Best Practices

Is access to patients the next big challenge?

Strategies for dealing with limited networks — or, “déjà vu all over again.”

By Derek Preece

In the mid-1990s, I tried to convince an insurance company executive to let a pediatric ophthalmologist join one of his health plan panels. Adamant, he insisted that the plan had “enough ophthalmologists” on it. I pressed, pointing out that the network had no fellowship-trained pediatric ophthalmologists within 40 miles, but he didn’t seem to understand the difference that made. Frustrated with my persistence, he finally said, “Derek, we’ve found that when we add more doctors to our health plans, the money we pay out for patient care goes up. We don’t need any more ophthalmologists on that panel.”

My retort was quick and unwelcome: “So you’re saying that limiting the number of doctors in your network is one way for you to ration care?” His immediate denials were followed by quick back-pedaling, as the executive tried to convince me that paying out less for care was not equivalent to rationing. The fact is, however, that insurance plans do pay out less money for care when fewer doctors are available to patients. In the current cost-cutting environment, insurers are beginning to revert to old tactics.

This time around has a new twist: Insurers are sometimes terminating doctors they deem to be “high cost,” many of whom have substantial numbers of patients on Medicare Advantage plans. Obviously, the impact on ophthalmology is significant. It appears some insurance companies have patterned their actions on principles codified in the Affordable Care Act (ACA), including the formation of private networks based on accountable care organizations.

PROTECTING YOUR PRACTICE

Whatever the reasons, shrinking health-care networks present a challenge for ophthalmology practices. Because patients are penalized financially for using out-of-network providers, most patients will opt for a new physician if their ophthalmologist is no longer in their network.

What can a practice do to protect itself from losing patients? There is no silver bullet to ensure patient access, but the odds favor the practice remaining on an insurance panel that:

• Monitors utilization of services, patient satisfaction and insurer evaluations, making corrections where needed.

• Builds relationships with insurers rather than seeing third-party payers only as adversaries.

• Remains open to new ways of working with insurers and hospitals or large multispecialty practices that control insurance contracts.

• Becomes savvy enough about its financial structure to accurately evaluate insurance plan contracts.

• Maintains a “seat at the table” with regard to patient access discussions in its local community.

PUTTING IT INTO ACTION

Building a reputation with insurers as a reasonable, helpful administrator can yield big dividends for your practice. But how do you do that with a third-party payer? One administrator I know contacted an insurer when he was credentialing a provider. He spoke to a manager about its physician networks. During subsequent phone calls, the two built a relationship as the practice administrator asked his counterpart exactly what the insurer was looking for in terms of ophthalmic providers and how the practice could better provide services to members. Those questions — unusual from providers — led to further discussions and a growing, cooperative relationship.

Later, when that insurance company manager needed to build a network for a new plan, he naturally called his “friend” and offered him an exclusive contract.

In the late 1990s, the patient-access pendulum swung away from very restricted networks, with insurance companies finding that employers didn’t want to buy their insurance plans because of their workers’ complaints about not having access to enough doctors. Soon, we saw advertisements touting insurance plans that featured “the largest network of doctors in the state.”

Will the same thing happen this time? It’s possible, but now the difference is the ACA is pushing insurers and providers to reduce costs, so the pendulum may not swing back as readily as it did two decades ago. OM

Derek Preece is a principal and executive consultant with BSM Consulting, an internationally recognized health care consulting firm headquartered in Incline Village, Nev. and Scottsdale, Ariz. For more information about the author, BSM Consulting, or content/resources discussed in this article, please visit www.BSMconsulting.com.