Behavioral health, nephrology, and oncology shortages are structural — plans that wait for the market to fix itself will lose adequacy in those specialties for years.
The Shortage Is Not a Cycle. It's a Structure.
Every year, network build leaders hear some version of the same reassurance: the specialty shortage will ease as more providers graduate, as reimbursement rates improve, as the market self-corrects. That reassurance is wrong — and plans that build strategy around it are going to file inadequate networks for years.
The behavioral health shortage is projected to reach 250,000 unfilled positions by 2025 and worsen through the end of the decade. Nephrology has been in structural decline since the early 2010s, with fewer physicians entering the field than retiring from it. Oncology faces a similar compression: demand is rising faster than supply, and the geographic distribution of practicing oncologists is heavily skewed toward urban academic centers. These are not market inefficiencies that will correct. They are long-duration structural deficits.
Plans that acknowledge this reality early have a significant operational advantage. Those that don't will spend every filing cycle scrambling to explain the same gaps — to CMS, to state regulators, and eventually to their boards.
Telehealth Pathways Are Now a Legitimate Adequacy Tool — Use Them
CMS has expanded its recognition of telehealth in network adequacy determinations, and the best plans are treating this as a first-order strategy rather than a fallback. In certain specialties — behavioral health being the clearest example — a telehealth-credentialed provider can now satisfy time-distance standards in ways that were not available three years ago.
This is not a workaround. It reflects the reality of how care is delivered. A member in a rural county who has reliable video access to a licensed behavioral health provider is receiving meaningful access to care. CMS has caught up to that logic, and plans should use it.
The execution requirement is real: the telehealth provider must be properly credentialed, the service agreement must cover the specific county, and the documentation must be precise. But for behavioral health in particular, telehealth pathways are one of the few areas where a plan can legitimately close a gap that the physical provider market cannot fill.
Academic Medical Centers as Network Infrastructure
Leading plans have shifted their thinking about academic medical centers from "high-cost outlier" to "adequacy anchor." In markets where private-practice oncologists or nephrologists are unavailable, an AMC contract may be the only path to a compliant network.
This requires confronting the cost reality directly. AMC rates are higher. But the alternative — filing an inadequate network, receiving a deficiency notice, or being unable to expand into a county — has its own cost, and it tends to land harder on operations than a rate negotiation. The plans that are doing this well have a clear internal framework: they treat AMC contracts in high-shortage specialties not as premium spend, but as infrastructure cost, similar to the cost of operating in a frontier market.
The contracting posture matters. AMCs respond to volume commitments and multi-year agreements. Plans that approach AMC negotiations with a transactional mindset — trying to squeeze rates on a single-year deal — lose the negotiation before it starts. Plans that come with a multi-county, multi-year view tend to close agreements.
Exception Documentation as a Proactive Strategy
In markets where no provider will contract — and those markets exist across nephrology, oncology, and behavioral health — the options are not "find a provider" or "file inadequately." The option is to build a documented good faith record that supports an exception request.
CMS expects plans to demonstrate genuine effort: multiple outreach attempts across different contact methods, documentation of provider responses (or non-responses), and in some cases evidence that the plan has explored alternative arrangements. Plans that treat this as a checkbox exercise — a form letter sent once, filed in a folder — are building a weak exception record that will not hold up under scrutiny.
The plans doing this well start their exception documentation 9 to 12 months before submission. They build a traceable record of outreach, track provider responses systematically, and frame their exception requests with specificity: which county, which specialty, what outreach was attempted, and what alternative access arrangements exist for members. In frontier counties and single-provider markets, this documentation record is often the difference between an approved exception and a deficiency notice.
The specialty shortage is not going to solve your network adequacy problem. Your documentation strategy, your telehealth contracts, and your AMC relationships are the only tools that will.
Realistic planning means accepting that some counties will never have the physical provider density that CMS's original standards assumed. The plans that accept this early — and build their strategy around telehealth pathways, AMC infrastructure, and robust exception documentation — will file cleaner networks and spend less time in deficiency remediation than the plans still waiting for the market to change.