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 Under the act, also known as Obamacare, the federal marketplace
offers subsidized private health insurance to consumers in states
that didn't establish their own health insurance exchanges.
About one in seven health insurance plans offered on the federal
marketplace in 2015 did not provide access to in-network doctors for
at least one medical specialty, researchers found.
"People need to be really mindful of what they’re actually getting
with their plans," said lead author Stephen Dorner, of the Harvard
T.H. Chan School of Public Health in Boston.
He and his colleagues write in JAMA that nearly 12 million Americans
gained health insurance through the 2010 law's marketplaces. By law,
insurance plans are supposed to ensure "reasonable access" to
providers.
For the new study, the researchers looked at 135 health insurance
plans in 34 state marketplaces that were available during the 2015
open enrollment period, when people can select their plans.
Using the plans' physician directories, they looked for in-network
specialists who would be covered by insurance, including
obstetricians/gynecologists, dermatologists, cardiologists,
psychiatrists, oncologists, neurologists, endocrinologists,
rheumatologists and pulmnologists.
Overall, in April 2015, 18 plans in nine states lacked in-network
specialists for at least one specialty within a 100-mile search
area, and 19 lacked specialists within a 50-mile radius.
Endocrinology, rheumatology and psychiatry were the most commonly
excluded specialties.
Another seven to 14 plans had fewer than five in-network doctors in
those fields.
When the researchers repeated their search in May, six of the 19
plans lacking specialists had added more providers.
The researchers also found that people enrolled in plans that lacked
access to specialists had high out-of-network charges for doctors'
visits and medication. In some cases, they had to pay half or more
of all costs.
"What this basically translates into is huge out-of-pocket costs for
the consumers," Dorner said.
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Clare Krusing, the press secretary for America's Health Insurance
Plans, told Reuters Health by email that the new research ignored
state standards for time and distance requirements.
Also, Krusing said the researchers did not account for the number of
specialists operating in specific states, and didn't acknowledge
that plans have processes and programs in place to ensure patient
access.
"The study's limitations speak for themselves, and account for the
fact that the report presents a misleading picture of what's
happening in the market today," she said. "Health plans must meet
state and federal network adequacy requirements that ensure patients
have a wide range of providers and specialists available to them."
The researchers say the study relied on network directories, which
are known to overestimate in-network providers (see Reuters Health
story of Oct. 29, 2014 here: http://reut.rs/1N5R0mS). They add that
the problem of access to in-network specialists may be even worse in
rural areas.
"I think on the consumer side, they need to be really watchful of
what is actually contained in their plans and what they’re getting,"
Dorner said.
Additionally, he said the terms to evaluate plans should be better
defined, and existing regulations should be enforced.
SOURCE: http://bit.ly/1N5SwFt JAMA, online October 27, 2015.
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