By Trudy Lieberman
Community Health News Service
The next time you hear someone — likely a politician or spokesperson for a medical special interest group — argue that America’s health insurance arrangements are fine because they offer lots of choice for patients, don’t take them seriously.
What choice are they talking about? Almost anyone navigating the health system over the last decade knows that insurers have limited where they can go for care and whom they can see.
The concept of limiting patients’ choice of doctors, hospitals and other medical services like radiology practices or speech therapy began a few decades back with HMOs. The health management organizations argued that, to assure quality, they were allowing their insured patients to see only the best providers.
The theory sounded good, but in practice the health providers squawked and networks gradually became more inclusive. That changed again as costs continued to rise and insurers started to choose only doctors who accepted their fee schedules. Things got kind of muddy for patients because they didn’t know for sure whether a doctor was in the network because they charged low prices or because they offered superior care.
The way networks operate has gotten even more opaque and manipulated, according to new research from Simon Haeder, Penn State assistant professor of public policy, and his colleagues. Their research tells us more about how insurance carriers are limiting patient choice.
Do insurers deliberately exclude doctors offering certain specialties in the hope of forcing out the “lemons” among their insured patients — those likely to be sick? Haeder told me that may be happening.
For example, diabetics need to see endocrinologists periodically to help manage their disease. However, if the insurer constructs a network with no or few endocrinologists, patients may be forced to seek care elsewhere or pay out of pocket. Such a strategy, says Haeder, allows an insurer “to offload costs” they don’t want to pay.
It’s even harder to find doctors in fields where there are fewer providers such as cardiac surgeons, podiatrists, and in some cases, obstetricians and gynecologists. The problem is even greater in rural areas where it’s common for patients to drive many miles to find a practitioner to treat them.
Haeder and colleagues also found that the problems with network adequacy also applied to coverage offered through Medicare Advantage (MA) plans. Sales presentations for MA plans often omit the fact they restrict choice through narrow networks.
Haeder’s study examined MA plan networks in California and found that seniors may have trouble accessing care. His research showed that large numbers of them might have to travel 30, 60, or even 120 miles to find a higher quality doctor.
Furthermore, he noted, an analysis of coronary stent procedures in New York State showed that provider networks might be more restrictive for MA plan members than for those who get coverage from policies sold in the Affordable Care Act marketplace.
Inaccurate and out-of-date directories also limit patient choice. If directories report that certain specialists for treating kidney problems are located nearby, but when you call for an appointment and you find they are no longer practicing, what do you do? Go without care? Pay out-of-pocket? Or search far and wide for someone who takes your insurance?
When the Affordable Care first went into effect and for a few years after that, the media and advocacy groups did point out that many plans had few providers and others offered directories that were out of date. They singled out those plans.
There’s not much of that kind of reporting or outrage these days. Maybe it should come back to highlight the significant barriers to care Haeder uncovered.
“We thought if we gave people insurance everything would be great,” he told me. “But there’s a difference between having insurance and having access to care.”
The focus of advocates, policymakers and even some insurers became the premium people would pay. But the premium is only one element of a policy that determines the final bill to the consumer. Coinsurance, copays and deductibles, all of which have risen astronomically in the last few years, are equally important and are contributing to the rising medical debt.
Knowing which providers are in a network is important, so is understanding the games insurers play to do what insurers always do: limit their risk of paying out money for sick people.
Have you had experience finding doctors nearby? Write to Trudy at [email protected]