Thursday, October 29, 2015

qotd: ACA plans do not always have a full complement of in-network specialists

October 27, 2015
Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under
the Affordable Care Act
By Stephen C. Dorner, MSc; Douglas B. Jacobs, ScB; Benjamin D. Sommers,

In this study of federal marketplace plans, nearly 15% completely lacked
in-network physicians for at least 1 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 plans 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.

We also found substantial turnover in directory listings. 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.

(R)ural regions are known to have fewer physicians and may have an even
higher prevalence of specialist-deficient plans.


Comment by Don McCanne

This study shows that not all health plans in the ACA insurance
exchanges have a full complement of specialists in their networks. When
patients have to obtain their care out of network, they may face
impaired access and financial penalties. If private insurers cannot
provide the basics, why would we want to include them in our health care
system in the first place?

Single payer.

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