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Struggle Over HIX Provider Networks Will Get Rough

Christopher Cheney, for HealthLeaders Media, February 12, 2014

A hospital CEO in rural New Hampshire told me last month that his service pricing was not a factor when the only player in the Granite State's public exchange decided to leave his facility out of its provider network. With costs outstripping revenue by 40 percent, he said any income from commercially insured patients is better than no income, adding the hospital would have accepted almost any offer to participate in the public exchange.

CMS Steps into the Fray
With the battleground set, CMS threw down the gauntlet last week and released proposed guidelines for the public exchanges for 2015.

"CMS is working to strengthen the network adequacy requirements that took effect for this year for the first time under the Affordable Care Act," a CMS spokesperson told me last week. "These are important provisions and include requirements that insurers have adequate provider networks for consumers, including access to essential community providers that serve low-income, medically underserved individuals."

In the struggle ahead, insurers will face a formidable adversary in the physician community, which is showing growing determination to fight over crucial points in the healthcare reform debate.

"Healthcare delivery has changed to a business," Ferguson told me. "We need to get back to being a profession."


Christopher Cheney is health plans editor at HealthLeaders Media.
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