ACA health plans limit access to specialists: 7 findings

Health insurance plans through the Affordable Care Act could be making enrollees pay additional money for specialist care, according to a study published in JAMA.

The study looked at access to specialists in U.S. physician networks participating in the ACA's insurance marketplaces in 2015. Specifically, the authors looked at physician networks in 34 states offering plans through the federal marketplace during 2015 open enrollment using the rating area (geographic unit for marketplace premiums) containing each state's most populous county.

Here are five findings from the study.

1. Using a broad search radius of 100 miles and a narrow search radius of 50 miles relative to each rating area's most populous city, 18 plans and 19 plans, respectively, of 135 plans were specialist-deficient, meaning the plans did not have a specialist physician.

2. Two plans included dermatologists and oncologists in the broad search radius but not the narrow search radius.

3. Endocrinology, rheumatology and psychiatry were most commonly excluded, and an additional seven to 14 plans had fewer than five in-network physicians in those specialties.

4. There was no significant difference in the proportion of plans without a specialist physician across insurance plan premium levels.

5. Nine of 34 states (24 percent) had at least one plan without a specialist physician. Twelve different insurers had at least one plan without a physician specialist.

6. Beneficiaries of plans without a specialist physician had high out-of-network costs, according to Medical Xpress. Specifically, five of 19 plans (26 percent) did not cover out-of-network services, whereas 11 of the remaining 14 plans (79 percent) required cost-sharing of 50 percent or more. In additional, nine of 19 plans (47 percent) did not cover medications prescribed by out-of-network physicians, Medical Xpress notes.

7. In writing about plans that lack in-network physicians for at least one specialty, authors of the study said "this likely violates network adequacy requirements, raising concerns regarding patient access to specialty care," according to Medical Xpress. They added, "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."


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