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New Data Brief On Networks Ensuring Affordable, Accessible Specialty Care

posted by Alicia Caramenico

on July 13, 2015

For patients managing complex health conditions, health plans’ networks include a broad range of specialty provider and hospital groups that have a proven track-record of delivering high-quality care, according to a new AHIP data brief.

Oftentimes, care delivered at specialty hospitals can cost thousands of dollars more for the same services delivered at non-specialty hospitals. That’s why health plans’ provider networks are an important tool for getting patients the best prices for medical treatments and therefore, the best value for their care.

The data brief highlights how health plans develop provider networks to ensure access to safe, effective, evidence-based, and affordable specialty care. Health plans contract with facilities that meet certain criteria as Centers of Excellence (COE). The complex set of criteria gets routinely evaluated to ensure patients have sufficient access to providers and facilities that deliver the specialty medical services they need.

Health plans take into account guidelines and recommendations from the medical community and quality measurement experts, as well as how satisfied patients are with care coordination and multidisciplinary care teams. Data and evidence also play a major role in network design, with health plans reviewing medical literature, clinical outcomes, and cost-effectiveness, among other performance metrics. Infrastructure capabilities of specialty hospitals, such as the size and scope of programs for particular conditions or procedures, also play into hospital network criteria.

The data brief also examines plans’ continuity of care policies, through which patients can continue to receive care from a provider no longer in their network at in-network rates for a certain period of time. These policies help avoid disruptions in treatments, giving consumers peace of mind if their coverage changes. These efforts to provide beneficiaries with high-quality, affordable health care aren’t going unnoticed, as recent surveys show members are highly satisfied with their health plans.

Given all of the work that goes into creating provider networks, the data brief underscores just how important health plan flexibility with benefit design and network development is to meeting individuals’ needs.