There is broad agreement among policymakers and experts that health care costs continue to increase at an unsustainable rate and that more must be done to reduce costs and assure an affordable health care system for all Americans. While costs have moderated recently, the U.S. still spends more on health care than any other industrialized country and health care spending continues to take up a larger share of our nation’s gross domestic product—which, in turn, crowds out other important priorities and is a major contributor to the nation’s budget deficit and national debt.
Health plans have been at the forefront of health-system delivery and payment reforms that hold promise in reducing costs, while also improving efficiency of care delivery and enhancing quality of care and patient outcomes. The implementation of the Patient Protection and Affordable Care Act (ACA)—which has significantly expanded access to coverage and includes a number of targeted changes aimed at improving quality and reducing costs—has brought about increased focus on the range of tools that health plans have used to keep coverage as affordable as possible for consumers. The use of high-value provider networks is one of the tools used by health plans to reduce costs and provide incentives for high-quality and cost-effective care for consumers. By identifying providers that consistently meet quality and safety metrics and are more efficient relative to their peers, health plans have created an important tool that can be used to advance and improve the provision of high-quality care.
This paper primarily focuses on the development of high-value networks in the new marketplaces and how these tools are evolving to meet the healthcare cost and quality challenges ahead. The major findings include:
- The use of high-value provider networks can help reduce premiums and promote more affordable coverage options for consumers—with premium reductions of 5 percent to 20 percent or more when compared with broad network plans.
- High-value networks are developed through a deliberative evolution process considering more than just fee levels.
- Health plan provider networks—including high-value networks—must comply with state and federal laws and regulatory requirements, including network adequacy standards.
- Active cooperation and collaboration—between the health plan and participating providers—is a hallmark of successful high-value networks plans.
- Performance on quality measures is the key part of the criteria used for provider selection and inclusion in a plan’s network.
- Integration of the value network into plan designs is being used to improve the efficiency of care management and quality of care.
