AMA policy on narrow networks

New policy calls for adequate networks for patient access, choice

AMA Wire, November 10, 2014

The new AMA policy, which is part of a new report by the AMA Council on Medical Service, calls for health insurers to make changes to their provider networks before the open enrollment period gets underway each year. Implementing changes to provider networks at this time will help prevent patients from being stuck with plans that drop their physicians after they already have enrolled.

The policy also reiterates the need for health insurers to provide patients with an accurate, complete directory of participating physicians through multiple media outlets. These lists also should identify physicians who are not accepting new patients.

Other provisions of the new policy include:

  • Promoting state regulators as the primary enforcers of network adequacy requirements. These regulators can ensure compliance with state network adequacy laws and regulations that are intended to make sure patients have access to adequate provider networks throughout the plan year.
  • Calling for insurers to submit quarterly reports to state regulators. These reports should provide data on several measures of network adequacy, including the number and type of physicians who have joined or left the network, the provision of essential health benefits, and consumer complaints received.
  • Calling on insurers to treat patient visits to out-of-network physicians the same as in-network visits if the plan’s provider network is deemed inadequate.
  • Supporting regulation and legislation that require out-of-network expenses to count toward a patient’s annual deductibles and out-of-pocket maximums when a patient is enrolled in a plan with out-of-network benefits or is forced to go out of network as a result of network inadequacies.



By Don McCanne, MD

If any organization should be able to devise policies that would correct the deficiencies of narrow provider networks, it is the AMA. When you read their new recommendations, clearly they leave in place the fundamentally flawed policy of restricting patient choices of physicians. Tweaking a policy that needs to be eliminated is not an adequate response.

They speak of ensuring network adequacy, but networks are not adequate if they eliminate your primary care provider, if they require greater distances to travel in seeking care, if they limit access to specialists, if they exclude physicians at centers of excellence, or if they include any of the other restrictions that result from not having freedom to choose from all available physicians in the community and in referral centers.

Keeping provider lists current is almost impossible. Physicians often do not notify the insurers when they close their practices to new patients or when they move their offices. List changes of physician attrition (retirement, license revocation, death, etc.) or of new physicians entering the community can be difficult to keep current.

Requiring prior authorization for out-of-network services is a barrier to care, if it is even allowed at all.

One of the more important AMA recommendations is to allow the cost of out-of-network care to be applied to the deductibles and to the out-of-pocket maximums. But then there would be little reason for patients to stay in network unless they had catastrophic expenses that could expose them to large balance-billing costs. Regardless, the patient is still exposed at least to the high deductibles and high out-of-pocket maximums, creating financial hardships for many of the insured.

The AMA recently again rejected recommending single payer proposals. That’s too bad. Single payer would have taken care of not only the narrow network problem, but also the thousands of other deficiencies that are unique in our highly dysfunctional, market-oriented non-system of health care financing.