Do We Really Need Choice in Healthcare?

The concept of narrow networks is one of the most hotly debated topics in healthcare today, with supporters touting their ability to lower costs and detractors condemning their restricted access.

In theory, consumers prefer greater access. However, when the rubber meets the road — that is, when the consumer actually selects a health plan — financial issues are the number one factor influencing that decision. To wit, a recent study by the Urban Institute found, "Marketplace enrollees most often rate the premium (67.1 percent), the deductible (62.0 percent), and the maximum annual out-of-pocket spending limit (57.8 percent) as very important."

If consumer participation in health exchanges grows (as is expected), and if more consumers are enrolled in narrow-network plans as a result, what would this mean for the quality of care they receive? Will patients be barred from accessing the physicians and facilities providing top-quality care?

Narrow networks do not inherently reduce quality, says New York Times columnist Ezekiel Emanuel, MD, but they have the potential to limit an individual's access to high-quality providers if the health plan does not ensure the network providers provide the highest-quality care. In a recent column, he writes:

"Despite the fact that so many Americans are already in selective networks, they are nervous that the Affordable Care Act, which I helped design as an adviser to the Obama administration, will further restrict their choice of doctors or make them pay higher out-of-network charges. There was a similar backlash in the 1990s, when managed care was on the rise.

But selective networks themselves are not a problem. The problem is that not all networks are of consistently high quality.

Millions of people enroll in top-flight managed care plans like Kaiser Permanente, limiting themselves to the physicians employed by these companies. Rarely do you hear Kaiser beneficiaries complain about the tyranny of their restrictive network. Why should they, when they have first-rate providers?"

Yet, he writes, "Inevitably, some insurance plans will offer narrow networks with poor-quality providers."

So, while narrow networks can provide access to high-quality providers at a lower cost than traditional plans, how can policymakers ensure that all narrow network plans provide access to quality providers?

Dr. Emanuel offers four suggestions:

1. Require narrow networks "adequate" access as defined by the the National Committee for Quality Assurance's Network Adequacy Requirements. These requirements are intended to ensure health plans provide in-network access to an adequate number of physicians, spanning all subspecialties, within a geographic area.

2. Increase transparency around insurers' guidelines for network inclusion. Ideally, "high-performing" status would not look at costs alone, but also at outcomes and C-HCAHPS scores.

3. Improve measures for rating health plan quality. Currently, no reliable measurement systems exists to assess a plan's access to high-quality providers.

4. Encourage/require insurers to provide out-of-network consults at selected centers of excellence around the country, at in-network rates for patients with complex, serious conditions, such as cancer.  "Any enrollee who develops a serious condition like cancer [could] obtain a second opinion at a recognized center of excellence (like Memorial Sloan–Kettering, for cancer, or the Cleveland Clinic, for heart disease) for the price of an in-network deductible or co-payment," Dr. Emanuel explains.

Narrow networks need not be a dirty word in healthcare. They present a promising approach for containing healthcare costs — something our country desperately needs. Further, if network develop considers both efficiency and quality, those in narrow network plans could actually receive higher-quality care than those with greater access, since larger networks could potentially have less-strict quality requirements, all in the name of more choice.

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