Health Plan Quantity, Quality, and Customer Communication

December 30, 2015

When you choose your insurance health plan, what matters more: that the participating doctors be good or that there be lots of them? 

The question takes on practical meaning because, according to this report, a lawsuit filed in the Manhattan Supreme Court alleges that a health plan falsely inflated the number of its providers. For example, it states that of the 216 gynecologists one member found on the plan site, only 8 were actually participating.

Why would a health plan inflate the number of providers? Does quantity of providers matter?

Healthcare delivery is largely financed through remote, clinically removed third parties. These third-party payers manage cost by contracting providers for services at specified allowed amounts. These third-party payers sell their services to customers that include employers such as county governments, school boards, law firms, manufacturers, and the like.

The customers are themselves remote, clinically removed third parties. Their human resource departments are charged with opening access to clinical care for employees and their families. These members need numerous services ranging from pre-natal care to cancer screening to psychiatric treatments. In this scenario, there is a legitimate pressure by members on employers on payers for quantity: more doctors, more locations, more services.

According to the report, the health plan manages a network 67,000 providers. Plenty of quantity, but what about quality? The health plan is clearly sensitive to the latter and says right on its website that it providers "quality ... health insurance coverage." So what does it mean by "quality?" 

Let's consider an example. The plan web site Quality Management page devotes a section to Provider Report Cards. This language has from time to time been used to suggest that providers are scored for quality. Not in this case. The Provider Report Card page is actually about notifications sent to doctors when claims data do not show that certain services have been taken by the patient. They would almost seem to point to the quality of the patient, not the doctor. As a customer, it does not answer my questions about the quality of the network. 

In developing this post, we did not review every page of the health plan web site. It is possible that other sections address the question of physician quality. Here are some of the questions we would want answered:

     - how is provider quality defined?
     - who oversees provider qualification?
     - what are the provider inclusion criteria?
     - what are the provider exclusion criteria?

Each patient has specific, individual needs. In this light, it is obvious that choice is good and that broad, accessible networks are appealing. But at what price? Does a plan serve its customers well by increasing quantity at the expense of quality? Does it serve them well by not precisely and transparently disclosing both quantity and quality? 

To earn trust, the quantity, type, and location of providers should be presented precisely and transparently. So should the quality be presented precisely and transparently. A health plan that delivers and precisely and transparently communicates the quantitative and qualitative aspects of its network of providers will earn the trust of its customers.


About the Author: