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ABSTRACT Insurers are increasingly adopting narrow network strategies. Little is known about how these strategies may affect children's access to needed specialty care. We examined the percentage of pediatric specialty hospitalizations that would be beyond existing Medicare Advantage network adequacy distance requirements for adult hospital care and, as a secondary analysis, a pediatric adaptation of the Medicare Advantage requirements. We examined 748,920 hospitalizations at eighty-one children's hospitals that submitted data for the period October 2014-September 2015. Nearly half of specialty hospitalizations were outside the Medicare Advantage distance requirements. Under the pediatric adaptation, there was great variability among the hospitals, with the percent of hospitalizations beyond the distance requirements ranging from less than 1 percent to 35 percent. Instead of, or in addition to, time and distance standards, policy makers may need to consider more nuanced network definitions, including functional capabilities of the pediatric care network or clear exception policies for essential specialty care services.
The Affordable Care Act (ACA) prohibits insurers from excluding or charging higher premiums to people with preexisting conditions or restricting access to certain medications or medical services. These restrictions prevent insurers from reducing costs (and resulting premium prices) through the exclusion of high-cost patients. To reduce costs, insurers have instead turned to paying providers less.1-3 Most plans offered on the Marketplaces have reduced provider compensation (and premium prices) by adopting narrownetwork strategies.1,4 Using these strategies, insurers contract with fewer providers, which allows insurers to exclude some high-cost providers and to engage in more aggressive reimbursement negotiations with potential providers.5,6 Approximately half of the plans offered on the Marketplaces are considered to be narrow,3 and narrow networks are becoming increasingly prevalent outside the Marketplaces as well. Patients in narrow networks potentially risk delays in receiving appropriate care or high out-of-pocket spending if care is required out of the network.
Insurers' use of narrow provider networks has come under increasing regulatory scrutiny. State regulations of health plan network adequacy generally provide qualitative requirements (for example, requiring "reasonable" or "sufficient" access to providers), as do federal regulations in Medicaid and the Children's Health Insurance Program (CHIP).7 The Department of Health and Human Services (HHS), however, has adopted quantitative network adequacy standards for Medicare Advantage plans. Approximately half of the state regulations of Marketplace...