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Insurers Limiting Numbers of Providers? That’s How the New Healthcare Model Is Supposed to Work.

By Michael L. Taylor/Thursday, September 19, 2013

Mike Taylor imageA Los Angeles Times article published over the past weekend seemed in some ways to imply that consumers who choose smaller-sized provider networks through the new California health insurance exchange could have problems gaining access to their doctors — which would contradict the intent of the Affordable Care Act.

But the fact that insurance plans are limiting network size to give healthcare consumers affordable options is a rational, direct intent of reform — and an example of natural market forces at work. The reason it may feel uncomfortable to some, though, is that it is a different approach to healthcare than the model we’ve seen in the U.S. in the past.

In a fee-for-service environment, it has long been in the best interests of insurers to have networks that were as wide and all-inclusive as possible. The focus of the old model was on more — more providers involved, more services performed.

Now, the focus in a value-based model is to provide the best care at the best price. Therefore, insurers are reaching out to different target audiences with different plan products. And one of the ways an insurer can meet the needs of a consumer who wants high-quality care at the lowest-possible cost is to offer a limited-network plan.

That’s logical — and no different for the newly eligible consumers, really, than the conventional health plan consumers (who are currently insured through their employers) who must make choices based on cost and in- and out-of-network options.

The aim of the health insurance marketplaces is not only to cover more Americans, but to also offer choice and competitive pricing. As the Times article stated, there are 12 different insurers offering plans through the California exchange. Consumers can choose, more than ever before, the price point they are comfortable with for their situations.

Of course, it will be important for both exchanges and insurers to use data and analytics to stay on top of consumer satisfaction and provider capacity, and to evolve offerings as needed.

In the meantime, as the federal exchange information site states, consumers are urged to “compare plans based on what's important to you, and choose the combination of price and coverage that fits your needs and budget.” Those decisions don’t have to be made in the dark, either. With one exchange marketplace application, consumers can compare coverage options side-by-side.

Michael L. Taylor, MD FACP
Chief Medical Officer
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