Insurers May Cut Out More Physicians: What Are Your Options?

Leigh Page

Disclosures

August 14, 2018

In This Article

Specialists Are in Danger of Being Removed

The most excluded group of physicians in narrow networks are specialists—and subspecialists in particular. A 2014 study led by Gruber, the MIT professor, found that people who switched to narrow plans actually saw an increase in primary care services compared to their old plans, whereas reductions in spending came entirely from specialists and hospital care.[19]

Among hospitals, academic medical centers are affected the most, owing to their higher costs. A 2013 study found that in "ultra-narrow networks"—where 70% of local hospitals are shut out—only 35% included an academic medical center, compared with 94% in broad networks.[20]

Thompson says most of the Connecticut doctors dismissed in UnitedHealthcare's purge were specialists. A dearth of specialists in that network meant that a patient in Stamford had to drive 40 miles to New Haven to see an in-network nephrologist, he reports. Nationally, a 2015 poll of emergency physicians showed that more than 80% were having difficulty finding specialists for patients in narrow networks.[21]

Some narrow plans have no doctors at all in certain specialties. A 2015 study found that 15% of exchange plans lacked a doctor in at least one specialty.[22]

The situation is even worse for subspecialties. For example, a recent study of exchange plans found that 43.8% had no available pediatrics subspecialists in the area.[23]

A list of doctors needed to meet federal network adequacy regulations includes many specialties, but most subspecialties are not on it, says Howard Rogers, a Mohs surgeon in Connecticut.

Mohs surgery, a branch of dermatology involving procedures for skin cancer, is not on the list, and it's often hard to find such surgeons in narrow networks, according to Rogers, who is a trustee of the American College of Mohs Surgery.

When narrow plans use algorithms to evaluate the costs that physicians generate, Rogers says they count Mohs surgeons as dermatologists, rather than as a separate group. Because Mohs doctors perform relatively expensive surgery, they are treated as expensive dermatologists and removed from the network, he says.

Rogers met with the medical directors of several plans and with officials of Optum, maker of one of the most widely used algorithms, to show them why Mohs surgeons are more expensive and should be evaluated in a separate category from dermatologists. But none of them agreed to do so, he says.

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