What are consumers willing to pay for a broad network health plan?: Evidence from covered California

Determinants of referral network size for screening colonoscopies in the Veterans Health Administration after the implementation of the MISSION Act

OBJECTIVE

To measure key characteristics of the Veterans Health Administration's (VHA) Community Care (CC) referral network for screening colonoscopy and identify market and institutional factors associated with network size.

DATA SOURCES

VHA electronic health records, CC claim data, and National Plan and Provider Enumeration System.

STUDY DESIGN

In this retrospective cross-sectional study, we measure the size of the VHA's CC referral networks over time and by VHA parent facility (n = 137). We used a multivariable linear regression to identify factors associated with network size at the market-year level. Network size was measured as the number of physicians who performed at least one VHA-purchased screening colonoscopy per 1000 enrollees at baseline.

DATA EXTRACTION

Data were extracted for all Veterans (n = 102,119) who underwent a screening colonoscopy purchased by the VHA from a non-VHA physician from 2018 to 2021.

PRINCIPAL FINDINGS

From 2018 to 2021, median network volume of screening colonoscopies per 1000 enrollees grew from 1.6 (IQR: 0.6, 4.6) to 3.6 (IQR: 1.6, 6.6). The median network size grew from 0.63 (IQR: 0.30, 1.26) to 0.92 (IQR: 0.57, 1.63). Finally, the median procedures per physician increased from 2.5 (IQR: 1.6, 4.2) to 3.2 (IQR: 2.4, 4.7). After adjusting for baseline market characteristics, volume of screening colonoscopies was positively related to network size (β = 0.15, 95% CI: [0.10, 0.20]), negatively related to procedures per physician (β = -0.12, 95% CI: [-0.18, -0.05]), and positively associated with the percent of rural enrollees (β = 0.01, 95% CI: [0.00, 0.01]).

CONCLUSIONS

VHA facilities with a higher volume of VHA-purchased screening colonoscopies and more rural enrollees had more non-VHA physicians providing care. Geographic variation in referral networks may also explain differences in the effects of the MISSION Act on access to care and patient outcomes.

Physician patient sharing relationships within insurance plan networks

OBJECTIVE

To quantify shared patient relationships between primary care physicians (PCPs) and cardiologists and oncologists and the degree to which those relationships were captured within insurance networks.

DATA SOURCES

Secondary analysis of Vericred data on physician networks, CareSet data on physicians' shared Medicare patients, and insurance plan attributes from Health Insurance Compare. Data validation exercises used data from Physician Compare and IQVIA.

STUDY DESIGN

Cross-sectional study of the PCP-to-specialist in-network shared patient percentage (primary outcome). We also categorized networks by insurance market segment (Medicare Advantage [MA], Medicaid managed care, small-group or individually purchased), insurance plan type, and network breadth.

DATA EXTRACTION

We analyzed data on 219,982 PCPs, 29,400 cardiologists, and 22,745 oncologists who, in 2021, accepted MA (n = 941 networks), Medicaid managed care (n = 293), and individually-purchased (n = 332) and small-group (n = 501) plans.

PRINCIPAL FINDINGS

Networks captured, on average, 64.6% of PCP-cardiology shared patient ties, and 61.8% of PCP-oncologist ties. Less than half of in-network ties (44.5% and 38.9%, respectively) were among physicians with a common organizational affiliation. After adjustment for network breadth, we found no evidence of differences in the shared patient percentage across insurance market segments or networks of different types (p-value >0.05 for all comparisons). An exception was among national versus local and regional networks, where we found that national plans captured fewer shared patient ties, particularly among the narrowest networks (58.4% for national networksvs. 64.7% for local and regional networks for PCP-cardiology).

CONCLUSIONS

Given recent trends toward narrower networks, our findings underscore the importance of incorporating additional and nuanced measures of network composition to aid plan selection (for patients) and to guide regulatory oversight.

Dynamic Price Competition for Low-Cost Silver Plans on Healthcare.gov 2014-2021

More than 16 million people receive health care coverage through the Affordable Care Act's (ACA) individual health insurance marketplaces. Many enrollees receive premium subsidies that are tied to the premium of the second least expensive silver plan available. This study investigates the consistency of the least expensive silver plan offered on Healthcare.gov from 2014 to 2021 and finds that on average, from one year to the next, the same insurer offered the least expensive silver plan in 63.1% of counties representing 54.7% of the population. However, even when the same insurer offers the least expensive plan, almost half the time, they introduce a new, less expensive plan in the next policy year. Consequently, ACA enrollees who previously purchased the least expensive silver plan may face incremental premium costs unless they spend time and effort to carefully reevaluate their choices each year. We estimate the potential premium cost of inattention and show how it varies over time and across states.

