Network Adequacy will be the biggest publicly visible challenge of health insurance plans in 2015. The fundamental issue is that there is a set of significant disconnects at multiple points. A network can be deemed adequate by state and federal regulators but the public as a whole will find it grossly inadequate as people can’t find providers who are willing to take them as a new patient or schedule an appointment in a reasonable time frame.
The first disconnect is what does a regulating entity consider adequate coverage compared to what people consider adequate coverage. Mayhew Insurance has to file its networks every year with the state regulating entities as well as a private, non-profit quality assurance enity (NCQA). When we file with the state, we have to show that for seven categories of providers that we have at least 90% of the potentially covered lives are within either thirty or sixty driving minutes of two providers, and for another twenty or so categories, there is at least one provider available. For Big Central County which hosts an NFL team, an NHL team, an NBA team and a team that theoretically plays Major League Baseball although the results don’t support that contention, we could theoretically file a single county network with only twelve primary care providers and have it meet state regulatory guidelines. State regulators have access standards, they don’t have ratio standards. NCQA has access and ratio standards. Submitting that same theoretical network of 12 primary care providers in Big Central County would lead to a failing grade from NCQA as that would be one PCP for every 200,000 potential lives and one PCP for every 12,000 covered lives.
There are two problems with these regulatory level filings. The first is that the standards are very low for large urban counties. These are loose standards. When Mayhew Insurance is attempting to sell a network to a new large group, the filing standards that we brag about are significantly different. We brag that we have three PCPs that accept new patients within 5 miles of 95% of the employees of that group. Our selling point is that their employees will have an easy time finding lots of providers that will take the patients. The HR department of a sales target does not care if there are thirty three docs near their employees if their employees can never get an appointment for them. Those docs are from the sales target point of view, superfluous.
The second is that they are mainly counting providers who will are contracted for that network; not providers that are contracted for the network and accepting new patients. This is known as panel status, and it is a critical distinction. This is where most valid complaints about companies baiting and switching consumers on the basis of their networks will come from. The providers are in network, and willing to take patients at the contracted rate, but they are not taking new patients. Current patients who changed insurance won’t be kicked out of the practice, but new patients won’t be allowed in. Insurers will advertise that 94% of providers in a region take their coverage while members who sign up on the basis of that claim can’t find a provider who will take them as a new patient.
Panel status is a key challenge from a data perspective. Panels can be open to all, they can be closed to all, and they can have five hundred shades of gray in between. For instance, the dad of one of my daughter’s friends is a dermatologist. He is par with Mayhew Insurance for all products. We use him to demonstrate network adequacy in a pair of outlying counties for the dermatology specialty but he is a real world data problem.
For filing purposes, he is marked as active and open. However, in reality, he has research and teaching committments for 70% of this time, 20% of his time is spent at a weekly teaching clinic at a Major Academic Medical Center and 10% of his time is spent in those two outlying counties. He shares an office with several other specialists so the first and third Thursday of the month, he spends the morning in Middle of Nowhere County and after lunch he goes to East of Nowhere County. For those Thursdays, he takes anyone who makes an appointment. The rest of his time, his panel status is still considered open, but it is only open to absolutely fascinating cases that aid in his research and publication priorities.
How do you categorize his availability? It is limited but open. For regulatory filing purposes, he counts as proving access to three counties. To the HR department of a target sales group, he is open and on all the geo-accessibility reports of being willing to provide care for the employees of the target group. However for the individual who has something funky going on and needing help, there is a very good chance that his panel is either completely closed as his scheduler will redirect a phone call for wart removal or practically closed as the next appointment available in East Nowhere County is in four months.
He is a bit of an extreme case, but these data challenges drive confusing as hell policy and publication decisions.