Hold health plans accountable for physician network inadequacies

It is important for health plans to have adequate networks to provide access to in-network physicians and hospitals that meet enrollees’ care needs. But when networks are inadequate, it creates obstacles for patients seeking new or continued care. It also limits patients’ choice of physicians and facilities.

That is why network adequacy standards and other requirements are used by regulators to ensure that health plan subscribers can access in-network care within reasonable distances and timeframes, according to an AMA Council on Medical Service report whose recommendations were adopted at the 2023 AMA Interim Meeting.

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

According to the AMA council’s report, “Physicians and other providers are also impacted by the adequacy of a network and, although strong network adequacy standards should incentivize health plans to negotiate fairly, inadequate networks can negatively impact physicians’ bargaining power.”

The report adds that “network inadequacies often lead to excessive appointment wait times and overburden many in-network physicians, contributing to increased burden and potential liability for delayed care.”

To address network adequacy and reduce the burden placed on physicians, the AMA House of Delegates adopted policy to “support establishment and enforcement of a minimum network adequacy standard requiring all health plans to contract with sufficient numbers and types of physicians and other providers, including for mental health and substance use disorder, such that both scheduled and unscheduled care may be provided without unreasonable travel or delay.”

The AMA also will encourage:

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

Under the newly adopted policy, the AMA affirms “that in-network physicians who provide both in-person and telehealth services may count towards health plan-network adequacy requirements on a limited basis when their physical practice does not meet time and distance standards, based on regulator discretion, such as when there is a shortage of physicians in the needed specialty or subspecialty within the community served by the health plan.”

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

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

In addition, the House of Delegates adopted policy “to encourage the use of multiple criteria to evaluate the sufficiency of health plan physician networks,” including:

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

Additionally, the AMA will “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:

• The breadth of a plan’s provider network, by county and geographic region or metropolitan statistical area.
• Average wait times for primary and behavioral health care appointments as well as common specialty and subspecialty referrals.
• The number of in-network physicians treating substance use disorder who are accepting new patients in a timely manner, and the type of substance use disorder medications offered.
• The number of in-network psychiatrists and other mental health providers accepting new patients in a timely manner.
• Instructions for consumers and physicians to easily contact regulators to report complaints about inadequate provider networks and other access problems.
• The number of physicians versus nonphysician 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 prior calendar year.

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

Many insurance companies limit access to their networks for new physicians. This limits a physician’s ability to establish a practice and provide patient care. But some states have adopted “any willing provider” laws, which allow physicians to contract with insurance companies, according to a resolution that was presented at the Interim Meeting.

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

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

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

Read about the other highlights from the 2023 AMA Interim Meeting.