The following is an excerpt from an article by Ezekiel J. Emanuel, an oncologist and former White House adviser, a vice provost and professor at the University of Pennsylvania. He is a contributing opinion writer for The New York Times on a range of topics including health and health policy.
Frankly much of what he says here and in other articles makes a lot of sense, but, of course, is contrary to the views of average people and in conflict with how they act. He eludes here to the backlash to networks in the 1990s, probably including much of the 1980s and the backlash toward HMOs and managed care with limited and closed networks.
Perception is everything and even today (although driven by increased cost sharing, on a lesser scale) the idea exists that the best doctors are not in networks, that if a doctor accepts network fees he or she cannot be top quality and that if I get really sick, I want the freedom to go to the best facility in the world. Patients at the point of service are not interested in the Big Bang for the buck.
None of this has to do with Obamacare, use of networks was standard long before 2009. Employers rarely, if ever, offer open plans, but rather increase co-insurance substantially if services are provided out-of-network.
The key to acceptance of networks is the assurance that participating providers are selected and accepted based as much, if not more, for their efficiency and quality as they are for their willingness to accept network fees. We are not there yet. Frankly, we don’t have the needed quality measures for individual physicians plus insurers build networks mainly on patient volume and cost.
We have an ongoing dilemma. Patients want the best (perceived) care possible; insurers and employers want lower costs, but presumably good quality health care, patients also want “affordable” health insurance… and nobody agrees on the definition of either quality or affordable.
The issue patients should be focused on is not the provider network per se, but the coordination of their total health care. Insurers must guarantee that a network will not inhibit the ability for a patient to receive the most appropriate and best care possible.
Many Americans can relate to this. Last year, a Kaiser survey reported that almost all individuals and families with employer-sponsored health insurance have policies that come with at least some network restrictions. These plans steer us toward certain providers and away from others.
This saves a lot of money. Insurance companies can negotiate with in-network physicians and hospitals to accept lower payments in exchange for more patients. They can include in their networks only physicians who are more efficient — who order fewer unnecessary tests, use more generic drugs and tend to keep patients healthier and out of the hospital. As a result, they can ensure that they, and their customers, get more bang for the buck.
Despite the fact that so many Americans are already in selective networks, they are nervous that the Affordable Care Act, which I helped design as an adviser to the Obama administration, will further restrict their choice of doctors or make them pay higher out-of-network charges. There was a similar backlash in the 1990s, when managed care was on the rise.
Here is some reader reaction to the Manuel piece. Needless to say they reinforce my view on perceptions. There simply is no easy answer. People want everything, but nobody wants to pay.