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So-called “narrow networks” have been a prominent tool by insurers to restrict access to care. Extremely low payment rates and/or administrative burdens are often cited as reasons by providers for not participating in networks. Additionally, some insurers have advertised “phantom” networks including names of clinicians who are no longer taking new patients, have moved out of the geographical area, or, in some cases, have died.
Jane M. Zhu, M.D., and colleagues at the University of Pennsylvania identified 531 unique provider networks offered by 281 different insurance issuers in the ACA marketplaces in all fifty states plus the District of Columbia, using a database of 5,022 on-market qualified health plans. The final analysis sample consisted of 535,114 primary care providers and 562,379 mental health care providers, of whom 51,499 were psychiatrists and 103,328 were psychologists. (The other mental health providers included nurse practitioners, physician assistants, behavioral specialists, counselors, and therapists.)
Overall, 120,453 (21.4%) of the mental health care providers and 243,718 (45.6%) of the primary care providers in the sample participated in at least one ACA Marketplace network. Specifically, 42.7% of psychiatrists participated in at least one network compared with 58.4% of primary care physicians, a difference of 15.7 percentage points. A similar difference was observed between the two fields among non-physician providers.
“In the context of efforts to provide mental health benefits on a par with those for general medical conditions, these findings highlight important structural barriers to parity that not only necessitate provider-side interventions to encourage greater network participation, but also require consensus about and regulation of network adequacy standards,” the authors wrote.
Irvin “Sam” Muszynski, J.D., APA senior policy advisor and director of parity implementation and enforcement, said network inadequacy is a significant parity issue and an advocacy priority for the APA. “The contributing factors—provider payment rates and managed care protocols—are themselves parity issues,” he said. “Many states are grappling with this currently and the APA is working with several of them to develop a solid analytical approach to evaluating the problem respecting parity compliance.”
For more information, see the Psychiatric News article “APA Study Reveals Network Inadequacy in D.C. Exchange Plans.”
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