Quelle Surprise! Study Confirms that ACA Narrow Networks Exclude Top Cancer Doctors

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Lambert and once in a great while yours truly have written about one of the nasty-by-design ways insurers game Obamacare: via so-called narrow networks. Bear in mind that there is no precise definition, but a “narrow network” is one that restricts access to specialists. We’ve pointed out that this feature can allow insurers to engage in underwriting by stealth, effectively not covering certain not-common, costly-to-treat conditions by excluding doctors who know how to treat them from ACA networks.

Note that Naked Capitalism was one of the first sites to focus on this issue, aided by the granular work of some of our readers. For instance, from a 2013 post by Dromaius:

As we venture into the world of narrow health care provider networks, I thought I would take some time to study what they really mean, in terms of how the new networks might affect patients’ access to specialty care services. To do this, I compared the current landscape of provider networks with those that will be available on the Exchanges. I used Washington State as a case study. Your mileage may vary, but you will very likely find similar information by querying insurance providers in your state, given that the narrow networks on the Exchange plans are a nationwide paradigm change…,

Bending the “cost curve” in this way appears to also bend “the care curve”
As you can see from my results, the most under-represented specialties (on the left) are the ones that typically provide services to truly sick patients, such as oncology, cardiology, internal medicine, neurology. And no doctor specialty has more than about 75% representation on the Exchange provider networks. Hospitals are also included on the right of the graph. Their numbers are diminished in the Premera Exchange plan network via excluding specialty hospitals that are crucial to good care in this region, such as Children’s Hospital and the Seattle Cancer Care Alliance.

What we’re seeing has been described as a quasi-Medicaid level of doctor access. I would have little problem with plans that “streamline care”. But using Premera as a case in point along with reading about left-out doctors and hospitals all over the nation, I see a pattern of drastically reducing access to care for the sickest patients. This is a method for insurers to subvert the mandated yearly patient out of pocket maximums, (as well as the loss of insurers’ ability to cap lifetime maximum payouts) by making access to expensive care difficult or impractical, especially for the poorest and sickest patients. And by limiting tax subsidies to Exchange plans only, I believe the Democrats wrote their law deliberately to let insurers do this.

Oddly, the mainstream media has chosen for the most part to ignore this issue. It may be because this trick appears to have been implemented most aggressively in where the insurers can pretend they have an excuse, as in areas that are thin on medical resources anyhow, such a rural or semi-rural areas, or mid-sized cities that don’t have university with a medical school, and hence won’t be well-endowed with specialists who are go-tos for exotic or difficult cases.

But this week, McKinsey-UPenn study focused only on ACA plan areas that included hospitals with top-tier oncologists and showed how they are very much underrepresented in narrow networks. From Bloomberg:

For the study, researchers from the University of Pennsylvania analyzed data on 23,442 oncologists in the U.S., evaluating how often doctors affiliated with National Cancer Institute-designated centers were covered by lower-cost insurance plans. The University of Pennsylvania is an NCI-designated cancer center.

Oncologists working at the U.S.’s 69 NCI facilities in the U.S., which offer access to scientific research and are known for their handling of complex cases, were twice as likely to be excluded from plans with the narrowest networks, according to the study.

“Most common cancers can be treated well anywhere,” said Justin Bekelman, associate professor of radiation oncology, medical ethics and health policy at the University of Pennsylvania, and one of the researchers. “But there are many patients with rare or uncommon tumors who need access to the most advanced clinical trials, and that access is often only at these NCI cancer centers. On the individual market, when people are spending their own hard-earned dollars, they can chose to have access or not. But right now they are choosing in a blind way.”….

The Penn researchers analyzed 248 insurance networks across the U.S. operating in areas with NCI-designated centers. They found that one in every three significantly limited the number of oncologists in their insurance plans. Of all the cancer doctors who were part of those narrow networks, 17 percent worked at NCI centers. Of all the doctors who were excluded from those plans, 35 percent participated at NCI centers.

Philly.com provided additional details:

Because such centers tend to be in big cities — Philadelphia has three — the nation’s 69 top centers are located in only 51 ACA insurance marketplaces. The remaining 407 markets have no NCI-designated centers, the study found.

Of the 248 networks offered in those 51 markets, 33 networks, or 13 percent, excluded all oncologists from the top cancer centers. Two-thirds of networks in the 51 markets included just under half of the oncologists who were affiliated with top cancer centers, the study found.

