Medical expenditures for hypertensive disorders during pregnancy that resulted in a live birth among privately insured women.

OBJECTIVE: To estimate the excess maternal health services utilization and direct maternal medical expenditures associated with hypertensive disorders during pregnancy and one year postpartum among women with private insurance in the United States. STUDY DESIGN: We used 2008-2014 IBM MarketScan® Commercial Databases to identify women aged 15-44 who had a pregnancy resulting in live birth during 1/1/09-12/31/13 and were continuously enrolled with non-capitated or partially capitated coverage from 12 months before pregnancy through 12 months after delivery. Hypertensive disorders identified by diagnosis codes were categorized into three mutually exclusive types: preeclampsia and eclampsia, chronic hypertension, and gestational hypertension. Multivariate negative binomial and generalized linear models were used to estimate service utilization and expenditures, respectively. MAIN OUTCOME MEASURES: Per person excess health services utilization and medical expenditures during pregnancy and one year postpartum associated with hypertensive disorders (in 2014 US dollars). RESULTS: Women with preeclampsia and eclampsia, chronic hypertension, and gestational hypertension had $9,389, $6,041, and $2,237 higher mean medical expenditures compared to women without hypertensive disorders ($20,252), respectively (ps < 0.001). One-third (36%) of excess expenditure associated with hypertensive disorders during pregnancy was attributable to outpatient services. CONCLUSIONS: Hypertensive disorders during pregnancy were associated with significantly higher health services utilization and medical expenditures among privately insured women with hypertensive disorders. Medical expenditures varied by types of hypertensive disorders. Stakeholders can use this information to assess the potential economic benefits of interventions that prevent these conditions or their complications.

Association of insurance type with time course of care in head and neck cancer management.

OBJECTIVES/HYPOTHESIS: To determine differences in time course of care based on major insurance types for patients with head and neck squamous cell carcinoma (HNSCC). STUDY DESIGN: Retrospective cohort study. METHODS: Retrospective study of Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Medicare patients with biopsy-proven diagnosis of HNSCC referred to an academic tertiary center for tumor resection and adjuvant therapy. In addition to patient demographic information and tumor characteristics, duration of chief complaint and the following time points were collected: biopsy by referring physician, first specialty surgeon clinic appointment, surgery, and adjuvant radiation start and stop dates. RESULTS: There was a statistically significant increase in time interval for HMO (n = 32) patients from chief complaint to biopsy (P = .003), biopsy to first specialty surgeon clinic appointment (P < .001), and surgery to start of adjuvant radiation (P < .001) compared to that of Medicare (n = 31) and PPO (n = 41) patients. Adjuvant radiation was initiated ≤6 weeks after surgery in 22% of HMO (mean duration of 59 ± 17 days), 48% of Medicare (44 ± 13 days), and 61% of PPO (41 ± 12 days) patients. CONCLUSIONS: Compared to PPO and Medicare patients, HMO patients begin adjuvant radiation after surgery later and experience treatment delays in transitions of care between provider types and with referrals to specialists. Delaying radiation after 6 weeks of surgery is a known prognostic factor, with insurance type playing a possible role. Further investigation is required to identify insurance type as an independent risk factor of delayed access to care for HNSCC. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E587-E592, 2020.

Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value.

BACKGROUND: Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored. METHODS: Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices. RESULTS: Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact. CONCLUSIONS: Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.

Provider Acceptance And Beneficiary Access Under TRICARE's PPO Health Plan.

TRICARE provides health benefits to more than nine million beneficiaries (active duty and retired military members and their families). Complaints about access to civilian providers in TRICARE's preferred provider organization (PPO) plan led Congress to mandate surveys of beneficiaries and providers to identify the extent of the problem and the reasons for it. The beneficiary survey asked about beneficiaries' perceived access to care, and the provider survey asked about providers' acceptance of TRICARE patients. TRICARE's civilian PPO plans are required to maintain provider networks wherever TRICARE's health maintenance organization option (known as Prime) is offered. For the years 2012-15, we describe beneficiary access and utilization and provider participation in TRICARE's PPO plans in Prime and non-Prime markets. We also compare individual market rankings for access and acceptance. In both market types, most providers reported participating in TRICARE's PPO network, and most PPO users reported using network providers. In areas where Prime is not offered, PPO users reported slightly better access, and providers were more likely to accept new PPO patients. Areas with low access and acceptance, or where multiple access measures indicate problems, may be fruitful for in-depth investigation.

