No matter what kind of health plan consumers choose, they will find fewer doctors and hospitals in their network — or pay much more for the privilege of going to any provider they want. These so-called narrow networks, featuring limited groups of providers, have made a big entrance on the newly created state insurance exchanges, where they are a common feature in many of the plans.
Smaller networks are also becoming more common in health care coverage offered by employers and in private Medicare Advantage plans. Insurers, ranging from national behemoths like WellPoint, UnitedHealth and Aetna to much smaller local carriers, are fully embracing the idea, saying narrower networks are essential to controlling costs and managing care. Major players contend they can avoid the uproar that crippled a similar push in the 1990s.
“We have to break people away from the choice habit that everyone has,” said Marcus Merz, the chief executive of PreferredOne, an insurer in Golden Valley, Minn., that is owned by two health systems and a physician group. “We’re all trying to break away from this fixation on open access and broad networks.”
Simply put: the preponderance of empirical evidence indicates that, compared to physicians, NPs provide as good — if not better — quality of care. As I’ve written previously, patients are often more satisfied with NP care — and sometimes even prefer it.
The Institute of Medicine is unambiguously clear about this:
No studies suggest that APRNs [Advanced Practice Registered Nurse] are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs.
This is Austin Frakt:
However, from another point of view, the formula — as flawed as it is — has helped keep Medicare spending lower than it might otherwise have been. Instead of cutting physician payments by the large amount the S.G.R. demands, Congress has increased payment rates, but typically by only tiny amounts — at an annual rate of just 0.7 percent.
But, although fees have only increased 8 percent since 2000, Medicare’s spending on physicians has increased 69 percent per patient. This is because the number and intensity of treatments has increased significantly. Could doctors have responded to lower real fees by cranking up volume?
This is Aaron Carroll:
I’m truly conflicted here. Like any good “economist”, I’m worried about future health care spending. I know that fee-for-service just sucks, and that the financial incentives for practice are totally misaligned. But I remain totally skeptical about pay for performance (see this, this, this, this, this, this, and this). I don’t see much evidence that programs like that work, and I don’t believe that the things we can measure are necessarily the same as how we’d ideally define quality.
I’m also concerned with making doctors the ones responsible for deciding what’s “worth it.”
One doctor reports:
I can see a Medicaid or Medicare patient for five minutes or forty-five, and up until now, because I work for a Federally Qualified Health Center, the payment we actually receive is the same.
I can chat briefly with a patient who comes in for a dressing change done by my nurse, quickly make sure the wound and the dressing look okay and charge for an office visit. But I cannot bill anything for spending a half hour on the phone with a distraught patient who just developed terrible side effects from his new medication and whose X-ray results suggest he needs more testing…
Most people are aware these days that procedures are reimbursed at a higher rate than “cognitive work”, but many patients are shocked to hear that doctors essentially cannot bill for any work that isn’t done face to face with a patient. This fact, not technophobia, is probably the biggest reason why doctors and patients aren’t emailing, for example.