How Narrow or Broad Are ACA Marketplace Physician Networks?
Report
Hospitalists are specialists whom consumers are less likely to have the opportunity to choose, and who are more likely to charge higher out-of-network fees. However, the No Surprises Act protects Marketplace consumers, in some circumstances, from so-called surprise out-of-network bills from these physicians. It is yet to be seen whether this law will encourage more hospital-based physicians to join provider networks.
Compared to other specialties, a higher share of psychiatrists have opted out of Medicare (7.7%). In addition, psychiatrists only billing private payers are not included in the MD-PPAS data and as a result, are not included in this analysis. This analysis includes only physicians and so does not measure network inclusion of other non-physician mental health professionals such as psychologists, clinical social workers, or counselors. A higher share of psychiatrists are not accepting new patients covered by Medicare than other specialties.
In addition, other state policy decisions impact Marketplace enrollment. For example, while six counties in New York State rank in the top 30 by population, none rank in the top 30 counties by Marketplace enrollment because some New Yorkers are eligible for the Basic Health Plan.
In total, 921 doctors were practicing in Hidalgo County, TX, a quarter of the workforce of similar size counties. Among the 30 counties with the largest Marketplace enrollment, four (Clark County, NV; Hidalgo County, TX; Riverside County, CA; and Osceola County, FL) have census population to primary care physician ratios that place them in the top 25% of most underserved counties in the U.S. HHS Area Resource File identified 406 primary care physicians (M.D. and D.O.) in Hidalgo, fewer than the rest of the counties with high enrollment except Osceola County, FL. Health Resources and Services Administration (HRSA) identifies part of all 30 counties as primary care shortage areas, with the exception of Collin County, TX (Plano).
People of color include people of any race who identify as Hispanic or those that identify as Black/African American, AIAN, or NHOPI, or two or more races. County classifications are from the CDC/ATSDR Social Vulnerability Index.
Studies have illustrated that the number of plans available to enrollees continues to increase. Assistant Secretary for Planning and Evaluation (ASPE) found that the average number of plans in HealthCare.gov states increased from approximately 26 in 2019 to 61 in 2021 and 108 in 2022. This average is weighted to county-level Marketplace enrollment. When considering only plans with enrollment, the average Marketplace consumer had access to 56 plans in 2021.
Maine Marketplace plans were part of this pilot until opening its own state-based Marketplace website.
Companies and related subsidiaries were grouped by their parent or group affiliation using data obtained from HHS Medical Loss Ratio public use files, Mark Farrah Associates Health Coverage Portal TM, and supplemented with additional research, including insurer press releases and healthinsurance.org. Mark Farrah Associates collects data from plan regulatory filings from the National Association of Insurance Commissioners (NAIC). The level of coordination between subsidiaries sponsored by a single parent varies. This approach follows the method used here and here. BCBS member organizations are grouped together based on the categorization by Mark Farrah. For the purposes of this report, Elevance (formerly Anthem) is not included with other BCBS plans.
In total, 58% of Marketplace enrollees were covered by a plan whose parent company had at least some Medicaid enrollment in their state. Insurers that also had Medicaid enrollment participated in 74% of counties nationally. Insurers in states without comprehensive, risk-based MCOs (AL, AK, CT, ID, ME, MT, OK, SD, VT, WY) were not classified as MCOs. Insurers were classified as sponsoring an MCO if they had Medicaid enrollment in Mark Farrah Associates Health Coverage PortalTM.
Graves et al., similarly used Ideon 2019 data and found that large group plans cover 57.3% of primary care physicians compared to 45.7% in Marketplaces. This analysis considers a different definition of local markets, and does not weight network breadth by enrollment.