Balancing Quality, Access, and Cost in Patient-Provider Matching
- Katie Barone
- 2 days ago
- 2 min read
Originally published by HealthCorum
Network adequacy standards have long been an operational requirement for health plans. These formal standards ensure that provider networks have enough physicians, specialists, and facilities to meet basic geographic and access needs. However, adequacy alone should be viewed as the bare minimum. It does not account for how well providers deliver care, whether they are cost-effective, or how they align with the needs of individual patients. In today’s environment, where every dollar matters and outcomes are under the microscope, simply having enough providers is not sufficient.
Building better networks and guiding patients to the right care requires moving beyond adequacy to thoughtfully balance access, quality, and cost. Doing this well starts with recognizing that high-performing providers should not only be included but also financially incentivized, especially in underserved areas. Supporting these providers with favorable contracting terms or increased steerage can help expand access to better care and improve outcomes in populations that historically face barriers.
Getting the right patient to the right provider is essential. When patients are misdirected, it can set off a chain reaction: they may land in the wrong specialist’s office, undergo unnecessary tests, receive inappropriate or delayed diagnoses, and ultimately incur higher costs. These inefficiencies are not just costly; they erode trust and delay access to the right care. Higher-performing providers consistently deliver better outcomes, avoid unnecessary services, and achieve results that lower-quality peers cannot. Their care can offset raw rate differences through fewer complications, lower downstream costs, and better patient experiences.
Designing a network that meets the needs of an entire insured population is not easy. It requires balancing broad access with the ability for individual patients to find providers suited to their specific needs. Networks built purely for adequacy may satisfy regulatory requirements but leave gaps for individual members. Not every patient will be able to easily identify which providers are clinically appropriate or who excels in treating their condition.
This is where modern technologies can play a critical role. Think AI, integrated data systems, and advanced analytics should make it possible to meet both objectives. On one level, health plans must design networks that provide access across regions and patient demographics. On another, they should empower patients and care navigators to locate the best fit for specific care journeys. Combining population-level strategy with patient-level navigation closes the gap between regulatory adequacy and meaningful access.
Networks have always been a core lever for health plans, but they are becoming equally important for employers and other risk-bearing entities. With healthcare costs rising faster than wages and budgets tightening, networks are no longer just about access; they are a crucial tactic for managing spend and improving outcomes. As such, network strategy must evolve. It is not enough to think only in terms of top-down metrics or bottom-up patient pathways. Both perspectives must work together.
A modern network should serve two goals simultaneously.
It should provide broad and equitable access at the population level
It should ensure that individual patients can be efficiently connected to high-performing providers who can deliver the right care at the right time
Achieving this balance is not easy, but it is essential for any organization serious about driving value and improving care quality.