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- Title
Mixed signals: The inadequacy of provider‐per‐enrollee ratios for assessing network adequacy in California (and elsewhere).
- Authors
Haeder, Simon F.; Weimer, David L.; Mukamel, Dana B.
- Abstract
Health insurance regulators often set minimum ratios of provider = per‐enrollee for health insurance plans to try to ensure that their provider networks offer enrollees adequate access to medical care. However, plan‐specific ratios only have an unambiguous interpretation when each provider participates in only one single network. Based on network data, we show that endocrinologists, obstetrician–gynecologists, cardiologists, and pediatricians in California participate on average in 64, 66, 72, and 63 networks, respectively. Such high participation rates in networks make provider‐per‐enrollee ratios measured at the plan level meaningless as metrics for access. We recommend that plan‐specific ratios be abandoned in favor of a more qualitative approach with strong dispute resolution protections as well as "police patrols" (e.g., regulator surveys to assess waiting times for appointments) and "fire alarms" (e.g., investing resources in consumer advocate organizations). Key points: • Provider‐to‐enrollee ratios are one of several tools used by regulators to ensure adequate networks for consumers. • These ratios are only meaningful indicators of network adequacy in very rare circumstances. • Reliance on these ratios thus does little to ensure access to medical care for consumers. • Qualitative standards with strong dispute resolution protections, consumer empowerment, and regulatory oversight may provide better protections.
- Subjects
CALIFORNIA; DISPUTE resolution; POLICE patrol; HEALTH insurance; CONSUMER cooperatives; FIRE alarms
- Publication
World Medical & Health Policy, 2023, Vol 15, Issue 3, p258
- ISSN
1948-4682
- Publication type
Article
- DOI
10.1002/wmh3.466