NEW YORK (MainStreet) — When I had a suspicious breast lump diagnosed from a recent biopsy as Stage 2 Invasive Ductal Carcinoma, I was informed I would need to find a breast surgeon...stat. My participating well-woman doctor gave me a list of names and I found none on my provider list of the new Florida Blue health plan I bought through the Healthcare.gov exchange. So, I asked the participating women's MRI facility that performed my covered mammogram and biopsy for names of local breast surgeons they routinely work with and none of those names were on my provider list either.

Flummoxed, I called up Blue Cross to ask why I could not find a local breast cancer surgeon on my provider list and to ask why surgeons that work with a participating doctor, lab or imaging facility were not on the plan. The agent told me, "Honey, you bought a cheaper plan with a very small network of doctors." Then she instructed me how to search under, "General Surgeons."

Finally after a lot of calling and asking around and cross-checking names, the local, most revered plastic surgeon, who was on my provider list, referred me to the local general surgeon he worked with most often on breast cancer surgeries. Finally, somebody recommended was on my plan. I was also able to find another participating breast cancer surgeon specialist, 50 miles away, who I saw for a second opinion.

The fewer the provider choices, the narrower the network

The official term for this problem of not having much choice in providers is the "Narrow Network." I originally thought this was a bad thing, because I had trouble finding a recommended participating doctor or oncologist, and I was denied at the main cancer teaching hospital in Tampa, Fla. (Moffitt Cancer Center). But, once I did choose the participating breast cancer surgeon, my care became automatically coordinated among that participating surgeon, the oncologist, all the imaging centers and labs I would need and the reconstructive plastic surgeon. All of my doctors including the main cancer oncology center where I need to go weekly for blood tests and chemotherapy infusions, and later for radiation treatments, are within five minutes of my house, as is the hospital (the only one on the plan out of three in town).

Since then, I have not had one out of network charge, and my care has been handled seamlessly. The McKinsey Center for U.S. Health System Reform compiled a report entitled "Hospital networks: Configurations on the exchanges and their impact on premiums" to analyze hospital network data from 120 unique 2014 individual exchange market plans in the silver tier offered by 80 carriers, along with corresponding hospital network data from 2013 individual market plans. The data spanned 20 urban rating areas across a geographic range to categorize networks in terms of number of hospital providers: Broad, narrow and ultra-narrow.

So what defines a narrow network?

A health insurance plan with a narrow network, like mine, limits the number of providing doctors and hospitals to plan members.

In the McKinsey study on hospitals in plan networks, a broad network has less than 30% of the 20 largest hospitals by bed size within 50 miles of rating area's most populated zip code not participating. A narrow network has 30% to 69% of the 20 largest hospitals not participating and an ultra-narrow network has at least 70% of 20 largest hospitals not participating.

Another definition of narrow is "hyper-local," says Jonathan Wu, CEO and insurance analyst of Valuepenguin.com, a consumer finance site that specializes in helping consumers make decisions about insurance. He has been analyzing new ACA plans issued in 2014 in several states and says he's seen few nationwide options.

"Most plans, especially those with lower premiums, are designed to be local and are city and state-specific, not providing for any out-of-network coverage," he says.

 

So, for those families opting to keep adult kids on the plan until age 26, if they are away at college or living in another state, they'll be hard-pressed to find providers on the plan. Some carriers narrow plans by offering a PPO, a preferred provider organization, with an "out-of-network" option where the plan pays 50% (or some smaller portion) for those doctor visits. So, I could see other doctors but foot half their bill in coinsurance, instead of my plan's 10%.

Kaiser Permanente plans could also be considered hyper-local with a narrow network of providers offered all in one building with one hospital, but members give Kaiser some of the highest satisfaction ratings despite the lack of provider choice.

"I think this image of Kaiser and other HMO and limited networks as these evil gatekeepers who save money at any cost to your health is dead wrong," says Joanna Gatsolis, a five-year Kaiser member from Los Angeles. "I see Kaiser as an impressive example of how much more affordable health care can be and how great doctors can flourish when money concerns and insurance/paperwork concerns are taken off the table during a doctor's visit."

Gatsolis admits there isn't much choice of specialists or hospitals, although you can choose among any of their primary care providers and switch among them. "My only major complaint is Kaiser has no emergency room near me, and I would have to go to the city's non-Kaiser emergency room should I be in that situation and be on the hook for an out-of-network co-pay if I was not admitted," she said. Occasionally she has to travel 30 minutes to see a particular specialist.

Narrower networks save plans and members money

The McKinsey report found narrow networks are more prevalent in plans on the 2014 healthcare exchanges and that's one way insurers manage costs. In addition, broad network (a choice of a wide network of providers) plans are fewer compared to 2013, but were found available in almost every rating area analyzed. Across silver tier networks in the 20 analyzed rating areas, 84% of the lowest-price silver plans use narrow or ultra-narrow networks. The broader network plans averaged premiums that were 26% higher.

"A lower premium among the plan choices is one tip-off you might be choosing a plan with a narrow network. Another is no out-of-network coverage." says Wu. "For consumers, it's a trade-off between premium cost versus choice of doctors." He says to check the provider list yourself by clicking over to the provider plan documents and looking at the actual doctor, lab and hospital provider list."

The abbreviation EPO, for Exclusive Provider Organization, is another tip-off that the network might be narrow, because these are participating providers who receive even lower negotiated rates in exchange for the new patients.

Wu says those consumers switching health plans this year might be more aware of the provider network because they may be searching for continued care with their chosen doctors, but for the previously uninsured, they might be choosing a plan based on lower premiums, deductibles or maximum out-of-pocket costs and might not consider the network choice, as I did not.

About Kaiser's costs, Gatsolis adds, "Our Kaiser plan costs me so much less than what we had before it, I feel it gives me room to go outside the Kaiser network when necessary."

Narrow networks lower costs with the same quality of care

One aspect worth considering, especially if you have known health issues, is access to the local Academic Medical Centers (AMC, or, the teaching hospitals) where disease research and clinical studies are being done and care is purported to be, "The best." The McKinsey report confirmed that AMCs are participating in just 44% of the lowest-priced health plans compared to 91% participation in the highest-price plans. Participation of an AMC in any plan results in an average 10% increase in premium, compared to other similar tier offerings without an AMC.

The McKinsey report reviewed Centers for Medicare and Medicaid Services' (CMS) readmissions records and its composite score of 20 other quality and patient satisfaction measures and found no major differences in performance scores among the hospitals participating in ultra-narrow, narrow and broad networks. The report found that while costs are higher and choices abound in the broader networks, in those that do offer access to the teaching hospitals, care or patient satisfaction is not necessarily better.

I suppose if I had the choice of getting my second opinion from the Moffitt Cancer Center with all its expensive tests and doctors (they quoted me a $5,000 cash down-payment for a second opinion), I would have cost the health plan and myself a fortune, while the standard of care for my grade of breast cancer is already well-proven.

The Affordable Care Act expanded network adequacy requirements in terms of the minimum number and types of providers, and the maximum driving distance and wait time, and since I've seen it work successfully in action, I am no longer afraid of the narrow network.

--Written by Naomi Mannino for MainStreet

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