Have you seen those commercials for wireless coverage, with the children sitting around a table answering focus groups questions about which is better: faster or slower, more or less, bigger or smaller? In the "more or less" spot, one of the kids gleefully cheers, "We want more! We want more!"
That has also been the rallying cry among many advocates as health reform rolls out, when it comes to a different kind of network coverage: the number of providers included in a health insurance plan. Some argue that plans with narrow networks -- meaning that only a small number of doctors are included -- limit patients' options and access to care. And a new federal proposal will strengthen the existing network adequacy requirements established in the Affordable Care Act, in a move to ensure that newly insured, low-income patients have sufficient access to care.
Of course, access is an extremely important issue; having an insurance card is meaningless if you are unable to find a doctor or get care when you need it. And having access to a high-quality network of providers is critical, as Ezekiel Emanuel pointed out in a recent Times op-ed.
Here in New York State, debate is heating up about whether to require plans sold through the marketplace, www.NYStateofHealth.ny.gov, to include out-of-network benefits in case of emergencies or when a standard network does not include a needed provider of specialty care. In those special circumstances, patients could go out of network but pay the same price as for in-network services.
What concerns me is that the pendulum could swing too far in the direction of broad networks and, as a result, limit opportunities to contain health care costs and improve the coordination and delivery of care. Narrow networks are important for keeping health care affordable; if the network is too wide, health care payers have limited bargaining power to keep prices affordable.
The cost issue is of real concern, and much of the debate about network size has been framed as a trade-off exclusively between access and costs. What has been largely missing from the conversation about network size is the opportunity a slim network offers for improving health care quality through better coordination of care and services.
Right now, my commercial health insurance plan offers me a pretty wide network of providers, and I've been happy with that. I can get care from an excellent ophthalmologist, an excellent cardiologist and primary care doctor, and the dentist and the dermatologist I've been seeing for 20 years -- all of them are covered. This is America, why would I not want as many choices as possible?
But, am I really getting the best "system" of care possible? After all, my dermatologist and dentist are in Princeton, NJ, my ophthalmologist is at Cornell, and my primary care doctor and cardiologist are NYU physicians. They can't really communicate with one another (except for the two NYU physicians who can and do communicate because they are in the same group practice). Would I be worse off or better off if I were forced to choose physicians from one health system?
And... what if I could save $1,000 each year if I agreed to use one health system? One thing for sure is that many Americans would like the choice to save that $1,000.
It's true, I'd be giving something up, leaving behind doctors whom I trust and have a long relationship with. And moving toward a more integrated model with a narrow set of providers means I'd be betting on one team, which is a little scary. The challenge -- and the opportunity -- is to ensure that that one coordinated team is a better bet than a fragmented bunch of free agents.
That tension between access to a wide array of providers and the pressure of containing health care costs will continue to persist, without a doubt. It's telling -- though perhaps not surprising -- that a recent Kaiser Family Foundation poll found that a majority of the general public, particularly those with employer-sponsored coverage, want more choices and broader provider networks .
But the poll also found that people who are uninsured and who are most likely to be purchasing coverage through the health care exchanges prefer narrow networks, especially when they understand that access to a broader provider network will increase the cost of the plan.
Patients may have fewer choices about which doctors to see, but the providers that are in that network -- the primary care doctors and the endocrinologists and the eye doctors and the OB/GYNs and the psychiatrists -- will be in a better position to provide coordinated care. This type of system, in which care is less fragmented and providers come together as a team with the patient at the center, is an important health reform goal.
The challenge, as is so often the case when it comes to health care, is finding the right balance. We need networks to be just the right size: sufficient to meet patients' care needs, but not so wide that health plans are unable to hold down rates and coordinate care. The best way to calibrate that tension is to let the market do its job, not to overregulate the size of networks.