Study: Pediatric Specialty Physicians are More Likely to be Missing from Provider Networks in Affordable Care Act (ACA) Plans than Adult Specialists

March 01, 2017

Authors recommend that marketplace network adequacy standards consider child health needs when developed

The Patient Protection and Affordable Care Act (ACA) was created to provide access to comprehensive and affordable healthcare in the U.S. Concerns have been raised about patient access under plans in the ACA because of limited or narrow physician networks. To date, no studies have examined the supply and geographic distribution of pediatric specialty physicians in these networks.

In a paper published in the April 2017 issue of Pediatrics, Charlene A. Wong, MD, MSHP, Kristin Kan, MD, MPH, MSc, and colleagues collected and analyzed data from the ACA silver-level health insurance plans to describe the physician networks of specialists covered by the plans. By quantifying networks into categories based on the fraction of providers in the underlying rating area that participated in the network, they were able to identify “narrow networks” – those with no or limited numbers of physicians. They also categorized physicians into specialties, such as pediatric cardiology and adult cardiology, and determined the availability of those specialists in the networks. The findings show that narrow networks were more prevalent among pediatric specialty providers than among adult specialty providers. In addition, the proportions of networks where no specialists were included, even if specialists practiced in the area covered by the network, were significantly higher for all pediatric than adult specialties except nephrology.

Wong, an adolescent medicine pediatrician and health policy researcher at Duke University, said, “Even before the ACA was adopted, narrow networks were being used as a way to control healthcare costs. We didn’t know to what extent the increase in narrow networks might affect pediatric healthcare access compared to adult healthcare access until we analyzed the data. Our hope is that these results catalyze a policy discussion around network adequacy standards.”

Specialties where they found more narrow networks for pediatric providers included pediatric cardiologists, hematologists/oncologists, infectious disease, endocrinologists, nephrologists, neurologists and psychiatrists.

“Studies such as ours show that there are implications to how networks are designed. Children, particularly those with chronic medical conditions, have unique needs when it comes to access to pediatric specialists through the health insurance marketplace,” said Kan. “We are concerned that referring physicians might not recognize that pediatric specialty care may only be available to some families out of network, leading to considerable out-of-pocket costs for families. It is also critical for families to have tools to evaluate network size and access when shopping for health insurance plans so that they are able to make the right decisions regarding healthcare coverage.”

The authors believe that children's access to healthcare should be included in broader health policy discussions moving forward. “The availability of pediatric providers in any network, whether it be employer-sponsored insurance, a public insurance program or the next generation of individual marketplaces under the Trump administration, is critical to ensuring high quality healthcare for our country's children and youth,” said Wong.

Charlene A. Wong, MD, MSHP, is Assistant Professor of Pediatrics at Duke University Medical Center. She conducted this research as an Adolescent Medicine fellow at the Children’s Hospital of Philadelphia and a Senior Fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

Kristin Kan, MD, MPH, MSc, is Research Assistant Professor at the Mary Ann & J. Milburn Smith Child Health Research Program at Stanley Manne Children’s Research Institute, attending physician in the Division of Academic General Pediatrics and Primary Care at Ann & Robert H. Lurie Children’s Hospital of Chicago, and Instructor of Pediatrics at Northwestern University Feinberg School of Medicine. She conducted this research as a Robert Wood Johnson Foundation Clinical Scholar at the University of Michigan.

Wong and Kan are co-first authors on the publication: Wong CA, Kan K, Cidav Z, et al. Pediatric and Adult Physician Networks in Affordable Care Act Marketplace Plans. Pediatrics. 2017;139(4):e20163117.

The study was supported by a grant from the Robert Wood Johnson Foundation.

About the Stanley Manne Children’s Research Institute

Research at Ann & Robert H. Lurie Children’s Hospital of Chicago is conducted through the Stanley Manne Children's Research Institute. The institute is focused on improving child health, transforming pediatric medicine and ensuring healthier futures through the relentless pursuit of knowledge. In partnership with Northwestern University Feinberg School of Medicine, our scientists work in labs, in clinics, at the patient bedside and in the community to unravel the root causes of pediatric and adolescent disease, to understand childhood injury and to find factors that precipitate health problems in childhood and over a lifetime. Our researchers work every day to develop new therapies and prevention strategies.