Emeline M. Aviki, MD, MBA; Stephen M. Schleicher, MD, MBA; and Thomas W. Feeley, MD
- Narrow networks represent one strategy to contain costs and make health insurance more
- affordable to patients.
- Narrow networks are more likely to limit access to specialty cancer centers, but there are no data that suggest patients enrolled in narrow network plans experience worse cancer-specific outcomes.
- We need greater transparency about health plan coverage and costs to help patients with cancer choose plans most aligned with their individual goals.
For decades, insurance plans have used limited provider and hospital networks as a strategy to contain costs and lower insurance premiums.1 In recent years, the issue of limited or “narrow” networks has drawn attention both as a strategy used by insurers to reduce costs and as a potential barrier for patients to access specialty services such as cancer care. We traced the acceleration of this trend to the implementation of the Affordable Care Act, which introduced federal- and state-based health insurance exchanges, preexisting disease protection clauses, limits on maximum out-of-pocket spending, and minimum standardized benefits. These provisions eliminated many of the cost-containment strategies traditionally used by insurance plans and led to an increased reliance on narrow networks to remain competitive. These narrow network plans have effectively provided lower-cost health insurance options for Americans, many of whom were previously uninsured.2 Yet, there are growing concerns that narrow networks limit access to high-quality specialty care, particularly for patients with cancer. Here, we discuss the impact of narrow networks on cancer care access, potential implications for patients with cancer, and directions forward.
What Makes a Network ‘Narrow’?
Network breadth is defined as the number of eligible providers or hospitals participating in a network divided by the total number of eligible providers or hospitals in a market. Categories of network breadth have been established using a variety of arbitrary cutoffs for the purpose of providing consumers with tools to compare plans. Networks are considered “narrow” when coverage is limited to less than 25% of eligible providers or less than 70% of eligible hospitals.
Impact of Narrow Networks on Access
Since 2014, approximately half of the plans offered on the individual market exchanges have been defined as narrow3; however, the narrow network trend is not limited to plans offered on the exchanges. For example, the percentage of employers whose largest health plan included a narrow network increased from 15% in 2007 to 23% in 2013.1 The growing prevalence of these plans may be attributed to their ability to offer lower premiums to price-sensitive consumers by controlling where patients receive care. In fact, narrow network plans offered on the 2017 marketplace had premiums that were priced 18% to 35% lower than plans with broader networks.3 It is important to consider that even with subsidies, the cost of health insurance remains a major barrier to expanding access for the uninsured. Therefore, lower premiums offered by plans with narrow networks may improve access to cancer care simply by increasing the number of patients that can afford insurance.
Cancer outcomes may vary based on where a patient receives treatment. Pfister et al4 reported a 10% overall survival advantage in patients treated at a specialty cancer center compared to community centers, and numerous studies have reported improved cancer-specific outcomes associated with care at National Comprehensive Cancer Network and National Cancer Institute (NCI)–Designated Cancer Centers.5
Several recent studies have reported the extent to which narrow networks limit access to specialty centers. An Associated Press survey conducted in 2014 showed that only four of 19 nationally recognized comprehensive cancer centers were covered in their state exchange plans.6 In 2016, we similarly reported that more than half of all exchange plans excluded four of the 11 standalone cancer centers that make up the Alliance of Dedicated Cancer Centers.7 Most recently, Yasaitis et al8 analyzed provider networks in the 2014 individual exchanges and found that narrow networks contained fewer oncologists affiliated with National Comprehensive Cancer Network or NCI-Designated Cancer Centers, despite including a similar total number of oncologists in their plans. These data suggest that for patients diagnosed with cancer, narrow network plans are more likely to limit access to the cancer care at specialty centers.
