WASHINGTON – Some of America’s best cancer hospitals are off-limits to many of the people now signing up for coverage under the nation’s new health care program.
Doctors and administrators say they’re concerned. So are some state insurance regulators.
An Associated Press survey found examples coast to coast. Seattle Cancer Care Alliance is excluded by five out of eight insurers in Washington’s insurance exchange. MD Anderson Cancer Center is in less than half of the plans in the Houston area. Memorial Sloan-Kettering is included by two of nine insurers in New York City and has out-of-network agreements with two more.
In all, only four of 19 nationally recognized comprehensive cancer centers that responded to AP’s survey said patients have access through all the insurance companies in their states’ exchanges.
Not too long ago insurance companies would have been vying to offer access to renowned cancer centers, said Dan Mendelson, CEO of the market research firm Avalere Health. Now the focus is on costs.
“This is a marked deterioration of access to the premier cancer centers for people who are signing up for these plans,” Mendelson said.
Those patients may not be able to get the most advanced treatment, including clinical trials of new medications.
And there’s another problem: It’s not easy for consumers shopping online in the new insurance markets to tell if top-level institutions are included in a plan. That takes additional digging by the people applying.
“The challenges of this are going to become evident … as cancer cases start to arrive,” said Norman Hubbard, executive vice president of Seattle Cancer Care Alliance.
Before President Barack Obama’s health care law, a cancer diagnosis could make you uninsurable. Now, insurers can’t turn away people with health problems or charge them more. Lifetime dollar limits on policies, once a financial trap-door for cancer patients, are also banned.
The new obstacles are more subtle.
To keep premiums low, insurers have designed narrow networks of hospitals and doctors. The government-subsidized private plans on the exchanges typically offer less choice than Medicare or employer plans.
Insurers can cut costs by not including top cancer centers. It may also shield itself from risk, delivering an implicit message to cancer survivors or people with a strong family history of the disease that they should look elsewhere.
For now, the issue seems to be limited to the new insurance exchanges. But it could become a concern for Americans with job-based coverage, too, if employers turn to narrow networks.
Melanie Lapidus, vice president for managed care at Barnes-Jewish Hospital in St. Louis, home to Siteman Cancer Center, said she doesn’t think patients realize the exchanges offer a more restrictive kind of private insurance.
Lapidus cited Anthem Blue Cross and Blue Shield, which includes Siteman in many of its plans outside the Missouri exchange, but none within the exchange.
“We have had many people say to us, ‘I picked Anthem because you guys are always in their products, and I assumed you would be in their exchange products,’ ” Lapidus said. “It’s still hard to tell who is in network and who is not.”
In a statement, Anthem said its network was based on research involving thousands of consumers and businesses. “What we learned was that people are willing to make trade-offs in order to have access to affordable health care,” the company said. “Our provider networks reflect this.”
Huntsman Cancer Institute in Salt Lake City is included by five of six Utah insurers, but Mark Zenger, who manages the center’s negotiations with insurance companies, said he’s concerned about getting left out by Humana, a major carrier.
“We are worried about the potential to have these Humana exchange members seek treatment and have no other option,” said Zenger.
Humana spokesman Tom Noland said patients can have access to Huntsman for complex procedures, on a case-by-case basis.
Some state insurance regulators see a problem.
“I want insurers to be able to innovate and come up with new product designs,” said Mike Kreidler, insurance commissioner for Washington state. “At the same time, there is a requirement for regulators like myself to be vigilant to make sure there aren’t unreasonable compromises.”
The Obama administration says it has notified insurers that their networks will get closer scrutiny for next year in the 36 states served by the federal exchange. Cancer care will be a priority, it says.