Mixed signals: The inadequacy of provider‐per‐enrollee ratios for assessing network adequacy in California (and elsewhere)

Abstract

AbstractHealth insurance regulators often set minimum ratios of provider = per‐enrollee for health insurance plans to try to ensure that their provider networks offer enrollees adequate access to medical care. However, plan‐specific ratios only have an unambiguous interpretation when each provider participates in only one single network. Based on network data, we show that endocrinologists, obstetrician–gynecologists, cardiologists, and pediatricians in California participate on average in 64, 66, 72, and 63 networks, respectively. Such high participation rates in networks make provider‐per‐enrollee ratios measured at the plan level meaningless as metrics for access. We recommend that plan‐specific ratios be abandoned in favor of a more qualitative approach with strong dispute resolution protections as well as “police patrols” (e.g., regulator surveys to assess waiting times for appointments) and “fire alarms” (e.g., investing resources in consumer advocate organizations).