have worked to preserve, even as laws have set minimum levels of adequacy for them. And, according to several industry sources, that will be a difficult hurdle to clear.

Read more at TSSColorado.com

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