Access to Specialty Care Lacking in Many ACA Plans

Nicola M. Parry, DVM

October 30, 2015

Data from a new study show that nearly 15% of federal marketplace insurance plans lack in-network physicians for at least one specialty, highlighting concerns about patients' access to healthcare specialists.

Stephen C. Dorner, MSc, a student at the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and colleagues published the results of their study in the October 27 issue of JAMA.

Although nearly 12 million Americans currently have health insurance coverage through the Affordable Care Act's marketplace plans, which mandates access to a sufficient number and type of providers, “concerns remain about network adequacy,” the authors say.

This study therefore aimed to assess whether federal marketplace plans included physicians in a range of specialties. Plans without various types of specialist physicians were categorized as specialist-deficient.

Dorner and colleagues examined physician networks during a week in April 2015 in 135 plans in 34 states that offered plans through the federal marketplace. In the most populous cities in the plans’ coverage areas, they searched the plans’ online directories to identify in-network physicians across various specialties, using a broad (100 mile) and narrow (50 mile) search radius. Specialist-deficient plans were reassessed 1 month later, and findings were corroborated by calling insurers directly.

Data from the broad and narrow searches of the 135 plans showed specialist deficiencies in 18 (13.3%; 95% confidence interval [CI], 8.5% - 20.3%) and 19 (14.1%; 95% CI, 9.1% - 21.1%) plans, respectively. Endocrinology, rheumatology, and psychiatry, which were the three most commonly excluded specialties, were lacking in 8 (5.9%; 95% CI, 3.0% - 11.5%), 9 (6.7%; 95% CI, 3.4% - 12.4%), and 6 (4.4%; 95% CI, 2.0% - 9.6%) plans, respectively; an additional 7 to 14 plans also included fewer than five in-network physicians in these specialties.

At least one specialist-deficient plan was also identified in each of nine of the 34 states (23.5%; 95% CI, 11.8% - 41.5%) examined, as well as among plans offered by 12 different insurers. However, "there was no significant difference in the proportion of specialist¬-deficient plans across insurance plan premium levels," the authors note.

Specialist-deficient plans also carried high out of-network costs. Among 19 plans, 5 (26.3%; 95% CI, 10.4% - 52.4%) did not cover out-of-network services, and 11 of the remaining 14 plans (78.6%; 95% CI, 46.0% - 94.0%) involved cost-sharing of 50% or more. Nine of 19 plans (47.4%; 95% CI, 25.0% - 70.8%) did not cover medications prescribed by out-of-network providers.

"We also found substantial turnover in directory listings," they add. "This may contribute to inaccuracies in listings, which prompted more stringent federal requirements for 2016. However, physician listings without any specialists (even if inaccurate) may confuse or impede consumers' access to physicians. Future research exploring this practice among different marketplace categories, as well as waiting times for in-network specialists, could provide additional insights," the authors say.

Dr Sommers serves part-time as a senior advisor to the US Department of Health and Human Services. The other authors have disclosed no relevant financial relationships.

JAMA. 2015;314:1749-1750. Abstract

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