NCI-Affiliated Oncologists Excluded From Narrow Insurance Networks

So-called “narrow network” healthcare plans are more likely to exclude oncologists who are associated with National Cancer Institute (NCI)-designated or National Comprehensive Cancer Network (NCCN) Cancer Centers, according to a new study.

“NCI Cancer Centers may have a negotiating advantage given their NCI status, and this would raise their reimbursement rates,” said senior study author Daniel Polsky, PhD, executive director of the University of Pennsylvania’s Leonard Davis Institute of Health Economics, in an email. Insurers that want to create a lower-cost health plan option to attract customers-a narrow network-might exclude those higher priced physicians. “Second, beneficiaries with cancer have higher expenditures for the health plan. Leaving the doctors out that might attract these patients can reduce the expenses of the health plan.”

The researchers looked into this question in a study published online ahead of print last month in the Journal of Clinical Oncology. They examined provider networks offered on individual health insurance exchanges in 2014, and identified practicing physicians with a specialty of hematology/oncology or radiation oncology. In total, they examined 407 “rating areas,” or regions, without an NCI Cancer Center, and 51 with such a center. This covered a total of 23,442 physicians.

Areas with high-quality centers were more likely to have insurance plans that excluded oncologists from those centers. NCI Center areas had 13.7 oncologists per 100,000 residents, with 4.9 healthcare networks in those regions covering a mean of 39.4% of those oncologists. Regions without an NCI-designated Cancer Center, meanwhile, had 8.8 oncologists per 100,000 residents, with 3.2 networks covering 49.9% of the oncologists in the region.

The majority of networks in the markets that did contain an NCI-designated Cancer Center covered fewer than 50% of the oncologists practicing in that market. In spite of the narrowness of these networks, however, there was still a higher average number of covered oncologists per 100,000 residents in markets with an NCI-designated Center, at 4.5 compared to 3.8 (all comparisons between NCI Center-containing and non-containing markets, P < .001).

Polsky said that in spite of apparent reduced access to the NCI-associated oncologists, the impact of this trend is not necessarily a reduced access to care for people who purchase the narrow network plans. This is because those lower-cost plans may result in some people having health insurance that otherwise would not.

“The impact could be a lack of fairness,” he said, “in that some people might learn they don’t have access to a doctor they might need only after they purchase insurance. It is hard to know you are getting the health plan you want or need because it is a very complicated product to purchase.”

The study also examined a subset of markets that contained an NCCN Cancer Center, and found similar results. In those 27 markets, there were 14.7 oncologists per 100,000 residents, and 5.0 networks offered that covered 38.8% of the oncologists practicing there. The authors concluded that “narrower provider networks have a higher likelihood of systematically excluding oncologists affiliated with NCI-Designated or NCCN Cancer Centers. These hospitals are recognized for their high-quality clinical cancer care, education, and research programs.”

Polsky pointed out that this situation could lead to a sort of “race to the bottom” effect. If insurers exclude certain cancer facilities, one insurer that does include those facilities might end up with the more expensive cancer patients, and thus may end up with a plan that is too expensive to compete in the individual insurance market.

Interestingly, other research has suggested that this effect may not extend to other types of health care. One study in California found that hospitals included in narrow networks perform just as well with regard to various process-of-care quality measures as hospitals excluded from those networks.

Simon F. Haeder, PhD, of West Virginia University, was the lead author on that study, published in Health Affairs in May 2015. In an email, he told Cancer Network that the new study specifically on oncology is an important one, and highlights the need to involve patients in decision-making and for increased transparency from insurance companies.

“We also need to do much better at measuring quality and presenting it to consumers,” Haeder said. “Only then are consumers able to make the trade-off between costs and network breadth/provider quality, etc.” He noted that the study raises important questions about healthcare rationing, in a sense. Individual insurance marketplaces generally serve lower-income individuals, he said, and many people using them get subsidies. When the government is providing support to those who cannot fully support themselves when it comes to healthcare, what quality of service should be provided? “Of course, it comes as no surprise that, indeed, access to high-quality medical care is not equal in the United States.”

Haeder added that he does not believe narrow networks to be a bad concept in general. “I think they are actually a good idea. They work well to hold down costs,” he said. “They may help exclude bad providers. Excluding low-quality providers would be a great thing for everyone.”

In an editorial in the Journal of Clinical Oncology, experts led by Stephen M. Schleicher, MD, MBA, wrote that the exclusion of NCI-affiliated centers from narrow health plans “is a symptom that our cancer delivery system remains broken after the [Affordable Care Act].” They suggested that transparency on the part of insurance companies and patient education to help understand what individuals are actually purchasing would go a long way toward improving the situation, since requiring the inclusion of the centers would likely not be feasible.

“A better and more sustainable way for health plans to control costs is by taking a value-based approach to benefit design,” they wrote. “They should reward cancer care providers who effectively coordinate care, collect and report outcomes that matter to patients, and control costs.” Such value-based approaches might close gaps in outcome and in cost.

Polsky said that network adequacy regulations should be enforced as a first step toward addressing the issue, to provide a guarantee that networks meet at least some standard for access. Also, he pointed out that many insurers do actually provide exceptions and pay network rates for certain cases when an individual requires out-of-network care, which could come up in the oncology field. “These exceptions are critical for fairness and should be made easier to obtain for the clear cases where they are needed,” Polsky said.