Much Ado About (Narrow) Networks

Much Ado About (Narrow) Networks

A recent Wall Street Journal article about narrow networks described it as new pressure on insurers. Sorry, WSJ, not new.

Employers have pressured insurers about access to their employees’ providers for years. What is new is the increased willingness of some buyers (read that as insurers including Medicare) to accept an insurer’s narrow network in the name of savings.

While making public statements about ensuring quality, the reality may be very different, largely because cost becomes the real driver, and the cost of dealing with high quality providers in very small practices is overridden by the economies of dealing with an “OK quality” large provider group.

The result is that physicians are being told they are being dropped from certain insurers’ networks, often without appropriate notices and, more importantly, the reasons why. Lawsuits result.

The blogosphere is buzzing with the school of thought that those who are dropped must have been “dropped for a reason.” Those dropped protest that they have received high quality scores and don’t understand why they were dropped.

What’s missing? Were providers dropped for quality concerns, or just cost issues? I always worry about the silent lurkers, those who were dropped and recognize, grudgingly, why. Several other questions arise, and I think the lack of answers right now should be what employers (and all of us) should be upset about.

Here’s what we need answers about:

  1. What were the criteria that caused a practice to be dropped? We need to know explicitly what basis the insurer used to say this practice is no longer in the network.
  2. Are the criteria legitimate measures of quality and value? I include value here because we have to decide whether additional cost is worth the “bang for the buck” on quality.
  3. Was there a chance for the practice to remedy whatever was wrong? Let’s assume for a moment that the issue was quality in some form. Was the practice informed and given an adequate period of time to make corrective changes to bring its quality up to whatever standard was set?
  4. Finally, are there sufficient providers in this particular location so that dropping a provider will not cause an access problem? I’m not saying that bad quality is better than no provider, but we need to account for losing a provider and causing access problems.

If you want to be upset, ask these questions. And demand answers. Any insurer not willing to answer these questions as they drop providers should be held accountable.

Let’s face it: physicians and other stakeholders have to work together to make the hard decisions about quality and value. But let’s do that, otherwise like the adage in real estate, “Location, location, location,” we’ll be a health system based on price, price, price.

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