Holding health plans accountable for shortcomings in the physician network

It is important that health plans have sufficient networks to provide access to in-network doctors and hospitals that meet the care needs of enrollees. But when networks are insufficient, they create obstacles for patients seeking new or continuing care. It also limits patients’ choice of doctors and facilities.

That’s why regulators use network adequacy standards and other requirements to ensure health plan enrollees can access in-network care within reasonable distances and time frames, according to a report by the AMA Council on Medical Services whose recommendations were adopted at the AMA’s 2023 interim meeting.

Regulators must do more to ensure network adequacy so that “patients have choices in accessing care,” said AMA President Jesse M. Ehrenfeld, MD, MPH. The newly approved policy “will help the AMA encourage a multi-layered approach to regulatory oversight that includes meaningful standards, transparency in network breadth, standards of out-of-network care, and effective monitoring and enforcement of existing standards.”

According to the AMA Council report, “Physicians and other providers are also affected by network adequacy, and although strong network adequacy standards should incentivize health plans to bargain fairly, insufficient networks can negatively impact physicians’ bargaining power.”

“Network deficiencies often lead to excessive wait times for appointments and burden many in-network doctors, contributing to increased burden and potential liability for delayed care,” the report adds.

To address network adequacy and reduce the burden on physicians, the AMA House of Delegates adopted a policy “to support the establishment and enforcement of minimum network adequacy standards that require all health plans to contract with adequate numbers and types of physicians and other providers, including mental health and substance use disorder, So that scheduled and unscheduled care can be provided without unreasonable travel or delay.

The AMA will also encourage:

• Develop and disseminate network adequacy assessment tools that allow patients and employers to compare insurance plans and make informed decisions when enrolling in a plan.
• Use claims data, audits, secret shopper programs, complaints, enrollee surveys, or interviews to monitor and verify in-network provider availability, wait times, network stability, and accuracy of the provider directory, and to identify other access or quality issues.

Under the newly approved policy, the AMA asserts that “in-network physicians who provide in-person and telehealth services may count toward health plan network adequacy requirements on a limited basis when their physical practice does not meet time and distance standards, based on the regulator’s discretion, as This is when there is a shortage of doctors in the desired specialty or subspecialty within the community served by the health plan.

Notably, the policy says the AMA “does not support counting physicians who only provide telehealth services to meet network adequacy requirements.”

Delegates also voted to “support regulation to hold health plans accountable for network deficiencies, including through the use of corrective action plans and significant financial penalties.”

In addition, the House of Delegates adopted a policy to “encourage the use of multiple criteria to evaluate the adequacy of health plans’ physician networks,” including:

• Minimum physician-to-registrant ratios across specialties and subspecialties, including mental health and substance use disorder providers accepting new patients.
• Minimum percentages of non-emergency physicians available on nights and weekends.
• Maximum time and distance standards, including for registrants who rely on public transportation.
• A clear standard for wait times for network appointments across specialties and subspecialties, developed in consultation with appropriate specialty societies, for both new patients and continuing care, that is tailored to the patient’s urgent and non-urgent health care needs.
• Sufficient physicians to meet the care needs of people with economic or social marginalization, chronic or complex health conditions, disability or limited English proficiency.

Additionally, the AMA would support “requiring health plans to report to regulators annually and prominently display network adequacy information so that it is available to enrollees and consumers shopping for plans.” This includes:

• Breadth of the plan’s provider network, by county, geographic region, or metropolitan statistical area.
• Average wait times for primary and behavioral health care appointments as well as general specialty and subspecialty referrals.
• The number of in-network doctors who treat substance use disorder and who are accepting new patients in a timely manner, and the type of substance use disorder medications provided.
• The number of in-network psychiatrists and other mental health providers accepting new patients in a timely manner.
• Instructions for consumers and doctors to easily contact regulators to report complaints about inadequate provider networks and other access problems.
• Number of doctors versus non-physician providers in the network overall and by specialty and practice focus.
• The number, geographic location, and medical specialty of any physician contracts terminated or added during the previous calendar year.

In a separate measure, delegates moved to address “any willing provider” laws that allow doctors to contract with insurance companies to participate as in-network doctors without discrimination.

Many insurance companies limit access to their networks for new doctors. This limits the physician’s ability to establish a practice and provide care to patients. But some states have adopted “any willing provider” laws, which allow doctors to contract with insurance companies, according to a resolution introduced at the interim meeting.

The AMA “believes that access to quality health care should not be limited by insurance company practices that limit physicians’ ability to establish a successful practice,” the resolution says.

To this end, the House of Delegates directed the AMA to:

• Develop and advocate for “any willing provider” model legislation nationwide, enabling all physicians to build successful practices and deliver high-quality patient care.
• Lobby for federal regulations or legislation requiring insurers to carry “any willing provider” policies as a prerequisite for participation in federally supported programs.
• Working with state and national organizations, including insurance companies, to promote and support the adoption of “any willing provider” laws, we will monitor the implementation of these laws to ensure they have a positive impact on access to quality health care.

Read about other highlights from the 2023 AMA Interim Meeting.