If you try to use Medicare Advantage, figuring out which doctors are available (and where) can be exceedingly difficult, if not impossible.
Medicare Advantage is the government-subsidized, private plan alternative to the traditional public Medicare program. It has had strong enrollment growth for years.
That growth has received a boost from the Trump administration, which has sent emails to people using Medicare to promote how much more coverage they could get for less money from private plans. Missing from those emails, however, is a mention of one big limitation of those plans: Many cover far fewer doctors than the traditional program.
That may not be a problem if you can find a plan that includes doctors you prefer, or if you can find covered doctors in convenient locations.
But that isn’t often the case, as government audits of Medicare Advantage plan directories show. The Centers for Medicare and Medicaid Services, which oversees the program, found that nearly half of entries had one of three problems: address errors, incorrect phone numbers, or doctors who were not accepting new patients. In 2017, the Department of Justice reached a settlement with two Medicare Advantage plans over charges of misrepresentation of their networks to regulators.
CreditPablo Martinez Monsivais/Associated Press
Other research reveals that Medicare Advantage provider directories are relatively poor sources of information. For example, a study published in the American Journal of Managed Care found that Google was more accurate.
“Directory accuracy is hard,” said the study’s lead author, Michael Adelberg, a former senior Health and Human Services regulator in Washington and now a leader of health care strategy for the Faegre Baker Daniels law firm. “But when a consumer joins a plan to get to a doc in the directory and then cannot, that consumer has a very legitimate beef.”
(I was a co-author on the study, along with Daniel Polsky, a health economist with Johns Hopkins, and Michelle Kitchman Strollo, a vice president and associate director of NORC’s health care department at the University of Chicago.)
Not only is it difficult for the average person to assess Medicare Advantage plan networks, but it’s also hard for researchers. Nevertheless, a few things have been teased out.
Working with plan directories — flawed though they may be — a Kaiser Family Foundation analysis examined the physician networks of almost 400 Medicare Advantage plans offered by 55 insurers in 20 counties in 2015. It found that networks of these plans included 46 percent of physicians in a county, on average.
In other words, if you selected a plan at random in these counties, you could expect that a bit less than half of doctors would be covered, at least according to its directory. (This does not necessarily mean those who are covered are taking patients or practicing in locations convenient for you.)
The study found considerable variation by specialty. Psychiatrists are least likely to be included in plan networks; a typical plan covered fewer than one-quarter of them. Ophthalmologist are most likely to be included; a typical plan covered nearly 60 percent of them. Depending on what kind of care you need, the extent to which plans cover specific specialists would be important to know. But there is no single source that meaningfully compares Medicare Advantage plans’ networks in the aggregate, much less by specialty.
This could change. A recent draft regulation would require Medicare Advantage, as well as other kinds of plans, to provide their directories in an electronic format that third parties could use to compare them, for example through apps or online.
Why do plans’ networks vary anyway? One possibility is that plans may strategically narrow or broaden their networks of certain specialties to try to attract more of the kind of enrollees they want (healthier, cheaper) and fewer of those they don’t (sicker, more expensive). Studies have shown that sicker beneficiaries are less attracted to Medicare Advantage, perhaps for these reasons. Another possibility, suggested by an Urban Institute study, is that plans narrow networks to control productivity and quality — for instance, covering only doctors who meet quality standards and tend to provide more efficient and valuable care.
A study of Medicare Advantage plans offered in California in 2017 found that the quality of obstetricians-gynecologists, cardiologists and endocrinologists covered by those plans tended to be comparable to those available through traditional Medicare. But some plan enrollees, particularly those in more rural areas, would need to travel far — in some cases exceeding 100 miles — to see those covered physicians.
The Kaiser Family Foundation study found that broader-network plans tended to charge higher premiums than “narrow network” plans (narrow network means covering less than 30 percent of doctors in a county).
One limitation of analyzing plan directories is that even if physicians are listed as in-network, they may not really be accessible because they’re too busy to accept new patients. So another way to assess the influence of Medicare Advantage networks on people’s access to care is to observe which doctors people in a specific plan actually see.
Looking at it this way, which colleagues and I did on a recent study published in Health Affairs, reveals that 80 percent or more of Medicare Advantage plans provide access to at least 70 percent of primary care physicians in their markets. Our study also suggests that narrow network plans are not growing over time in Medicare Advantage, which runs counter to the narrative that they’re taking over health care.
Still, because there is no way for Medicare beneficiaries to compare plan networks, people could easily stumble into a narrow network plan without knowing it. As with many things in health care, it’s hard to make an informed decision.
