Medicare Advantage Hospital Networks: How Much Do They Vary?
Findings on the Adequacy of Provider Directories
Provider directories are the main resource available to beneficiaries who want to know which providers are in the different networks of Medicare Advantage plans. Plans are required by CMS to make a provider directory available to all current and potential enrollees, but the CMS website used by consumers to compare plans does not include a link to plan directories or provide a tool that can be used by plan shoppers to check to see whether their preferred doctors or hospitals are included in plans’ networks. While this analysis focused only on hospitals, and not physicians or other providers, it adds to a growing body of literature that shows that provider directories currently have a number of problems that limit their value in helping to inform beneficiaries. These limitations generally fall into two categories: burden and accuracy of information.
Plans are required to make their provider directory available to current and potential enrollees, and typically provide the information on the firm’s website. In gathering information for our study, we found accessing and using these directories to identify provider networks to be challenging. The plan websites varied in overall layout, the grouping of plans into provider directories, and the format in which the directory is available. Some companies have only one directory that includes all of its HMO and PPO plans, others have separate directories for each individual plan, and some do not have a current directory available at all.
As an example, in 2015, a Medicare beneficiary in Cook County, Illinois could choose from 19 HMO or local PPO Medicare Advantage plans, which had 10 unique provider networks offered by eight different firms. Once beneficiaries go to the applicable firm’s website, locate the link to learn about plans offered in their area, and input some geographic information, they have access to information about the plan’s provider network, but the information is not available in a consistent format across plans. In Cook County, seven of the 10 plan networks had a provider directory that could be downloaded as a PDF from the firm website. For two networks (covering five plans), the only way to learn about the providers in the network was to search the firm’s online database by type of provider or facility to generate a list of providers. For the one remaining network in Cook County (one plan), the provider network was available as a separate downloadable list for each type of provider.
Among the seven directories that were available as a PDF document in Cook County, the content and organization varies. Three of the seven list the network pharmacies, while the other four have a separate document or require an online search to find pharmacy coverage. Dental and vision services are also only included in three of the directories. Information about other services, such as transplant facilities or providers with translation capabilities, is included in some but not all directories. One of the Cook County directories does not include a table of contents or index and is over 600 pages long. (Similarly, other counties, such Los Angeles, have directories with page-counts in the thousands.)
Errors in Directories
In all 20 counties included in this study, errors in the provider directories were common. For example, some directories list facilities as acute-care hospitals when the facilities are actually outpatient centers or rehabilitation institutes. Hospitals with the same address are frequently listed by different names across directories, often reflecting failures to update the directories when hospitals change their names or ownership. In other cases, there are blatant errors. For example, a directory for a plan in Miami-Dade County lists Larkin Community Hospital twice, once with the correct address and once with the address of St. Catherine’s Rehabilitation Hospital.
One of the most obvious signs that some directories are not up-to-date is that some directories include hospitals that have been closed for several years. In 2015, 11 out of the 231 directories examined in this study include hospitals that had been closed or torn down, including one directory that listed a hospital that had been closed since 2005. Another plan’s website provided a directory for its 2015 plan that stated it was last updated in August 2013. A call to the plan’s customer service line confirmed that all of the most current documents were posted online, but that the online search tool should be used for the most up-to-date information. Similarly, this study excluded seven plans offered by three companies because either a provider directory was not available for 2015 and the company declined to provide a directory when contacted, or the searchable directory embedded in the company website did not allow for information to be saved.
Overall, while information about provider networks is available for the vast majority of plans, finding the information often requires Medicare beneficiaries to invest significant time to locate the directories, many of which are inaccurate or incomplete, and none of which facilitate comparisons across multiple plans or firms.