Study raises concerns about patient access to specialists within insurance plans under ACA

Vanderbilt University Medical CenterNov 6 2015

While 12 million Americans are enrolled in health care networks through the Affordable Care Act's (ACA) insurance marketplace, a recent study in the Journal of the American Medical Association (JAMA) raises concerns about patient access to specialists within these insurance plans.

The study, "Adequacy of outpatient specialty care access in marketplace plans under the Affordable Care Act," shows that nearly 15 percent of the plans lacked in-network physicians for at least one specialty.

"That was really surprising," said lead author Stephen Dorner, M.Sc., a fourth-year student at Vanderbilt University School of Medicine. "In theory, this scenario is not supposed to happen based on the way the regulation is written, which states that a sufficient number and type of provider should be contained in the plans to guarantee access to care.

"If they have no physicians whatsoever in the network, it seems to me that they are not meeting the standard," he said. "It raises questions about the enforcement of the existing regulations."

Dorner and his colleagues reviewed networks from 34 states, Tennessee included, offering plans through the federal marketplace during the 2015 open enrollment period. Study investigators used the online directories to search for in-network specialty physicians within a 100-mile radius and found that endocrinology, rheumatology and psychiatry were the most commonly excluded specialties.

Nine of the 34 states had at least one specialist-deficient plan while 12 different insurers had at least one specialist-deficient plan. According to study results, there were no significant differences in the proportion of specialist-deficient plans across plan premium levels.

"The major takeaway from this, which is really bad for the patients, is that if they needed access to these specialists they do not have it," said Dorner. "This also translates to really high costs for the patient."

"Such plans precipitate high out-of-pocket costs and may lead to adverse selection (i.e., sicker individuals choosing plans with broader networks), which is similar to concerns over restrictive drug formularies," reads the study.

The National Association of Insurance Commissioners is currently revising its model language for insurance regulations, said Dorner. Much of the present language from that model law, which has not been updated since 1996, was incorporated into the existing regulation.

"The goal, our hope, is that in demonstrating these access issues that we can either enhance the enforcement of the current regulation or incorporate some new thinking into the language that is being drafted.

"The overarching goal is to improve patient access to affordable care."