Study finds some marketplace health plans lack network doctors in key specialties

Consumers who buy their health insurance on the federal government's insurance exchange may find their provider network lacks physicians in some key specialties.

As many as 14 percent of health plans on the federal exchange set up under the Affordable Care Act are lacking physicians in at least one common specialty from their networks, according to a JAMA study.  

Researchers at Harvard's T.H. Chan School of Public Health conducted the study to look at the access to outpatient specialists in federal marketplace plans. They examined 135 physician networks in 34 states and found that 19 of them lacked in-network specialists in some areas, most commonly in the specialties of psychiatry, rheumatology and endocrinology.

Researchers looked for specialists within 50 miles and 100 miles of the largest city where each plan was offered. In some cases, specialists were not within close distance, but network physicians could be found further away. In some cases, the number of specialists in a network was limited, making access difficult. Enrollees in specialist-deficient plans also had high out-of-network costs, the study found.

Nine of the 34 states had at least one plan where the option to see a specialist was lacking in the network. The ACA requires that insurance plans provide "reasonable access" to a sufficient number and type of providers. The fact that almost 15 percent of plans completely lacked in-network physicians for at least one specialty, "likely violates network-adequacy requirements and raises concerns regarding patient access to specialty care," the researchers concluded.

Network adequacy has become a hot-button issue, with different levels of regulation depending on the state. Some states have guidelines in place to assure consumer access to providers, and others maintain specific requirements. The amount providers bill consumers for out-of-network care also varies greatly from state-to-state, one analysis found.

To learn more:
- read the JAMA study