Patients With Cancer and Narrow Networks
Although narrow networks are more likely to limit access to specialty cancer centers, there are no published reports suggesting that patients enrolled in narrow network plans experience worse cancer-specific outcomes. In fact, the benefits associated with increased access to affordable health insurance by offering lower-cost narrow network plans may be profound for patients with cancer, many of whom already face a high financial burden associated with their diagnosis. For example, previous studies have shown that a cancer diagnosis can lead to an increased rate of bankruptcy, and that health-related bankruptcy is associated with increased mortality.9,10 There is evidence that increasing access to health insurance can reduce financial stress and improve overall quality of life,11 as well as lead to higher rates of early-stage disease at diagnosis.12
The tradeoff between increased access to affordable health insurance and limited access to the highest-quality cancer centers should be considered by consumers when choosing a health plan. To make an informed decision regarding health insurance plans requires both insurance literacy and information transparency. This may not always be feasible, as the vast majority of patients do not understand basic health insurance concepts.13 A McKinsey & Company survey found that 44% of previously uninsured patients who signed up for health insurance exchange plans in 2015 were unsure of their network breadth.14 Patient education will be an important component of future strategies to ensure informed insurance plan choice.
Providers and provider organizations
Providers and provider organizations must focus on improving value to prevent long-term exclusion from health plans. Not only is access important for patients themselves, but patient volume is also crucial for NCI-Designated Cancer Centers and members of the Alliance of Dedicated Cancer Centers to continue to advance cancer care through research, training physicians, and caring for patients with complex cases. To attract patients during times of increased financial pressures, these centers need to demonstrate value beyond brand equity and must lead the initiative toward greater transparency.
Health services researchers
It remains unknown if patients enrolled in narrow network plans experience different cancer-specific outcomes compared to those enrolled in broad network plans. This represents an area where health services researchers can provide important insights to help guide policymakers as they consider minimum coverage mandates for specialty cancer services, as well as to price-conscious consumers who are attempting to make an informed decision regarding which health plan to purchase.
Although there are no data to confirm that patients in narrow networks experience worse outcomes, several studies have confirmed improved survival and fewer complications when care is received at an NCI-Designated Cancer Center. Given the available information, policymakers should consider adopting reforms to ensure consistent access to these cancer centers across all health plans offered on the exchanges. One such proposal would be for federal and state regulators to require that all plans offered on the individual exchanges include at least one in-network NCI-Designated Cancer Center. By including at least one recognized center of excellence, the increased costs associated with cancer care would be distributed over a large population of beneficiaries rather than born only by the limited number of individuals with cancer diagnoses who choose to receive care at an NCI-Designated Center.
Finally, insurers need to recognize other ways to control cancer costs than simply excluding providers. In the long run, worse outcomes cost health care delivery systems more and narrow networks may send patients to providers who have worse outcomes that decrease long-term value for patients. A better and more sustainable way for health plans to control costs is by taking a value-based approach to benefit design. They should reward cancer care providers who effectively coordinate care, collect and report outcomes that matter to patients, and control costs. They should accelerate the pace of evaluating value-based reimbursement techniques such as bundled payments and oncology medical homes, the goals of which are to improve outcomes and control costs. They should also stop paying for treatments given in a high-cost environment when the same care can be provided in a lower-cost environment.
Narrow networks represent one strategy to contain costs and make health insurance more affordable to patients. However, these networks limit patient access to certain care providers. Whether narrow networks benefit or harm patients diagnosed with cancer remains unknown. More research is needed to answer this question and help guide policymakers to intervene in the insurance marketplace appropriately. Additionally, we need greater transparency about health plan coverage and costs to help patients with cancer choose plans most aligned with their individual goals. The broader focus for the cancer community, however, is the need for providers and provider organizations to improve the value of patient care. Only then can all patients, independent of socioeconomic status, have a chance to receive the highest-quality treatment.
About the Authors: Dr. Aviki is a gynecologic oncology fellow at Memorial Sloan Kettering Cancer Center. Dr. Schleicher is a medical oncology fellow at Memorial Sloan Kettering Cancer Center. Dr. Feeley is a senior fellow at the Harvard Business School and professor emeritus at The University of Texas MD Anderson Cancer Center.