Copyright 7.2014: Scientific Cowboys – Nancy C Everitt, PMP

The concept of narrow networks is not new. There is a great deal of hoopla in the media that narrow networks are driven solely by the ACA “Obamacare”.

Seriously?

Read on… we explore if narrow networks are works of art or an evil curse.

From the 80’s I personally recall limited network HMO’s, exclusive provider networks, preferred provider networks etc.  There are few new concepts, rather just a rebranding or freshening of a concept.

In the 90’s as managed care professionals we created mega networks so that payors could offer broad network access. However quality and cost continued to spiral out of control

Why has Kaiser been so successful? Through a captive group model providers are aligned and participate actively around the quality measures, outcomes and treatment protocols. Alignment, common goals, good stuff!

That being said are narrow networks helpful or hurtful?

It depends upon which seat you are in.

  • Members: Members generally prefer larger less restrictive networks unless there is a direct financial incentive to save money. If you’re not spending your own money, more access can mean greater convenience. Bring it on! However we all know that healthcare will not pivot until members understand the correlation between cost and quality.
  • Providers: Having sat in the provider seat for a publicly traded hospital corporation for over a decade,  this perspective is split. Many smaller providers prefer larger open networks so that they can get a seat at the table. Providers with market clout generally prefer smaller, more restrictive networks so that they can garner greater market share and direct referrals.
  • Payors: Narrow networks are a necessity for at risk payors. The right providers can minimize financial risk while yielding high customer satisfaction. Non risk bearing payors lean both ways on the advantages of narrow networks depending upon whether they have a sales driven approach or a quality driven approach.

What’s on the horizon…3 Trends to Watch!

Specialized Narrow Networks: Our research shows that specialized narrow networks add value and can be more palatable to the general public. PCP’s may flinch with having fewer specialists and ancillaries to refer to however if these resources are reliable and create great outcomes for their patients, this should be considered.

  • Access to new networks like HEOPS CENTIPEDE Health Network, a national HCBS network that finally opens an access point to care that has not previously been available for home based care and care coordination.
  • Also take a moment to look at Grand Rounds for second opinions with a narrow network, this is an intriguing application of the narrow network concept. Actually Grand Rounds belongs in both the Narrow Network and TeleHealth Category.

TeleHealth: This segment is exploding as many organizations are throwing their hat into the ring. Plus millenials love the convenience, a strong hint as an engagement strategy!

  • While key players like Teladoc are ahead of the competition right now, niche based offerings and those solutions with a different take on the value proposition will make inroads.
  • Breakthrough Behavioral for telepsychiatry deserves a look with a clean interface and simplified flow from consult to billing to make psychiatric consults more comfortable and convenient.

Network Reduction: Yep, this is a hot potato. You’ve seen several payors in the headlines over the past 6 months as they’ve reduced networks for the ACA and also focused on trimming providers below acceptable STAR values for Medicare Advantage.

  • From a birds eye view network reduction is an emotional process for providers. We’ve led compliance and tracking project for a national payor and emphasize that a strong workflow be in place and that defensible criteria be established. Fine tuning networks is necessary as quality data becomes available, however approach is key.

Summary: Narrow Networks: Helpful or Hurtful?

At the end of the day helpful or hurtful is driven by individual perspective. All parties can rationalize their views.

The key takeaways are:

  • Narrow networks can refine a network to the most impactful providers; note I did not say just the cheapest. The intersection of Cost, Quality and Outcome should drive network selection.
  • Be alert and open to the use of impactful technologies such as telehealth and specialty networks because “focus” and specialization can yield great results.
  • When deciding to reduce a network, plan and evaluate carefully, ensure that your workflow and resources are ready. Providers will likely seek reconsideration and that’s okay, if there is a good reason, withdrawal of a termination is appropriate.

 

About the Author:

Nancy C. Everitt, MBA, PMP  is the President and CEO of HEOPS, Inc., CentEO of CENTIPEDE Health Network and Editor in Chief of Scientific Cowboys. Ms. Everitt is lead strategist to Clients’ on the design and fulfillment of patient access solutions such as network development and provider engagement, quality analytics, Medicare Advantage STARS strategy, disruption analysis and mapping. Ms. Everitt has been involved in the strategy of each engagement and provides significant perspective on industry best practice.

In addition to serving as Editor in Chief on Scientific Cowboys, Ms. Everitt is a frequent contributing writer to the publication sharing real world advice and operational insights on process and performance improvement. Questions on this article may be addressed directly to neveritt@heops.com.

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