Potemkin Protections: Assessing Provider Directory Accuracy and Timely Access for Four Specialties in California

CONTEXT

The accuracy of provider directories and whether consumers can schedule timely appointments are crucial determinants of health access and outcomes.

METHODS

We evaluated accuracy and timely access data obtained from the California Department of Managed Health Care, consisting of responses to large, random, representative surveys of primary care providers, cardiologists, endocrinologists, and gastroenterologists for 2018 and 2019 for all managed care plans in California.

FINDINGS

Surveys were able to verify provider directory entries for the four specialties for 59% to 76% of listings or 78% to 88% of providers reached. We found that consumers were able to schedule urgent care appointments for 28% to 54% of listings or 44% to 72% of accurately listed providers. For general care appointments, the percentages ranged from 35% to 64% of listed providers or 51% to 87% of accurately listed providers. Differences across markets related to accuracy were generally small. Medi-Cal plans outperformed other markets with regard to timely access. Primary care consistently outperformed all other specialties. Timely access rates were higher for general appointments than for urgent care appointments.

CONCLUSIONS

Our finding raise questions about the regulatory regime as well as consumer access and health outcomes.

Association of Expanded Health Care Networks With Utilization Among Veterans Affairs Enrollees

IMPORTANCE

Health insurers alter the size of their networks, offering lower premiums in exchange for a more limited set of care choices. However, little is known about the association of network size with health care utilization and outcomes, particularly outside of the context of private insurance plans.

OBJECTIVE

To evaluate changes in health care utilization after an expansion in the Veterans Affairs Health Care System (VA) health care network.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included individuals enrolled in the VA from 2015 to 2018. Considering that the health care network expansion only affected a portion of enrollees, only those who lived between 20 and 60 miles from a VA facility were included. Data analysis was conducted from September 2020 to February 2021.

EXPOSURES

Individuals who lived 40 or more miles away from a VA facility were automatically eligible for an expanded health care network through non-VA practitioners (VA community care); those living less than 40 miles away from a VA facility were not automatically eligible.

MAIN OUTCOMES AND MEASURES

A regression discontinuity analysis of individuals who became eligible for an expanded network based on geographic residence was performed. Inpatient and outpatient utilization rates per VA enrollee during the study period, with utilization differentiated by whether services were provided by a VA or non-VA practitioner, were calculated.

RESULTS

The study included more than 2.7 million unique individuals whose characteristics largely reflected the demographic characteristics of the VA system (mean [SD] age, 62 [17] years; 2 589 252 [90%] men; 282 168 [10%] Black; 2 203 352 [77%] White). Patient characteristics (age, race, and comorbidities) did not vary significantly by eligibility status. Outpatient utilization was 3.2% higher (95% CI, 1.0% to 5.3%) among those with access to an expanded network. Increased utilization was most pronounced among those with a higher VA disability rating (3.1%; 95% CI, 0.5% to 5.7%) and among younger individuals without service-connected disabilities (7.0%, 95% CI, 1.7% to 12.3%). There was no evidence of changes to inpatient utilization (1.2%; 95% CI. -2.5% to 4.9%; P = .37) for those with access to the expanded network.

CONCLUSIONS AND RELEVANCE

In this study, expanded network access was associated with increased total health care utilization among affected enrollees in the VA. Understanding how network size affects utilization is immediately informative for the VA, but it can also help to guide policies for insurance markets.

Why do narrow network plans cost less?

Narrow network health insurance plans have been shown to have lower premiums and lower costs to insurers. This paper decomposes and quantifies the magnitudes for various mechanisms by which networks may reduce premiums and costs. Using data on the Colorado non-group market, we examine three mechanisms through which a narrow network might achieve lower costs: (1) enroll a population with lower utilization, (2) negotiate lower prices, or (3) steer patients away from high-cost hospitals. We find that all three mechanisms play a role. Narrow plans are partly able to achieve lower costs because they both steer patients to lower cost hospitals and, for a given hospital, negotiate lower prices than broad plans. The lower negotiated prices mechanism accounts for 15% of the cost savings to narrow network plans, and the steering away from higher cost hospitals accounts for about 18%. Both of these mechanisms can be ways to efficiently lower costs. The remaining 67% of the cost savings is due to lower utilization of narrow network plan enrollees. These findings are important for policymakers considering how to balance containing healthcare costs with concern for the appropriate regulation of narrow network plans.

Going the Extra Mile? How Provider Network Design Increases Consumer Travel Distance, Particularly for Rural Consumers

CONTEXT

The practical accessibility to medical care facilitated by health insurance plans depends not just on the number of providers within their networks but also on distances consumers must travel to reach the providers. Long travel distances inconvenience almost all consumers and may substantially reduce choice and access to providers for some.