Primary Care Physician Networks In Medicare Advantage.

Medicare Advantage (MA) plans often establish restrictive networks of covered providers. Some policy makers have raised concerns that networks may have become excessively restrictive over time, potentially interfering with patients' access to providers. Because of data limitations, little is known about the breadth of MA networks. Taking a novel approach, we used Medicare Part D claims data for 2011-15 to examine how primary care physician networks have changed over time and what demographic and plan characteristics are associated with varying levels of network breadth. Our findings indicate that the share of MA plans with broad networks increased from 80.1 percent in 2011 to 82.5 percent in 2015. Enrollment in broad-network plans grew from 54.1 percent to 64.9 percent over the same period. In an adjusted analysis, we detected no significant time trend. In addition, narrow networks were associated with urbanicity, higher income, higher physician density, and more competition among plans. Health maintenance organizations had narrower networks than did point-of-service plans, whose networks were narrower than those of preferred provider organizations.

Patient responsiveness to a differential deductible: empirical results from The Netherlands.

Health insurers may use financial incentives to encourage their enrollees to choose preferred providers for medical treatment. Empirical evidence whether differences in cost-sharing rates across providers affects patient choice behavior is, especially from Europe, limited. This paper examines the effect of a differential deductible to steer patient provider choice in a Dutch regional market for varicose veins treatment. Using individual patients' choice data and information about their out-of-pocket payments covering the year of the experiment and 1 year before, we estimate a conditional logit model that explicitly controls for pre-existing patient preferences. Our results suggest that in this natural experiment designating preferred providers and waiving the deductible for enrollees using these providers significantly influenced patient choice. The average cross-price elasticity of demand is found to be 0.02, indicating that patient responsiveness to the cost-sharing differential itself was low. Unlike fixed cost-sharing differences, the deductible exemption was conditional on the patient's other medical expenses occurring in the policy year. The differential deductible did, therefore, not result in a financial benefit for patients with annual costs exceeding their total deductible.

Gatekeeping and patterns of outpatient care post healthcare reform.

OBJECTIVES: As US healthcare spending increases, insurers are focusing attention on decreasing potentially avoidable specialist care. Little recent research has assessed whether the design of modern health maintenance organization (HMO) insurance is associated with lower utilization of outpatient specialty care versus less restrictive preferred provider organization (PPO) plans. STUDY DESIGN: Observational study of Massachusetts residents aged 21 to 64 years with any HMO or PPO insurance coverage from 2010 to 2013. METHODS: We examined rates and patterns of primary care visits, new specialist visits, and specialist spending among HMO versus PPO enrollees. We estimated multivariable regression models for each outcome, adjusting for patient and insurance characteristics. RESULTS: From 2010 to 2013, 546,397 and 295,427 individuals had continuous HMO or PPO coverage, respectively. HMO patients had fewer annual new specialist visits per member versus PPO patients (unadjusted, 0.37 vs 0.43), a difference after adjustment of 0.05 annual visits, or a 12% relative decrease among HMO members (P <.001). These visits were more likely to be with a specialist in the same health system as the patient's primary care physician (44.9% vs 40.7%; adjusted difference, 2.8 percentage points; P <.001). Mean annual spending on new specialist visits and subsequent follow-up per member was lower in HMO versus PPO patients (unadjusted, $104.10 vs $128.10), translating to 12% lower annual spending (adjusted difference, -$16.26; P <.001). CONCLUSIONS: Having HMO insurance was associated with lower rates of new specialist visits and lower spending on specialist visits, and these visits were less likely to occur across multiple health systems. The impact of this change on overall spending and clinical outcomes remains unknown.

Do Medicare Advantage Plans Respond to Payment Changes? A Look at the Data from 2009 to 2014.

