Choose a high ranked hospital and lose your choice of plans

Most Regionally Ranked Hospitals Stay In-Network with Marketplace Plans, But Participation Declines

By Katherine Hempstead, PhD, MA
Robert Wood Johnson Foundation,  February 6, 2016

Looking at network participation by state, nearly all highly ranked regional hospitals were in-network with at least one marketplace plan in both 2015 and 2016.

Key Findings

*  Network participation decreases significantly, however, as more than half of hospitals reduce the number of networks in which they participate between 2015 and 2016.

*  The percent of hospitals in-network with only one marketplace plan increased from 7 percent in 2015 to 20 percent in 2016.

*  Network participation declined more in metro areas.

*  Customers loyal to a particular hospital can in most cases still find a marketplace plan that includes it, but choices are narrowed in 2016 relative to 2015; plans with these hospitals may be more expensive.


Many consumers returning to the marketplace in 2016 may find that their choices have changed in ways that limit their access to certain providers. Yet it is still the case that almost all of these highly rated hospitals are in-network with at least one marketplace plan.

Brief (15 pages, mostly tables):



By Don McCanne, M.D.

A well-functioning health care system should be designed such that patients who would specifically benefit from the services of a highly ranked regional hospital should be assured of access to that hospital. Instead, we have a health care system that ignores the primacy of the patient, and, in this instance, places the highest priority on the business relationship between the hospital and the insurer. As a result, far too many insured patients do not have coverage for highly ranked regional hospitals.

In many communities, only one insurer includes the highly ranked hospital. Thus the patient must make a choice between buying that plan, which is usually more expensive, or buying a competing plan which otherwise may be more suitable because of the many other variables between plans. This is getting worse since participation of highly ranked hospitals in multiple plan networks is declining.

A far better system would provide the patient with a choice of primary care services wherein guidance can be provided to ensure access to the most appropriate facilities and specialized services in the community. To inject into the consideration private insurer restrictions on what services and facilities can be used is the epitome of poor health planning. Yet this is the system that many politicians and policy wonks insist that we must protect, limiting changes to incremental tweaks.

What incremental change would fix this? Should we require all insurers to cover all health care professionals and all facilities? If so, then how would an insurer have any power to negotiate lower rates with a provider that must be included? Instead of negotiating individually with providers should we set standard rates, as Medicare does? If so, then why would we continue to use a wasteful, fragmented market of private plans and public programs when one public entity could administer the system much more efficiently?

These are not examples of incremental steps that preserve our multi-payer system. This is one step that replaces our dysfunctional financing system with a single payer national health program. Our financing system is beyond repair, and incremental additions won’t change that. It’s the fundamentally flawed financing infrastructure that needs to be replaced.