A patient’s entry point to receive the care they need is shaped by which providers are in their health insurer’s contracted network. Often, because of limited provider capacity and availability, or language and cultural barriers, patients are left with limited choices in who they can select for care. This paper examines alternative network characteristics that may be realistically considered by purchasers to better define a truly accessible, adequate, and equitable network.

Provider networks and the contracts that bind them are a central component of a health plan’s offering to individuals, employers, and government entities. Across the country, purchasers of care such as Medicare, state Medicaid agencies, health plans, employers, and individuals judge the value of their health benefits in part by the experience they and their constituents get through interactions with contracted network providers. Assessing patient satisfaction is usually a requirement for providers and is now commonplace for inpatient and outpatient visits using the inpatient-focused Consumer Assessment of Healthcare Providers and Systems (CAHPS), its outpatient focused counterpart, the Clinician and Group Survey (CG-CAHPS), and other survey instruments. If satisfaction is low, then a patient should be able to choose an alternative provider. In reality, patients may not have multiple provider choices to receive needed care—even in networks that meet all required access and adequacy standards. Current standards attempt to ensure that members have access to providers that are conveniently located. However, what is convenient for one patient may not be convenient for another. True adequacy is subjective and personal to each patient.

How are provider networks currently measured?

To understand potential limitations in member choice under existing provider networks, it’s important to first understand how networks are currently defined as adequate. While definitions vary slightly among Medicare Advantage, Medicaid, Affordable Care Act (ACA) plans, TRICARE, and other sources of health benefits coverage, the foundations of most existing standards for measuring networks are measures of drive time and distance. These measures require that, for a given provider specialty, the network must maintain a contracted provider within a certain driving distance (miles) and time (minutes) from members’ home addresses. These standards are usually represented in a table and include standards that vary by the population density of a county or geography for over 30 unique specialties (for Medicare Advantage and qualified health plan standards). An example of how time and distance standards are usually represented is provided in Figure 1.

Typically, standards must be met for a particular percentage, say 90%, of covered members. While this approach can establish a reasonable standard that ensures members have a choice of providers within a defined driving distance from their home, meeting these standards does not guarantee that an appointment can be made or that any of the available providers meets the member’s criteria. In addition, standards are not developed or enforced evenly across different markets. For example, ACA health plans in state-based exchanges have traditionally been free to establish different access rules from those found in federal ACA exchanges. While these rules are shifting and becoming more uniform, they are still focused on the measurements of driving time and distance.²

Why don’t health plans increase capacity?

Strategies for network development vary widely, with some plans opting for very broad networks, others focusing on narrowed or tiered networks, and multiple iterations in between. Regardless of their strategy—broad or narrow—network development is an ongoing health plan activity. Plans are constantly seeking to recruit new providers to replace those who retire or leave the network for other reasons. They are also constantly working to eliminate network inadequacies—geographic areas where their networks do not meet standards for access and adequacy.

However, some plans may choose to focus on increasing capacity beyond what is required or dictated by standards. On the surface, it would seem that plans should simply contract with more providers to increase capacity. However, adding additional providers is not always a simple undertaking. There are key considerations for health plans which can limit their ability to increase capacity through traditional contracting.

Provider availability

Provider availability may be limited by capacity if a provider’s panel is already full or if a provider does not wish to accept additional membership volume from a certain payer due to concerns with rates or administrative burdens of working with the payer. Alternatively, new providers may not be available to contract. This issue is especially prevalent in rural areas where there are usually fewer practicing specialists.

Cost of care

When health plans contract with new providers, they risk the erosion of their rates. Contracting with a provider who may have high rates could have adverse effects on the health plan’s ability to offer competitive premiums in the market. In addition, plans may have formal or informal exclusivity agreements with providers in exchange for more favorable rates. Contracting with new providers threatens to erode these arrangements.

Provider integration

Adding additional providers to a network can have a negative impact on the cost of care, quality of care, and member satisfaction if the new provider is not well aligned with the other providers in the network. Health plans must be selective in choosing new providers. Networks with strong provider integration typically share data freely and may share an electronic medical record (EMR). They also coordinate the delivery of care more closely with the health plan, leading to fewer duplicated services, less waste, and potentially lower cost for members. When new providers are added to a network the plan’s control over quality measurement can be degraded.

Health plans shouldn’t simply seek a provider with the right specialty to fill the demands of their network. They should seek a provider that has the right cost of care, integration, and availability to meet their business goals.

In the inevitable case that the ideal provider characteristics aren’t aligned, health plans may consider working with targeted providers to mitigate gaps. For example, a health plan could work closely with a key specialty group to increase integration, offering training, access to software, and protocols to encourage the use of the preferred EMR. Additionally, the plan could offer providers access and coverage for e-consult solutions and contracted telehealth networks to manage availability and overflow. This type of support will be most sustainable when health plans focus on a limited set of network provider gaps that have been identified through examination of utilization, cultural, and geographic demands of their member populations. For instance, plans may evaluate their claims experience to understand where the greatest specialty demands are for their unique member populations and can monitor and compare their network quality against national standards such as the Health Effectiveness Data and Information Set (HEDIS).

How can networks be more personalized and accessible?

