Pennsylvania State University.
University of Wisconsin-Madison.
J Health Polit Policy Law. 2019 Dec 1;44(6):937-954. doi: 10.1215/03616878-7785835.
In order to increase access to medical services, expanding coverage has long been the preferred solution of policy makers and advocates alike. The calculus appeared straightforward: provide individuals with insurance, and they will be able to see a provider when needed. However, this line of thinking overlooks a crucial intermediary step: provider networks. As provider networks offered by health insurers link available medical services to insurance coverage, their breadth mediates access to health care. Yet the regulation of provider networks is technically, logistically, and normatively complex. What does network regulation currently look like and what should it look like in the future? We take inventory of the ways private and public entities regulate provider networks. Variation across insurance programs and products is truly remarkable, not grounded in empirical justification, and at times inherently absurd. We argue that regulators should be pragmatic and focus on plausible policy levers. These include assuring network accuracy, transparency for consumers, and consumer protections from grievous inadequacies. Ultimately, government regulation provides an important foundation for ensuring minimum levels of access and providing consumers with meaningful information. Yet, information is only truly empowering if consumers can exercise at least some choice in balancing costs, access, and quality.
为了增加医疗服务的可及性，扩大覆盖范围一直是政策制定者和倡导者的首选解决方案。这种思路看似简单：为个人提供保险，他们在需要时就能获得医疗服务。然而，这种思维方式忽略了一个关键的中间步骤：医疗服务提供者网络。由于医疗保险提供商提供的医疗服务提供者网络将可用的医疗服务与保险覆盖范围联系起来，因此其广度调节了医疗保健的可及性。然而，医疗服务提供者网络的监管在技术、后勤和规范方面都非常复杂。目前的网络监管是什么样子的，未来应该是什么样子的？我们对私人和公共实体监管医疗服务提供者网络的方式进行了盘点。保险计划和产品之间的差异非常显著，没有基于经验依据，有时甚至是荒谬的。我们认为，监管者应该务实，关注可行的政策杠杆。这些包括确保网络的准确性、为消费者提供透明度，以及保护消费者免受严重不足的影响。最终，政府监管为确保最低水平的可及性和为消费者提供有意义的信息提供了重要基础。然而，只有当消费者在平衡成本、可及性和质量方面至少有一定的选择权时，信息才能真正具有影响力。
