D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2017 . No. 6 RELATION BETWEEN NARROW NETWORKS AND PROVIDERS OF CANCER CARE Laura Yasaitis, Justin E. Bekelman, and Daniel Polsky Journal of Clinical Oncology, July 2017 KEYFINDINGS Narrower provider networks offered on the health insurance exchanges are more likely to exclude oncologists associated with high-quality National Cancer Institute (NCI)-Designated Cancer Centers. These findings suggest that narrower oncology networks, while offering lower premiums, may involve a tradeoff between cost and quality of cancer care. THE QUESTION The authors identified 248 provider networks in these 51 markets. Networks in these markets were narrower than in other markets, covering To reduce the cost of insurance plans, health insurers are increasingly an average of 39.4% of area oncologists versus 49.9% in other markets. marketing plans that restrict access to providers (both hospitals and Despite this narrowness, the average number of covered oncologists physicians). These narrow provider networks allow insurers to offer price- per 100,000 residents was higher than in markets containing a NCI- competitive plans, often through lower reimbursement rates or selective Designated Center than other markets (4.5 vs. 3.8). However, 33 of contracting with providers treating lower-cost patients. Whether narrow 248 networks did not contain a single physician affiliated with an NCI networks limit access to high quality providers is not known. center; these networks were narrower (covering only 14.1% of local NCI-Designated Cancer Centers, and a subset of them identified as oncologists) than networks including at least one NCI-affiliated physician National Comprehensive Cancer Network (NCCN) Cancer Centers, are (covering 42.3% of local oncologists). The figure on the front shows that recognized for their scientific leadership, cutting-edge medical technology, oncology network breadth was associated with inclusion of NCI-affiliated and lower mortality rates among severely ill patients. These prestigious oncologists, indicating that narrower networks are more likely to exclude cancer centers are more likely to attract patients requiring costly care, and these physicians. insurers have a strong incentive to exclude oncologists associated with NCI or NCCN Cancer Centers from narrow networks. In this study, the THE IMPLICATIONS authors assess the extent to which narrow networks systematically exclude NCI or NCCN-affiliated oncologists, and address the implications for This is the first study to demonstrate a correlation between narrow whether narrow networks require a tradeoff between cost and quality. networks and exclusion of NCI- and NCCN-affiliated providers. These hospitals are recognized for their high-quality cancer care, education, and research programs. Thus, this finding suggests that narrow networks may THE FINDINGS not just offer fewer providers, but that the limited number of providers included may not offer the same quality care as those who have been Of 407 markets (rating areas) in the country, 51 had an NCI-Designated excluded. This highlights a critical tradeoff that consumers face when Center; 27 of them had an NCCN center. The supply of oncologists was purchasing a narrow network plan: they may benefit from the lower greater in markets with an NCI-Designated Cancer than other markets premiums charged by narrow network plans, but they may face reduced (13.7 vs. 8.8 per 100,000 residents). access to higher-quality providers in their market. These findings are relevant to replacement proposals for the Affordable Care Act, that emphasize shoppable insurance plans for consumers. As consumers seek to learn about providers and coverage included in their plans, accurate information about these providers is essential. In 2016, COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI those with NCI (or NCCN) affiliation among the market’s oncologists excluded from the network. Values greater than one indicate relative inclusion—and values less than one relative exclusion. Then, the authors assessed the relationship between network breadth and the inclusion measure for all networks offered in any market containing an NCI-Designated Cancer Center. They also ran separate analyses for NCCN centers, but the results did not differ for this subset of cancer centers. Yasaitis, L., Bekelman, J., Polsky, D. (2017), Relation Between Narrow Networks and Providers of Cancer Care. Journal of Clinical Oncology. http://ascopubs.org/ doi/abs/10.1200/JCO.2017.73.2040 the Centers for Medicare & Medicaid Services THE STUDY enacted rules for publishing user-friendly The authors used a registry of all office-based provider directories that include a provider’s physicians to identify practicing physicians with location, contact information, specialty, medical group, and any hospital affiliations. This study’s a specialty of hematology/oncology or radiation ABOUT LDI oncology, and identified oncologists affiliated findings indicate that inclusion of quality with one of the 69 NCI-Designated Cancer Since 1967, the Leonard Davis Institute indicators in these provider directories – such as Centers, and the subset that were NCCN of Health Economics (LDI) has been the NCI or NCCN affiliation for cancer providers – Cancer Centers. They examined provider leading university institute dedicated to data- may prove useful to consumers shopping health networks offered on the 2014 individual driven, policy-focused research that improves plans. health insurance exchanges using a previously our nation’s health and health care. Originally The question this study raises, but cannot integrated dataset, and identified 51 markets founded to bridge the gap between scholars answer, is whether or not insurers specifically (rating areas) containing at least one NCI- in business (Wharton) and medicine at exclude physicians at higher rates because of Designated Cancer Centers. their NCI or NCCN designation, or whether the University of Pennsylvania, LDI now The breadth of each network was calculated connects all of Penn’s schools and the exclusion results from an additional correlated as the number of oncologists included in Children’s Hospital of Philadelphia through factor. For example, group practice size may be the network divided by the total number of its more than 250 Senior Fellows. associated with market power and pricing, and oncologists practicing in that market. They may be a factor in an insurer’s choice to exclude measured a network’s likelihood of including a provider. Furthermore, the data do not identify LDI Research Briefs are produced by high-quality oncologists within each market by differences in actual care quality between NCI LDI’s policy team. For more information the proportion with NCI (or NCCN) affiliation and non-NCI centers. Future research should please contact Janet Weiner at among the market’s oncologists included in examine the relationship between narrow weinerja@mail.med.upenn.edu. the network, divided by the proportion of networks and cancer care outcomes. LEAD AUTHOR DR. LAURA YASAITIS Laura Yasaitis, PhD is a postdoctoral researcher in Health Policy at the Perelman School of Medicine. She completed her doctoral training in Health Policy at The Dartmouth Institute in 2013, and was a postdoctoral research fellow for two years at the Center for Population Studies and Development at Harvard’s T.H. Chan School of Public Health. Her research interests include the study of large datasets, including surveys and administrative data, to better understand the quality and outcomes of health care in the United States. She is also interested in the application of spatial analysis methods to further our understanding of local trends in health and health care.