Lack of Specialists Found in Federal Marketplace Insurance Plans

Nearly 15% of federal marketplace insurance plans lack in-network physicians for at least 1 specialty, according to researchers at the Harvard T.H. Chan School of Public Health in Boston. Their study, published as a Research Letter in JAMA, raises concerns about patient access to specialty care among the nearly 12 million Americans who have enrolled in healthcare coverage through the insurance marketplaces set up by the Affordable Care Act.

Stephen C. Dorner, MSc, and colleagues examined physician networks in 34 states offering plans through the federal marketplace during 2015 open enrollment. They analyzed 4 silver-level plans (the category of plans purchased by 69% of consumers): lowest, second lowest, median, and highest-premium plans (a total of 135 plans). Using the online directories provided by the plans, the researchers searched for in-network specialist physicians for various specialties.

Using a 100-mile and 50-mile search radius, 18 (13%) and 19 (14%), respectively, of 135 plans were specialist deficient (plans without a specialist physician). Endocrinology, rheumatology, and psychiatry were the most commonly excluded specialties. It is notable that psychiatry is among the largest-volume nonsurgical specialty, and endocrinology and rheumatology are specialties that treat common outpatient conditions. An additional 7 to 14 plans had fewer than 5 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%) had at least one specialist-deficient plan; 12 different insurers had at least one specialist-deficient plan.

The researchers found that beneficiaries of specialist-deficient plans had high out-of-network costs. Five of 19 (26%) did not cover out-of-network services and 11 of the remaining 14 plans (79%) required cost-sharing of 50% or more. Nine out of 19 (47%) plans did not cover medications prescribed by physicians who were out of network.

There was no significant difference in premiums between specialist-deficient plans and other plans.

The investigators said that their finding that nearly 15% of plans completely lacked in-network physicians for at least one specialty “likely violates network adequacy requirements, raising concerns regarding patient access to specialty care.” They caution that such plans precipitate high out-of-pocket costs and may lead to sicker individuals choosing plans with broader networks, a concern that is similar to concerns about restrictive drug formularies.

The authors noted that the study focused on the largest population center in each state because rural regions are known to have fewer physicians; thus these states may have an even higher prevalence of specialist-deficient plans if rural areas are surveyed.