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On the Third Hand: Network shifts

by Allison Bell

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The New Year is about to begin, and I’m now closely connected with people who are shifting to a new provider network because their health plan sponsor changed insurers.

On the one hand, the new coverage seems to be great, platinum-level coverage.

The plan switchers are healthy. All they usually need is need checkups, and an occasional dose of reassurance about a nagging cough. 

The fact that the new plan has a shorter provider directory should not be that big of a deal, because the physicians in the new directory appear to be world-class physicians.

But, on the other hand, the plan switchers are still facing what to them seems like a nightmare. 

In theory, there’s nothing so terrible about asking healthy people to shift from one world-class primary care doctor to make the U.S. health care system more efficient. 

In reality, a network shift highlights other weaknesses in the U.S. health care system.

See also: Plan design changes expand ‘skin protector’ market

One issue is that, even though care coordination is a popular buzzword, provider directories do nothing to support enrollees who want well-coordinated care.

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My plan-switcher friends have been getting an older kind of de facto care coordination by using what amounts to a group medical practice shopping mall affiliated with a local hospital. The group practices are legally separate enough to satisfy insurer anti-self-referral rules but close enough that patients can walk from one office to the other and get any extra procedures needed during the same visit. The mall setup eliminates the need for the patient to go on a scavenger hunt for an in-network facility that can handle a simple cholesterol test or mammogram.

The challenge here, is that the new plan’s provider directory does nothing to help enrollees figure out which providers are in medical shopping malls, accountable care organizations or any other arrangements that promote care coordination.

Another, more serious problem is the lousy state of electronic health record (EHR) standards. My plan switcher friends are discovering that even getting basic checkup and immunization records from the old in-network primary care doctor to the new in-network primary care doctor will probably be a nightmare because, even though the doctors in the old network are using a fancy EHR system, there’s no guarantee whatsoever that their EHR system will connect with the new doctors’ EHR system.

See also: Intel executive: Let my health records go

On the third hand, the great thing about network shift glitches is that they can really cut down on the pennies plans spend on preventive care in the short run. Of course, there might be some concerns about the pounds spent in the long run, but, hey, this is America. We don’t know what a pound is, and we aren’t too clear about what the “long run” is, either.

See also: 

PPACA experiment may expand after $384 million in saving

University to test ‘medical home’ plan

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