Restrictiveness of Medicare Advantage provider networks across physician specialties

OBJECTIVE

The objective was to measure specialty provider networks in Medicare Advantage (MA) and examine associations with market factors.

DATA SOURCES AND STUDY SETTING

We relied on traditional Medicare (TM) and MA prescription drug event data from 2011 to 2017 for all Medicare beneficiaries in the United States as well as data from the Area Health Resources File.

STUDY DESIGN

Relying on a recently developed and validated prediction model, we calculated the provider network restrictiveness of MA contracts for nine high-prescribing specialties. We characterized network restrictiveness through an observed-to-expected ratio, calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based on the prediction model. We assessed the relationship between network restrictiveness and market factors across specialties with multivariable linear regression.

DATA COLLECTION/EXTRACTION METHODS

Prescription drug event data for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017.

PRINCIPAL FINDINGS

Provider networks in MA varied in restrictiveness. OB-Gynecology was the most restrictive with enrollees seeing 34.5% (95% CI: 34.3%-34.7%) as many providers as they would absent network restrictions; cardiology was the least restrictive with enrollees seeing 58.6% (95% CI: 58.4%-58.8%) as many providers as they otherwise would. Factors associated with less restrictive networks included the county-level TM average hierarchical condition category score (0.06; 95% CI: 0.04-0.07), the county-level number of doctors per 1000 population (0.04; 95% CI: 0.02-0.05), the natural log of local median household income (0.03; 95% CI: 0.007-0.05), and the parent company's market share in the county (0.16; 95% CI: 0.13-0.18). Rurality was a major predictor of more restrictive networks (-0.28; 95% CI: -0.32 to -0.24).

CONCLUSIONS

Our findings suggest that rural beneficiaries may face disproportionately reduced access in these networks and that efforts to improve access should vary by specialty.

Rural-urban differences in out-of-network treatment initiation and engagement rates for substance use disorders

OBJECTIVE

To examine rural-urban disparities in substance use disorder treatment access and continuation.

DATA SOURCES AND STUDY SETTING

We analyzed a 2016-2018 U.S. national secondary dataset of commercial insurance claims.

STUDY DESIGN

This cross-sectional study examined individuals with a new episode of opioid, alcohol, or other drug use disorders. Treatment initiation and engagement rates, and rates of using out-of-network providers for these services, were compared between rural and urban patients.

DATA COLLECTION

We included individuals 18-64 years old with continuous employer-sponsored insurance.

PRINCIPAL FINDINGS

Patients in rural settings experienced lower treatment initiation rates for alcohol (36.6% vs. 38.0%, p < 0.001), opioid (41.2% vs. 44.2%, p < 0.001), and other drug (37.7% vs. 40.1%, p < 0.001) use disorders, relative to those in urban areas. Similarly, rural patients had lower treatment engagement rates for alcohol (15.1% vs. 17.3%, p < 0.001), opioid (21.0% vs. 22.6%, p < 0.001), and other drug (15.5% vs. 17.5%, p < 0.001) use disorders. Rural patients had higher out-of-network rates for treatment initiation for other drug use disorders (20.4% vs. 17.2%, p < 0.001), and for treatment engagement for alcohol (27.6% vs. 25.2%, p = 0.006) and other drug (36.1% vs. 31.1%, p < 0.001) use disorders.

CONCLUSIONS

These findings indicate that individuals with substance use disorders in rural areas have lower rates of initial and ongoing treatment, and are more likely to seek care out-of-network.

Rural and frontier access to mental health prescribers and nonprescribers: A geospatial analysis in Oregon Medicaid

OBJECTIVE

Medicaid enrollees in rural and frontier areas face inadequate access to mental health services, but the extent to which access varies for different provider types is unknown. We assessed access to Medicaid-participating prescribing and nonprescribing mental health clinicians, focusing on Oregon, which has a substantial rural population.

METHODS

Using 2018 Medicaid claims data, we identified enrollees aged 18-64 with psychiatric diagnoses and specialty mental health providers who billed Medicaid at least once during the study period. We measured both 30- and 60-minute drive time to a mental health provider, and a spatial access score derived from the enhanced 2-step floating catchment area (E2SFCA) approach at the level of Zip Code Tabulation Areas (ZCTAs). Results were stratified for prescribers and nonprescribers, across urban, rural, and frontier areas.

RESULTS

Overall, a majority of ZCTAs (68.6%) had at least 1 mental health prescriber and nonprescriber within a 30-minute drive. E2SFCA measures demonstrated that while frontier ZCTAs had the lowest access to prescribers (84.3% in the lowest quintile of access) compared to other regions, some frontier ZCTAs had relatively high access to nonprescribers (34.3% in the third and fourth quartiles of access).

CONCLUSIONS

Some frontier areas with relatively poor access to Medicaid-participating mental health prescribers demonstrated relatively high access to nonprescribers, suggesting reliance on nonprescribing clinicians for mental health care delivery amid rural workforce constraints. Efforts to monitor network adequacy should consider differential access to different provider types, and incorporate methods, such as E2SFCA, to better account for service demand and supply.

