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.