Health Law Concerns for Cancer Centers

By Ricardo Alonso-Zaldivar
Associated Press, March 19, 2014

Cancer patients relieved that they can get insurance coverage because of the new health care law may be disappointed to learn that some the nation’s best cancer hospitals are off-limits.

An Associated Press survey found examples coast to coast. Seattle Cancer Care Alliance is excluded by five out of eight insurers in Washington state’s insurance exchange. MD Anderson Cancer Center says it’s 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 (members of the National Comprehensive Cancer Network) said patients have access through all the insurance companies in their state exchange.

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 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 whether top-level institutions are included in a plan. That takes additional digging by the people applying.

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.

By not including a top cancer center an insurer can cut costs. 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.

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.”…

Members of the National Comprehensive Cancer Network (


2015 Letter to Issuers in the Federally-facilitated Marketplaces

CMS, March 14, 2014

Section 3. Network Adequacy

Pursuant to 45 C.F.R. 156.230(a)(2), an issuer of a QHP that has a provider network must maintain a network that is sufficient in number and types of providers… to assure that all services will be accessible to enrollees without unreasonable delay. All issuers applying for QHP certification will need to attest that they meet this standard as part of the certification/recertification process.

CMS will assess provider networks using a “reasonable access” standard, and will identify networks that fail to provide access without unreasonable delay as required by 45 C.F.R. 156.230(a)(2).

If CMS determines that an issuer’s network is inadequate under the reasonable access review standard, CMS will notify the issuer of the identified problem area(s) and will consider the issuer’s response in assessing whether the issuer has met the regulatory requirement and prior to making the certification or recertification determination.…


Kaiser Health Tracking Poll: February 2014

By Liz Hamel, Jamie Firth and Mollyann Brodie, February 26, 2014

The latest Kaiser Health Tracking Poll finds that, in general, the public leans towards more expensive plans with broader networks. About half (51 percent) say they would rather have a plan that costs more money but allows them to see a broader range of doctors and hospitals, while just under four in ten (37 percent) prefer a plan that is less expensive but allows them to visit a more limited range of providers. While older individuals and those with higher incomes exhibit a clearer preference for more expensive plans with broader networks, younger adults and those with lower incomes are more evenly divided in their preferences. But those who are either uninsured or currently purchase their own coverage – a group that is most likely to be in a position to take advantage of new coverage options under the ACA – are more likely to prefer less costly narrow network plans over more expensive plans with broader networks (54 percent versus 35 percent). Those who currently get their insurance through an employer (and are more protected from the cost of coverage) have the opposite preference: 55 percent prefer a more expensive plan with a broader network, while 34 percent would rather have a cheaper narrow network plan.

Those who prefer narrow network plans may be less likely to prefer them if it means they can’t see their usual providers. When those who prefer a less costly narrow network plan are presented with the possibility that they would not be able to visit the doctors and hospitals they normally use, the share who continue to prefer this option drops from 37 percent to 23 percent among the public overall, and from 54 percent to 35 percent among the uninsured and those who buy their own insurance.

On the other hand, when those who initially prefer a more expensive plan with a broader network are told that they could save up to 25 percent on their health care costs, the share continuing to prefer the more expensive option drops from 51 percent to 37 percent among the public overall, and from 35 percent to 22 percent among those the uninsured and those with non-group coverage.…

For decades we have been hearing heartrending stories of children and adults under 65 who develop cancer but were uninsured. For those of us striving for a comprehensive health care program for everyone, there could not be a greater motivating force than the desire to eliminate forever the twin tragedies of impaired access to care and personal financial ruin for these unfortunate cancer victims.

The Affordable Care Act brought us expanded access to private insurance plans with incentives for the insurers to provide plan innovations to help slow spending on health care. Although plans already were using limited networks to leverage lower prices from the providers, the degree to which they would further narrow networks was not expected, except perhaps by the cynics amongst us.

But the insurers have no shame. Cancer management is expensive. What better place to restrict access could there be than to remove most members of the National Comprehensive Cancer Network from many of their insurance networks. Only four of nineteen of these centers are included in all exchange plan networks within their respective states.

CMS tells us that they will use a “reasonable access” standard when the plans are recertified for the federal exchanges next year. This is a relative rather than an absolute standard. They have no intention of opening up insurer networks to all comers. That would defeat the insurance innovation of controlling costs by blocking access to out-of-network providers, especially the expensive ones such as the members of the National Comprehensive Cancer Network.

The latest Kaiser tracking poll is of concern since it shows that lower-income and uninsured people will select the plans with more restricted networks simply because the premiums are lower. No centers-of-excellence cancer care for them.

Although insurers are prohibited from denying coverage, just think of the advantage they would have in avoiding adverse selection by being able to tell those patients who have cancer that they really don’t want to buy the plans they offer since the nation’s noted cancer institutions are not covered. They can do the cancer victim a favor by sending her to a competitor. Then they can retreat into their headquarters to devise yet more insurance innovations that work this well.

A single payer national health program would not have networks. Patients could go anywhere. With an improved primary care infrastructure, they would receive assistance in obtaining the best care for their medical condition. For those with cancer, there would be no private insurers profiting off of discount cancer care, though the single payer system would take care to see that the services are priced right for the benefit of us taxpayers who would be financing our health care system.