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Time to Demand Network Adequacy

Marketplace plans contain at least 25% of area physicians, but are they the right mix? (Volume 10, Issue 23)

While the Affordable Care Act was specific about minimum standards for health insurance plans, it was vague in defining adequate access in the Marketplace. Repeal efforts have focused on more insurance plan choices but offered little discussion about widening the number or variety of healthcare providers.

Health policy researchers studied Marketplace provider networks and examined premiums, cost sharing, physician and hospital characteristics, and enrollee demographics. They are the first to compare the association between network size and enrollment and enrollees’ characteristics. They demonstrated that the physician networks were stable from 2015 to 2016.

The majority of Marketplace networks contained at least 25% of local area physicians. As discussed previously, narrow networks are a result of negotiations between insurers and providers. However, there is no mention of the ratio of primary care physicians to specialists. A higher ratio of primary care doctors leads to lower rates of death from heart disease and cancer.

Additionally, ensuring the spectrum of services available and accessible to patients is important. The ACA established essential health benefits, but if physicians have objections to prescribing contraception or the nearest mental health provider is an hour away patients will not be able to easily access the care they need.

Furthermore, it is not surprising that lower-income enrollees selected cheaper, narrow network plans. Many people with limited resources must figure out the best use of their money. However, it is hard for patients to find out whether they are getting good value for their health care dollar.

When people look up in-network providers, they cannot always compare quality. Patients cannot see whether one PCP appears better at ensuring her patients are receiving appropriate health screenings or is more likely to prescribe antibiotics for colds.

Quality metrics themselves are not perfect. Electronic medical records have to capture the right data, outside reports must be scanned, and information about the socioeconomic status of the patient population is limited. Physicians and hospitals may limit the types of patients they treat in order to improve quality reports.

In the future, we should look at the types and numbers of providers to define network adequacy. Disparities in health outcomes between different plans should be evaluated to ensure high quality and promote health equity.

commentary by May Nguyen, MD, MPH


The Affordable Care Act allows commercial insurers participating in the Marketplaces to vary the size of their provider networks as long as the providers are “sufficient” in numbers and types. Concerns have been growing over the increasing use of restricted-provider or narrow networks in Marketplace plans because of their implications for reduced access to care, but little is known about the breadth and stability of these networks over time or what types of enrollees choose such plans. Using national data, we found that in 2016, 60 percent of provider networks in plans offered in the federally facilitated Marketplaces included at least one-quarter of local-area physicians, and that consumers’ access to broad-network plans remained stable between 2015 and 2016. Hispanic and low-income people made up a disproportionate share of enrollees in smaller-network plans (those with fewer than one-quarter of local-area physicians). It will be important to monitor the impact of narrow networks on access to and quality of care as well as on health outcomes. PMID: 28874489 

Sen, AP, et al. Health Affairs. 2017; 36(9): 1615-1623.

Bich-May Nguyen, MD, MPH
About Bich-May Nguyen, MD, MPH

Dr. Nguyen Bich-May Nguyen, MD, MPH, FAAFP cares for patients at a patient-centered medical home and teaches medical students and residents in the clinic and hospital setting. She received an MD in the Underserved Track from Baylor College of Medicine and an MPH with a concentration in health policy from Harvard School of Public Health. She completed her residency training in Family Medicine at Boston University. Dr. Nguyen is involved with the National Physicians Alliance and serves on the Executive Committee of the New Leaders Council Houston. You can follow her at @bicmay. She began contributing to Policy Prescriptions™ in 2013. Contact: Website | Facebook | Twitter | Google+ | More Posts