Even our single-payer system is a nightmare. If you try to use Medicare Advantage, figuring out which doctors are available and where can be exceedingly difficult, if not impossible. That's the topic of this week's Healthcare Triage.

[Intro]

Special thanks to Austin Frakt, who's Upshot column this episode was adapted.

Medicare Advantage is the government subsidized private alternative to the traditional public Medicare program. It's had strong enrollment growth for years. That growth has received a boost from the Trump administration, which 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 often isn't 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 the 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. 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.

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% of physicians in a county, on average. If you selected a plan at random in these counties, you could expect that a bit less than half of all doctors would be covered, at least according to its directory. This does not necessarily mean doctors who are covered are taking patients or practicing in locations convenient for you, though. 

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. Ophthamologists are most likely to be included; a typical plan covered nearly 60% 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 many strategically narrow or broaden their networks of certain specialties to try to attract more of the kind of enrollees they want (healthier and cheaper), and fewer of those they don't (sicker and 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% of doctors in a county.

One limitation of analyzing plan directories is that even if physicians a re 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 access to care, is to observe which doctors people in a specific plan actually see. Looking at it this way, in a recent study published in Health Affairs, reveals that 80% or more Medicare Advantage plans provide access to at least 70% of primary care physicians in their market. The 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's 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 healthcare, it's really hard to make an informed decision. 

[Outro]

Did you enjoy that episode? You might enjoy this episode on the advantages of Medicare Advantage.

We'd especially like to thank our research associate, Joe Sevits, and, of course, our surgeon admiral, Sam. And, like them, you can support the show at Patreon.com/HealthcareTriage. 

And, you can support me by buying my book, The Bad Food Bible. It's out in paperback.