Adam Lang in comments raised a very good point about accessibility of providers in narrow networks yesterday:
so far we’ve called 77 local doctors from their list, and we have a list of exactly six that are accepting new patients from the exchange plans, and those are uniformly the ones that have gotten awful reviews on Yelp or one of the rate-my-MD sites (and none of them specialize in women’s health, and they’re all men). I wonder, when does a ‘narrow network’ become a ‘nonexistent network’?
That is a damn good question, and the answer will vary by state, as the states determine what configuration of providers is the minimally adequate network. The Commonwealth Fund has a good overview of minimal adequate network regulations:
27 states had rules requiring at least some network-based marketplace plans to satisfy one or more quantitative measures of sufficiency ….Most frequently, states specified the maximum amount of time and/or distance an enrollee must travel to access covered services….New Jersey, which obligates its managed care plans to have available at least two primary care physicians within 10 miles or 30 minutes driving or public transit time of 90 percent of its enrollees.…
Twenty-one states had qualitative standards to assess the adequacy of plans’ provider networks. For example, Maryland requires carriers to maintain a panel of in-network providers that is “sufficient in numbers and types of available providers to meet the health care needs of enrollees…..
California actually has somewhat strict regulations as they have distance to provider, provider to population ratio, extended hour and maximum wait time regulations. But there is a big gap between minimal qualifying standards and what reasonable people who have medical needs believe to be reasonable wait times and accessibility.
Adam is identifying two issues.
The first is whether or not the network is adequate?
By his description of the situation that there are at least six doctors in network with open panels (as they are taking new patients) and seventy seven doctors that are in network. The network meets the distance to provider and provider to population metrics. I assume extended hours availability is also being met. The only area where there is a legitimate gripe that the state regulators can act on is the potential for maximum wait times being violated.
The second issue is panel status. Panel status is whether or not a provider will take on new patients and what types of patients they’ll take on. A provider can be in the network but have a closed panel. One of Mayhew Insurance’s Exchange products is a narrow network with a low reimbursement rate. It was quite popular for 2015. Providers who were not on the initial provider list asked to be included so that they could continue to care for one or two of their patients who bought that particular product. We did not use those providers to receive state approval, but they are on the web directory but for this particular product they have a closed panel. I think a similar dynamic is happening in Adam’s area for a decent number of the seventy seven docs that he has called.
Panel data is fuzzy data. If a panel is designated as closed, but somehow a new patient gets an appointment, that claim will pay after the patient is seen by the doc. If a panel is designated as open, but there are no available appointments, new callers will get turned away for a month or more for PCPs and several months for specialists. No one really owns the verification of panel status; it is a soft indicator of preference but it does not control claims payment or anything else of monetary value to the provider. States don’t actively audit or regulate panel status data.
The network is legally adequate but it has few open panels and those panels are for docs who suck goat balls. The short term response is to change insurers at the next open enrollment period and make it known to Blue Cross that they are losing a low utilizing but premium paying customer (ie a profitable customer) because their network is functionally inadequate. Switching to either a broader network, or a higher paying network that has more open panels will probably cost Adam’s friend more money, but those are some of the explicit trade-offs in the Exchange design.
always thank you for the information you bring.
Adam asked a question that arose for me literally yesterday. I was referred to a specialist, whose scheduler called to advise me they were out-of-network for me, and that there were no specialists in network in that specialty in the town where I live. I get insurance through my employer, and I was utterly gobsmacked that the nearest specialist (the only one in the state in the network) is easily 150 miles away by Interstate. I wonder if my insurance being employer-provided changes the obligations, but what is really startling I don’t expect you to answer (to wit, how the biggest university in the state can negotiate an insurance policy that has no specialists in the town where its campus is located).
Since you answered the original question so ably, I was wondering if you had any advice on how to find out what my state requires for network availability so that I can figure out if my insurer is playing fast and loose.
Sadly, I think a lot of the “awful” reviews on yelp, etc. are caused by the doctors being foreign-born. Some of this is attributable to speaking English with an accent or different cultural norms of the foreign born doctors, but some of it is straight-up racism.
Part of the problem is the AMA oligopoly which deliberately trains too few doctors to keep fees up. We have the lowest number of doctors per population of any major developed country, and the UK is the only one even close to us.
Yup, yelp reviews are right up there with Louie Gohmert for informed, insightful opinions.
Medical school is incredibly expensive which makes it tough to pay off loans if you become a GP. If only we could invest in public funding for medical training- but we are increasingly too stupid to play world’s superpower.