Issue: Medicare Advantage (MA) enrollment has grown significantly since 2009, despite legislation that reduced what Medicare pays these plans to provide care to enrollees. MA payments, on average, now approach parity with costs in traditional Medicare. Goal: Examine changes in per enrollee costs between 2009 and 2014 to better understand how MA plans have continued to thrive even as payments decreased. Methods: Analysis of Medicare data on MA plan bids, net of rebates. Findings: While spending per beneficiary in traditional Medicare rose 5.0 percent between 2009 and 2014, MA payment benchmarks rose 1.5 percent and payment to plans decreased by 0.7 percent. Plans' expected per enrollee costs grew 2.6 percent. Plans where payment rates decreased generally had slower growth in their expected costs. HMOs, which saw their payments decline the most, had the slowest expected cost growth. Conclusions: In general, MA plans responded to lower payment by containing costs. By preserving most of the margin between Medicare payments and their bids in the form of rebates, they could continue to offer additional benefits to attract enrollees. The magnitude of this response varied by geographic area and plan type. Despite this slower growth in expected per enrollee costs, greater efficiencies by MA plans may still be achievable.

Behavioral Health Coverage Under the Affordable Care Act: What Can We Learn From Marketplace Products?

OBJECTIVE: The 2008 federal parity law and the 2010 Affordable Care Act (ACA) sought to expand access to behavioral health services. There was concern that health plans might discourage enrollment by individuals with behavioral health conditions who tend to be higher cost. This study compared behavioral health benefits available in the group insurance market (nonmarketplace) to those sold through the ACA marketplaces to check for evidence of less generous behavioral health coverage in marketplace plans. METHODS: Data were from a 2014 nationally representative survey of commercial health plans regarding behavioral health services (80% response rate). The sample included the most common silver marketplace product and, as a comparison, the most common nonmarketplace product of the same type (for example, health maintenance organization or preferred provider organization) from each health plan (N=106 marketplace and nonmarketplace pairs, or 212 products). RESULTS: Marketplace and nonmarketplace products were similar in terms of coverage, prior authorization, and continuing review requirements. Marketplace products were more likely to employ narrow and tiered behavioral health provider networks. Narrow and tiered networks were more common in state than in federal marketplaces. CONCLUSIONS: Provider network design is a tool that health plans may use to control cost and possibly discourage enrollment by high-cost users, including those with behavioral health conditions. The ACA was successful in ensuring robust behavioral health coverage in marketplace plans. As the marketplaces evolve or are replaced, these data provide an important baseline to which future systems can be compared.

Comparing The Effects Of Reference Pricing And Centers-Of-Excellence Approaches To Value-Based Benefit Design.

Various health insurance benefit designs based on value-based purchasing have been promoted to steer patients to high-value providers, but little is known about the designs' relative effectiveness and underlying mechanisms. We compared the impact of two designs implemented by the California Public Employees' Retirement System on inpatient hospital total hip or knee replacement: a reference-based pricing design for preferred provider organizations (PPOs) and a centers-of-excellence design for health maintenance organizations (HMOs). Payment and utilization data for the procedures in the period 2008-13 were evaluated using pre-post and quasi-experimental designs at the system and health plan levels, adjusting for demographic characteristics, case-mix, and other confounders. We found that both designs prompted higher use of designated low-price high-quality facilities and reduced average replacement expenses per member at the plan and system levels. However, the designs used different routes: The reference-based pricing design reduced average replacement payments per case in PPOs by 26.7 percent in the first year, compared to HMOs, but did not lower PPO members' utilization rates. In contrast, the centers-of-excellence design lowered HMO members' utilization rates by 29.2 percent in the first year, compared to PPOs, but did not reduce HMO average replacement payments per case. The reference-based pricing design appears more suitable for reducing price variation, and the centers-of-excellence design for addressing variation in use.

Narrow Networks on the Individual Marketplace in 2017.

This Issue Brief describes the breadth of physician networks on the ACA marketplaces in 2017. We find that the overall rate of narrow networks is 21%, which is a decline since 2014 (31%) and 2016 (25%). Narrow networks are concentrated in plans sold on state-based marketplaces, at 42%, compared to 10% of plans on federally-facilitated marketplaces. Issuers that have traditionally offered Medicaid coverage have the highest prevalence of narrow network plans at 36%, with regional/local plans and provider-based plans close behind at 27% and 30%. We also find large differences in narrow networks by state and by plan type.

Variation in Screening Mammography Rates Among Medicare Advantage Plans.

