Access to Accredited Cancer Hospitals Within Federal Exchange Plans Under the Affordable Care Act

Abstract

Purpose The Affordable Care Act expanded access to health insurance in the United States, but concerns have arisen about access to specialized cancer care within narrow provider networks. To characterize the scope and potential impact of this problem, we assessed rates of inclusion of Commission on Cancer (CoC) -accredited hospitals and National Cancer Institute (NCI) -designated cancer centers within federal exchange networks. Methods We downloaded publicly available machine-readable network data and public use files for individual federal exchange plans from the Centers for Medicare and Medicaid Services for the 2016 enrollment year. We linked this information to National Provider Identifier data, identified a set of distinct provider networks, and assessed the rates of inclusion of CoC-accredited hospitals and NCI-designated centers. We measured variation in these rates according to geography, plan type, and metal level. Results Of 4,058 unique individual plans, network data were available for 3,637 (90%); hospital information was available for 3,531 (87%). Provider lists for these plans reduced into 295 unique networks for analysis. Ninety-five percent of networks included at least one CoC-accredited hospital, but just 41% of networks included NCI-designated centers. States and counties each varied substantially in the proportion of networks listed that included NCI-designated centers (range, 0% to 100%). The proportion of networks that included NCI-designated centers also varied by plan type (range, 31% for health maintenance organizations to 49% for preferred provider organizations; P = .04) but not by metal level. Conclusion A large majority of federal exchange networks contain CoC-accredited hospitals, but most do not contain NCI-designated cancer centers. These results will inform policy regarding access to cancer care, and they reinforce the importance of promoting access to clinical trials and specialized care through community sites.

Fig 1.

(A) In-network Commission on Cancer (CoC) –accredited hospitals by county. The color of each county on the map indicates the proportion of networks containing at least one CoC-accredited hospital among all networks offered within that county for which data were uploaded to the Centers for Medicare and Medicaid Services. (B) In-network CoC-accredited hospitals by state (n = 295 networks). When networks were offered in more than one state (n = 21), they were counted once for each state in which they were offered.

Fig 2.

(A) In-network National Cancer Institute (NCI) –designated centers by county. The color of each county on the map indicates the proportion of networks containing at least one NCI-designated center among all networks offered within that county for which data were uploaded to the Centers for Medicare and Medicaid Services. (B) In-network NCI-designated centers by state (n = 295 networks). When networks were offered in more than one state (n = 21), they were counted once for each state in which they were offered.

Fig A1.

Database components. NPI, national provider identifier.

Fig A2.

In-network National Cancer Institute (NCI) –designated centers within counties containing NCI-designated cancer centers. Each vertical bar represents one of the 35 counties in federal exchange states that contain NCI-designated cancer centers. When networks were available in more than one such county, they were counted once for each county in which they were available.