Narrow networks refer to the issue that some insurance plans, especially those offered on ACA exchanges, contain too few options for covered physicians and services. Negotiating contracts with specific providers, and then steering beneficiaries to those providers, is one of the ways in which private insurance companies can reduce spending. Unfortunately, the tradeoffs are that this restricts choice, and access, in exchange for lower costs.

While much of the publicity around this issue has focused on adults, many have argued that narrow networks are an even bigger problem for children. There are fewer pediatric subspecialists to begin with, of course, and policies often fail to consider many childhood services "necessary" when benefits are determined.

recent study published in Pediatrics focused on both adult and pediatric physician networks in ACA marketplace plans. The authors aggregated data on physician networks and specialties in all 2014 silver plan offered in the ACA marketplaces in 2014. This alone is an impressive achievement. There were 1836 unique networks identified, and all physicians were standardized into 47 specialty groups for the purpose of this analysis. Narrow networks were defined as those that had no 10% of fewer of the available providers in an area available to beneficiaries. 

Narrow networks accounted for about two-thirds of pediatric specialty networks and about one-third of adult specialty networks. So right off the bat, kids are at a disadvantage. The proportion of narrow networks was highest for pediatric infectious diseases (77%) and nephrology (74%). Even neonatology was often narrow (69%). Among adult physicians, the proportion of narrow networks was highest for psychiatry (50%) and endocrinology (41%).

Almost 44% of pediatric networks had no specialists whatsoever available to beneficiaries. This was much higher than for adult beneficiaries (10%). Narrow networks were more common for pediatric care in every single specialty. They were also more common in rural areas. In areas with a low population, many specialties saw narrow networks approaching 100%, and pretty much all of them saw proportions above 80%.

It's bad enough when it's hard to find a specialist in-network. But in large proportions of these narrow networks, there were simply no specialists to be found. 

Again, some of this is likely due to the fact that there are too few pediatric specialists. They also tend to live and work in more urban and higher population areas. But they also tend to work in academic medical centers, which are often more expensive and are therefore excluded from narrow network plans. Some have even posed the idea that this is a benefit to insurers. By excluding specialty care from its core offerings, narrow plans are more likely to attract healthier beneficiaries and less likely to attract chronically ill children, leading to lower overall spending.

No matter what the reason, this is a real problem for pediatric care, especially the care of children with special health care needs. The majority of pediatric specialist networks lack specialists. This inevitably will lead to increased spending for children who need care, barriers to their obtaining it, and a reduction in the quality of the care they receive.

There's no easy answer here either. It's unlikely we're going to see a real increase in the number of pediatric specialists, or any reason that private incurance will seek to broaden its networks, especially as premiums are already too high for many Americans. As with many issues in health care, tradeoffs are always involved. We can increase access, but likely only by spending a lot more money.