Politics and Network Adequacy – It’s All Local


I once had a local politician tell me that a poll reflects the mood of the particular day it was taken and often ends up wrong in the end. For him, people were fickle and he wouldn’t let one poll dictate his fate.

Perhaps wishful thinking, but this comment has always resonated with me as it’s a good reminder that politics and life are fluid. The same can be said with respect to the issue of network adequacy.

Any census of a health plan’s network is only a reflection of the network on the day the survey was conducted. Since plans build networks through contractual relationships with providers, any change in the agreement, brought on by the provider, the health plan, or an external factor, may trigger a change in the “adequacy” of the network.  A census of providers is also an incomplete tool to assess a health plan’s network as it discounts the perspective of the individual consumer. For example, if a health plan includes enough providers in its network to meet government defined time and distance targets but individual enrollees view the predetermined 30-minute or 30-mile commute targets as unreasonable, is that network to be considered adequate?

In case you’re thoroughly confused here’s a refresher on this topic from the National Association of Insurance Commissioners:

“The issue of network adequacy refers to a health plan’s ability to deliver the benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all health care services included under the terms of the contract.”

This issue, sparked by requirements in the Affordable Care Act, is often couched in policy debates as binary – either a health plan has a “narrow network” or they have a “broad network.”

While debate is often focused on the merits of narrow vs. broad networks, URAC believes that a network adequacy standard based on enrollee needs is superior to an arbitrary number.

Like politics, all healthcare is local. Any solution to address access issues must reflect the unique features of the enrollees and communities served. This belief led URAC to develop a Health Plan Accreditation that is not limited to specific time and distance targets nor does URAC require a certain number of providers in a geographic area. Since the two most commonly accepted formulas for the minimum number or types of providers to be included in a network do not work for every community, URAC standards are focused on a health plan’s ability to monitor and adapt its network against the identified clinical needs and contractual benefits provided to its enrolled population.

For example, URAC-accredited health plans operating on Health Insurance Marketplaces must conduct surveys of member experiences. The plans must then utilize the results of these surveys to inform their evaluation of their network and assess if any changes are required. The plan must have a clear and demonstrable process it follows to conduct the surveys, assess the results against its network, and address any issues that should arise.

URAC’s Health Plan Accreditation also has standards that protect the rights of consumers when they seek access to services. To protect consumers from the risk of poor quality, URAC’s accreditation requires health plans to adhere to these principles:

A health plan must have a network in place that is capable of providing access to the care that their enrollees deserve. We cannot limit our examination of access to a binary discussion on network breadth because we discount the unique needs of consumers and their communities. We can only ensure appropriate access to care if we take a broader view and are focused on the process by which health plans assess their enrollees’ needs and the health plan’s ability to continuously build a high-quality network that meets their enrollees’ needs at an affordable cost.

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