Many Medicare Advantage members have narrow provider networks
Medicare Advantage (MA) has gained popularity with members and payers, but a new study of 2015 data by the Kaiser Family Foundation (KFF) found that MA plans offered narrow networks to many enrollees.
In what KFF said is the first study to examine the size and composition of MA plans’ physician networks, researchers found that 35% of MA enrollees were in narrow-network plans compared to 22% who were in broad-network plans in 2015.
The report also found that an average of only 46% of all physicians in a county were in MA networks, which limited doctor offerings for members.
About one-third of those in Medicare have an MA plan, and the CMS predicted that number will increase in 2018. Payers have also been bullish about MA’s future. UnitedHealth Group, which is the largest MA payer, expects that eventually half of all Medicare beneficiaries will have an MA plan.
The KFF analysis looked at 2015 data for 391 plans offered by 55 insurers in 20 counties, which made up 14% of MA enrollees.
Researchers found that physician network size varied greatly. Access to psychiatrists was more commonly restricted compared to other specialties. MA plans only provided an average of 23% of psychiatrists in a county. That includes 36% of MA plans that had less than 10% of psychiatrists in their county. Other specialty problems included few cardiothoracic surgeons, neurosurgeons, plastic surgeons and radiation oncologists in many MA networks.
The narrower networks meant fewer physician options, but much lower prices for members. Broad-network HMOs averaged $54 per month compared to $4 for narrow-network plans, and broad-network PPOs were $100 a month compared to $28 for narrow-network plans.
Payers have increasingly turned to narrow networks as a way to control costs and improve quality of care. To take part in the narrower networks, physicians usually have to agree to payer demands about cost and quality.
So, though the narrow networks are reducing costs and are cheaper for MA members, the trade-off is fewer in-network doctors. If there’s an emergency, MA members in narrower networks are unlikely to make sure providers are in-network, so may receive out-of-network care and face hefty medical bills.
“Differences across plans, including provider networks, pose challenges for Medicare beneficiaries in choosing among plans and in seeking care, and raise questions for policymakers about the potential for wide variations in the healthcare experience of Medicare Advantage enrollees across the country,” said KFF.
KFF's findings aren't the only concern about MA provider networks. The CMS has said that many MA provider directories include incorrect information, such as which providers are taking patients. The CMS found that 45% of MA provider directors had wrong information. The CMS is requesting more oversight over MA payers’ provider networks, so insurers will give current and accurate information about their providers.
- Kaiser Family Foundation Medicare Advantage: How Robust Are Plans’ Physician Networks?