ACA Update: Coverage for Specialized Care?
According to a recent report from Avalere Health, for the most popular health plans on the state healthcare marketplace, coverage of comprehensive stroke centers and selected physicians affiliated with them is highly variable. The Avalere report was prepared for the American Heart Association (AHA).
Comprehensive stroke centers are acute-care hospitals jointly certified by the AHA/American Stroke Association and the Joint Commission, there are approximately 80 centers nationwide.
Avalere selected 10 metropolitan regions across 9 states to examine in-network coverage of comprehensive stroke centers and affiliated physicians, including Atlanta, Georgia; Chicago, Illinois; Denver, Colorado; Durham, North Carolina; Los Angeles, California; Louisville, Kentucky; Nashville, Tennessee; New Jersey, Philadelphia, Pennsylvania; and San Jose, Texas.
The researchers examined coverage by the state exchanges' silver plans, which make up approximately 65% of the market share on the exchange.
The selected physicians included cardiologists, neurologists, and diagnostic radiologists affiliated with the comprehensive stroke centers. The 30 physicians chosen in each region, 10 for each specialty, were those who had the highest volume of Medicare claims in their specialty.
The main findings of the report were:
- Coverage of physicians in the examined plans varies by region, ranging from an average of 8% in Los Angeles to an average of 83% in Philadelphia
- Except in New Jersey and Philadelphia, coverage of diagnostic radiologists was more limited than that of cardiologists and neurologists
- Facility coverage varied greatly across plans and regions, but more facilities than physicians were included in the insurance networks
- Average facility coverage varied from 11% in Atlanta to 100% in New Jersey
The researchers emphasized that this was a high-level study and did not presume to reach any conclusions about network adequacy; however, the report did note that due to the Patient Protection and Affordable Care Act’s limits on deductibles and out-of-pocket expenses and its requirements for actuarial value and benefits, health insurers are using network designs to keep insurance premiums low.
Another problem is a disconnect between coverage of comprehensive stroke centers and their specialists in some markets. For example, the Avalere report found that in San Jose, 2 of 3 silver exchange plans include all 3 comprehensive stroke centers in the market, but the plans covered fewer than half of the selected physicians.
The Centers for Medicare & Medicaid Services is investigating network adequacy in the exchange plans, according to the report.—Kerri Fitzgerald
Source: Medscape. 2014; ACA Exchange Coverage Varies for Stroke Centers, Specialists.