And that’s before you get to the many other hazards to your financial health posed by narrow networks…like getting stuck with a ginormous medical bill if an ambulance takes you to an emergency room not in your network

And insurers generally have been to narrow networks under the ACA. From a February 2017 write-up of an earlier McKinsey study:

The McKinsey analysis of exchange plans included findings from 50 states and Washington, DC. Researchers found a “majority of carriers are continuing to shift toward managed offerings,” such as health maintenance organizations (HMOs) or exclusive provider organizations (EPOs), which have narrow provider networks….

According to the Wall Street Journal (WSJ), narrowing a network holds down costs “in part, because hospitals and specialists with the highest reimbursement rates can be cut out.”

For example, Premera Blue Cross will no longer sell PPO plans on Washington State’s exchange after losing money last year on its 49,100 participants. In 2017, Premera will offer EPOs that do not include out-of-network coverage, the WSJ noted…

The shifting mix of plans available on the Affordable Care Act (ACA) insurance exchanges is dramatic. In 2014, when exchanges first opened, broader network plans, such as preferred provider organizations (PPOs) and point-of-service offerings, had a 58% share of the total ACA marketplace, McKinsey found. By 2016, that percentage fell to 45%, before tumbling another 8% in 2017, to 37%

So it is distressing to see citizens feeling they have to defend the ACA against Republican attacks, when it already (ex Medicaid expansion) was at best a mixed bag for consumers and has been getting worse as death spiral dynamics take hold. While the stresses on the system are finally starting to generate some discussion of single payer, it’s not hard to anticipate the sudden willingness of Democratic party leaders like Nancy Pelosi to give it lip service means they intend to define “single payer” in a way that will fall fall short of what Americans need and deserve.

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  1. allan

    The way that some exchange plans have been labelled/advertised can mislead the patient about what sort of expertise they are going to get access to. I saw this up close with Premera’s (now defunct) PPO plans in the Seattle area, several of which were labelled “UW Health” (as in the University of Washington) or something similar, but in fact excluded the main UW Medical Center and faculty there from the network.
    Unless you had existing relationships at the UW mothership, you would need to be know how academic medical centers are structured in order to figure this out.
    You can’t make a neoliberal policy omelette without breaking some information symmetry eggs.

    1. Pespi

      Your case is absolutely not the exception. I’ve seen this bait and switch myself with a dozen University hospital system of note.

      Anyone reading this should take heed.

  2. Arizona Slim

    Wasn’t the ACA designed to be a short-term bailout for the insurance industry?

    1. Benedict@Large

      Healthcare economics overall in the US was failing, and as anyone on the inside could tell, the quickest (albeit temporary) fix was to toss the insurers out in favor of a government-run (probably single payer) program.

      The ACA then was NOT intended as a short term bailout for the insurance industry. It was intended to cement the insurers into the system so firmly it would be almost impossible to dislodge. As bad as the ACA was (excepting the Medicaid expansion), it was meant to be permanent.

      [Note: But even at that, the ACA would have led to a continuous crapification of the insurance product itself. (You would have insurance, but it would be increasingly worthless.) In the long, this would mean increased and increasing rationing of healthcare based on income and/or net work. The only fix for healthcare, and no one wants to touch it, is price controls.]

      1. tegnost

        good points, this is why I’m thinking the end result of all the kayfabe will be medicaid expansion to all 50 states, with the mean spirited class warfare of the clawback being universal as well, basically setting up a caste system, complete with all the necessary justifications for why the rich need to be richer in order to provide for their snowflakes (expensive education, expensive healthcare, expensive healthy food), the grindstone for the middle (who also will be the buffer between rich and poor with the the I worked for mine and you get yours free argument), and a massive crop of guinea pigs (the poors) who will put boots on the ground at the hospitals and take what they’ve been deemed to deserve, while phama, medi device, hospital supply, and admin rake in the dough.. The ACA did as intended, create an albatross that can’t be dismantled.

      2. jrs

        sometimes I think the best way to implement price controls and fully eliminate all the parasites would be a full NHS system (insurance aren’t the only medical parasites sucking us dry, or maybe even the biggest). But realistically it’s not the most likely to ever see the light of day, so price gouging by hospitals etc. will just have to be tightly regulated.

