Obamacare Deficient in Rheumatologists, Other Specialists Save

The October 27 issue of JAMA reports a study of federal marketplace insurance plans shows roughly 15 percent completely lacked in-network physicians for at least one specialty, a practice found among multiple states and issuers.

Nearly 12 million individuals have enrolled in coverage through the Affordable Care Act's insurance marketplaces. Amidst concerns about network adequacy, researchers show that most plans were deficient in specialsts, including rheumatology.

Analysis of 34 states and 135 plans demonstrated ~13 percent of plans were specialist-deficient plans. Endocrinology, rheumatology, and psychiatry were most commonly excluded, and an additional 7-14 plans had fewer than 5 in-network physicians in those specialties. Nine of 34 states (24 percent) had at least one specialist-deficient plan. Twelve different insurers had at least one specialist-deficient plan.

Not only were these plans deficient in specialty services, they were also less likely to pay for out of network specialists. Beneficiaries of specialist-deficient plans had high out-of-network costs; 5 of 19 (26 percent) plans did not cover out-of-network services, whereas 11 of the remaining 14 plans (79 percent) required cost-sharing of 50 percent or more. Nine of 19 (47 percent) did not cover medications prescribed by out-of-network physicians. There was no significant difference in premiums between specialist-deficient plans and other plans.