Avalere is a health care consulting firm. They do really good work that informs both policy makers and the public. They just released an ACA study where their language conflates two distinctive concepts.
The number of providers in a network is not directly tied to the restrictiveness of the plan type.
New analysis from Avalere finds that health plans with more restrictive networks, including health maintenance organizations (HMOs) and exclusive provider organizations (EPOs), continue to be the most common types of plans in the exchange market, with 72% of the 2019 market comprised of such plans. The remaining plans are Preferred Provider Organizations (PPO) and Point of Service (POS) plans, which tend to offer comparatively broader coverage.
“Provider networks are getting narrower, which means it is more important than ever that patients understand what kind of plans they are buying,” said Chris Sloan, director at Avalere. “Unknowingly enrolling in a narrow network plan could lead to patients being unable to see their preferred doctor or go to their most convenient hospital.”
Narrow or broadness refers to the number of providers in a network.
Restrictiveness refers to gate keeping and out of network benefit structures.
These are two very different concepts.
We’ve looked at the in and out of network benefit and gatekeeper structures of the different plan types before:
Avalere’s first graphic makes a very good point that plan designs are moving towards more restrictive plans (HMO/EPO).
This is very valuable information. This is a good description of the reality on the ground. Insurers want more control over costs which means more control on which doctors and hospitals their policy holders use.
However an HMO is not necessarily a narrow network with few doctors in it. An HMO can be a narrow network. An HMO can also having a hundred hospitals and ten thousand doctors in network.
A PPO is not necessarily a broad network with every doctor around in it. It can be a narrow network.
Plan type does not dictate network size or breadth.
There may be correlations in network size and restrictiveness but there is not a requirement that a PPO be a broad network and an HMO be a narrow network.
This Issue Brief describes the breadth of physician networks on the ACA marketplaces in 2017. We find that the overall rate of narrow networks is 21%, which is a decline since 2014 (31%) and 2016 (25%). Narrow networks are concentrated in plans sold on state-based marketplaces, at 42%, compared to 10% of plans on federally-facilitated marketplaces.
They are looking into the question of how many doctors and hospitals are available to patients. That is a very different question than the one that Avalere is answering which is how many hoops do patients have to jump through.
It is a subtle difference but it is a difference worth teasing out.