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.
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.