Healthcare reform means millions of people will gain access to health insurance, prompting some concern about the availability of PCPs and specialists.  There is also concern that the narrow networks being offered by many health plans to contain costs will limit access.

New Healthcare Requirements for Monitoring Access

Health plans can be required to monitor their members’ access to appropriate and timely care by state and federal regulatory authorities. In order to meet standards for accreditation by entities such as NCQA, health plans are also required to monitor access.

To monitor member perception of access to care, some health plans use the CAHPS Survey.  Overall, national results for commercial health plans show that approximately 86% of members ‘always’ or ‘usually’ get the care or appointments they need right away.

As noted, health plans are required to monitor access for accreditation.  If health plans notice problems with access from their CAHPS results or from other measurements, new updates to standards require the plan to drill down for more information.

Two Solutions for Monitoring Access to CareAccess to care

SPH Analytics recommends two drill-down solutions to identify where there might be problems with access:  Provider Access Audits and Member Access Tracking Studies.

Provider Access Audits

When TMG conducts provider access audits, our experienced agents contact provider offices to ask about and document appointment availability and after-hours protocol.  TMG collects appointment dates and times so that we can calculate the amount of time between the call date and time and the appointment dates and times.

These wait times are compared to the plan’s access to care standards to provide pass/fail information and compliance rates that plans can use to follow up with its network providers.

Member Access to Care Tracking Studies

The Member Access to Care Tracking Study consists of outreach to members who have filed a claim recently, and serves to measure satisfaction with several potential topics related to access and satisfaction.  For example:

  • Office wait time,
  • Appointment wait time,
  • Ease of scheduling an appointment,
  • Doctor communication

This study is recommended on an ongoing basis to keep a pulse on what is going on in the provider network.

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