A new “secret shopper” study shows that problems exist for patients with acute conditions accessing services for patients. Effectively addressing issues of network adequacy may require more accurate provider information.
Access to healthcare remains a challenge through the Affordable Care Act and commercial health plans, according to a study in the July issue of Health Affairs.
In the summer of 2015, Simon F. Haeder, assistant professor, department of political science, John D. Rockefeller IV School of Policy and Politics, West Virginia University, Morgantown, and colleagues, sought to learn more about network adequacy and access to care. They investigated two questions: first, no matter the nominal size of a network, can patients gain access to primary care services from providers of their choice in a timely manner? Second, how does access compare to plans sold outside insurance Marketplaces?
They conducted a “secret shopper” survey of 743 primary care physicians from five of California’s 19 insurance marketplace pricing regions- Northern Counties, San Francisco, Central Valley, Inland Empire, and San Diego.
They found that inaccurate and outdated provider information and a resistance to new patients were commonplace, both inside and outside California’s marketplace, with only about 30% of efforts to make an appointment with a specific primary care physician ending in success.
“The numbers improved slightly when shoppers were willing to see other providers than the one originally selected, including physician extenders,” Haeder says. “Problems accessing services for patients with acute conditions were particularly troubling with wait times 10 days. We conclude that more frequent updating, potentially coupled with incentives and penalties for both providers and insurers, might be the only path to improved access for patients. Problems were slightly worse for plans sold on Covered California but virtually equally problematic outside of Covered California.”
Keeping provider directories updated is incredibly challenging and resource-intensive, according to Haeder.
“Challenges appear rampant across health plans and across the country,” he says. “At the same time, consumers should know exactly what providers are in a network when they select and purchase a plan. Cooperation between regulators, insurers, providers, and consumers is crucial to improve access and avoid unnecessary costs. It is important that we resolve issues of network accuracy before tackling the equally important issue of network adequacy.”
Haeder says that he and his colleagues were surprised by two main findings. First, there are very few differences between plans sold on and off the marketplaces.
“The latter do slightly better,” he says. “Going into the study, we thought the differences might be larger.”
Second, the authors were surprised at how challenging it was to schedule an appointment at all. The finding show that shoppers were able to schedule appointments with their preferred providers in less than 30% of cases.
“We had expected those numbers to be higher,” Haeder says.