For years, health plans have worked hard to expand coverage and help millions of Americans get health insurance. But having a health plan does not always mean people can actually get the care they need.
Patients are facing long wait times for doctor and care appointments, limited provider choices, transportation challenges, paperwork, and rising cost shares, which force them to delay their care. Health plans need to improve patient outcomes, lower their member’s costs, and keep members satisfied to focus on real access.
Coverage Is Only the Beginning
Many people believe having health insurance solves the access problem, but that is not the case. Health plans should measure success in new ways.
Instead of just counting how many people sign up, they should also track:
- Time to first appointment
- Primary care attachment rates
- Specialist availability
- Medication access
- Preventive care completion
Access to health care means being able to get timely, high-quality services and prescription medications, and having a regular place to go for care. It is more than just having an insurance card. These metrics better reflect whether members can actually use their benefits.
Provider Networks Must Prioritize Access, Not Just Cost
Lower premiums and patient cost shares often result from smaller, more engaged provider networks. These smaller provider networks make it harder for people to access care.
Health plans address this problem by expanding high-need specialty networks, monitoring appointment availability across network providers, and conducting ongoing evaluations of network adequacy using real-world utilization data. They should also use telehealth to fill provider gaps in rural and other underserved areas with a shortage of health providers.
If members can’t find in-network providers, they might put off care or end up using costly emergency services instead. A provider listed in a directory is not enough if patients cannot actually get an appointment.
Administrative Burdens Need to Shrink
Many patients who deal with healthcare compare it to feeling like a second job. Prior authorizations, changes to medication lists, step therapy rules, and complicated paperwork slow down their treatment because they’re not familiar with the jargon or how most of it works.
Health plans should simplify the member experience by:
- Automating approvals for evidence-based treatments
- Reducing repetitive documentation requests
- Improving digital self-service tools
- Providing care navigators for complex cases
Research shows that administrative barriers are major obstacles to getting care, especially for people with chronic conditions. Every unnecessary step creates another opportunity for a patient to abandon care.
Address Social Determinants of Health
Medical care alone can’t solve many of the issues that influence health outcomes. Forward-thinking health plans are increasingly:
- Screening for social needs
- Partnering with community organizations
- Offering transportation assistance
- Supporting food and housing resource referrals
Factors such as housing, transportation, education, food security, and income significantly affect whether people can access and benefit from healthcare. Helping a member reach an appointment can be just as important as paying for it.
Invest in Better Data Sharing
Members often move between primary care doctors, specialists, hospitals, pharmacies, and community groups. When these systems do not share information, gaps in care can happen.
Health plans that facilitate real-time data exchange, shared care management platforms, and the integration of pharmacy clinical information and population health analytics identify members at risk of delayed care. New research suggests that better data sharing and the inclusion of social factors can improve care continuity and patient outcomes. Better information leads to better intervention.
Focus on Long-Term Relationships
Having a usual source of care is an important indicator of access. Health plans should encourage continuity by:
- Incentivizing primary care engagement
- Supporting value-based care partnerships
- Rewarding preventive care participation
- Helping members establish long-term provider relationships
Patients who have steady relationships with their primary care doctors are more likely to get preventive care and manage chronic conditions well. Healthcare works better when patients know where to go before a crisis happens.
The Future of Access Is Member-Centered
Real access is not about how many insurance cards are handed out, but about whether people find the doctors they need, make appointments to see them, afford their medication, navigate the system, and receive care when they need it. Academic research consistently shows that to improve access, health plans need to work on network design, reduce administrative hurdles, address social factors, support ongoing care, and improve data sharing.
Plans that take this wider view of access will improve member experiences, build healthier communities, and help make healthcare more sustainable. Are you ready to help us make a difference?
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