Why you should go beyond surprise bills and report on narrow networks — especially in rural America

Simon Haeder has studied narrow health insurance networks for years, looking at what the size of one’s health insurance network means for quality and access to care. But it wasn’t until the professor had a personal experience with his 4-year-old’s cracked tooth that he really appreciated the practical implications of a network’s size.

Despite having health insurance through his work, Haeder couldn’t find an in-network provider to handle his kid’s injured tooth and the jarring pain that followed: “We were so desperate,” he said. “We were willing to drive all over the state.”

Ultimately, they ended up paying out-of-pocket for a provider near The Pennsylvania State University, where he’s an assistant professor of public policy. That costly experience isn’t uncommon for people who have insurance but may not understand their network’s limitations until an accident or sudden health problem, Haeder said. The problem is especially troublesome in rural America, regions already plagued with a sicker and poorer population, less public transport and the devastating toll of the opioid crisis. 

I chatted with Haeder about his recent research on network adequacy, rural health care and story suggestions for health reporters. While articles on “surprise medical bills” make for splashy headlines, Haeder encouraged reporters to explore the more nuanced impact of narrow health insurance networks, especially in rural areas. Our conversation is lightly edited for clarity and length.  

Q: You’ve published a lot on network size, quality and adequacy. Why is this important? 

A: There’s a perception that getting health care coverage solves all problems. Give people an insurance card and things will work out. But it really isn’t that simple. There’s a crucial connection between having insurance and getting care, and that’s provider networks. It’s important and not a lot of people are paying attention to it.

Q: Who is being affected by narrow provider networks?

A: It really depends on where you are and what resources you have. If you live in a large metro area, you’re pretty much OK. And, there’s probably some public transportation. But if you’re in a rural area and you don’t have a car, or you’re really poor or you’re working hourly, it could be very challenging to access care.

Q: Does this apply to just specialists or could your community’s only hospital be out of network?

A: Yes, there are cases where people get their coverage through the Affordable Care Act and their public hospital isn’t in their plan. It’s hard to tell the frequency of this nationwide. We focused on California and New York because that’s where there is enough data. 

Our work has shown that networks tend to be narrower for ACA plans with regard to both hospitals and specialists. We have also found data showing network problems for Medicare Advantage (privately run plans that now covers one-third of Medicare beneficiaries) for a number of specialists in California and a type of angioplasty in New York.

Q: How do narrow provider networks impact health outcomes?

A: It can’t be good. You probably can’t access care as much as you should. As a result, your condition probably gets worse, and it might get more pricey to treat it eventually. Again, your socioeconomic status likely plays a big role here. On the flip side, narrow networks tend to come with lower premiums.

Q: Are there any areas of the country where steps have been taken to address narrow networks, such as telemedicine or regulations requiring larger plans?

A: Telemedicine has been branded as transforming medical access for about 20 years now. But there are challenges. You need high-speed internet access. which isn’t going to work well in some rural areas. Just like in-person visits, you have to mesh a patient’s schedule (and often their primary care provider) with a specialist willing to see the patient. 

Some states and the federal government have tried to get a hold of this. I have another paper that thinks about how difficult it is to regulate provider networks across multiple plans and agencies. It’s hard to figure out what an adequate provider network is. Say there’s one cardiologist for every 1,000 beneficiaries in one plan. That might sound adequate, but you’re not accounting for the fact that same cardiologist might be in other plans, too — often hundreds of them. Suddenly, the ratio changes.

For now the best way to move forward is with transparency so that consumers can find the kind of products that work for them. This plays into provider directory accuracy as well.

Q: How is consolidation among provider and hospitals as well as rural hospital closures exacerbating the narrow network problem in rural areas?

A: Consolidation isn’t good for this. The likely reason insurance companies exclude providers is because they’re too costly to include. (Consolidation has been shown to increase how much providers charge.) If they cost as much as the average provider to include, they’d probably include them. 

Hospital closures are making it harder for rural Americans to get access to care since the closures add travel distance.

Q: How does this relate to surprise medical bills, an area that’s gotten a lot of media coverage?

A: Surprise medical bills have all the aspects that make for good newspaper reporting. It’s harder to personalize topics like narrow networks in rural areas. You could try to find a kid with a chronic condition who can’t see a specialist. Or, find someone who decides to stick with a provider even if that doctor is no longer in their insurance network. 

It’s good for journalists to write about massive bills, but what likely happens much more is that people knowingly go to an out-of-network provider because the one in their network is too far away or isn’t accepting new patients. That has to be happening so much more frequently, especially among the more socially disadvantaged. We have a survey out on this issue and we’re still analyzing the findings. But we’re finding there are people who know they will be billed out of network, yet they’re doing it anyway. Why?  

Q: How might reporters better tell the story of health care access in rural America?

A: If you go to a Walmart in rural West Virginia (Haeder previously worked at West Virginia University), you see people with massive health conditions. Talk to them. Or, go sit in a restaurant in rural America and start talking to people. Interview people at school-based health centers.  

You can learn tremendous things about the ubiquity of access challenges that people face. Ask them how their health access has changed over the last 20 years.

Q: What are you currently working on? What areas do you plan to research next?

A: We are looking into the NICU where you likely need every single provider to be in your network. We’re trying to figure out how that works for ACA and commercial plans. What if almost everyone is in your network except a couple of providers? How should you manage that? We’re interested in the same kind of analysis with provider networks for veterans and access to VA facilities. What are the wait times and distances there?