Helping States Address Transparency of Health Plan Provider Networks

A recently published issue paper written by my colleagues Sabrina Corlette, Kevin Lucia and Sandy Ahn explores insurers’ rationales for offering narrow networks and what that means for regulators and consumers. The paper presented some interesting information learned through interviews with insurers offering on six state marketplaces.  From the interviews, it seems clear that the driving force behind narrow networks is the desire to control premium increases. While regulators and consumers are on board with that goal, the proverbial jury is still out on consumer satisfaction with narrow networks.

Despite some negative reports about narrow networks, there are many who believe they can be beneficial to consumers, especially when they achieve the goal of curtailing premium increases without sacrificing quality. The primary pushback from consumers and their advocates seems to be based on the lack of information available to potential enrollees about just how narrow the networks are. Consumers may end up purchasing policies without knowing their network restrictions, and, later, they may learn that that the providers they want to see are not in their policy’s network. Or, even if consumers are conscientious enough to check the provider directory before purchasing a policy, they may find that their preferred doctor has closed his or her practice by the time they make their first appointment.

The paper notes that only three of the six states studied are strengthening provider directory requirements and only one of them is requiring updates more frequently than every thirty days. Maryland is requiring updates every 15 days and, it’s noted, they are “attempting to upgrade an 18-year-old provider network intake system to allow the marketplace to better display network differences to consumers.”

A piece in the October 7 New York Times newsletter, The Upshot, pointed out that the federal marketplace is not faring any better in terms of provider network transparency. In the article, titled “ Still Suffers From Lack of Transparency,” the writer reports that chief executive Kevin Counihan’s stated goal for the web site is “…to create a consumer experience so satisfying that it would result in ‘raving fans’ for the insurance shopping site.” However, the writer states that the shopping experience is not likely to achieve that goal because does not allow shoppers to review a list of physicians who participate in each plan.

The current and projected growth of narrow networks could be a good development for consumers, but if that growth is not being met with rigorous transparency requirements the benefits could be negated. Any benefit consumers may gain from the lower premiums narrow networks may offer could be wiped out if consumers have to pay higher, or even prohibitive cost-sharing amounts to see the providers of their choice.

Earlier this year, my colleagues and I created a Network Adequacy Planning Tool for the Robert Wood Johnson Foundation’s State Health Reform Assistance Network. The planning tool presents regulatory considerations in eleven categories for states to use when updating and enhancing their narrow network standards. In anticipation of the trend toward narrower networks, an entire page of the five-page document is devoted to transparency considerations.

The Planning Tool includes regulatory options like special enrollment periods for enrollees who find that a provider listed as accepting new patients when they purchased a policy has stopped taking new patients by the time the enrollee attempts to schedule an appointment. Another regulatory option is to require prominently displayed announcements both online and on all narrow network plan print materials that state the network is limited and urge shoppers to review the provider directory before choosing a policy.

There are all sorts of transparency tools that could be developed and employed to help consumers choose a policy with eyes wide open about which providers will be available to them. Another option would be the development of online maps – much like the maps that are used on apartment finder web sites – that show the location of each provider in a network. A consumer using one of these maps would be able to click on the provider location to see details, such as a provider’s education, board certification, and whether the provider is accepting new patients.

Another way to address the problem of closed practices would be to require insurers to include a provision in their provider contracts requiring providers to give two months’ (or more) notice before closing their practices to new patients, and to commit to keeping their practices open for a year following each open enrollment period.  Provisions like these would provide consumers adequate time to find a new provider before a practice is closed for any reason, except the illness or death of a provider.

Most of these transparency and disclosure mechanisms should be do-able by insurers but, like so many other consumer protections, will probably not be implemented without regulatory mandates. There are other ways to make narrow networks more palatable, like assuring there are enough plans offered on the marketplace to provide access to, and choice among, all area providers, but achieving greater transparency would go a long way to make narrow networks less of a problem and more of a benefit for consumers.





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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.