Kept in the Dark About Doctors, but Having to Pick a Health Plan

The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

It’s open enrollment season, for Affordable Care Act marketplace plans, Medicare Advantage plans and many employer-sponsored plans as well. Lots of evidence suggests you should shop around, and shop carefully, though this is harder than it sounds.

When you select a health care plan, you probably consider premiums, and maybe you check deductibles and other cost sharing. But you can’t easily scrutinize the plans’ networks and the quality of the doctors in them. That’s too bad, because you may be missing something important.

Many health insurance options offered by employers or sold on the Obamacare marketplace come with narrower networks — covering treatment from a limited slate of doctors and hospitals. (Though there’s no official definition of a “narrow network,” many studies classify networks as narrow when they include less than about 30 percent of doctors or hospitals in the area.)

Narrow network plans are cheaper, and insurers say they try to maintain quality as they narrow the choices they cover. Some appear to succeed, but some don’t, and that’s hard to fully assess before you sign up.

It’s virtually impossible to thoroughly check the quality of doctors in each insurance plan. A typical plan, even a narrow one, may have a network of hundreds or thousands of physicians. It is a potentially simpler task just to know if you’re enrolling in a narrow or broad network plan. But in a study of Obamacare enrollees, for example, as many as 40 percent didn’t know this information, either.

That confusion is understandable. A study of 2016 marketplace offerings in 13 states found that only two provided indications of network size. Eight of them, as well as, provided a way to look up whether a doctor was in a plan’s network, but only two could filter plans to show only those with providers a consumer selects.

“To our surprise, we also found that few marketplaces could indicate which hospitals were in plans’ networks,” said Charlene Wong, a pediatrician and researcher at the Margolis Center for Health Policy at Duke University and lead author of the study. “In addition, none of these tools indicated network breadth by specialty.” This means that a “broad” network plan might actually be quite narrow for some specialists, without consumers knowing.

A crop of new studies shows some of the specialties for which networks are likelier to be narrow, and suggests that what consumers don’t know might hurt them. Researchers at the University of Pennsylvania found that plans with more narrow networks systematically excluded oncologists affiliated with higher-quality cancer centers. In part, this is how the plans offer lower premiums, because higher-quality cancer centers may demand higher payments. But it’s pretty likely consumers don’t know that they may be trading quality for price.

“Unless you already have cancer, it’s pretty unlikely you’ll check the quality of oncologists covered by health plans when making an enrollment decision,” said Daniel Polsky, a health economist with the University of Pennsylvania and a co-author of the study.

Another study by Mr. Polsky and colleagues, published in Health Affairs, found that many marketplace plans offer relatively few choices of mental health care professionals. Even plans with wide primary care networks can have narrow mental health ones, the study found. Though only 39 percent of plans had very narrow networks of primary care physicians — covering less than 10 percent of those in their markets — 57 percent of plans had very narrow networks of psychiatrists.

Marketplace plans also tend to be narrower for pediatric specialists than for adult specialists, according to other work by Dr. Wong and Mr. Polsky. And parents might have no idea until a child is ill.

“A beneficiary needing more specialized care may only then discover the less attractive features of their health plan,” Mr. Polsky said. “The priority should be improved provider network transparency at the time a plan is purchased.”

Scrutinizing the extent and quality of a plan is daunting. To find out which doctors are covered by a plan, you could consult its provider directory. But such directories are known to be error prone — listing physicians not in networks or failing to list those who are. Ideally, marketplaces would provide a sense of the breadth of a plan’s network. The marketplaces could directly provide metrics for how many doctors are covered, by specialty and by reasonable distance from your house, for example. First steps toward doing so have been planned but have yet to be widely adopted.

Assessing hospital quality with online tools is also something consumers can do, but it takes effort, particularly if comparing networks of hospitals across plans. There are fewer ways to assess physician quality, but some sites like Yelp and may be worth a look. None of these tools are integrated into websites that consumers use to shop for marketplace or Medicare Advantage plans, however.

And these resources can’t overcome another challenge some people face — a lack of access to broad network plans. Health insurance markets are local, and a recent Health Affairs study found that Hispanic Americans, for example, live in areas with plans less likely to have very broad networks.

What can be done? Insurers that wish to offer narrow network plans could be required to also offer broad network ones. This would provide a fuller menu of options to more consumers. Additionally, online marketplaces could start to provide much clearer indications of the extent and quality of doctors included in plans’ networks, not just over all but by specialty. Consumers still may not avail themselves of the information, but at least it would be more readily accessible.


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