By: Andrea S. Rodriguez Lebron, AcademyHealth
Over the past ten years, access to healthcare has been a main topic of discussion in the United States. Passage of the Affordable Care Act (ACA) expanded access to more affordable health insurance for many Americans, though uncertainty remains over patients’ ability to gain timely access to care within their network, particularly for individuals purchasing insurance sold through Markeplaces established by the ACA. A recent study in Health Affairs explored this issue of network adequacy for insurance plans sold inside and outside insurance Marketplaces. Authors found that gaining timely access to primary care providers is challenging regardless of where the plan was purchased and attribute many of these issues to errors and inconsistencies in provider listings within the networks.
In the study by authors Haeder, Weimer, and Mukamel, researchers posed as “secret shoppers” to simulate and compare the experiences of health insurance consumers in California with plans in two different markets: (1) the Covered California insurance Marketplace, and (2) equivalent “mirrored” plans sold outside of the Marketplace. Using provider directories, the secret shoppers acted as potential patients and called 70 physician offices in each of the five California insurance Marketplace pricing zones studied. For all calls, one of the secret shoppers presented with insurance through the Marketplace, and the other with a plan outside the Marketplace. In half of the calls, shoppers asked for a physical and in the other half, for appointments due to illness.
The authors found that securing an appointment with a provider was difficult regardless of plan type; secret shoppers with the study had a less than 30% chance of successfully securing an appointment with any randomly selected provider within his or her network. While patients with commercial plans fared better than those with Marketplace plans, these results were often not statistically significant and were overshadowed by larger issues of access seen in both plan types. The authors noted that the average wait time to get an appointment for an illness was eight to 12 days in both plans. Although this was half the wait time to schedule a physical, the authors noted that this was concerning given that many patients presenting with acute conditions are in need of timely care. The authors suggested that many of these problems could be attributed to inaccurate provider directories that list either incorrect or out-of-date information about providers participating in a particular network.
In their conclusion, the authors noted that “access to health insurance is not necessarily synonymous with access to healthcare services.” Though the study reveals important issues around network adequacy for patients in both Marketplace and commercial plans, it also highlights the related issue of network listing inaccuracies. Authors suggest that their findings in California may be generalizable to other states, and that there is a need for future research to explore the impact of required improvements to network accuracy (e.g., regular, timely updates to network listings) and network capacity on access to care. Although the ACA has made strides in providing expanded access to affordable health insurance, these study findings suggest that barriers around timely access to care remain.
Andrea S. Rodriguez Lebron was an Intern at AcademyHealth supporting the Translation and Dissemination Institute through her involvement with the Evidence Roadmap and Rapid Evidence Reviews projects. She is also an MPH candidate at Columbia University’s Mailman School of Public Health.