In a study of federal marketplace insurance plans, nearly 15 percent completely lacked in-network physicians for at least one specialty, a practice found among multiple states and issuers, raising concerns regarding patient access to specialty care, according to a study in the Oct. 27 issue of JAMA. Nearly 12 million individuals have enrolled in coverage through the Affordable Care Act’s insurance marketplaces. The U.S. Department of Health and Human Services regulates plans, applying a “reasonable access” standard to ensure access to “a sufficient number and type of providers.” Concerns remain about network adequacy, according to background information in the article.
Stephen C. Dorner, M.Sc., of the Harvard T. H. Chan School of Public Health, Boston, and colleagues examined physician networks in 34 states offering plans through the federal marketplace during 2015 open enrollment; this analysis included 135 plans. Using plans’ online directories, the authors searched for in-network specialist physicians for various specialties.
Using a 100 mile and 50 mile search radius, 18 (13 percent) and 19 (14 percent), respectively, of 135 plans were specialist-deficient plans (plans without a specialist physician). Endocrinology, rheumatology, and psychiatry were most commonly excluded, and an additional seven-14 plans had fewer than five in-network physicians in those specialties. There was no significant difference in the proportion of specialist deficient plans across insurance plan premium levels. Nine of 34 states (24 percent) had at least 1 specialist-deficient plan. Twelve different insurers had at least one specialist-deficient plan.
Beneficiaries of specialist-deficient plans had high out-of-network costs; five of 19 (26 percent) plans did not cover out-of-network services, whereas 11 of the remaining 14 plans (79 percent) required cost-sharing of 50 percent or more. Nine of 19 (47 percent) did not cover medications prescribed by out-of-network physicians. There was no significant difference in premiums between specialist-deficient plans and other plans.
Regarding plans that lack in-network physicians for at least one specialty, “this likely violates network adequacy requirements, raising concerns regarding patient access to specialty care,” the authors write. “Such plans precipitate high out-of-pocket costs and may lead to adverse selection (i.e., sicker individuals choosing plans with broader networks), which is similar to concerns over restrictive drug formularies.”
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