What you need to know about provider networks under PPACA

On the other end of the spectrum, Dr. Don McCanne, a staffer at Physicians for a National Health Program, used stories about narrow exchange plan networks as evidence that the country would be better off with a government-run, “single payer” health finance system.

But it might be useful for agents and brokers to remember that network size preferences were oscillating wildly decades before anyone had trouble knowing how to pronounce PPACA.

3. Get wonky.

You don’t need to bury yourself in medical journals, but it might not hurt to root around on PubMed once in a while, during the time you might normally spend watching kitten videos, to see what serious, peer-reviewed researchers are saying about network adequacy.

A team led by Kevin M. Gorey reported in two papers published in 2011, for example, that the physician supply in California seemed to be big enough for local area supply variations not to have much effect on breast cancer or colon cancer survival rates. But Gorey’s team reported that the physician supply in Ontario seems to be small enough that local variations do seem to affect cancer survival rates there.

David Nyweide and colleagues concluded in Health Affairs in 2011 that Medicare enrollees’ perceptions of their health care, and their access to care, seemed to have little to do with local physician supply levels.

But Chiang-Hua Chang and colleagues looked at hospitalization and mortality rates in an article in the Journal of the American Medical Association around the same time and found that, even after they adjusted for factors such as income, Medicare enrollees in communities with more primary care doctors seemed to do noticeably better in terms of decreasing both the hospitalization rates and the mortality rates.

4. Pay attention to what everyone is saying about network adequacy.

State agencies, the National Association of Insurance Commissioners (NAIC) and health care quality groups have been trying to come up with workable network standards since the days of the staff model HMOs, and many states now have standards that apply solely or mainly to HMOs.

In Tennessee, for example, an HMO is supposed to minimize the number of enrollees who have to drive more than 30 minutes to get to a primary care physician. California requires plans to update their provider directories every three months. In Texas, both HMOs and preferred provider organization plans must update their provider directories quarterly, according to Sally McCarty and Max Farris of the Georgetown University Health Policy Institute.

McCarty and Farris published a helpful paper on the current state of network adequacy rules in August 2013, which was distributed by the Robert Wood Johnson Foundation.

The researchers reported that PPACA itself requires the “qualified health plans” sold through the PPACA exchanges to offer a “sufficient choice of providers,” and the “essential community providers” that typically serve poor people, but the law does not set the same kinds of numerical standards that states like Tennessee and Texas have set.

The NAIC recommended standards in a Managed Care Plan Network Adequacy Model Act adopted in 1996. Like PPACA, the NAIC model leaves out specific quantitative standards for provider access. The National Committee for Quality Assurance, an accreditation group, has suggested that network adequacy standards should address provider quality, not just quantity.

5. Look at the insurers’ own provider directories.

Jeff Ungvary, president of Strategic Wellness & Insurance Management Services Inc., said he thinks brokers should also talk about the ramifications of network decisions when helping customers choose health coverage.

When he helps midsize employers analyze networks, he gets a list of the enrollees’ primary care doctors and specialists, then checks to see how many are in the current health plan network and how many would be in other networks the employer is considering.

At one employer, for example, the employees were using 136 doctors, and 18 of the doctors were not in any of the networks under consideration.

When an employer compares the percentage of the listed doctors who would be in-network in Plan A and in Plan B, some employers will choose the cheaper network, and some will choose the bigger network, Ungvary said.

Some have suggested that the exchange plans may now have especially narrow networks. Ungvary said he thinks that, even if the new, narrow networks are often too small for many enrollees to keep their doctors, they are still larger than the staff model HMO networks of the 1980s.

“Realistically, people will still be able to get care,” Ungvary said.

See also: Does PPACA make silver networks narrow?

6. Listen to the customers

Some employers have to make the cost of coverage the top consideration. Others can offer richer plans.

Some want to see information about provider networks displayed in a clear way, and then make their own choices. Others want brokers or consultants to make the choices.

The goal for producers is to understand what roles they are willing to play, to manage the risks associated with those roles, and to make sure someone is paying them to assume the responsibility they’re assuming.