By Alicia Bloom, COO, Empassion
For decades, network adequacy has served as the baseline metric for healthcare access. The premise is simple: ensure patients have reasonable access to the providers and services they need across geographic regions and clinical specialties. Access is, and always will be, essential, but in the realm of serious illness care, we are finding that access alone is no longer a sufficient endpoint. As health plans prioritize clinical outcomes for their medically complex populations, a more urgent operational question emerges: What happens after access is established?
The Gap Between Access and Quality
Network design was built to answer an important, primarily logistical, question: Can our members receive care? It was not engineered to answer the clinical question: How well is that care being delivered?
On paper, two hospice organizations or palliative care programs might look identical. They check the same credentialing boxes, meet the same contracting requirements, and appear side-by-side in a provider directory. Yet, as a clinician, I know that their daily performance, clinical rigor, and operational capabilities can be vastly different.
For health plans managing serious illness, treating provider participation as the finish line is a missed opportunity. It must be viewed as the starting point.
Why Serious Illness Care Defies Episodic Measurement
Traditional healthcare is largely episodic. A patient undergoes a procedure, receives a diagnosis, or attends a follow-up appointment, and the encounter is closed. Serious illness care fundamentally rejects this pattern.
These patients require longitudinal support—often spanning months or years—across multiple progressive conditions, care settings, and transitions. The true markers of quality in this space aren’t captured by simply verifying that a visit occurred. They are found in daily clinical practice: the proactive symptom management that prevents a weekend ER visit, the responsiveness of after-hours triage, and the psychosocial support provided to an exhausted family caregiver. These are the critical factors that dictate patient outcomes and total cost of care long after network access has been verified.
Uncovering the Variance in Provider Performance
Healthcare leaders are increasingly confronting the reality that provider participation does not equal provider performance. In serious illness and end-of-life care, the variance between organizations can be staggering.
While all in-network providers meet minimum participation standards, their ability to consistently deliver high-quality care differs significantly in areas that drive real value, including:
- Clinical Staffing Models: Do they utilize true interdisciplinary teams?
- Symptom Management Expertise: Can they manage complex acuity in the home?
- After-Hours Responsiveness: Are they equipped to divert crises 24/7?
- Care Transition Processes: How seamlessly do they move patients between settings?
- Caregiver Support: Do they actively engage and support the family unit?
For health plans accountable for member experience, clinical outcomes, utilization, and total cost of care, ignoring these variances is no longer tenable.
The Next Evolution: Pairing Access with Accountability
As value-based care models mature and Medicare Advantage footprints grow, payers are under intense pressure to evaluate the efficacy of the care being delivered, not just its availability. This requires a paradigm shift. The future of serious illness strategy demands unprecedented visibility into provider performance, rigorous quality oversight, and objective frameworks to measure the patient experience.
We must pair access with accountability.
Network adequacy will always be the foundation—without it, care cannot happen. But we cannot confuse a robust directory with high-quality care. For members navigating a serious illness, the variance between a baseline provider and a high-performing partner profoundly impacts their quality of life, the burden on their families, and the strain on the broader healthcare system.
The next evolution of network strategy isn’t just about who participates in the network. It is about ensuring those organizations consistently deliver the standard of care our patients deserve. Because ultimately, the goal is not just access to care—it is access to the right care.
Alicia Bloom is Chief Operating Officer of Empassion, a national leader in serious illness and hospice care.
