Study shows silver plans offer sparse radiologist coverage in 10 stroke-center markets

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A new analysis shows radiologists carved out of lower-cost exchange-purchased insurance plans to a notably greater degree than cardiologists and neurologists.

The sample pointing out the discrepancy is small, as the survey only looked at coverage of select stroke centers and the three main specialties serving them, in 10 markets. However, radiology inclusion lagged in nine of the 10. The greatest gaps were observed in Chicago, where 77% of cardiologists and 33% of neurologists were included in plans to no radiologists at all, and Nashville, where the numbers were 60% for neurologists, 53% for cardiologists and 17% for radiologists.

New Jersey was an interesting anomaly, as radiologists were covered to the tune of 73% versus 57% for cardiologists and 50% for neurologists.

The analysis presents not a representative test group reflective of national trends but, rather, a snapshot of the 10 markets. “It’s meant to give some sort of directional sense of what coverage looks like in the exchanges at the stroke centers for the leading-by-market-share providers in the specialties,” Jennifer Kowalski, a vice president with D.C.-based Avalere Health, which conducted the survey for the American Heart Association, told RadiologyBusiness.com.

Avalere decided to home in on lower-cost silver-tier plans because those enrollees are “sensitive to premium pricing and subsidies are tied to the cost of the second lowest cost silver plans,” according to the firm’s website.

Its lead conclusion was that exchange-plan coverage of such facilities and specialty physicians is “highly variable” across the 10 analyzed markets.

And how. The survey report shows overall physician coverage ranging from 8% in Los Angeles to 83% in Philadelphia. Average facility coverage was similarly inconstant, fluctuating from 11% in Atlanta to 100% in New Jersey.

For the most part, what the observed states had in place lined up with the federal government’s network adequacy requirements, said Kowalski.

“There have certainly been anecdotal reports of some notable medical centers excluded from exchange-plan coverage in some states,” she added. “But there is of course a fine balance in some cases between access to a very broad swath of providers and keeping premiums affordable for individuals who want to enroll in exchange coverage. And there’s certainly a middle ground, where you can have robust and good access to high-quality physicians, but maybe it’s not every last physician or every last hospital in your area—but the price is more affordable.”

The 10 markets analyzed were Atlanta, Chicago, Denver, Durham, N.C., Louisville, Los Angeles, Nashville, New Jersey, Philadelphia and San Jose, Calif.

To download a PDF of Avalere’s analysis, titled “Access to Comprehensive Stroke Centers & Specialty Physicians in Exchange Plans,” click here