State Efforts to Regulate Provider Networks and Directories: Lessons for the Future

Managed care arrangements are the dominant form of insurance coverage in the United States today. These arrangements rely on a network of contracted providers to deliver services to their enrollees. After the managed care backlash, governments moved to ensure consumer access by issuing a number of requirements for carriers related to the composition and size of their networks and how this information is shared with consumers. The authors provide a comprehensive review of these state-based efforts to regulate provider network adequacy and provider directory accuracy for commercial insurance markets. In addition to common measures of adequacy, they also include requirements specifically targeted to underserved populations. Their assessment comes on the heels of recent empirical work that has raised significant questions about whether these efforts are effective, particularly considering the limited nature of enforcement. They also provide a brief overview and assessment of recent federal government efforts that replicate these state regulations with a focus on lessons learned from state regulations that may help improve their federal counterparts. Furthermore, they outline a future research agenda focused on a more comprehensive evaluation of efforts to ensure consumer access.

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.

State Policy and the Breadth of Buprenorphine-Prescriber Networks in Medicaid Managed Care

Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares network breadth across provider specialties and market segments within the same state, we investigated the association between three Medicaid policies and the breadth of MMC networks for buprenorphine prescribers: Medicaid expansion, substance use disorder (SUD) network adequacy criteria, and SUD carveouts. We found that both Medicaid expansion and SUD network adequacy criteria were associated with substantially increased breadth in buprenorphine-prescriber networks in MMC. In both cases, we found that the associations were largely driven by increases in the network breadth of primary care physician prescribers. Our findings suggest that Medicaid expansion and SUD network adequacy criteria may be effective strategies at states' disposal to improve access to buprenorphine.

An observational study of health care provider collaboration networks and heterogenous hospital cost efficiency and quality outcomes

Provider network structure has been linked to hospital cost, utilization, and to a lesser degree quality, outcomes; however, it remains unknown whether these relationships are heterogeneous across different acute care hospital characteristics and US states. The objective of this study is to evaluate whether there are heterogeneous relationships between hospital provider network structure and hospital outcomes (cost efficiency and quality); and to assess the sources of measured heterogeneous effects. We use recent causal random forest techniques to estimate (hospital specific) heterogeneous treatment effects between hospitals' provider network structures and their performance (across cost efficiency and quality). Using Medicare cost report, hospital quality and provider patient sharing data, we study a population of 3061 acute care hospitals in 2016. Our results show that provider networks are significantly associated with costs efficiency (P < .001 for 7/8 network measures), patient rating of their care (P < .1 in 5/8 network measures), heart failure readmissions (P < .01 for 3/8 network measures), and mortality rates (P < .02 in 5/8 cases). We find that fragmented provider structures are associated with higher costs efficiency and patient satisfaction, but also with higher heart failure readmission and mortality rates. These effects are further found to vary systematically with hospital characteristics such as capacity, case mix, ownership, and teaching status. This study used an observational design. In summary, we find that hospital treatment responses to different network structures vary systematically with hospital characteristics..

Variation in network adequacy standards in Medicaid managed care

OBJECTIVES

To describe the types and breadth of network adequacy standards used by state Medicaid programs with managed care arrangements.

STUDY DESIGN

Document analysis of Medicaid provider network reports, managed care plan contracts, access monitoring review plans, Medicaid services manuals, quality strategy reviews, and state statutes and regulations.

METHODS

We analyzed 52 primary documents from 2017 to 2020, representing 39 of the 40 states (including the District of Columbia) with Medicaid managed care. We conducted descriptive analyses of network adequacy standards, variation in standards by type of provider, timely access standards, nonquantitative network access standards, and monitoring or enforcement plans.

RESULTS

A majority (89.7%) of states applied time and distance standards for network adequacy, stratified by population size or geography. Time and distance standards ranged from 15 to 90 minutes for a primary care provider (mean, 44.7 minutes in rural areas and 28.9 minutes in urban areas) to 30 to 135 minutes for a cardiologist (mean, 72.1 minutes in rural areas and 40.4 minutes in urban areas). Most states also used timely access or appointment availability standards. Relatively few states applied other quantitative standards, such as provider to enrollee ratios, or provided detailed enforcement plans in cases of poor compliance.

CONCLUSIONS

Most states use travel time and distance to account for local contexts and geographies, but there is considerable variation across Medicaid programs. Several states do not publicize their network adequacy regulations, or they rely on qualitative standards despite federal requirements. For network adequacy to be meaningful, states must balance the tension between flexibility and accountability and ensure that regulations are monitored and enforced accordingly.

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.

Inadequate in the Best of Times: Reevaluating Provider Networks in Light of the Coronavirus Pandemic

The coronavirus has affected billions of people worldwide. As of early June, estimates of infections exceeded six million individuals, about double the number from early May. The United States has experienced more cases than Spain, Italy, France, the United Kingdom, Germany, Turkey, Canada, Japan, and Russia combined. To make things worse, the structure of the U.S. health‐care system may significantly impede access to needed medical services while exposing patients to financial liabilities. One particularly concerning feature may be the limitations on access imposed by provider networks. This article briefly reviews what we know about the narrowing of provider networks, and how findings from a series of recent articles illustrating the often‐severe restrictions imposed by these networks may be particularly detrimental in the middle of a global health emergency. I also highlight how the actions taken by policymakers to temporarily mitigate these problems have fallen short and what potential long‐term solutions might look like.

