title: Access to In-Network Emergency Physicians and Emergency Departments Within Federally Qualified Health Plans in 2015.
abstract: BACKGROUND
  Under regulations established by the Affordable Care Act, insurance plans must meet minimum standards in order to be sold through the federal Marketplace. These standards to become a qualified health plan (QHP) include maintaining a provider network sufficient to assure access to services. However, the complexity of emergency physician (EP) employment practices - in which the EPs frequently serve as independent contractors of emergency departments, independently establish insurance contracts, etc… - and regulations governing insurance repayment may hinder the application of network adequacy standards to emergency medicine. As such, we hypothesized the existence of QHPs without in-network access to EPs. The objective is to identify whether there are QHPs without in-network access to EPs using information available through the federal Marketplace and publicly available provider directories.
  
  
  RESULTS
  In a national sample of Marketplace plans, we found that one in five provider networks lacks identifiable in-network EPs. QHPs lacking EPs spanned nearly half (44%) of the 34 states using the federal Marketplace.
  
  
  CONCLUSIONS
  Our data suggest that the present regulatory framework governing network adequacy is not generalizable to emergency care, representing a missed opportunity to protect patient access to in-network physicians. These findings and the current regulations governing insurance payment to EPs dis-incentivize the creation of adequate physician networks, incentivize the practice of balance billing, and shift the cost burden to patients.
authors.affiliation: Harvard T.H. Chan School of Public Health, Department of Health Policy & Management, Boston, Massachusetts; Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, Tennessee.
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Dorner
authors.affiliation: Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
authors.affiliation: Brigham and Women's Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts.
authors.forename: Jeremiah D
authors.initials: JD
authors.lastname: Schuur
authors.affiliation: Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.
authors.forename: Ali S
authors.initials: AS
authors.lastname: Raja
mesh_terms: D004636:Emergency Service, Hospital / Q000458:organization & administration*; D062265:Health Insurance Exchanges / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D006284:Health Plan Implementation / Q000458:organization & administration*; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D019458:Insurance Coverage; D058991:Patient Protection and Affordable Care Act / Q000331:legislation & jurisprudence / Q000458:organization & administration; D010820:Physicians; D014481:United States / Q000453:epidemiology
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