Study finds access to health insurance does not ensure timely appointments

Employer-based commercial and marketplace plans compared across five California regions

Having insurance coverage in California does not mean that consumers can easily schedule an appointment or quickly get in to see their first choice of physician for either preventive or urgent care, according to a new study coauthored by a University of California, Irvine health policy researcher. Regardless of geography, population density, size of provider network, or type of policy, the study concludes that it is “challenging” for California consumers to access healthcare services, primarily due to inaccurate provider network information.

“We were surprised by our findings,” said Dana B. Mukamel, PhD, a study team member and professor of medicine, public health and nursing at UC Irvine. “We started out assuming that patients with employer-based commercial insurance would have better access and an easier time getting an appointment than patients with insurance through the California Covered health insurance marketplace established under the Affordable Care Act, but this was not the case.”

Entitled “Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those in Marketplace and Commercial Plans” the study appears in the July issue of Health Affairs.

The study focused on network adequacy and accuracy. Network adequacy is the ability of the health plan to provide enrollees with timely access to a sufficient number of in-network providers. Network accuracy refers to the correctness of the provider information. California Covered marketplace plans were compared with employer-based commercial plans across a mix of urban and rural areas in five regions across the state. Both types of plans offered the same panel of providers and benefits structure.

Study results showed that new patients in either commercial or marketplace plans had a less than 30 percent chance of securing an appointment with their initially selected provider, due to one of the following reasons:

• Providers listed in directory no longer with the group or had never been with the group
• Specialty listed in provider directory did not match the one stated by the office receptionist
• Inability to contact the provider despite repeated attempts due to disconnected lines, messages not returned, wrong number listed, or line constantly busy

“Although the accuracy of network listings is a separate issue from adequacy, the network is only as adequate as the information it contains is accurate,” Mukamel said. “Network listing accuracy impacts both a patient’s ability to access providers and the regulator’s ability to assess adequacy.”

The study found that commercial plan patients had a somewhat higher rate of provider acceptance of their insurance, as well as a shorter time to appointment, but only if they agreed to see the first available, rather than the initially selected, provider in the practice.

“States have to regulate insurers to make sure that network directories get updated more frequently and insurers and providers must be held responsible for the accuracy of the data, including information on the provider’s specialty and if the provider is accepting new patients,” Mukamel said. “Consumers trying to navigate the current system should take a deep breath and persevere.”

Researchers contend that their findings are representative of the behavior of insurers and providers across the country, based on the study’s diverse range of demographic, economic, political, health care delivery and financial environments, as well as the carriers – BlueCross and BlueShield - two of the nation’s largest insurers.

The research team was led by Simon F. Haeder, an assistant professor in the Department of Political Science at the John D. Rockefeller IV School of Policy and Politics, West Virginia University. David L. Weimer, professor at the La Follete School of Public Affairs, University of Wisconsin-Madison, also participated in the study. 

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