Restrictive plan types are not the same as narrow networks

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.

Penn LDI’s Dan Polsky, Janet Weiner and Yuehan Zhang looked at the number of providers in networks through 2017.

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.

4 replies
  1. 1

    Ugh, the stupid Marketplace app is SO unwieldy!!!! I typically just enroll my son but I wanted to see if I could afford a plan for both of us so I entered us both as seeking coverage. Got to the plans and realized there was no way I could afford even the crappy Bronze plan so I wanted to remove myself from the application, which would probably cut the premium in half but the stupid website won’t let me. Once you’ve completed the eligibility/application part it won’t let you go back and edit it. So I tried to remove it and got an error that said it wasn’t removed, to log out, wait 30 minutes and try again. At this rate, I’ll go without insurance another year because of how expensive plans are and my son will go without because the website is a piece of crap.

    Also, David or anyone, how are these plans much better than a catastrophic plan? Seriously. The cheapest plan available to me had a $7,900 individual deductible so I’d still be paying full price for my prescriptions and I can’t tell from the info whether my prescription costs would even count towards said deductible. So the only reason I would have the policy is in case of something catastrophic. It won’t help me with anything typical.

    BTW, I’m in that sweet spot you discussed a week or two ago where I make too much for assistance but still cannot afford a decent plan.

  2. 2

    After a 15 minute wait for assistance, I received help from Customer Support. I was able to remove myself from the app. Still am wondering about how a Bronze plan or any plan with a high deductible is any better than a regular catastrophic plan though.

  3. 3
    Yarrow says:

    @Mrs. D. Ranged in AZ:

    I’d still be paying full price for my prescriptions

    In case you aren’t already familiar with it, you can use GoodRx, which is sort of a free prescription discount service online. You just put in your prescription and location and it gives you the cost at pharmacies near you. It has always been close in price to what my prescription plan has offered. It’s worth a look rather than just paying full price at the pharmacy.

    Of course that money doesn’t go to any deductible or anything, but at least it’s not full price.

  4. 4
    Elizabelle says:

    @Yarrow: I’ve used GoodRx, and it’s a marvelous help.

    Le sigh. I just signed up for a Marketplace plan. I am looking at it as “asset protection plan” rather than much in the way of actual healthcare — although I believe a physical and a little more is covered before you hit the deductible. Which might be enough, since I don’t require much care.

    Signed up mainly to protect my financial assets, which would disappear in event of cancer or another catastrophe.

    Is this a great country or what?

Comments are closed.