How Healthy Is Your Health Care Provider Network?
By Tamar Thompson, Chair, HealthyWomen Board of Directors
For an increasing number of Americans, having health insurance may not be enough to guarantee coverage and access to care when you need it most. Narrowing provider networks may prevent you from being able to see the appropriate provider to treat a medical condition or to maintain your health.
As health care costs rise, many insurance enrollees are not surprisingly focused on obtaining health care coverage at the lowest possible price, keeping their premiums low. But you may not be aware of how this can impact your ability to receive timely, high-quality health care.
If your insurance plan's network of health care providers is too narrow, it can limit your access to sufficient care and in the end, raise your health care costs by forcing you to into out-of-network providers.
How healthy is your provider network?
A "provider network" refers to a health care provider or group of providers who contract with a health plan to offer their services at lower rates. Provider networks are used for Medicare Advantage programs, Managed Medicaid programs, and commercial health insurance models such as Preferred Provider Organizations (PPO) and Health Maintenance Organizations (HMO).
All provider networks are not created equal, however. If too narrow, a network can result in low quality care, lack of access to care, and/or higher prices for out-of-network providers. "Network provider adequacy" judges networks on their ability to accommodate patients with a sufficient number of primary care physicians, specialists, hospitals, and more.
Price competitiveness in the health insurance marketplace has prompted many insurers to offer ever narrower provider networks, designed to keep prices down. In the end, consumers may find their insurance goals contradictory, pitting low-cost with provider access—and find they no longer have access to a sufficient number of in-network providers.
The result is an expensive conundrum: drive too far from home, tap a more expensive out-of-network provider for care, or forgo needed care all together.
Legislation will not solve the problem
The federal government has very little direct jurisdiction over the commercial payer market. However, because many commercial payers serve as administrators for government programs such as Medicare Advantage and Managed Medicaid programs, federal legislative and regulatory policy often influences the decisions of commercial payers. Conversely, state governments have greater influence over the commercial health insurance market. State legislators have the ability to regulate how commercial payers operate in a particular state.
For example, the Affordable Care Act, also known as the ACA, included many reforms intended to make quality health care more affordable and accessible, including federal network adequacy standards for Medicare Advantage beneficiaries. Seventeen states have network adequacy requirements. Such laws mandate that plans establish standards for the creation and maintenance of provider networks that are sufficient to assure that managed care plan enrollees can access necessary services without unreasonable delay.
Nevertheless, these standards are not be enough to protect you as a health care consumer. Even with these laws, a managed care plan can create additional rules to restrict access. One such policy common among payers is to ensure a provider is available within a certain mileage radius (as in ensuring that plan members have access to at least one hospital within a 75 mile radius). Policies such as this can create health care disparities and other challenges particularly for those patients living in rural communities as well as as lower-income or elderly patients.
In this case, the plan may meet federal or state requirements but still won't satisfy your specific health care needs.
Consider this in another way. About 10 years ago I had a membership for a fitness center close to my house. It was great. I went to the gym regularly and was in great shape! But then we moved. I called the gym to cancel the membership but was surprised to learn that in the super fine print the contract stated that I was unable to cancel the membership if there was another fitness center within 30 miles of my home.
That requirement might not have been a big deal in Texas (where I signed the contract) because I had a car and most miles are highway miles. However, 30 miles in the Washington, DC, area is not a reasonable radius for a daily commute to a fitness center. For reasons such as this most gyms and fitness centers have forgone these draconian policies and now promote flexible month-to-month agreements. If such policies are unacceptable for fitness center memberships, why on earth would we accept such policies for patient access to health care?
Taking charge of your health care
At HealthyWomen, we encourage health care consumers to become savvy health care navigators and to learn about the health care options available to them before they become sick or need to have a procedure.
Open enrollment is a great time to start. Every year, in October and November, health care consumers have the opportunity obtain coverage or make changes to their policies. If there is a particular provider you know you want to or need to see during the coming year, make sure that the provider is in network for the upcoming plan year.
Providers often leave managed care networks for a host of reasons. You may opt to stay with your provider even if he or she is no longer in network and your health plan may cover some of the cost associated with your visits depending on the type of plan you select (i.e., PPO or HMO). However, when making this very important decision you should consider the financial differences and patient protections as a plan member associated with choosing to stay with your provider.
The only way to know is to ask. Do not be afraid to contact your health plan and your providers, including primary care physicians and specialists, to find out if they are in your network—and if not, why not, so you can make an educated choice in selecting the type of health care coverage that suits your needs.
Whether you choose to change health care plans, health care providers, or not, obtaining information you need ahead of time will help you make an informed decision and avoid surprise medical bills.
Unfortunately, for a growing number of patients, having health insurance does not guarantee the ability to use it in a practical way when needed. Consumers should be aware of the challenges narrowing provider networks may present and have the needed knowledge mitigate any issues while also attempting to seek necessary health care.
Tamar Thompson has served on the board of directors for HealthyWomen for a decade and as chair of the board since 2017. She is also head of Federal Executive Branch Strategy and State Government Affairs at Bristol-Myers Squibb Company.
The views and opinions expressed in this blog are those of the author on behalf of HealthyWomen and do not necessarily reflect the official policy or position of Bristol-Myers Squibb.