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{
    "pk": 9444,
    "title": "Access to In-Network Emergency Physicians and Emergency Departments Within Federally Qualified Health Plans in 2015",
    "subtitle": null,
    "abstract": "Introduction: \nUnder 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.\nResults: \nIn 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.\nConclusion: \nOur 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.",
    "language": "en",
    "license": {
        "name": "Creative Commons Attribution 4.0",
        "short_name": "CC BY 4.0",
        "text": "Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\r\n\r\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.",
        "url": "https://creativecommons.org/licenses/by/4.0"
    },
    "keywords": [
        {
            "word": "Health Policy"
        },
        {
            "word": "Health Reform"
        },
        {
            "word": "Insurance"
        },
        {
            "word": "Emergency Medicine"
        }
    ],
    "section": "Emergency Department Access",
    "is_remote": true,
    "remote_url": "https://escholarship.org/uc/item/7x22k9hg",
    "frozenauthors": [
        {
            "first_name": "Stephen",
            "middle_name": "C.",
            "last_name": "Dorner",
            "name_suffix": "",
            "institution": "Vanderbilt University School of Medicine, Nashville, Tennessee; Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts",
            "department": "None"
        },
        {
            "first_name": "Carlos",
            "middle_name": "A.",
            "last_name": "Camargo, Jr.",
            "name_suffix": "",
            "institution": "Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts",
            "department": "None"
        },
        {
            "first_name": "Jeremiah",
            "middle_name": "D.",
            "last_name": "Schuur",
            "name_suffix": "",
            "institution": "Brigham and Women’s Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts",
            "department": "None"
        },
        {
            "first_name": "Ali",
            "middle_name": "S.",
            "last_name": "Raja",
            "name_suffix": "",
            "institution": "Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts",
            "department": "None"
        }
    ],
    "date_submitted": "2015-11-06T23:37:33Z",
    "date_accepted": "2015-11-06T23:37:33Z",
    "date_published": "2016-01-20T08:00:00Z",
    "render_galley": null,
    "galleys": [
        {
            "label": "",
            "type": "pdf",
            "path": "https://journalpub.escholarship.org/westjem/article/9444/galley/5294/download/"
        }
    ]
}