        1. lyle

          But the system suggested above is precisly the way the NHS works for most things you can go private for an appropriate fee. Many corporations buy the upgrade insurance for their execs for example in the UK. So the NHS provides a base standard of care, and if one has the resources one can have better care.

      3. Jim

        Why not enforce 100-year old law requiring medical providers to tell patients what prices are BEFORE treatment?
        How about EITHER State AGs OR FedGov (Rethuglican, Demoncrap- what does it matter anymore?) remind the “health care” industry they lost the battle to be excluded from this body of law (15 USC Chapter 1, btw) before the Supremes TWICE and demand they post prices for all procedures, and offer the same price to everyone?

        Why is an MRI ten times cheaper in Japan than in the US? Both countries have aging demographics so that’s not it…

        Is there anything in the ACA that Dick Chenny – or Hillary Clinton – would NOT have loved?

        fixhc.org — fixhc.org –fixhc.org — fixhc.org –fixhc.org — fixhc.org –fixhc.org — fixhc.org

    2. sgt_doom

      Yes, plus, to those of us who actually studied the legislation, it is overall financially structured to be a wealth transfer from the middle-class to the very poor, thus further hollowing out the middle-class and working-class in America.

      Of course, the republicon program will always be worse, but that is part of the usual script.

      (With the global economic meltdown, and increased jobs offshoring and replacement of American workers with foreign visa workers and undocumented workers — the health insurance industry took a mighty hit since most American workers receive their health insurance through their place of employment. Please recall that the second appointment to head DHSS by President Obama — afraid I’ve forgotten her name — came from the CEO position of an insurance company which became an overnight bank holding company in order to access those TARP bailout funds.)

      1. jason

        Any health care system that uses its own funding (rather than being funded by the income tax) will always be transferring from the middle class to the poor. Insurance premiums just aren’t progressive enough at the top end to do otherwise.

  3. Doubtful

    If money is the primary concern – which, obviously it is otherwise we’d all have single-payer insurance – then why the most difficult and presumably rarest conditions should be of preeminent concern is beyond me.

    1. reslez

      Cancer isn’t rare, but an individual diagnosis of a particular subtype of cancer could be. I don’t think people with cancer or other expensive conditions should be condemned to die without treatment because it pads a private company’s bottom line and its billionaire CEO’s annual bonus. Meanwhile the federal government is subsidizing these private insurance plans to the tune of $100 billion per year.

  4. roadrider

    The Medicaid expansion was also a very mixed bag as I can tell you from my own experience with it. Good luck finding providers that accepted that coverage and the directory of providers was of little help as it contained outdated and inaccurate information that caused me to have to call provider after provider only to find that they either didn’t accept the coverage or were no longer accepting new patients with that coverage.

    Then there’s the claw back provision for those over 55 (that was me although I’m not sure whether or not my state – MD – will do that). And I’m not even getting into the crapified experience of enrollment and re-enroillment – that’s too long and painful a story for now.


    getting stuck with a ginormous medical bill if an ambulance takes you to an emergency room not in your network

    Correct me if I’m wrong, but I thought there was a provision in the ACA that emergency procedures had to be treated as in-network regardless? Or are there accounting shenanigans to get around that?

    1. ChiGal in Carolina

      The devil is in the details: emergency stabilization is covered but as soon as they begin to treat, you’re on your own. The docs where you are – an out of network ER – will do what they do, provide indicated medical interventions, and you’re probably not in any condition to tell them to stop when they reach the magical dividing line, unless you have a very medically savvy advocate present.

    1. JL

      Same thing in my area, Blue Cross dropped Lucille Packard Children’s Hospital because they couldn’t agree on a contract.

      Although I have no doubt the insurance companies are in a network-exclusion death spiral, I wonder to what extent premier providers are trying to position themselves as a “luxury” product, where people of means won’t have to encounter the sick, unwashed masses.

      1. reslez

        The hospitals certainly appear happy to spend millions on millions of dollars for expensive granite tile, gleaming hardwoods and yearly remodels. What purpose could that possibly serve except to glorify the egos of MBA management and attract well-heeled private patients. I would rather skip all that and have a no-frills hospital with a very low error and hospital acquired infections rate. I wish they’d advertise those stats instead.

      2. Erika

        Of late, hospitals have been negotiating much higher compensation rates. In some markets, largely thanks to hospital consolidation, insurers have to pay out more or risk having too few hospitals and doctors in network.

