Study indicates exchange plans can vary widely on provider inclusion

A new study released today by the American Heart Association on the inclusion of cardiovascular and stroke providers by exchange health plans reveals that access to specialty physicians and facilities can vary widely based on a consumer's plan and location.

The association commissioned the study, conducted by Avalere Health, to examine whether qualified health plans offered on health insurance exchanges included in-network coverage of Comprehensive Stroke Centers (CSCs), along with the cardiologists, neurologists and diagnostic radiologists affiliated with these centers.

The study was not meant to be comprehensive, rather to serve as an illustration of the insurance plans available across the country. Three lower-cost silver insurance plans were selected in 10 regions across nine states, and a sampling of 30 physicians – 10 of each specialty – were chosen for the study. Key findings of the study include:

• Coverage of specialty physicians by the plans analyzed was highly variable depending on the region, ranging from an average of 8 percent (Los Angeles, Calif.) to 83 percent (Philadelphia, Penn.).
• In general, cardiologists and neurologists included in the study's specialty physician list were more likely to be covered by plans than were diagnostic radiologists across all regions examined.
• Inclusion of CSCs in plan coverage also varied by location and ranged from an average of 11 percent covered in Atlanta, Ga., to 100 percent coverage in New Jersey and Philadelphia.
• There are approximately 90 CSCs nationwide, the majority of which are jointly certified by the American Heart Association/American Stroke Association and The Joint Commission. These acute-care hospitals have demonstrated that they can provide state-of-art care on a 24/7 basis to patients suffering from the most complex strokes.

In addition, researchers found numerous challenges with insurance plan provider directories, such as:

• It was difficult to identify which provider directories corresponded to which plan.
• Consumers were sometimes required to search in multiple locations to identify all providers covered by a plan.
• Search results were occasionally inconsistent – for instance researchers obtained different results for a specific provider, depending on the time of day they searched.

"This study points to the need for tougher network access standards, greater transparency and more up-to-date directories of health care professionals," said Stephanie Mohl, senior government relations advisor for the American Heart Association. "Consumers need to keep in mind the tradeoffs they may have to make between premium cost and plan coverage when they shop around for health care insurance."