Founded at the Abramson Cancer Center at the University of Pennsylvania

Shopping for Health Insurance? Buyer Beware, Especially if You Have Cancer


Payment Models and Affordability

Having health insurance doesn't necessarily mean you'll get the care you need when you need it.



By Laura Yasaitis, Daniel E. Polsky and Justin E. Bekelman

The national conversation over plans to reform health care in America has been focused on who would lose coverage and who would keep it under newly proposed plans, but this masks a different problem that’s just as significant: many Americans who currently have insurance may not be able to get the care they need when they get sick, and they may not even know it.

Confusing and difficult
Shopping for health insurance is notoriously confusing and difficult. Amid an overload of information regarding deductibles, coinsurance, and copayments, the most easily understood feature of any plan is likely to be the premium—the monthly price consumers pay for health insurance. Unfortunately, many consumers may be surprised to find that cheaper plans are more likely to exclude high-quality health care providers in their region.

Insurance companies want to create a competitive health insurance product, and they will try to do whatever they can to lower their premiums. One approach that is becoming increasingly common is to sell plans with what are called “narrow networks of providers” – only a small subset of providers (hospitals or physicians) are included in plan’s network. By only contracting with a selected few providers, insurance companies can negotiate lower prices. This could be a good thing; it could improve the efficiency of health care by avoiding providers with unnecessarily high prices.

However, there’s reason to suspect that for cancer care, insurers may be excluding providers with the most expertise. Hospitals with a lot of experience treating cancer patients, as well as advanced research programs in the most cutting edge treatments, are often recognized as National Cancer Institute (NCI)-Designated Cancer Centers. Some of those centers also recognized by the National Comprehensive Cancer Network (NCCN) for excellence in patient care.

More complex treatments
Chances are that the most well-regarded cancer hospital in your region falls into one of these categories. Centers with these designations often have the market power to command higher prices. Additionally, these centers care for patients requiring more complex treatments. For both of these reasons, insurers trying to appeal to cost-conscious consumers may be more likely exclude these centers – and physicians associated with them – from their plans’ provider networks.

We just published a study in the Journal of Clinical Oncology examining this question using data from plans offered on the state health insurance exchanges in 2014. Focusing on all the networks offered in regions containing one of these centers, we found that cancer doctors included in narrower networks were less likely to have an affiliation with an NCI-Designated or NCCN Cancer Center. In many of the narrowest networks, not a single NCI- or NCCN-affiliated physician was included in the network.

No matter how we looked at the data – focusing on regions with multiple cancer centers or regions with fewer or more oncologists – the results were consist: narrower networks seem to be systematically excluding cancer doctors associated with NCI-Designated or NCCN Cancer Centers. Throughout the country, consumers purchasing narrow network plans may find themselves unable to seek care from exceptional cancer care providers in their region.

Tradeoffs for consumers
Faced with a choice between lower premiums and greater access to higher-quality providers, informed consumers may not select greater access. But health insurance is complex—and it’s hard to inform consumers fully about these tradeoffs. Just knowing who is in-network and who is out-of-network is challenging today. But insurers should do even more to promote transparency. For example, insurers should also publish indicators of provider quality, such as NCI- or NCCN-affiliation for cancer doctors, which could help consumers make better informed choices. Without greater efforts at transparency, consumers who purchase lower premium plans risk sacrificing access to higher-quality care—unknowingly—if they are subsequently diagnosed with a serious illness like cancer.

In cases where patients are unable to get the care they need in their network, providers should grant exceptions for out-of-network care without penalties. While many cancers can be treated successfully without seeking care at an NCI-Designated or NCCN Cancer Center, there may be specific cases, such as patients with other severe illnesses or less common tumors, that require the type of complex care or access to clinical trials only available at one of these centers. When such a situation arises, there should be a standard exception process to allow patients access to the care they need. Such exceptions should be tracked, since higher rates of exceptions could indicate an inadequate provider network.

In an ideal world, narrow networks could be a powerful tool to improve the efficiency of health care, allowing insurers to steer patients towards physicians and hospitals that provide the highest quality care at reasonable cost. Our research suggests that the real world falls short of this ideal. Greater transparency will allow consumers to assess these trade-offs themselves.

Related News