  6. marym

    While the stresses on the system are finally starting to generate some discussion of single payer, it’s not hard to anticipate the sudden willingness of Democratic party leaders like Nancy Pelosi to give it lip service means they intend to define “single payer” in a way that will fall fall short of what Americans need and deserve.


    Recently the CEO of Aetna said we should have a “debate” on single payer, “but said he does not think the federal government should run it.”

    A 2016 LA Times article about the profits insurance companies are making from Medicaid managed care refers to the government as the “single payer” for Medicaid and Medicare, but for Medicaid managed care (and Medicare Advantage) single payer pays the insurance companies, not the providers.

    The big profits have come not from the plans on the insurance exchanges, but via the ACA’s Medicaid expansion, in which the largest insurers play a major role. The same insurance executives who go out of their way to badmouth the ACA’s individual exchange plans talk as though they can’t get enough of the Medicaid business, especially its managed care component.

    “Managed Medicaid continues to emerge as the ultimate long-term sustaining solution for states,” United CFO Dave Wichmann told investors last month, adding that his company expected to compete for that business aggressively. 

    Is there an acronym for a single payer insurance or national health system that’s publicly financed, publicly administered, not-for-profit, comprehensive, and universal?

    1. different clue

      We could invent such an acronym.

      CCFA. for Canada Care For Americans. or for Canada Care For America. or both at once.

  7. Larry

    This is the kind of crap you get when insurers and their lobbyists write legislation. I have had better health insurance than most Americans for the majority of my life, and it is not easy to navigate the specialist networks and primary care rules that continually shift. I can only imagine what it’s like to be in this ACA markets with little choice and byzantine rules to follow. Democrats have successfully messaged that insurance = health care. Until that successful messaging unwinds, progress will be wanting.

  8. Bill H.

    Inclusion in networks is available to all doctors and medical facilities. The doctor or medical facilities accepts or declines the invitation to participate in the network, usually based on the payment rates offered by the insurer. If the payment rate is too low the doctor or medical facility will decline to participate.

    That means that the fault does not lie with the insurance company alone. Part of the blame lies with the doctor or medical facility for insisting on joining only those networks which offer high rates of pay. The modern bandwagon is to blame insurance companies for everything to do with a broken health care system, but it is the health care providers who generate the costs, and it is they who are the much larger part of the problem.

    1. Pat

      While I am sure this is a factor, I’m also quite sure there is the factor where the doctors or facilities do not get the invitation to join the network and never get the choice. There are multiple bad guys in the gaming of our bogus for profit system. And they are all playing the game. But when it is about networks, insurance companies are the bottom line.

      If it were only about the doctors refusing, wouldn’t you think the insurance companies should be trumpeting this to the skies whenever this came up? Of course they could make the limited nature of the networks clear and note that policies with the higher premiums are about higher rates being paid to the doctors and facilities. Thus going with that informed consumer thing we hear so much about. Funny how that is not happening.

      So what we get is deceptive marketing of the plans with the details carefully shielded, so you only find out that you can’t get treated until you buy the plan. AND everyone pretending that it is about the other, while raking in record or close to record profits. Why one might think it is a feature not a bug.

    2. Kate Smith

      Let me see if I understand what you are implying. You seem to be saying that physicians/medical facilities are some how greedy for not accepting what ever the network is offering despite your having no idea what it costs them to provide the service. You know physicians do not get business classes along with medical training, and being good as a physician does not mean you are good at everything let alone running a business. Should they be forced to offer services at below cost because the insurance thinks it should cost them x dollars to provide services? Should they be expected to pay every cost of being trained and then bare the expense of setting up a practice only to be called money grubbers for wanting to charge the amount they feel is fair? Would you be upset if someone outside your company came in and said you made plenty of money and your salary should be cut to allow less well off people to afford the services your company provides?

    3. different clue

      What if insurance companies which are seeking narrowed networks carefully figure out what the “break-even” figure is for those doctors and medical facilities . . . and then very cleverly offer to pay at less than that breakeven rate? That way, they could incentivize doctors and facilities to decline the invitation while trying to cast blame on the doctors and facilities for declining the invitation.

      ” I made him an offer he couldn’t accept.”

