152 Applying Network Adequacy Standards to Emergency Medicine

Abstract

The Affordable Care Act authorized the U.S. Department of Health and Human Services (HHS) to regulate qualified health plans’ (QHPs) network adequacy. QHPs must include a sufficient number and type of physicians within their provider network to deliver contracted benefits and services. HHS determines adequacy by applying a “reasonable access” standard using provider network data reported by QHPs. While the regulations apply to all specialties, emergency medicine (EM) is clinically and operationally unique due to emergency physicians’ distinct billing and employment practices. Although many emergency physicians employed by large urban hospitals are paid rates negotiated between the hospital and insurers, approximately 65% of hospitals staff their emergency departments with independently contracted emergency physicians, many of whom do not negotiate with insurers. We investigated whether applying the reasonable access standard to in-network emergency physicians provides sufficient information for determining network adequacy. We hypothesized that roughly 10% of plans would lack in-network emergency physicians. We examined Silver QHPs offered in the 34 states in the Marketplace in 2015. An estimated 65% of participants select Silver Plans. In each state, we sampled four plans available in the insurance rating area containing the most populous county: the lowest, second-lowest, median, and highest premium plans. Premium pricing information was obtained using publicly available QHP Marketplace data from the Center for Medicare and Medicaid Services. Using each QHP’s publicly available provider directory, we identified the number of in-network emergency physicians within 100 miles of the primary ZIP code for the rating area’s most populous city. If a directory’s maximum search radius was less than 100 miles, we selected the broadest search radius available. We applied this same methodology to identify in-network hospitals within the same search radius. Data were summarized using descriptive statistics. Among the 136 QHPs analyzed, the total number of identifiable in-network emergency physicians ranged from 0 to 840 (median: 28). We identified 30 plans (22%) with networks completely lacking emergency physician coverage. The number of in-network hospitals ranged from 0 to 500 (median: 28). Five plans (3.7%) lacked hospital coverage. Three plans (2.2%) covered emergency physicians but did not cover a hospital. Two plans (1.5%) lacked both in-network emergency physician and hospital coverage. Information regarding whether emergency physicians were hospital employees or independent contractors was not available. Our findings raise serious questions about the application of the network adequacy framework to EM. One-in-five plans lacked identifiable in-network emergency physicians, a situation that does not meet the reasonable access standard. The same is true of hospital coverage. There is a broad range of in-network coverage of both emergency physicians and hospitals. While some health plans cover a large number of in-network emergency physicians and hospitals, others lack coverage of both. The opaque nature of physician-hospital contracts and billing obscures the ability to identify whether an in-network hospital employs out-of-network emergency physicians, or vice-versa. In light of these obstacles, regulators seeking to determine emergency physician network adequacy will require additional information beyond that presently requested of QHPs.