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Sep 26, 2014

Avalere Analysis finds In-Network Coverage of Select CSCs and Affiliated Specialty Physicians Highly Variable

Published

Sep 26, 2014

A new analysis by Avalere Health, sponsored by the American Heart Association, examined the extent to which qualified health plans (QHPs) offered on the health insurance exchanges included selected comprehensive stroke centers (CSCs) and certain affiliated cardiologists, neurologists and diagnostic radiologists in their provider networks.

CSCs are acute care hospitals jointly certified by the American Heart Association, The American Stroke Association and The Joint Commission. CSCs have the highest level of certification available for the most complex acute stroke cases and must demonstrate that they have the infrastructure, staffing and standards in place on a 24 hour, seven day a week basis to provide state-of-the-art care. There are currently approximately 80 CSCs nationwide. 

The findings reveal that in-network coverage of such facilities and specialty physicians is highly variable across the ten analyzed regions. On average, physician coverage ranged from eight percent in Los Angeles to 83 percent in Philadelphia (Louisville, Kentucky was excluded from this range due to lack of physician coverage). Similarly, average facility coverage was highly variable, ranging from 11 percent in Atlanta to 100 percent in New Jersey. Overall, the plans examined included a greater portion of the selected facilities in their networks, as compared to the selected physicians. 

For the analysis, Avalere selected three lower cost silver QHPs in 10 regions to review in-network coverage of CSCs and selected physicians.  In searching provider networks on QHP issuer websites, Avalere found that the functionality and transparency of search tools is highly variable across issuers. While some issuers offer provider search tools that permit consumers to select a specific plan type and metal level, in other cases it can be difficult for a consumer to identify the network applicable to a specific exchange plan. 

Methodology:

Avalere analyzed whether QHPs offered on the health insurance exchanges include in-network coverage of select CSCs and a sample of cardiologists, neurologists and diagnostic radiologists affiliated with these centers. Avalere selected three lower cost silver QHPs in 10 regions across nine states to review in-network coverage of CSCs and affiliated physicians.  The decision to select lower cost silver tier plans was driven by the expectation that exchange enrollees are sensitive to premium pricing and subsidies are tied to the cost of the second lowest cost silver plans. 

The American Heart Association supplied Avalere with up to three CSCs per region. Using the CSC names and addresses provided, Avalere used Medicare data to identify affiliated physicians with the desired specialties to generate a list of 30 physicians (10 of each specialty) in each region. Avalere then searched the provider networks on the QHP issuers’ websites to determine if the applicable CSCs and selected physicians were included in the QHPs’ provider networks in each region. It is important to note that the analysis represents a limited sample of plans in 10 regions. Avalere’s analysis yields a high-level overview and is not intended to be comprehensive. 

This analysis was funded by the American Heart Association. Avalere maintained editorial control over the content of the analysis. 

View Avalere’s complete analysis attached. 

For more information about Avalere’s exchange network analysis, contact Jennifer Kowalski at JKowalski@avalere.com.

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