Kaitlin Howard

By Kaitlin Howard

Kaitlin Howard is a researcher and writer producing insightful content across the healthcare revenue cycle. She has written and produced content for Zelis, Waystar, and Recondo Technology, as well as agencies. With a B.A. in English and Writing from University of Denver, Kaitlin stays current on market updates on claims management and healthcare payments, publishing a regular educational blog series on industry trends and Zelis offerings.

In a recent Future Healthcare Today podcast Zelis Senior Product Analyst for Network Solutions Jillian Carlile and Zelis Senior Product Analyst for Network Analytics Paul Nance shared their thoughts on the enduring importance of both accessibility and adequacy.

We’ll discuss the highlights below, and you can listen to the full podcast here:

A bit of background

Two of the most important elements for healthcare today, accessibility and adequacy are no easy feat. Yet organizational and digital transformation have made both easier to establish and track.

But what exactly are accessibility and adequacy?

Think of accessibility as a way to measure if a health plan’s members have access to sufficient care in terms of the quality and quantity of providers available to them. That is often measured by how far a member has to go or how long they may have to wait to access a particular type of provider.

Adequacy is similar to accessibility, but it also serves as more of a regulatory concept. For example, adequacy would include a minimum provider requirement (e.g., the number of providers required to service a particular size beneficiary population). It’s one thing to have a provider in a particular service area, but if there is member need, it’s important to ensure there is more than one provider to provide an adequate network for that section of the population.

At their core, each theme revolves around the expectation that a health plan member can find the right healthcare provider for their needs.

The easier the process, the better.

But the COVID-19 pandemic has only made that challenge more difficult. Due to population shifts and a lack of medical practitioners, many health plans have found themselves scrambling to meet patient expectations and ensure adequate and accessible healthcare solutions are available in more places than ever before.

Now, the question becomes: how can plans adapt?

Key considerations for your accessibility and adequacy plan

While there are a lot of considerations when selecting an adequacy or accessibility solution, it may be helpful to break your plan into multiple parts.

First, ask yourself, “Who is this intended for?”

Establish if your solution will be primarily focused on helping your network team respond to the compliance piece of the puzzle or if it might be more useful to a sales team that needs to respond to RFPs and demonstrate how strong your network really is.

It’s vital that you choose a solution that matches your unique organization and processes, as well as your intended use. It’s not one size fits all.

If your analysis is going to be part of a network optimization process, you need an adequacy and accessibility solution that can produce results quickly and accurately. If it’s part of an iterative network build, then you need a solution with the ability to evaluate your competitors (e.g., how many are in your intended service area, how they stack up, etc.).

Perhaps even more importantly, you need a solution that is built to address gaps. Meaning: pinpointing the areas in which members do not have appropriate access to certain types of providers.

Best practices

Look for a solution that allows you to run access and adequacy on multiple networks at once.

Meeting the bare minimum for compliance isn’t going to cut it. To ensure you have a sufficient network, you need to be able to compare your network to those around you. After all, a little competition is a good thing.

Brokers (and members) want to know that you’re competitive with a strong network that will provide members more than just the bare minimum of access.

Look for a solution with built-in Medicare Advantage functionality.

More is more. There are numerous lines of business for which there are compliance requirements that need to be met. You need a solution that can meet them.

Look for process integration.

Your potential competitive analysis platform should include network build optimization with integrated access and adequacy. Meaning: you need a single platform with a single workflow.

The wrap up

Accessibility and adequacy refer to a health plan’s ability to deliver the benefits promised by providing reasonable access. Read that again. It’s your job to provide what you’ve promised. Members must be able to access care in a reasonable manner. That’s the bare minimum.

Like everything else in healthcare, that’s easier said than done, but we’re here to help.

To learn more about the role Zelis can play in bolstering your accessibility and adequacy strategy, click here.