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Marketplace insurance plans often lack access to in-network specialists

Almost 15% of insurance plans offered through the federal marketplace were considered ‘specialist deficient’, lacking in-network access to physicians in various specialties, according to recently published data.

Stephen C. Dorner, MSc, of the Harvard T. H. Chan School of Public Health, Boston, and colleagues examined physician networks in 34 states that offered plans through the federal marketplace in the 2015 open enrollment period to assess patient access to outpatient specialists through available plans. The researchers assessed plans based on their in-network access to specialists in gynecology and obstetrics, dermatology, cardiology, psychiatry, oncology, neurology, endocrinology, rheumatology and pulmonology. In total, 135 plans were included in the analysis.

Results demonstrated that when using a 100-mile and 50-mile search radius, 13.3% and 14.1% of plans, respectively, lacked at least one in-network specialist, according to the researchers.

The most commonly excluded specialties included psychiatry, rheumatology and endocrinology. Additionally, between seven and 14 plans only had fewer than five in-network providers in these specialties.

Nine states and 12 insurers had at least one specialty-deficient plan. Insurance plan premium levels was not associated with the proportion of specialists available, according to the researchers.

“In this study of federal marketplace plans, nearly 15% completely lacked in-network physicians for at least one specialty. We found this practice among multiple states and issuers. This likely violates network adequacy requirements, raising concerns regarding patient access to specialty care. Such plan precipitate high out-of-pocket costs and may lead to adverse selection (ie, sicker individuals choosing plans with broader networks), which is similar to concerns over restrictive drug formularies,” Dorner and colleagues wrote. – by Casey Hower

Disclosures:  Dorner reports no relevant financial disclosures. Please see full study for a list of all authors’ financial disclosures.