Secret shoppers find access to providers and network accuracy lacking for those in marketplace and commercial plans

Health Affairs

Volumn 35, Issue 7, 2016, Pages 1160-1166

  Haeder, Simon F ^a   Weimer, David L ^b   Mukamel, Dana B ^c  

^a WEST VIRGINIA UNIVERSITY   (United States)

^b UNIVERSITY OF WISCONSIN MADISON   (United States)

^c UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ACUTE DISEASE; ARTICLE; CALIFORNIA; COMMERCIAL PHENOMENA; CONSUMER; HEALTH CARE ACCESS; HEALTH INSURANCE; HUMAN; MEDICAL INFORMATION SYSTEM; PHYSICIAN; PRIMARY MEDICAL CARE; COMMUNITY CARE; CONSUMER ATTITUDE; COST CONTROL; ECONOMICS; FACTUAL DATABASE; FEMALE; FINANCIAL MANAGEMENT; HEALTH CARE PERSONNEL; HEALTH CARE POLICY; INSURANCE; MALE; ORGANIZATION AND MANAGEMENT; RETROSPECTIVE STUDY; STATISTICS AND NUMERICAL DATA;

CALIFORNIA; COMMUNITY NETWORKS; CONSUMER BEHAVIOR; COST SAVINGS; DATABASES, FACTUAL; FEMALE; HEALTH INSURANCE EXCHANGES; HEALTH PERSONNEL; HUMANS; INSURANCE COVERAGE; MALE; MARKETING OF HEALTH SERVICES; PATIENT PROTECTION AND AFFORDABLE CARE ACT; RETROSPECTIVE STUDIES;

EID: 84980322388     PISSN: 02782715     EISSN: 15445208     Source Type: Journal    
DOI: 10.1377/hlthaff.2015.1554     Document Type: Article

References (19)

1. California Medical Association. Blue Shield exchange/off-exchange plans leading to confusion among physicians [Internet]. Sacramento (CA): CMA; 2014 Feb 10 [cited 2016 May 18]. Available from: http://www.cmanet.org/news/detail/?article=blue-shield-exchangeoffexchange-plans-leading
2. Two of California's largest providers, Kaiser Permanente and Blue Shield, do not offer any non-mirrored plans. Blue Cross offers both mirrored and non-mirrored plans.
3. Haeder SF, Weimer DL, Mukamel DB. Narrow networks and the Affordable Care Act. JAMA. 2015; 314(7):669-70.
4. Haeder SF, Weimer DL. Inching toward universal coverage: statefederal health-care programs in historical perspective. J Policy Hist. 2015;27(4):746-70.
5. Rigby E, Haselswerdt J. Hybrid federalism, partisan politics, and early implementation of state health insurance exchanges. Publius. 2013; 43(3):368-91.
6. Béland D, Rocco P, Waddan A. Implementing health care reform in the United States: intergovernmental politics and the dilemmas of institutional design. Health Policy. 2014;116(1):51-60.
7. Haeder SF, Weimer DL. You can't make me do it, but I could be persuaded: a federalism perspective on the Affordable Care Act. J Health Polit Policy Law. 2015;40(2):281-323.
8. Haeder SF, Weimer DL, Mukamel DB. California hospital networks are narrower in Marketplace than in commercial plans, but access and quality are similar. Health Aff (Millwood). 2015;34(5):741-8.
9. Bauman N, Coe E, Ogden J, Parikh A. Hospital networks: updated national view of configurations on the exchanges. New York (NY): McKinsey and Company; 2014 Jun.
10. Wilensky GR. Asking the right questions about narrow networks. Healthc Financ Manage. 2014; 68(11):30-2.
11. Carroll J. Plans use narrow networks in exchanges; public, politicians predictably perturbed. Manag Care. 2014;23(1):5-6.
12. The secret shoppers presented as follows: First, they sought to verify the name and specialty of the provider listed in the directory; they then presented their insurance coverage verbatim as listed by the insurance carrier; finally, they stated the reason they sought care, for either an acute condition or a physical exam.
13. California Health Care Foundation. California Health Care Alamanac: regional markets. Sacramento (CA): CHCF; 2009.
14. Included in the 10 percent was a handful of cases in which providers demanded a "membership" fee in addition to insurance payments. This membership fee to be paid by the patient was as high as $2,200 per year.
15. Giovannelli J, Lucia KW, Corlette S. Implementing the Affordable Care Act: state regulation of Marketplace plan provider networks. Washington (DC): Commonwealth Fund; 2015 May.
16. Herman B. Insurers draw heat for error-riddled provider directories. Modern Healthcare [serial on the Internet]. 2014 Nov 19 [cited 2016 May 18]. Available from: http://www.modernhealthcare.com/article/20141119/NEWS/311199972
17. Abram S. California bill that requires accurate health provider directories signed into law. Los Angeles Daily News [serial on the Internet]. 2015 Oct 10 [cited 2016 May 18]. Available from: http://www.dailynews.com/government-and-politics/20151010/california-bill-that-requiresaccurate-health-provider-directoriessigned-into-law
18. California Department of Managed Health Care [Internet]. Sacramento (CA): DMHC; 2015. Press release, DMHC fines Blue Shield and Anthem for inaccurate provider directories; 2015 Nov 3 [cited 2016 May 18]. Available for download from: https://www.dmhc.ca.gov/AbouttheDMHC/Newsroom.aspx#2015
19. Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff (Millwood). 2010;29(5):799-805.