Before the second season of open enrollment on the health insurance exchanges began, I suggested six angles for reporters covering the story. As enrollment moves on through the holiday season, it’s time to take a closer look at one of those angles: narrow networks.
Insurers used to keep costs down in part by denying coverage to sick people with costly illnesses, but the Affordable Care Act requires insurers to provide coverage to everyone, sick or well. The companies have responded by offering plans that include only a limited number of providers, as a way to keep premiums lower: If doctors and hospitals won’t accept the fees insurers will pay, they’re out. “Narrow networks are sometimes used as substitutes for the old underwriting tools,” says Jim O’Connor, an actuary with Milliman, an industry consulting firm. These networks can bring premiums down by 20 percent or more, according to some estimates.
How do consumers feel about the trade-off? In the early going, the signals are mixed. A recent Georgetown study found “few consumer complaints” about narrow networks so far, and a Commonwealth Fund tracking survey found most people who had purchased a plan on the exchanges were happy with it and felt confident they could access needed care. (Commonwealth provides support for The Second Opinion.) On the other hand, it may just be too early for problems to have surfaced; it will be important to watch what happens as more people with exchange plans are diagnosed with new serious illnesses, and need to access surgeons or specialists. People also report difficulty just figuring out whether a doctor or hospital is in a particular plan. And in a case that was closely watched in the industry, South Dakota voters recently approved a ballot measure guaranteeing consumers more provider choice—despite insurer warnings that it will drive up costs.
So far, reporters have mostly focused on the basic consumer advice story by telling people to check if their doctors are in a network—or, more creatively, building tools that make it easier to do that.
But there are other ways to grab hold of the story, too. One is to focus on network adequacy. Are these plans holding costs down by limiting choice, or are they deterring unhealthy people with costly conditions from joining in the first place? A way for reporters to explore this aspect is to scrutinize an insurer’s directory. Pick a costly chronic disease and see how many doctors specialize in treating it and where they are located. If only three doctors treat pediatric cancer and families have to drive miles to see one, that could be a clue that the insurer doesn’t want a lot of people with that disease in the plan. Reporters can also check in with patient advocacy groups like the National Cancer Legal Services Network or the Center for Independence of the Disabled in New York to see if they’re hearing complaints.
Journalists trying to offer guidance to insurance-shoppers can also advise consumers of a new type of network, sometimes called “high-value” or “high-performance” networks. From insurers’ perspective, these narrow networks can be an effective way to manage and coordinate care among select providers. For a consumer, it’s another case where there’s not a lot of transparency, and it can be hard to tell what you’re signing up for—which means there’s a risk people might get stuck in a network with a lot of management they don’t want. There are limits to what journalists can reasonably do here, but they can flag the issue for shoppers, and explore what disclosures their states require and see if the plans comply.
In general, it’s a good idea to familiarize yourself with state regulations about network adequacy, and this report from the National Association of Insurance Commissioners is a place to start. New York, for example, requires that primary care doctors must be available within a 30-minute trip, or 30-mile drive by car in non-metro areas. But that standard is not required for specialists; the rules say instead the state prefers they meet that test. What are the rules in your state—and are providers, or consumers, fighting to change them?
Sabrina Corlette of Georgetown University’s Center on Health Insurance, writing about the NAIC report, concluded that “state regulation of network adequacy has a long way to go to protect consumers and ensure they have appropriate access to care.” If that’s true, reporting on the nuances of narrow networks and network adequacy could lead to better oversight. That’s the kind of old-fashioned journalism this twist in the Affordable Act offers enterprising reporters.
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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.