As healthcare costs continue to rise, payers and providers accept accountability for coordination of care, patient expectations change, and medical technology keeps advancing, health care is in a state of disruption. Innovation is changing the way patients and providers think about access yet health plan network adequacy standards have largely remained the same.
In this new environment, medical providers and health insurers are incentivized to develop new skills and strategies. The new emphasis is now on ensuring patients actually get the care they need and want, and this increasingly means providing nontraditional services, such as virtual care.
However, right now, network adequacy standards still focus largely on access defined by distance and time how far patients have to travel to visit a doctor and the amount of time it takes to get there. Other criteria include how long it takes to get an appointment and the ratio of health care professionals to patients. These structure and process types of metrics are only proxies for whether plan enrollees actually have meaningful and effective access to the services they need.
Learn more about why network adequacy standards in health care need to be updated.
Though patient and consumer advocates generally call for more regulation and broader health plan networks, narrower networks can actually make plan premiums more affordable and may also promote tighter controls over the quality and coordination of services. Better measurement criteria could help resolve this tension and help patients identify the health plans with providers that do a better job of getting their members the care they need when they need it.
Technology has also improved access to information to both patients and providers. Information can increasingly flow between doctors and patients and be shared with other doctors. Patients can use the Internet to consult with their doctors, check on tests, refill prescriptions and make appointments—making geographical distance less relevant. And the Internet of Things can facilitate the use of patient-generated health data to provide a more comprehensive picture of ongoing patient health—opening a window into how patients are doing between office visits and on an ongoing basis.
All these advancements have a common theme: They put the focus on patient outcomes rather than on structure and process. It now matters less where a doctor is located than the quality and value of care that he or she provides.
So access to quality health care needs to be measured in a totally different way. That means regulatory standards will have to be updated and reimagined. And they’ll have to be flexible enough to accommodate rapid changes in how medical services are delivered, ongoing advances in medical technology and changing patient demands.
Date: December 27, 2016