Executive Summary
A health plan's most valuable resource is its provider network, which includes primary care and specialty physicians, institutional providers like hospitals and nursing homes, and ancillary providers like home health agencies and rehabilitation centers. Many organizations, however, struggle in building and maintaining provider relations.
This ongoing challenge to recruit and retain providers puts health plan members at risk for poor access. Medicaid health plans are particularly sensitive to the importance of offering dependable access to specialty services because their patients experience more chronic illness and disabilities, and therefore may require more specialty care, than do patients of commercial health plans.
To identify the barriers to recruiting and retaining providers, the Association for Community Affiliated Plans (ACAP) conducted a study of its member plans in the spring of 2004. Four plans were selected for more in-depth case studies to examine practices that address provider recruitment and retention barriers.
Challenges and Obstacles to Recruiting and Retaining Providers
The top five challenges reported by plan leaders were: 1) low payment rates, 2) preference for private patients, 3) general scarcity of providers, 4) scarcity of providers in rural regions, and 5) frustration with referral and pre-authorization processes.
Matching Best Practices to Challenges
The plans repeatedly stressed the importance of sustaining relationships with providers through regular and meaningful communications. Additionally, plans were introducing technology applications as important tools in facilitating process improvement. Medicaid managed care plans looking to improve specialty recruitment and retention may gain as much from the simpler examples of operational change in this report as from the more innovative strategies.
ACAP plan leaders experienced the greatest success in improving provider relations in the following five areas: 1) payment practices, payment incentives, and financial assistance; 2) utilization management practices; 3) communications and provider outreach practices; 4) practices to simplify administrative burdens; and 5) enabling service practices.
Payment Practices, Payment Incentives, and Financial Assistance
The ACAP plans ranked low payment rates as the top frustration of both primary care providers and specialists, with 94 percent of the plans identifying this as a contracting challenge. Medicaid plans have had a limited ability to improve provider reimbursements, which have been linked to their states' historically low Medicaid rates. Instead they have tried to pay providers promptly and have offered financial incentives aligned with high-quality care. Most efforts to improve claims turnaround time concentrated on front-line processes, departmental reorganizations, new technologies, and financial incentive practices.
Utilization Management Practices
Most utilization management practices addressed providers' frustrations with the referral and authorization processes—one of the top three challenges to recruiting and retaining providers. Plans also introduced general improvements in utilization management customer service and used technology tools to facilitate authorizations and referrals.
Communications and Provider Outreach Practices
ACAP plans have invested in building and maintaining solid provider relationships through outreach. In-person meetings, or "face time" are highly valuable—particularly when plan representatives spend time in providers' offices. Regular written communications are also important to inform providers about changes to administrative procedures, clinical breakthroughs, quality measures, and legal updates.
Practices to Simplify Administrative Burdens
Providers spend more office time satisfying health plan and state reporting requirements for Medicaid managed care than they do for commercial or Medicare patients. ACAP plans are sensitive to this administrative burden and look for ways to simplify these requirements. Many of the surveyed plans have simplified eligibility and credentialing processes, and a few plans have taken similar steps to simplify the process for health care encounter data submission.
Enabling Service Practices
Just six of the ACAP plans reported success with using enabling services to improve provider relations. These services, which are aimed at patients who have trouble keeping appointments, address the social barriers that may prevent or interfere with members' ability to receive medical services. Examples include transportation services, child care arrangements, interpreter services, and providing members who lack telephone service with cell phones so case managers can contact them.
Conclusions
The recruitment and retention challenges and opportunities of the ACAP plans offer strategic advice for all health plans, from sophisticated technologies that reduce administrative burdens to the most basic and reliable forms of good communication and outreach. These tactics can help attract new providers, as well as improve quality of care, enhance member satisfaction, and achieve cost savings.
Certain specialties are more challenging to recruit and retain. One-third of respondents reported that 78 percent of the specialties included in the survey are severely or moderately challenging to recruit. Pediatric specialties of all kinds were considered among the most challenging providers to find. Other hard-to-fill specialties include dermatology, psychiatry, orthopedics, and plastic surgery.