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Talking Networks: How Narrow Is Too Narrow?

These “narrow networks” often have too few specialists, and sometimes not even enough primary care physicians.

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With Medicare Advantage plans designed to help them obtain quality health coverage, the plans so narrowly tailored that the number and type of physicians available leaves patients few options. This is especially the case when it comes to the quality and availability of specialty physicians to care for them.

These “narrow networks” often have too few specialists, and sometimes not even enough primary care physicians. Worse yet, some plans don’t seem to know who is actually in their network. It’s not uncommon to see a Medicare Advantage plan provider directory error rate of almost 50 percent. A 2014 national study found that almost 50 percent of dermatologist listings were duplicates and, of the remaining unique physicians, only about half were in the plan, at the designated address and willing to see new dermatology patients. In other words, the directory listing of dermatologists was inflated by almost 400 percent.

MA plans often have inadequate information about the subspecialty type of their physicians. As a result, they inappropriately narrow their networks by dropping those perceived as “outliers.” It’s not uncommon for sub-specialists to be dropped from networks for appearing more “expensive” relative to general specialists. As a result, patients with difficult skin cancers lose access to the most appropriate, cost-effective care by skilled surgeons. Patients are left to seek care from less experienced providers or travel long distances, sometimes to another state. Studies have shown that the best clinical outcomes are observed where a procedure is performed day-in and day-out, over and over again.

Furthermore, MA plans can terminate physicians at any time during the year, without cause and with relatively short notice to the doctors or the insured beneficiaries. This impedes the doctor-patient relationship and disrupts the continuity of care. Physicians who are terminated generally receive little information as to why they are being dropped, making it difficult to meaningfully appeal these determinations. Patients must either find a new MA plan, seek care from other providers, or worse, forgo care altogether, putting them at significant risk.

In the health insurance exchanges, or “marketplaces,” the federal government will now rely on states and private accrediting organizations to assess network adequacy. Neither consider nor adequately account for specialists. Additionally, the population-based measures that plans hold specialists like me accountable for are not related to care they can control. A review of the Qualified Health Plan Quality Rating System shows that the measures plans are held to are not generalizable to most specialists and sub-specialists, nor do they align with physician-level quality measures reported under the CMS’ quality improvement programs, such as the Merit-based Incentive Payment System. States aren’t prepared to ensure network adequacy, which is demonstrated by the plethora of state legislative proposals aimed at out-of-network or “surprise” medical bills, issues that are directly tied to the adequacy of an insurer’s network rather than specialists’ willingness to negotiate for fair payment with health plans.

In conclusion, the system must more closely monitor network adequacy to help our senior citizens get the care they deserve in MA plans.