If you try to use Medicare Advantage, understanding which doctors are available and where they’re located is becoming more and more difficult, if not outright impossible.
Medicare Advantage is the government-subsidized, private option to the traditional public Medicare program that is quickly growing in popularity over the last few years.
The Trump administration has significantly contributed to this recent growth by sending emails to people using Medicare to promote how much more coverage they could get for less money from private plans, but with one glaring omission:
Missing from those emails, is any mention of the one big limitation of those plans: They cover far fewer doctors than the traditional Medicare program.
If you can find a doctor you prefer or covered doctors in close convenient locations, this likely won’t be a problem for you but often, that is not the case. Government audits of Medicare Advantage plan directories show that 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 unscrupulous misrepresentation of their networks to regulators.
Despite being a multi-billion dollar industry dominated by some of the largest insurers in the world, basic research revealed that Medicare Advantage provider directories are notorious for not being accurate. For example, a study published in the American Journal of Managed Care found that Google was more correct.
“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.”
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.
Basically, 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.