Many Marketplace Health Plans Lack In-Network Specialists

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Nearly 15% of marketplace plans lack in-network physicians for at least one specialty.
Nearly 15% of marketplace plans lack in-network physicians for at least one specialty.

HealthDay News — A considerable proportion of federal marketplace plans lack at least one in-network specialist, according to a research letter published in the Oct. 27 issue of the Journal of the American Medical Association.

Stephen C. Dorner, from the Harvard T.H. Chan School of Public Health in Boston, and colleagues assessed access to outpatient specialists in federal marketplace plans using data from physician networks in 34 states offering plans through the federal marketplace during 2015 open enrollment. They searched for in-network specialists using online plan directories.

The researchers found that 13.3 and 14.1% of 135 plans were specialist-deficient, using a broad (100 miles) and narrow (50 miles) radius, respectively. Two plans included dermatologists and oncologists and three included endocrinologists in the broad, but not narrow, search radius. The most commonly excluded specialists were in endocrinology, rheumatology, and psychiatry; an additional seven to 14 plans had fewer than five in-network physicians in these specialists. Nine of the 34 states and 12 insurers had at least one plan that was specialist deficient. High out-of-network costs were seen for beneficiaries of specialist-deficient plans.

"In this study of federal marketplace plans, nearly 15% completely lacked in-network physicians for at least one specialty," the authors write. "This likely violates network adequacy requirements, raising concerns regarding patient access to specialty care."

Reference

Dorner SC, Jacobs CB, Sommers BD. Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act. JAMA. 2015; doi:10.1001/jama.2015.9375.

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