Narrowing Networks Doesn’t Mean Limiting Care

By Steven Shill and Bill Bithoney

Fewer options, lower quality of care delivery and dissatisfaction from consumers and providers alike are becoming all too familiar concepts for health insurers when talking about narrowing networks. But it doesn’t have to be this way. In fact, a study published in the health policy journal “Health Affairs” analyzed Covered California, the state’s exchange, and discovered that the care provided in these particular narrow networks was comparable, if not better, in some cases, than the care non-Covered California consumers were receiving.

“Narrow networks” comprise healthcare providers that meet pre-determined cost and quality measures, to the exclusion of providers that do not.

To replicate the Covered California findings, health insurers would be wise to conduct a three-phased approach to proactively selecting the right mix of providers.

Phase One: Discovery

Emphasizing strategic priorities that include both short- and long-term milestones, as well as key metrics and data sets, can help achieve this goal. First, determine which clinical management activities are of the greatest importance for a primary care provider, hospital, skilled nursing facility, etc., and consider, too, that these metrics should be highly scalable from an individual physician to an entire enterprise. As a next step, conduct a data assessment to identify target provider populations, covering both high and low performing physicians to compare and contrast successful and failing programs. This process not only sheds light on where deficiencies exist, but also uncovers room for opportunity. A deeper dive into the market dynamics of the populations served, care pathways and referral patterns, as well as compensation models, will also be beneficial in assessing what’s needed.

Phase Two: Development

Findings from the first phase will help build an infrastructure to engage providers, which is a vital next step in the selection process. Develop a strategic plan that covers the creation and implementation of training and education programs, future service needs, resource allocation, investment requirements, data sharing and infrastructure changes (e.g., development of electronic health record capacity to track patients across the care continuum). This approach serves as an important component to ensuring the proper combination of providers is included to best suit the covered populations.

Phase Three: Implementation

As an insurer moves through phases one and two, there will likely be areas where it can simply build upon and leverage existing practices, thus implementing the aforementioned approaches along the way. For those instances when it’s necessary to assemble new processes, consider digging deep into those findings and engaging firms with experience that is supported by regulatory, clinical, data analytics and financial knowledge. This can aid in the ultimate realization of an all-encompassing “narrow” network.