Solving the Access Issue Once and For All

With today’s behavioral health care staffing shortages and increasing prevalence of developmental disabilities and autism, it’s a major challenge to create enough capacity to be able to serve these communities.

But payers’ network adequacy is a key factor affecting access to care and it’s getting more attention from lawmakers because of “ghost networks,” particularly in behavioral health care.

A recent “secret shopper” study¹ conducted by the Senate Finance Committee found only 18% of shoppers could get an actual behavioral health care appointment, with one-third of contact information being unusable. At least one senator has called for legislative action to address the issue.² Countless other studies have identified similar issues, including those cited in a research letter to the JAMA Network Open.³

Network Adequacy

Provider networks are the payer’s network of clinicians and other caregivers typically listed in a directory. In the case of ghost networks, directories are out of date or otherwise erroneous, so when a member calls to try to get an appointment, they find many providers are no longer in-network or the listed phone numbers or physician details are wrong.

Narrow networks are not atypical ⁴ in qualified health plans that are offered through the healthcare marketplace via the Affordable Care Act. These plans typically have closed networks – meaning a provider is either in-network and their services are covered, or they are out of network and their services are not covered. Many of these are narrow networks, meaning a small percentage of available providers are actually in-network.⁵

The obvious solution to increasing demand would seem to be to add providers to networks. But the reality of network management is far more complex than simple supply and demand. Adding providers who are in short supply across behavioral health care risks higher costs from greater network management needs alone, without a guarantee of truly meeting members’ access needs.

In general, payers must meet network adequacy rules, though there is no national standard for what that means⁶ and standards vary across states and coverage types.⁷ The data used to determine whether adequate access exists are often quantitative inputs, such as the number of providers available within a certain time or distance for a geographic area. But whether demand is actually being served really isn’t measured. So, is network adequacy the wrong calculus for measuring access in the first place?

As some payers know, cost avoidance as a strategy in an area of rapidly growing need, as with autism and intellectual and developmental disabilities, doesn’t work well. One in 36 children is now diagnosed with autism spectrum disorder (ASD).⁸ In California, the prevalence is higher at one in 22.⁹ A backlog of unmet needs can lead to other healthcare issues that, left untreated, can spiral out of control.

The solution lies in building a balanced approach between providers and a new approach to network management – one that includes organizations with flexible treatment options that expand access by empowering caregivers and focusing on access, quality and value.

Partnering to Enhance Network Management Pays Off: Solving Network Adequacy Issues at the Source

One of the nation’s largest behavioral health networks, Catalight’s Advanced Care Solutions is designed to increase access while driving down the cost of care and improving outcomes. Catalight is committed to improving the well-being of people with autism and intellectual and developmental disabilities and their families, while maintaining focus on access, quality, and value.

Catalight gets results, including:

• Shorter referral time — Time from referral to appointment is four to seven days on average, with 90% seen for the second appointment within eight days.
  
• Cost and quality management — Value-based care (VBC) contracting leads to 30% cost reduction and reduces average member cost share by 7.5%. This efficient, standards-based approach means children make the same progress with fewer treatment hours.
  
• Clinical innovations — An 81% expansion in parent-mediated modalities, which helped improve parent self-efficacy by 20%.

With an approach emphasizing caregiver-led treatment as a key component of behavioral health care, Catalight has pioneered a way for networks to expand their capacity while capturing other benefits and reducing costs. Those include improved parental self-efficacy, resulting from parent-mediated applied behavior analysis (ABA). That has also been shown to reduce parental stress.

And any parent of a child with autism spectrum disorder will tell you their individual stress is through the roof.

Payers looking to optimize their behavioral health care offerings for ASD and intellectual or developmental disabilities (I/DDs) care should take a close look at provider networks that can not only deliver for today’s needs, but also have a plan for tomorrow’s needs and economic realities.

^[1] Major Study Findings: Medicare Advantage Plan Directories Haunted by Ghost Networks

^[2] Wyden Calls for Action to Get Rid of Ghost Networks, Releases Secret Shopper Study

^[3] 81% of Entries Are Inaccurate in Provider Directories of 5 Large Payers

^[4] Hospital networks: Perspective from four years of the individual market exchanges

^[5] Network Adequacy Standards and Enforcement

^[6] Health Benefit Plan Network Access and Adequacy Model Act

^[7] Health Insurance Network Adequacy Requirements

^[8] ASD Data Visualization

^[9] A Snapshot of Autism Spectrum Disorder in California