PURPOSE: Prior studies have shown higher screening mammography rates for beneficiaries in capitated managed care Medicare Advantage (MA) plans compared with traditional fee-for-service Medicare. The aim of this study was to explore variation in screening mammography rates at the level of MA managed care plans. METHODS: Using the 2016 MA Healthcare Effectiveness Data and Information Set Public Use File, screening mammography rates were identified for all 385 reporting MA plans. Associations were explored with a range of plan characteristics from this file, as well as from the CMS Part C and Part D Medicare Star Ratings Data File, Medicare Advantage Plan Directory, and Medicare Monthly Enrollment by Plan File. RESULTS: Overall MA plan screening rates were high (mean, 72.6 ± 9.4%) but varied substantially among plans (range, 14.3%-91.8%). Screening rates were higher in nonprofit versus for-profit plans (77.3% versus 71.8%, P < .001), as well as in health maintenance organization or local preferred provider organization plans versus private fee-for-service or regional preferred provider organization plans (71.9%-73.2% versus 65.5%-66.8%, P = .001). Among parent organizations with five or more plans, screening rates were highest for Kaiser Foundation (median, 88.4%) and lowest for Molina Healthcare (median, 65.3%). Screening rates showed small but significant associations with plans' contract lengths, enrolled populations, and counties served. Screening rates showed strong associations (r = 0.796-0.798) with colorectal cancer screening and annual flu vaccine rates and showed moderate associations (r = 0.283-0.365) with ambulatory and preventive care visits, osteoporosis screenings, body mass index assessments, and nonrecommended prostate-specific antigen screenings after age 70. CONCLUSIONS: Screening mammography rates vary considerably among MA plans. With increased federal interest in promoting the MA program, enhanced transparency will be necessary to ensure appropriate Medicare beneficiary participation decision making.

Medicare Advantage Enrollment Update 2017.

Purpose: The RUPRI Center for Rural Health Policy Analysis reports annually on rural beneficiary enrollment in Medicare Advantage (MA) plans, noting any trends or new developments evident in the data. These reports are based on data through March of each year, capturing results of open enrollment periods. Key Findings: (1) Nationally, 1 in 3 Medicare beneficiaries is enrolled in an MA plan. In non-metropolitan areas, nearly 1 in 4 (23.5 percent) beneficiaries is enrolled in an MA plan. (2) Enrollment in MA plans, measured either as an overall count or as a proportion of eligible Medicare beneficiaries, has increased in both metropolitan and non-metropolitan populations since 2004. (3) Between 2015 and 2017, the proportion of non-metropolitan Medicare-eligible beneficiaries enrolled in local preferred provider organization (PPO), regional PPO, and "other" plans (including cost, health care pre-payment [HCPP], medical savings account [MSA] and demonstration plans) remained relatively steady. During the same period, the proportion of Medicare-eligible beneficiaries enrolled in health maintenance organization (HMO) plans increased slightly (from 28.5 percent in 2015 to 29.8 percent in 2017) while the proportion enrolled in private fee-for-service (PFFS) plans decreased slightly (from 5.6 percent in 2015 to 3.8 percent in 2017).

Using the deductible for patient channeling: did preferred providers gain patient volume?

In market-based health care systems, channeling patients to designated preferred providers can increase payer's bargaining clout, other things being equal. In the unique setting of the new Dutch health care system with regulated competition, this paper evaluates the impact of a 1-year natural experiment with patient channeling on providers' market shares. In 2009 a large regional Dutch health insurer designated preferred providers for two different procedures (cataract surgery and varicose veins treatment) and gave its enrollees a positive financial incentive for choosing them. That is, patients were exempted from paying their deductible when they went to a preferred provider. Using claims data over the period 2007-2009, we apply a difference-in-difference approach to study the impact of this channeling strategy on the allocation of patients across individual providers. Our estimation results show that, in the year of the experiment, preferred providers of varicose veins treatment on average experienced a significant increase in patient volume relative to non-preferred providers. However, for cataract surgery no significant effect is found. Possible explanations for the observed difference between both procedures may be the insurer's selection of preferred providers and the design of the channeling incentive resulting in different expected financial benefits for both patient groups.

The Affordable Care Act and Access to Care for People Changing Coverage Sources.

