Exchange plans may have limited provider networks, but that doesn't equal poorer quality care

As more consumers buy health insurance plans on federal or state exchanges, patients and advocacy groups have criticized some of those marketplace options for offering overly limited health provider networks, or “narrow networks.”

To save costs, insurance companies may limit which hospitals or physicians a patient can see and still be covered in network. The concern is that the lower premiums could come at a cost, as patients find reduced access to health care providers and high-quality care.

California has been key to the critique of these narrow networks, a debate fueled in part by the exclusion of Cedars-Sinai Medical Center and the partial exclusion of the UCLA Medical Center from marketplace plans. Many of the stories have been personal, with patients concerned they aren’t able to see trusted providers or top specialists once they enter narrower marketplace plans. Complaints over network size have even led to lawsuits against insurers in California.

But when it comes to hospitals, fears of lower quality care and poorer access to doctors aren’t being realized, according to a recent Health Affairs study that examined California hospital networks under marketplace plans and evaluated their size, patient access and quality. It is true that marketplace plans have narrower networks than their commercial counterparts, the study found. But that doesn’t equate to differences in access or the quality of care.

“More surprisingly, depending upon the measure of hospital quality employed, the marketplace plans have networks with comparable or even higher average quality than the networks of their commercial counterparts,” write study authors Simon Haeder, David Weimer and Dana Mukamel.

The study offers fresh evidence on the effects of quality and access in narrow networks, a topic that previously has seen very little research.  Authors sought to broaden the debate about narrow networks to include access and quality instead of merely counting the number of hospitals, author Simon Haeder told Reporting on Health in an interview. The researchers focused on hospitals instead of physicians since the physician directories are changing so quickly, making it impossible to obtain the right data for comparisons, he said.

In the study, researchers compared provider networks among Covered California plans, focusing on four insurers (Blue Cross, Blue Shield, Health Net and Kaiser Permanente) that offered comparable products in both the private insurance marketplace and Covered California. They used census information to gauge access to providers, and gathered data for quality comparisons from the Agency for Healthcare Research and Quality, the California’s Office of Statewide Health Planning and Development (OSHPD), the Leapfrog Hospital Survey, and The Joint Commission.

With just a few exceptions (for example, the networks for both Kaiser options overlapped 100 percent), they found marketplace networks tend to be reduced versions of their commercial counterparts. In other words, the private plans tended to have more hospitals than the exchange plans, although the differences weren’t huge.

From there, researchers examined how smaller hospital networks affect people seeking care, such as those needing to travel long distances to find a network hospital. On average, 92 percent of residents with marketplace plans were within at least one hospital market area, which authors established as a 15-mile radius around each hospital. This was comparable to commercial plans. (One of the places where they did find access challenges was California’s Central Valley, Haeder said.)

Next, using California’s OSHPD data, researchers looked at health care quality and found there was no difference between marketplace and commercial plans in terms of quality. When they used other quality measures, such as the Leapfrog Hospital Survey and data from The Joint Commission, researchers likewise found there was no difference, or even that marketplace networks fared better.

“It seems plausible that insurers are deliberately excluding some hospitals that have not been designated as top performers,” the authors wrote.

But the authors also cautioned that their analysis focused on one state and findings may not apply nationally. And, even though they found little differences in access between the marketplace and private plan types, overall access to health care remains an important issue for both types of plans.

“One clear lesson is that there a certain benefits of having a state-based marketplace because you fully control the regulation of the insurance market, and can act quickly and more decisively than the federal government to correct any problems,” Haeder said.

[Photo by Jorgejesus4 via Wikimedia Commons.]