Patient Sharing and Health Care Utilization Among Young Adults With Congenital Heart Disease

Transitions from pediatric to adult care by young adults with chronic conditions are fraught with challenges. Poor transitions lead to discontinuities of care that are avoidable with better communication between providers. We tested whether exposure to providers with sustained patient-sharing relationships resulted in fewer emergent admissions of young adults with congenital heart disease (CHD). Care transitions are particularly important for young adults with CHD. Though it is not possible to avoid planned admissions for scheduled procedures, emergency admissions are avoidable with proper care. We tested whether several different patient-sharing relationship measures influenced emergent admissions and found that compared with less severe CHD patients, those with severe CHD experienced a 4 to 10 percentage point decline in emergent admissions given a 5 percentage point increase in practice-level patient-sharing relationships. These results are consistent with our hypothesis that patient sharing improves communication and continuity of care across providers, especially for severe CHD patients.

Association of Provider Performance with Changes in Insurance Networks

BACKGROUND

Medicaid managed care plans change provider networks frequently, yet there is no evidence about the performance of exiting providers relative to those that remain.

OBJECTIVES

To investigate the association between provider cost and quality and network exit.

DESIGN

Observational study with provider network directory data linked to administrative claims from managed care plans in Tennessee's Medicaid program during the period 2010-2016.

PARTICIPANTS

1,966,022 recipients assigned to 9593 unique providers.

MAIN MEASURES

Exposures were risk-adjusted total costs of care and nine measures from the Healthcare Effectiveness Data and Information Set (HEDIS) were used to construct a composite annual indicators of provider performance on quality. Outcome was provider exit from a Medicaid managed care plan. Differences in quality and cost between providers that exited and remained in managed care networks were estimated using a propensity score model to match exiting to nonexiting providers.

KEY RESULTS

Over our study period, we found that 21% of participating providers exited at least one of the Medicaid managed care plans in Tennessee. As compared with providers that remained in networks, those that exited performed 3.8 percentage points [95% CI, 2.3, 5.3] worse on quality as measured by a composite of the nine HEDIS quality metrics. However, 22% of exiting providers performed above average in quality and cost and only 29% of exiting providers had lower than average quality scores and higher than average costs. Overall, exiting providers had lower aggregate costs in terms of the annual unadjusted cost of care per-member-month - $21.57 [95% CI, - $41.02, - $2.13], though difference in annual risk-adjusted cost per-member-month was nonsignificant.

CONCLUSIONS

Providers exiting Medicaid managed care plans appear to have lower quality scores in the year prior to their exit than the providers who remain in network. Our study did not show that managed care plans disproportionately drop high-cost providers.

A Knotty Problem: Consumer Access and the Regulation of Provider Networks

In order to increase access to medical services, expanding coverage has long been the preferred solution of policy makers and advocates alike. The calculus appeared straightforward: provide individuals with insurance, and they will be able to see a provider when needed. However, this line of thinking overlooks a crucial intermediary step: provider networks. As provider networks offered by health insurers link available medical services to insurance coverage, their breadth mediates access to health care. Yet the regulation of provider networks is technically, logistically, and normatively complex. What does network regulation currently look like and what should it look like in the future? We take inventory of the ways private and public entities regulate provider networks. Variation across insurance programs and products is truly remarkable, not grounded in empirical justification, and at times inherently absurd. We argue that regulators should be pragmatic and focus on plausible policy levers. These include assuring network accuracy, transparency for consumers, and consumer protections from grievous inadequacies. Ultimately, government regulation provides an important foundation for ensuring minimum levels of access and providing consumers with meaningful information. Yet, information is only truly empowering if consumers can exercise at least some choice in balancing costs, access, and quality.

Quality Regulation? Access to High-Quality Specialists for Medicare Advantage Beneficiaries in California

Medicare Advantage enrollment has seen tremendous growth over the past decade. However, we know comparatively little about the experience of beneficiaries in the program. Our knowledge of Medicare Advantage provider networks is particularly limited. This article is one of the first major assessments of the issue. It seeks to answer 3 important questions. First, are Medicare Advantage plan networks made up of higher quality providers? Second, how significant are the network restrictions imposed by Medicare Advantage plans with regard to access to higher quality providers? And finally, how much provider choice are Medicare Advantage beneficiaries left with? To assess these questions, I utilize geospatial data and individual provider quality measures for cardiologists, endocrinologists, and obstetricians and gynecologists from California. I find that Medicare Advantage beneficiaries generally do well in large metropolitan areas compared to traditional Medicare. However, there are concerns for those in micropolitan and rural areas, and even those in standard metropolitan areas, at times. Crucially, the connection between provider quality and networks can only be fully understood when connected to assessments of provider access. These findings also raise questions about how we think about provider networks and the adequacy of current approaches to network regulation.