Media outlets have focused extensively on consumer complaints about “limited networks” and not being able to find a doctor under qualified health plans (QHPs) offered through the Health Insurance Marketplaces (HIMs). In response, the Obama administration released new standards which will require all QHPs to contract with a larger proportion of essential community providers within its service area. This means that health plans will be forced to accept more health care providers within their network, which may potentially increase costs for consumers.

At the heart of the recent changes lies a fundamental question worth exploring: Is consumer satisfaction with, and perceptions of health plan “network adequacy” grounded in the number of choices for doctors within network, or is it something different?

It seems unlikely that consumers would be interested in the former; after all, most consumers only need one primary care doctor and perhaps a specialist or two.  Also, if you ever had the experience of looking for a new doctor using traditional provider directories, you may have been overwhelmed by the sheer number of names and addresses to sort through.

This speculation is supported by behavioral economic research into choice overload: when consumers are faced with too many choices, it can lead to problems with decision making such as confusion or ‘choice paralyses’. It’s no wonder that a majority of consumers still rely on word-of-mouth referrals when picking a new doctor.

Instead, it’s possible that consumers might be better served by having information to help them “matchwith doctors or other health care providers based on factors of consumer preference, such as proximity and languages spoken, and provider availability, such as accepting new patients and number of days to the next available appointment.

This idea is rooted in economic search theory; if information can help consumers more easily identify available doctors and pick one that meets their needs, we reduce the costs of finding a doctor (time, effort, and frustration). Consumers need better information to help them easily find the, or at the least a doctor that is available and fits their needs.

Indeed, collective complaints surrounding “limited networks” that are reported in the media do not appear to be about the absolute number of providers listed within network, but are conflated with it. Some reports have focused on consumers having trouble finding a doctor, meaning that there is a lack, or perceived lack, of providers who are available to treat patients. Other reports highlight consumers not being able to see the particular doctor that he or she prefers; especially worrisome are reports of consumers expecting a doctor to be in-network based on provider directories, but finding that the doctor is in fact not within network.

There is no simple or single measureable definition or benchmark for network adequacy, and bluntly forcing QHPs across all markets to broaden their networks will not guarantee that a consumer’s preferred provider will now be included within a network, or that consumers’ experience of finding an available provider will be any easier.

The result of this continued lack of information is that consumers may still incur lost time and frustration, which builds dissatisfaction and distrust, undermining an important goal of the HIMs and QHPs. Further, HIMs hoping to attract and keep consumers satisfied will have to try to keep the need to broaden networks in check against cost.

In fact a survey conducted by the Kaiser Family Foundation found that HIM consumers might prefer lower costs to broader networks. Although making the difficult trade-off for a broader network at a higher cost may well be the best decision in some markets, policies which make better information available to consumers could improve consumer satisfaction and perceptions of network adequacy without unnecessarily forcing QHP networks to broaden their offerings.

What Could HIMs Do to Improve Consumer Perceptions of Network Adequacy Without Broadening QHP Networks?

The American Institutes for Research has extensive experience conducting research on consumer experience with health insurance. Drawing from our current work in developing consumer satisfaction surveys for QHPs and HIMs — our qualitative study of early care experiences under Covered California and our work in health insurance literacy, communication, and consumer engagement — we have considered policy approaches that could yield better outcomes of customer satisfaction with QHP networks.

HIMs should enable consumers to pick QHPs based on provider. Some consumers may highly prefer their choice of health care provider even at a higher cost, and HIMs may be able to help them with tools to easily filter plans by provider and/or facility. Some state HIMs, such as Minnesota and Washington, already enable users to filter plans by provider, but no states have currently incorporated factors of provider availability into the filters. Such a feature would help prevent consumers from guessing and contacting multiple offices to see where they can quickly obtain care.

HIMs should provide consumers with better information on how their health plan worksConsumers are not experts in using health insurance, and shouldn’t be expected to take that role. However, HIMs can help consumers understand the basic steps of finding a provider, obtaining care in-network, and understanding their rights. HIMs can activate patients to call a doctor’s office to ensure that they accept a particular plan, to ask specifically for in-network referrals for specialists, and file complaints with the appropriate authorities when necessary.

HIMs should require higher standards for provider directories to reduce guesswork. Foremost, provider directories are not useful to consumers if the information is not accurate and are a serious consumer protections issue. Several HIMs are beginning to consider accuracy standards for QHP carriers, but it is not clear how to best audit and keep carriers accountable. Carriers may have to work more closely with providers to clear up confusion about which plans are accepted by the provider, particularly with large group practices who sometimes contract out for its’ individual offices.

Aside from provider names, specialties, and addresses, HIMs could also require more robust information in provider directories such as provider-level availability or average wait time to next available appointment by plan, geo-location tools, and even provider-level quality information to help consumers find the right provider for their needs. In addition, HIMs could require usability standards that make provider directories more consumer-friendly.

Although some of the proposed remedies might require a significant investment and continued oversight from the HIMs, successful reforms could lead to spill-overs beyond just the HIMs. Better informed and engaged consumers are key to moving the entire health care market towards improved efficiency, and HIMs could play an important role in initiating it.

Author’s note: Thank you to Thomas Workman and Grace Wang for their contributions to this post.  

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