Challenges in Network Development

The sun is shining, kids are heading back to school, and fall will be here before we know it. Now is the perfect time to start planning for your network expansion needs. Plans need to be even more vigilant in managing their largest asset. Regardless of the size and scope of the organization, your plan’s network adequacy and accessibility is a cornerstone of any new initiative.

Screech…insert brakes squealing sound effect here… For those of us who have been in the Medicare Advantage (MA) field, this starts to sound like a broken record, right? The numbers guys tell us the best new areas to expand, the network folks build their strategy―you know, the one where we pull a list of all available Medicare providers in the area and pray the providers will accept 100% of Medicare or at least a rate that will keep us in business and meet the Centers for Medicare & Medicaid Services (CMS) network adequacy requirements. Network departments are now feeling the pressure to perform not only to meet their annual goals but to ensure other functional areas of the health plan, such as member satisfaction, Star Ratings, clinical, and risk adjustment, can meet their goals as well.

In today’s marketplace, it is no longer acceptable to meet the bare minimum Health Service Delivery (HSD) requirement. Consumers, and CMS, are demanding plans to be able to offer choices that include quality and cost efficiency. With consumer-savvy, newly aged in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their healthcare dollar. The new beneficiary is aging in from a world of patient engagement and incentives and rewards programs and will expect the same level of service. Health plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals and to be forward-thinking on how to best wrap risk adjustment and Star Ratings into the mix.

For beneficiaries and their caregivers, a top priority in the selection of an MA plan is the inclusion and availability of their physician and most commonly used facilities. MA directories have required the least amount of informative elements as compared to their counterparts, such as Qualified Health Plans (QHPs) and Medicaid Managed Care Organizations, and CMS is pushing hard to have uniformity across all government-sponsored health plans. We know the belt is tightening with day-to-day network directory management. Plans must reach out to their providers on a quarterly basis to confirm demographics and open/closed panel availability of their providers, ensure the information is updated in real-time with online directories, and close the loop between the providers submitted on the HSD tables versus those in the directory. CMS has begun the process of the pilot directory accuracy audits, and it will be interesting to see which plans have done their due diligence and what methods have proven to be the most successful.

Additionally, a recent investigation by the Government Accountability Office (GAO)[1] identified serious deficiencies in CMS’ oversight and enforcement of MA network requirements and recommended greater scrutiny of plans’ networks. The GAO found CMS reviews less than 1% of all networks and does little to assess the accuracy of the network data submitted by plans. It was found CMS relies primarily upon complaints from beneficiaries to identify problems with networks and does not assess whether plans are renewing their current contracts to continue to meet network requirements.

As we saw last year with CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. The result was a scramble to fill gaps and re-evaluate if previously approved exceptions were, in fact, still valid.  This requirement further supports the CMS commitment to monitor network adequacy for MA plans much more closely. It is time to set new network monitoring processes in place which ensure your CMS network submissions mirror your provider directories and that you are prepared to address directory complaints and ensure you are following the new directory requirements.

The Kaiser Family Foundation recently completed a study on MA hospital networks and how much they vary.[2]  The study was attempting to answer three questions:

  1. What share of MA plans have broad, medium, or narrow hospital networks, based on the share of hospitals and hospital beds included in the plan network, and to what extent does this vary across counties?
  2. Do MA plans typically include Academic Medical Centers and National Cancer Institute (NCI)-Designated Cancer Centers when one is located in the county?
  3. What is the relationship between network size and other plan features, including premiums, quality Star Ratings, per capita Medicare spending, parent organization, and plan tax status?

Some of the most interesting results found were:

  1. MA plans include about half (51%) of area hospitals in their network.
  2. Most plans (80%) include an academic medical center, but one in five did not.
  3. Two in five plans in areas with an NCI-Designated Cancer Center did not include the center in network.
  4. In 2015, 23% of MA plans in the study had broad hospital networks, while about 16% had narrow or ultra-narrow networks.
  5. Among Health Maintenance Organizations (HMOs), broad and narrow network plans had similar average premiums ($37/month vs. $36/month) and similar quality ratings (3.8 vs. 4.1 stars).

With hospitals having much more publicly available data with which to examine, as we move into the era of the Medicare Access & CHIP Reauthorization Act (MACRA), plans will need to use all available quantifiable data and work with providers more closely to ensure the provider networks we build are risk ready. As one of the only industries where technology has seemed to send us backwards rather than forward, we will need to ask ourselves, “Do we have a functional and connected ecosystem of providers, including hospital and ancillary providers, that are risk ready, AND are we ready to support them with real-time, transparent reporting to ensure healthy relationships with our providers?” “Do we have physician champions in the community, and does our internal leadership understand the importance of the new level of provider engagement that is required?”

Providers are scared and voicing their concerns. We are going beyond requesting providers follow up on gaps in care, HEDIS®, and Star Ratings measures. We are requiring coding accuracy and enforcing with audits to ensure we are on track with risk adjustment scores. We are going beyond pay for performance to paying for outcomes. As MACRA enters full swing, we know most providers will start out with the Merit-Based Incentive Payment System (MIPS) rather than the Advanced Alternative Payment Models (APMs), and yet there is still concern a small, single physician office will be able to survive.

In an election year where crazy things happen and we seem be more divided than unified, I, for one, would love to see all of these changes be the catalyst for plans and providers to come together―for providers to share their needs and concerns, for plans to offer tailored education programs that fit both the small office and the large integrated delivery systems, and for patient-centric care to truly mean the patient comes first.

How do we get there? I would have to say healthcare is still local, and we — plans and providers — need to meet on Main Street, USA, and start talking.

At Gorman Health Group, we have a long history of providing direct contracting assistance for plans, the ability do a deep-dive and ensure your specialty mapping meets CMS definitions for each category, to run multiple network adequacy and availability scenarios, and prepare your plan’s HSD, state, or Request for Proposal network tables. We also have the bench strength to help you develop a strong network strategy and provider engagement architecture that takes into consideration the quality, financial, Star Ratings, and risk adjustment goals you need to reach in the competitive landscape of healthcare. Let us know how we can work and plan together now and build strategic network operations to support your plan’s goals for growth. Planning now will allow us to ease into fall knowing we are prepared for the new season and new changes!



Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>

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Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

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