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The High Performance Health Plan
← The Framework

Component 03

Medical Network & Provider Economics

Are we paying reasonable prices for high-quality healthcare?

Clear definition

Medical network and provider economics is the ongoing work of evaluating actual allowed prices, quality, access and care settings rather than equating a network discount with value.

What to measure

Evidence before assumptions.

  • Allowed amounts
  • Price variation
  • Quality indicators
  • Access to high-value providers

Common mistakes

What weakens performance.

  • Assuming a large PPO discount means a low price
  • Treating network access as the only purchasing criterion
  • Ignoring site-of-care differences

High-performance practices

Build a deliberate approach.

01

Benchmark actual allowed prices

02

Evaluate provider quality and patient access alongside price

03

Consider direct contracting, reference-based pricing and centers of excellence where appropriate

Definitive employer guide

Network strategy is about the economics and outcomes of care delivered, not the size of a logo on an ID card.

This guide gives plan leaders an operating model for making the component measurable, accountable and connected to the rest of the health-plan strategy. It is educational guidance and should be applied with appropriate legal, financial and clinical advisers.

Define the care and market question

Identify the provider categories, services and geographies driving spend before selecting or defending a network arrangement. A broad network can be valuable, but breadth alone does not demonstrate access, quality or price discipline.

Pair claims analysis with member experience signals. The committee should understand where people receive care, what they pay and where a different site, provider or contract approach could improve value.

Make provider economics visible

Compare allowed amounts, unit prices, episode patterns and site-of-care differences for meaningful services. Normalize for population and clinical complexity when possible, and use ranges instead of a single average where variation matters.

Ask network partners to explain their payment model, attribution method and savings assumptions in plain language. A discount is not a complete economic story without a reliable reference price.

Create practical steerage

Steerage works when the preferred path is understandable, accessible and supported. Align navigation, incentives, primary care and communication so members can make a better choice before care is scheduled.

Protect continuity of care and avoid treating disruption as a savings strategy. Measure both access and migration results after any network change.

Govern the contract and performance

Define reporting rights, performance standards and escalation paths in the agreement. Review provider access, price and quality indicators on a cadence that allows correction before the next renewal.

The committee should retain the ability to test whether network recommendations serve the plan’s stated objectives.

Five metrics every employer should monitor

Access and experience

Can employees and leaders use the intended path without avoidable friction?

Cost and utilization

What patterns show whether the strategy is changing the relevant drivers?

Vendor performance

Are partners meeting contracted commitments with usable reporting?

Decision cadence

Are results reviewed early enough to guide a decision?

Documented outcomes

What changed, what was learned and what action follows?

Maturity progression

Crawl. Walk. Run. Sprint.

Crawl

Basic information is available, but decisions remain largely renewal-driven.

Walk

Leaders have a defined owner, baseline measures and recurring review.

Run

Strategy, contracts and employee experience are connected through active governance.

Sprint

The organization tests assumptions, shares learning and continuously improves.

Ten questions to ask

  1. 01What decision are we trying to improve?
  2. 02Who is accountable for the result?
  3. 03Which baseline measures will guide us?
  4. 04What assumptions are we treating as facts?
  5. 05What data rights do we need?
  6. 06How does this connect to other plan components?
  7. 07What employee friction could undermine the strategy?
  8. 08What does the vendor contract require?
  9. 09What will we review in the next 90 days?
  10. 10How will we document progress and adjust?

What good looks like

Managed, not merely renewed.

A high-performing approach is transparent, actively governed and connected to employee experience. It gives leaders a repeatable way to test assumptions, make tradeoffs and improve outcomes over time.

Related Employer Benefits IQ tools

  • Health Plan Score: identify the current gap
  • Three-Year Health Plan Roadmap: sequence the work
  • Framework component workbook: assign evidence and owners

Frequently asked questions

Where should an employer begin?

Begin with a clear decision, an accountable owner and a baseline that makes improvement visible.

How often should leaders review this component?

Review the operating measures at least quarterly, with more frequent attention when a material decision or risk requires it.

Is this component separate from the rest of the Framework?

No. Each component affects the others, so priorities and vendor actions should be coordinated rather than managed in isolation.

Sources & references

Evidence that supports the work.

This guide combines the Framework methodology with primary government guidance and independent health-policy research. Sources are included for further review and are not legal, tax or clinical advice.

Reviewed / updated
Framework component
Medical Network & Provider Economics
Book connection
Chapters 3–5 and 21
Author
Corry Hull, REBC®, CSFS® — Vice President of Employee Benefits, BHC Insurance; Health Rosetta Advanced Advisor; author of The High Performance Health Plan.
U.S. Department of Labor — Employee Benefits Security Administration↗Centers for Medicare & Medicaid Services — Transparency in Coverage↗U.S. Department of Health & Human Services — No Surprises Act↗Internal Revenue Service — Publication 15-B↗KFF — Employer Health Benefits Survey↗RAND — Hospital Prices Paid by Private Health Plans↗

Book connection

Chapters 3–5: What healthcare really costs

Chapters 3–5 and 21

These chapters distinguish a discount from a price and connect provider economics to actual employee access.

Explore the book

Health Plan Score connection

Medical Network & Provider Economics

Are prices, quality and site-of-care choices evaluated together when employees seek care?

A lower score suggests beginning with price variation and access evidence before changing network strategy.

Take the Health Plan Score

Decision-support documents

Put the strategy to work.

Employer Benefits IQresource

Medical Network Strategy Guide

A printable Employer Benefits IQ worksheet for defining the decision, evidence, accountable owner and review cadence.

Download the component workbook

Author perspective

Corry Hull, REBC®, CSFS® — Vice President of Employee Benefits Consulting at BHC Insurance, Health Rosetta Advanced Advisor, author of The High Performance Health Plan, founder of Employer Benefits IQ, 2026 Health Rosetta Rosie Award recipient, public speaker and employee benefits strategist.

Explore the Health Plan Score

Put the methodology to work

Apply the HPHP methodology with Employer Benefits IQ.

Employer Benefits IQ is the practical application platform for employers who want to use education, tools, data, vendor intelligence and decision support in real-world benefits decisions.

Use Employer Benefits IQ tools and decision support