  9. Karl Kolchak

    Lovely. I survived pancreatic cancer against all odds because of the treatments I received at Johns Hopkins Hospital. There’s a special place in you-kn-where for those who would deny a person cancer treatments.

  10. Eric377

    Well I have two doctor friends who have great reputations (ontology and cardiac) and have been cut out of various insurer networks but are super busy anyway. Being in-network wouldn’t actually get them to see more patients anyway is their view right now. Maybe there are some great doctors whose expertise is being wasted in this way, but is it possible that it just shuffles the patient deck a little differently?

  11. Wade Riddick

    When you understand the true nature of the chemistry involved, the tragedy becomes all the more grievous. There are some very simple, cheap approaches to cancer – especially early on – that are almost wholly dismissed by oncology because the profession is blinded by its pursuit of expensive, patented magic bullets. You can attack most cancer metabolism through Warburg effect simply by fasting – but then the food industry doesn’t want you knowing that its addictive sugar bombs programming you to overeat gave you cancer in the first place. You can also sometimes attack it with hydroxycitrate (ACC) and metformin (AMPK). I have yet to encounter a single practicing physician who has read his own oncology literature and applied these lessons.
    Other promising compounds like dehydroascorbate, cannabidiol, low-dose naltrexone, curcumin, heparin, alpha lipoic acid – even melatonin – have demonstrated effectiveness in lab animals, cell cultures and even small patient groups. Even baking soda may alter the pH of the tumor microenvironment enough to be effective. These are all promising enough to warrant extensive clinical trials but they are starved of funding precisely because they are public domain chemicals that deliver no monopoly rents to our new militantly ignorant overlords.
    Why do we fret so much about a coming age of artificial intelligence when we’ll likely never outgrow today’s artificial ignorance?
    These are conversations you are never, ever allowed to have in any way on commercial media. They know their bread is buttered by Pharma ads. They know $600 epipens have $2 of epinephrine in them. The last thing they want to discuss is the scientific reality they spend very dearly trying to suppress.
    The strangehold of Pharma is so severe, Washington is even shutting down access to simple, customized products from compounding pharmacies that have been used to treat numerous cancers for decades. For instance, you can’t use topical phenylbutyrate preparations anymore. Entire treatments are being banned by the FDA now not because they’re dangerous but simply because they are so old and so useful nobody ever bothered to apply modern (and very expensive) clinical trials to items we already knew worked. Oftentimes, they aren’t even bothering with a safety fig leaf to cover their actions. They are simply restricting market access in a variety of ways.
    Not everything your doctor ever gives you has to pass through a strict clinical trial for new drugs. For instance, do you want someone saying you can’t have any zinc for your zinc deficiency unless it goes through a $30 million double-blind clinical trial? Ditto parenteral feeding preparations, B12, carnitine and saline drips.
    Legislation from Reps. Morgan Griffith (R-VA) and Henry Cuellar (D-TX) aims to improve this: H.R. 2871, the Preserving Patient Access to Compounded Medications Act of 2017. You can read the bill at the PCCA site:

    1. Mel

      What happens? I know if you try to put angle brackets (looking kind of like ᚜URL᚛ ) around, as you might do in email, it gets mistaken for an HTML tag and that’s not what you want.
      Including the URL in a link works.

  12. Lynne

    Last year, the largest (and “non-profit”) hospital conglomerate (Avera) bought the largest health insurance company. There are only two major providers in the state. They’ve bought up or run out all other providers, to the point where Avera is also now the state’s largest employer. They announced the buyout of the insurance company right after the enrollment period ended and three months later, the other major providers are no longer in network after years of the insurance company having contracts with them. Except for state employees– they got a special deal and the governor’s office suddenly lost interest in the conflict of interest.

    A few days ago, the insurance co sent out renewal rates. My insurance is supposed to go up over $300 per month “due to rising costs.” All those costs are now controlled by the same “non-profit” that owns both the insurance co and hospital conglomerate.

    I guess Obama never promised that the bend in the health care expense would a bend down….

  13. Leslie A. Graves

    1) All the bashing of Obamacare makes me wonder if anyone here has addressed the fact that Marco Rubio managed to eliminate the billion dollar reserve for the risk pools, which would have addressed “uncertainty” in the health care markets?
    2) I recently got Obamacare, which reduced my monthly BCBS bill by a LOT, but also causes me to pay more for random doctors bills. Seems a fair trade-off to me.

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