Inequities in health care can be viewed every day when looking at which populations have easy access to specific levels of care and which ones do not.
A Special Committee on Race and Insurance workstream heard presentations on the problem this week during a 90-minute web call. The committee was established two years ago in the aftermath of the George Floyd murder in Minneapolis.
Work is divided among five different workstreams, with each receiving data and hearing presentations. The overall committee is charged with making final recommendations to the full National Association of Insurance Commissioners.
This week’s meeting by workstream #5 furthered its charge to “Examine and determine which practices or barriers exist in the insurance sector that potentially disadvantage people of color and/or historically underrepresented groups in the Health Insurance line of business.”
Maanasa Kona is an assistant research professor at the Georgetown University McCourt School of Public Policy. She discussed the barriers to accessing in-network providers.
Citing a 2022 Journal of the American Medical Association study, Kona pointed out that “counties with larger non-Hispanic Black populations tend to have fewer participating insurance carriers.” Residents of those counties tend to rely on Affordable Care Act marketplace plans, which tend to have “narrower networks.”
“The fact that marketplaces have narrow networks is very well documented in research,” Kona said, “particularly when compared to employer-sponsored plans. For example, a 2020 JAMA investigation of 1,200 plan networks found that while large employer plans on average include 70 % of in-network cardiologists in a one-hour radius, marketplace plans only include 45% And in terms of primary care providers, large employer plans on average include about 60% within a one-hour radius and marketplace plans only 35%. “
Insurers use narrow networks to control costs, steer enrollees to high-quality and low-cost
providers and maintain leverage when negotiating contracts with providers, Kona explained.
For Americans stuck in a narrow network, the results can mean limited choices, a lack of continuous care and spotty access to specialists. It is worse for those living in rural areas.
“Significantly more research is needed in this area to establish the connection between how the narrow network ends up impacting access measures like wait times or appointments and time and distance need to travel to a doctor or facility,” Kona said. “There have been some studies in the past that have shown that Black and Hispanic populations tend to experience longer wait times for appointments.”
States have tried a variety of compliance techniques to enforce network adequacy standards, Kona said. Some rely on data submission or complaints to keep tabs on networks, while some states are using “secret shopper” efforts.
Kona cited New Hampshire, in particular, for its efforts to monitor network standards.
Narrow networks are cheaper, Kona noted, but might be more costly to the health care system in the long run.
“A secret shopper study on marketplace plans in California found that only about 30% of attempts for appointments with specific primary care doctors were successful,” she said. “Patients are told to wait weeks to receive routine care and chronic disease management which then increases the likelihood that they’ll end up into emergency rooms and or become hospitalized because of his lack of routine care.”
The ACA regulations for network standards have varied in interpretation by different administrations, Kona noted, but new Biden administration standards bring back time and distance stipulations.
Beginning in the 2024 plan year, enrollees must be able to obtain an appointment for behavioral health services within about 10 business days, 15 days for routine primary care and 30 days for non-urgent specialty care, she added.
Otherwise, states vary widely in what time and distance requirements they place on health care delivery, or provider-to-enrollment ratios.
“For example, Michigan requires one primary care provider for every 500 enrollees, and Tennessee requires one primary care provider for every 2,500 enrollees,” Kona said.
InsuranceNewsNet Senior Editor John Hilton has covered business and other beats in more than 20 years of daily journalism. John may be reached at [email protected] Follow him on Twitter @INNJohnH.
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