METHODS

The authors assess mean and median travel distances to cardiac surgeons and pediatricians for participants in (1) plans offered through Covered California, (2) comparable commercial plans, and (3) unrestricted open-network plans. The authors repeat the analysis for higher-quality providers.

FINDINGS

The authors find that in all areas, but especially in rural areas, Covered California plan subscribers must travel longer than subscribers in the comparable commercial plan; subscribers to either plan must travel substantially longer than consumers in open networks. Analysis of access to higher-quality providers show somewhat larger travel distances. Differences between ACA and commercial plans are generally substantively small.

CONCLUSIONS

While network design adds travel distance for all consumers, this may be particularly challenging for transportation-disadvantaged populations. As distance is relevant to both health outcomes and the cost of obtaining care, this analysis provides the basis for more appropriate measures of network adequacy than those currently in use.

Comparison of Office-Based Physician Participation in Medicaid Managed Care and Health Insurance Exchange Plans in the Same US Geographic Markets

IMPORTANCE

Several recent policy proposals have sought to expand the role of Medicaid in providing health insurance for low-income Americans, but there is little recent information on how physician participation in Medicaid compares with alternative forms of coverage for low-income Americans.

OBJECTIVE

To compare the number of office-based physicians included in Medicaid managed care and health insurance exchange plans that operate in the same geographic markets.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used administrative data from physician network directories and survey data from office-based physicians for Kansas, Nebraska, New York, Tennessee, and Washington. The number of participants totaled 67 057 office-based physicians in the 5 sample states. Data were collected and analyzed from May 2018 to June 2019.

EXPOSURES

Physician participation in a Medicaid managed care or health insurance exchange plan network.

MAIN OUTCOMES AND MEASURES

The percentage of office-based physicians in a county who indicated during a phone survey that they participated in Medicaid; the percentage of office-based physicians in a county who participated in each Medicaid managed care and health insurance exchange plan network; and the percentage of office-based physicians in a county who participated in at least 1 Medicaid managed care plan or, separately, at least 1 health insurance exchange plan.

RESULTS

Of the 67 057 office-based physicians in our sample, 49 983 reported in a telephone survey that they accepted Medicaid. This survey-based measure undercounted the percentage of physicians participating in Medicaid by 5.2% (95% CI, 2.3%-8.1%; P < .001) relative to a measure based on physician network directories. Medicaid managed care physician networks covered a median (interquartile range) of 63.4% (48.0%-81.3%) of office-based physicians compared with health insurance exchange physician networks, which covered 51.0% (31.0%-70.5%). In adjusted analyses, Medicaid managed care plans covered 6.2% (95% CI, 3.2%-9.3%, P < .001) more office-based physicians than health insurance exchange plans operating in the same counties. In the states where the same insurers participated in both markets (New York, Tennessee, Washington), the Medicaid managed care physician networks were 6.5% (95% CI, 3.2%-9.8%, P < .001) larger than the health insurance exchange networks offered by the same insurer.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of physician network data, Medicaid managed care physician networks included more office-based physicians than the physician networks of health insurance exchange plans operating in the same geographic markets. This suggests that Medicaid remains a viable option for expanding coverage in the United States.

Individual market health plan affordability after cost-sharing reduction subsidy cuts

OBJECTIVE

To investigate how changes in insurer participation and composition as well as state policies affect health plan affordability for individual market enrollees.

DATA SOURCES

2014-2019 Qualified Health Plan Landscape Files augmented with supplementary insurer-level information.

STUDY DESIGN

We measured plan affordability for subsidized enrollees using premium spreads, the difference between the benchmark plan and the lowest cost plan, and premium levels for unsubsidized enrollees. We estimated how premium spreads and levels varied with insurer participation, insurer composition, and state policies using log-linear models for 15 222 county-years.

PRINCIPAL FINDINGS

Increased insurer participation reduces premium levels, which is beneficial for unsubsidized enrollees. However, it also reduces premium spreads, leading to lower plan affordability for subsidized enrollees. States responding to cost-sharing reduction subsidy payment cuts by increasing only silver plans' premiums increase premium spreads, particularly when premium increases are restricted to on-Marketplace silver plans. The latter approach also protects unsubsidized, off-Marketplace enrollees from experiencing premium shocks.

CONCLUSIONS

Insurer participation and insurer composition affect subsidized and unsubsidized enrollees' health plan affordability in different ways. Decisions by state regulators regarding health plan pricing can significantly affect health plan affordability for each enrollee segment.