Richard, one problem with this in California — there may not be any broader networks on the exchange. In an area like mine, the only options are Anthem and Blue Shield, and neither of them have either of the local urgent care centers in-network and both have similarly narrow networks.
I notice both exchange plans here are PPOs rather than the EPOs some people in larger urban areas mention from the Blues. Does that affect the state’s network adequacy determinations?
This is an interesting question. What type of specialist are you looking into? I am assuming you are looking for very high end/very specialized specialists… and that is where the regulatory schema fails.
Let’s take an example of you needing an orthopedic surgeon to do Tommy John surgery… there aren’t many of them that do it in any given state, but they get rolled up from the subspecialty/service level of Tommy John surgeons to the general level of Orthopedic Surgeon. At the general level of orthopedic surgeon, the insurer probably has dozens within a reasonable distance of your employer. At the subspecialty level, there might be two, and they both might be out of network or booked to next year. And thus you’re driving 5 hours.
You should contact your state’s department of insurance or department of health — whomever regulates commercial insurance, and find out what the standards are. From there, if the problem is a subspecialty availability, you can file a medical neccessity appeal with your insurer to allow you to go out of network at in-network rates as a multi-hour drive is not accessible care. That should be approved as most of the time, insurers will certify to the state regulators that if a member can not get approproiate in-network care within a reasonable waiting time frame AND within reasonable driving distance, they’ll treat out of network claims as if they are in-network from the member point of view. That will vary by state, but it is a common regulatory requirement.
Is there any way that panel status is exposed to the public?
One part of this complaint, I would think, is the 77 phone calls. It’s not the most critical part, but imagine if the 6 open doctors were a random sample of perfectly fine doctors rather than 6 of the worst. Making that many phone calls to find them would certainly still be very frustrating. At one point, dealing with a happily-relatively-minor, but somewhat urgent medical issue, we were more or less compelled to take the first doctor who said they’d offer an appointment relatively soon – if we didn’t say yes on the phone, after all, we might lose the slot. So we had to either pre-research every doctor possible and call them in rank order of who was best, or pretty much roll the dice.
In the information age, that’s not exactly what one hopes for. And I can only assume that even if you ultimately landed a great doctor, making 77 phone calls to find him would leave one thinking this insurance setup wasn’t exactly ideal.
@Ian: It varies by insurer and state, but panel status is often shown in web directories. I know that the choice to look for only Open panels for a given demographic or All panels is part of the Mayhew Insurance web directory.
I’m truely thankful for the ACA and the help it is providing those who previously had no access to health insurance. The problem I have right now is that it seems to have killed all discussion of the declining options for those who have employer provided health insurance. Since the ACA came out, my health insurance has gotten measurably worse. Who’s addressing that?
In some ways, namely deductibles and co-pays, insurance is getting worse across the board. Out of pocket expenses are still rising at double digit rates:
Hah. I pop away from here for a day and my name is being taken in vain!
A couple of things: yes, the Blue Shield network (not Blue Cross, they are the ones we hate and thus did not sign up for) is definitely well within the law: there are probably hundreds of MDs within San Francisco alone listed, and even if the ratio holds and only one tenth of them are actually accepting patients, there will still be at least a couple dozen within ten miles of our address. Of course, most of those require either a car and 60 minutes (15 minutes’ drive each way and 30 minutes looking for parking near them) or 60 minutes each way on public transit, but since the guidelines are designed for the suburbs (as are everything else) it doesn’t actually matter what the travel time is, just that the doctor is within x miles.
I suspect the ‘extended hours’ guidelines is being met by simply saying, ‘okay, go to the ER’ or something, or possibly there just have to be extended hour providers within 60 miles or something, because as far as I can tell there is literally no way for someone without a car to get to anyplace that offers extended hours with this network, unless there’s a place I overlooked in Oakland/Fremont/etc that’s accessible via BART. No urgent care facilities in SF seem to take it.
The wait time? Well, the earliest we could get a GP appointment for her was over a month away, but she wasn’t actually trying to browbeat people into getting her the earliest possible appointment (like ‘could you call me if someone cancels’ etc) so I don’t know.
As for Yelp reviews, what I look for is things like, ‘always run late’, ‘did not listen to my concerns’, ‘only spent 5 minutes with me’, ‘arrogant’, ‘condescending’, etc. If it helps any, all of the badly-reviewed options she ended up with except for one were white men, who seem to end up labelled arrogant and condescending at a much higher rate than the baseline. (Imagine that.)