UnitedHealthcare has been in the habit of making Medicare open enrollment interesting in Tampa Bay. In an effort to make its sprawling Medicare Advantage provider network more cost efficient and controllable, UnitedHealth slashed hospitals and physicians from its AARP Medicare Complete plans for 2014. The move has happened in markets throughout the nation but is attracting a lot of attention on the west coast of Florida, where UnitedHealth is the largest insurer. UnitedHealth will no longer offer in-network coverage at the venerable H. Lee Moffitt Cancer Center, and hundreds of physicians from Tampa Bay to Naples were taken off the MA plan's in-network roster for 2014.

This rollback comes a year after UnitedHealthcare entered a two-month impasse with BayCare Health System, the largest health system in the region. The BayCare standoff, which affected about a half-million commercial and Medicare UnitedHealthcare members, appears to have been mostly a function of reimbursement negotiations; BayCare announced new contracts with three other insurers during the impasse, all with accountable-care provisions. BayCare and UnitedHealth signed a five-year contract in January 2013.

The 2014 pruning is reportedly not part of negotiations; providers are simply being told that they are no longer part of the network. The insurer's latest modification of the provider network looks to be more permanent, and is part of the larger trend toward narrow networks in both the commercial and Medicare space. Many of the Medicare Advantage plans that have achieved higher star ratings (which lead to higher reimbursement and other rewards) have instituted greater controls on their network physicians -- controls which can be difficult with a very broad network. Humana, the largest Medicare player in Florida, achieved a 4.5 star rating for its flagship MA product in 2013, and Cigna-HealthSpring in Florida garnered a perfect 5-star rating for 2014. UnitedHealth's AARP MedicareComplete Choice Regional PPOs in Florida are rated 3 stars for 2014, tied for the lowest rated MA plan in the state. Subsidiary Preferred Care Partners garnered 4 stars.

The heart of Cigna-HealthSpring in Florida is Leon Medical Centers Health Plan, where members get much of their non-acute care from high-end health centers that offer ?white glove? treatment while also tightly coordinating care. The clinic gatekeeper is also used by Humana, which adopted the model after the 2004 acquisition of CarePlus and scaled it up. These tighter controls allow the insurers to make sure providers are conforming to the standards by which CMS measures star ratings, including certain screenings, evidence-based protocols, and customer satisfaction. Humana and Cigna-HealthSpring are the two largest Medicare players in the highly competitive (and lucrative) Miami Medicare market.

UnitedHealth is taking notes from its successful Medicare rivals in Florida. In 2012, UnitedHealth acquired two clinic-based South Florida Medicare HMOs (Preferred Care Partners and Medica HealthCare Plans), the same way Humana and Cigna went shopping for local Miami plans in previous years.

UnitedHealth's paring down of providers is similar to what Humana did in Jacksonville, Fla., in the summer of 2011, when the insurer booted the large UF Physicians academic group from its network, which also affected the hospital at UF Health (then called Shands Jacksonville), where UF Physicians refers to. But Humana cut providers during the middle of a plan year, so affected members were forced to switch physicians or pay more out-of-pocket. UnitedHealth has made the announcement during open enrollment, allowing customers to assess their personal cost/benefits when making a MA choice for 2014.

Maybe seniors in Tampa Bay will decide that they don?t need Moffitt or other newly out-of-network groups, such as Florida Orthopedic Institute and Tampa Eye Clinic, if the price is right. Granted, Moffitt is one of only two NCI-designated Comprehensive Cancer Centers in the state (Mayo Clinic has a program in Jacksonville), but the other health systems in Tampa Bay have their own cancer centers as well. Seniors in Connecticut have a harder decision, with the 1,200 physician Yale Medical Group being removed from UnitedHealth's MA network there.

Politicians of a certain stripe are already hoping for a redux of the ?If you like your health plan, you can keep it? imbroglio that controlled the ACA narrative for the past few weeks. If anything, these narrower networks should shed light on why the pre-ACA/post-HMO healthcare environment was so expensive. For about 15 years, insurers were expected to carry virtually all physicians and hospitals in their networks. Whenever there was an impasse between insurer and provider, the latter always had the advantage because no one understood the actual costs of healthcare.

Now, through both Medicare Advantage and more clearly on the health insurance exchange, we can see how much these broad networks cost. On the exchange, individuals can still keep their broad networks, if they are willing to pay for it. There are almost always narrow network alternatives that cost significantly less. While many have hoped for single-payer healthcare, or at least a public option, we may find that capitalism can be very good at producing quality, cost-effective products at a variety of price levels, as long as the consumer has access to all relevant information.  The Humana/UF and United/BayCare impasses did not register in the national media because they happened too early to fit the current anti-ACA narrative. Like the cancellation of individual insurance policies, what were once common insurance business practices are now portrayed as signs of the apocalypse.

Not too long ago, Republicans often argued that there was no such thing as being uninsured in America, since emergency rooms had to, by law, stabilize anyone who walked in. Now, the threshold is much higher: people should be able to go to whatever doctor they want, all the while holding onto their deficient mini-med individual policies.

Follow Mark Cherry on Twitter at MarkCherryHLI.

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