Muskie School of Public Service, University of Southern Maine, Portland, Maine 04103, USA. jean.talbot@.maine.edu
J Rural Health. 2013 Jun;29(3):327-35. doi: 10.1111/jrh.12012. Epub 2013 Feb 22.
The Affordable Care Act (ACA) requires Health Insurance Exchanges (HIEs) to specify network adequacy standards for the Qualified Health Plans (QHPs) they offer to consumers. This article examines rural issues surrounding network adequacy standards, and offers recommendations for crafting standards that optimize rural access.
This policy analysis reviews ACA requirements for QHP network adequacy standards, considering Medicaid managed care and Medicare Advantage (MA) standards as models. We analyze the implications of stringent vs flexible access standards in terms of how choices might affect health plans' participation in rural markets and rural enrollees' access to care. Finally, we propose strategies for designing standards with the degree of flexibility most likely to benefit rural consumers.
A traditional approach to safeguarding rural access is to impose strict network adequacy standards on plans in rural areas. However, if strict standards prove difficult to meet due to rural provider scarcity, they might diminish QHPs' willingness to serve rural areas. Thus, they could exacerbate rather than alleviate rural access problems.
To benefit rural communities, network adequacy standards must be strong enough to provide real protections for beneficiaries, yet flexible enough to accommodate rural delivery system constraints and remain attainable for QHPs. Useful strategies to achieve this balance might include: adjusting standards according to degrees of rurality and rural utilization norms; counting midlevel clinicians toward fulfillment of patient-provider ratios; and allowing plans to ensure rural access through delivery system innovations such as telehealth.
平价医疗法案（ACA）要求医疗保险交易所（HIE）为其向消费者提供的合格健康计划（QHP）制定网络充足标准。本文探讨了网络充足标准所涉及的农村问题，并为制定能够优化农村准入的标准提供了建议。
本政策分析审查了 ACA 对 QHP 网络充足标准的要求，同时考虑了医疗补助管理式医疗和医疗保险优势计划（MA）的标准作为模型。我们分析了严格与灵活准入标准在以下方面的影响：这些标准可能如何影响健康计划参与农村市场的意愿，以及农村参保者获得医疗服务的机会。最后，我们提出了设计标准的策略，这些标准具有最有可能使农村消费者受益的灵活性程度。
保障农村准入的传统方法是对农村地区的计划实施严格的网络充足标准。然而，如果由于农村提供者稀缺而难以达到严格的标准，它们可能会降低 QHPs 服务农村地区的意愿。因此，它们可能会加剧而不是缓解农村准入问题。
为了使农村社区受益，网络充足标准必须足够强大，以向受益人提供真正的保护，但又必须足够灵活，以适应农村交付系统的限制，并为 QHPs 所接受。实现这种平衡的有用策略可能包括：根据农村程度和农村利用规范调整标准；将中级临床医生计入患者与提供者比例的满足情况；并允许计划通过远程医疗等交付系统创新来确保农村准入。