Traditional metrics for measuring networks focus on distance and time, while ignoring other factors that affect the patient’s experience such as appointment availability and cultural competency. Network adequacy assessment should be personalized to the needs of the population and the goals of the purchaser. An individual’s perception of access and adequacy to healthcare is personal and may vary widely across different demographics and levels of healthcare need.

Beyond driving time and distance, employers and other purchasers may look for specific characteristics within their networks. Some of these characteristics may include:

• Health equity and cultural sensitivity: To the extent possible, networks should represent and reflect the social health needs, cultures, and languages of the plan’s membership.³ Networks can be structured to focus on providing access to providers who speak prevalent languages and/or share racial or ethnic backgrounds with major member populations, who represent similar gender and ages to that of membership, or that offer key subspecialty skills such as gender reassignment or addiction medicine, which may be uniquely in demand for a given population. These considerations appear to be gaining traction, with the federal government recently proposing new access rules for Medicaid that work to focus on health equity.²
• Clinical quality: While individual providers are often assessed for the quality of the care delivered, it is less common to assess the clinical quality of an entire network. Network quality can be aggregated from a range of HEDIS or other quality metrics to provide an additional dimension of total network value, which may be useful to purchasers when monitoring network performance.
• Timeliness and appointment availability: Participation in a provider network does not necessarily mean the patient can obtain a convenient appointment from the provider. Recognizing that lack of a timely appointment is a barrier to care, some states and the federal government are starting to implement standards for appointment availability.⁴ Measuring this is challenging. Many health plans conduct “secret-shopper” calls to try to determine a provider’s next available appointment, but the effectiveness of this measurement is questionable. The definition of “convenient” is also variable; a member may view an appointment in the next month as convenient depending on their schedule and the urgency of their request. When making appointments, patients typically trade off multiple considerations.
• Telehealth and digital strategies: The availability and use of digital strategies in a network should align with the needs, health levels, technical literacy, and access to reliable internet for the population being served. These offerings are typically facilitated by provider groups and may include easy access to electronic medical records, electronically available driving directions for appointments, telehealth options, home monitoring, and wearable technology. Physicians can also increase capacity and become more efficient through the use of lower-cost and highly convenient e-consults technology to enable communication between specialists and primary care physicians.
• Integration: To the extent that a local geography may offer opportunities for narrowed or tiered networks with access to a more limited selection of providers, purchasers may find value in networks that are more integrated. Such integration typically manifests as a large proportion of network providers using the same EMR, sharing appointment systems, and/or accessing a state-wide electronic data interchange (EDI).
• Cost: Purchasers, especially large employers and state agencies, can focus on the extent to which value-based purchasing models are used in the network and the risk-adjusted total cost of care for members. Finally, with the onset of new transparency legislation, purchasers may have greater visibility into the actual cost of procedures.

Importantly, a network’s composition and characteristics should reflect member needs and preferences. Networks should be built and maintained intentionally, based upon the specific utilization, health, and risk profiles of the population being served.

Where to start

Purchasers such as state agencies, the federal government, health plans, large employers, and consortiums have the most ability to influence how networks are evaluated. Aside from individual members, these purchasers stand to gain the most from improvements in access and adequacy. Purchasers should pursue collaborative approaches with health plans to make meaningful improvements to the networks serving their members. Network adequacy evaluation should be an ongoing process. This can be supported by developing standardized metrics, targets, and reporting cadences that serve to match the composition of the network to the characteristics of the population it serves and the goals of the purchasing organization. Some health plans have already started to measure and monitor network performance of these characteristics using regular scorecards and consistent metrics. However, purchasers may wish to set their own standards to ensure alignment with overall goals of the organization. Establishing contract terms and an effective oversight structure to manage performance against these goals will promote increased access and satisfaction with the available network, as well as quickly identify potential gaps or changes in population needs over time.

Summary

Employers, government purchasers, and health plans are looking for innovative ways to create targeted improvements in access where their populations need it most. It is important for health plans as well as coverage purchasers and regulators to understand the characteristics of a network and, to the extent possible, to match that network to the characteristics of the population it serves. Active, targeted network management strategies that focus on quality, cost, and access bring the potential for lower barriers to care, increased patient satisfaction, and a more equitable approach to creating the highest value to patients.

¹ CMS (2023). Qualified Health Plan Issuer Application Standards, Appendix F: Network Adequacy Standards. Retrieved December 20, 2023, from https://www.qhpcertification.cms.gov/s/PY2023QHPIssuerInstructions_NetworkAdequacyStandards.pdf?v=1.

² CMS (November 15, 2023). HHS Notice of Benefit and Payment Parameters for 2025 Proposed Rule. Retrieved December 20, 2023, from https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2025-proposed-rule.

³ Tanne, J.H. (November 9, 2002). Patients are more satisfied with care from doctors of same race, British Medical Journal. Retrieved December 20, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124573/#:~:text=Patients%20who%20could%20choose%20their,trust%20with%20such%20a%20physician.

⁴ Pollitz, K. (February 4, 2022). Network Adequacy Standards and Enforcement. Retrieved December 20, 2023, from https://www.kff.org/health-reform/issue-brief/network-adequacy-standards-and-enforcement/.