A Knotty Problem: Consumer Access and the Regulation of Provider Networks

Area of Science:

• Health Services Research
• Health Policy
• Healthcare Management

Background:

• Expanding health insurance coverage is a common strategy to increase medical service access.
• This approach often overlooks the critical role of provider networks in mediating access.
• Provider networks are complex to regulate, with current variations lacking empirical justification.

Purpose of the Study:

• To examine current regulations governing health insurance provider networks.
• To propose future directions for pragmatic and effective provider network regulation.
• To understand how network breadth influences healthcare access.

Main Methods:

• Inventory of regulations applied by private and public entities to provider networks.
• Analysis of the variation in network regulation across different insurance programs and products.
• Assessment of the technical, logistical, and normative complexities of network regulation.

Main Results:

• Significant and often unjustified variation exists in current provider network regulations.
• Existing regulations are not consistently grounded in empirical evidence.
• Current regulatory approaches are technically, logistically, and normatively complex.

Conclusions:

• Regulators should focus on pragmatic policy levers such as network accuracy and transparency.
• Consumer protections against network inadequacies are essential.
• Government regulation is foundational for minimum access and informed consumer choice, but consumer choice is key.