Most specialized cancer hospitals say they participate in the narrow provider networks of some exchange health plans, but health insurers have not been shy keeping some cancer hospitals out, according to a new survey from consulting firm Avalere Health.
The Avalere analysis follows an Associated Press report last year which found that many of America's most prestigious cancer hospitals were getting excluded from health plans sold on the Affordable Care Act exchanges in 2014.
Household names like MD Anderson Cancer Center in Houston and Memorial Sloan Kettering Cancer Center in New York City had in-network agreements with a handful of exchange plans, the AP reported. But other plans excluded them, and they were considered out-of-network and thus more costly for patients. Insurers said they weren't able to negotiate acceptable rates with cancer hospitals and other specialty providers, such as children's hospitals, in some markets.
Avalere, partnering with the National Comprehensive Cancer Network, surveyed 20 cancer centers and found that 75% of respondents were covered by at least “some” of the exchange plans in their state. Of that total, 13% had in-network rates for every exchange plan.
“We were surprised by the results because of what had been anecdotally reported,” said Sung Hee Choe, a director at Avalere who worked on the study. “This opens the door for further exploration and certainly challenges what we've seen.”
While 75% of cancer hospitals have some exchange plan contracts, that still left 25% with practically no network coverage among exchange plans. And three-quarters of respondents didn't offer specifics about their health plan arrangements, meaning they could be an in-network provider in one exchange plan or several.
Narrow-network plans, which are similar to HMOs of the 1990s, have blossomed on the ACA exchanges and in employer-based healthcare market. Insurers contend that consumers appreciate the lower premiums associated with these narrower products and are willing to make the trade-off of having fewer provider choices. But some consumer advocates and disease advocacy groups worry the narrow-plan designs are confusing and too limiting.
Excluding cancer hospitals raises several questions. What happens if patients develop a rare cancer that requires more specialized treatment? Do the cancer hospitals actually provide better care at a lower cost compared with other community-based providers? Are patients still willing to go to a cancer center even if it is out-of-network?
On the last question, the answer appears to be yes, according to Choe. The majority of survey respondents said they treat exchange patients who have trouble affording deductibles and other out-of-pocket costs associated with an out-of-network provider but who go the cancer hospital anyway.
There was a separate silver lining for cancer hospitals that have in-network agreements. Payment rates from exchange plans were generally a little lower than other commercial rates but higher than Medicare or Medicaid, survey respondents said. “This is better than some expectations that exchange rates would be in line with Medicaid managed-care rates,” Choe said.