Avalere Report: Exchanges Include 34% Fewer Providers

A report released by the healthcare research group Avalere Health claims that health insurance exchanges have a significantly narrow network compared with their commercial counterparts.

A report released by the healthcare research group Avalere Health claims that health insurance exchanges have a significantly narrow network compared with their commercial counterparts. The average provider networks, the report says, for plans offered on the health insurance exchanges created by the Affordable Care Act (ACA) include 34% fewer providers than the average commercial plan offered outside the exchange.

While it was reported back in 2013 that the ACA would limit the choice of providers and healthcare systems offered on the public exchanges, the Avalere report provides an objective view.

For this study, Avalere included the following 5 states: Florida, California, Texas, Georgia, and North Carolina. In these top 5 enrollment regions, Avalere compared the average number of providers included, for 5 provider types in exchange networks compared to commercial networks in the same geographic area. Commercial network data included plans offered in the group and individual markets outside the exchange. The analysis showed that the exchange plans offer the following number of in-network providers as a percentage of those offered on commercial plans:

  • 68% primary care
  • 76% hospitals
  • 68% mental health
  • 58% oncology
  • 58% cardiology.

“Patients should evaluate a plan’s provider network when picking insurance on the exchange,” said Elizabeth Carpenter, vice president at Avalere. “Out-of-network care does not accrue toward out-of-pocket maximums, leaving consumers vulnerable to high costs if they seek care from a provider not included in their plan’s network.”

While narrow network plans face dissatisfaction on the provider and consumer end, McKinsey & Co reported that 70% of plans sold on the exchanges in 2014 featured a limited network, and their premiums were up to 17% cheaper than plans with broader networks. Experts believe that these narrow network plans will survive, especially if they can force higher-cost hospitals to bring down their prices.