OBJECTIVES: We investigated how access to and continuity of care might be affected by transitions between health insurance coverage sources, including the Marketplace (also called the Exchange), Medicaid, and the Children's Health Insurance Program (CHIP). METHODS: From January to February 2014 and from August to September 2014, we searched provider directories for networks of primary care physicians and selected pediatric specialists participating in Marketplace, Medicaid, and CHIP in 6 market areas of the United States and calculated the degree to which networks overlapped. RESULTS: Networks of physicians in Medicaid and CHIP were nearly identical, meaning transitions between those programs may not result in much physician disruption. This was not the case for Marketplace and Medicaid and CHIP networks. CONCLUSIONS: Transitions from the Marketplace to Medicaid or CHIP may result in different degrees of physician disruption for consumers depending on where they live and what type of Marketplace product they purchase.

2014: Rural Medicare Advantage Enrollment Update.

Key Data Findings. (1) Reclassification of rural and urban county designations (due to the switch from 2000 census data to 2010 census data) resulted in a 10 percent decline in the number of Medicare eligible Americans living in rural counties in 2014 (from roughly 10.7 million to 9.6 million). These changes also resulted in a decline in the number of MA enrollees considered to be living in a rural area, from 2.19 million to 1.95 million. However, the percentage of Medicare beneficiaries enrolled in MA and prepaid plans in rural areas declined only slightly from 20.6 percent to 20.3 percent. (2) Rural Medicare Advantage (MA) and other prepaid plan enrollment in March 2014 was nearly 1.95 million, or 20.3 percent of all rural Medicare beneficiaries, an increase of more than 216,000 from March 2013. Enrollment increased to 1.99 million (20.4 percent) in October 2014. (3) In March 2014, 56 percent of rural MA enrollees were enrolled in Preferred Provider Organization (PPO) plans, 29 percent were enrolled in Health Maintenance Organization (HMO) or Point-of-Service (POS) plans, 7 percent were enrolled in Private Fee-for-Service (PFFS) plans, and 8 percent were enrolled in other prepaid plans, including Cost plans and Program of All-Inclusive Care for the Elderly (PACE) plans. (4) States with the highest percentage of rural Medicare beneficiaries enrolled in MA and other prepaid plans include Minnesota (49.1 percent), Hawaii (41.1 percent), Pennsylvania (35.4 percent), Wisconsin (34.3 percent), New York (30.4 percent), and Ohio (30.1 percent).

Use and Costs for Tumor Gene Expression Profiling Panels in the Management of Breast Cancer From 2006 to 2012: Implications for Genomic Test Adoption Among Private Payers.

PURPOSE: Tumor gene expression profiling (GEP) can be used to predict recurrence risk and the potential benefit of breast cancer treatment. Adoption of GEP among privately insured patients has not been well studied. Our objectives were to characterize trends in GEP use and to evaluate per-use patient and health plan payments from 2006 to 2012. METHODS: We used Truven Health Analytics MarketScan administrative claims database to examine GEP testing among women with breast cancer from 2006 to 2012 (N = 154,883). We estimated trends in the proportion of women who received GEP using segmented regression. We summarized average reimbursement for GEP, including insurer payments and patient out-of-pocket payments. RESULTS: Overall, 18,575 women received GEP. The average age was 53.6 years, and most were enrolled in a preferred provider organization health plan. The adjusted proportion of women with breast cancer who received GEP grew from 2.2% in 2006 to 18.8% in 2012 (adjusted risk ratio, 8.4; 95% CI, 7.6 to 9.3). Out-of-pocket costs to the patient ranged from $0 to $4,752. Most patients paid nothing for GEP (median, $0; interquartile ratio, $4). Mean patient out-of-pocket costs were $175 (standard deviation [SD], $484). Private-insurer reimbursed amounts for GEP increased annually from an average of $3,125 (SD, $1,523) in 2006 to $3,680 (SD, $835) by 2012. CONCLUSION: GEP has rapidly diffused into clinical practice. Reimbursements by insurers have increased slowly, and average out-of-pocket costs to patients have decreased, seemingly driven by improved coverage for testing over time. As more genetic tests become available, it will be important to understand how these technologies will affect cancer care costs across the US health care system.

2015: Rural Medicare Advantage Enrollment Update.

Key Findings. (1) Rural enrollment in Medicare Advantage (MA) and other prepaid plans increased by 6.8 percent between March 2014 and March 2015 to 2.1 million members, or 21.2 percent of all rural residents eligible for Medicare. This compares to a national enrollment in MA and other prepaid plans of 31.1 percent (16.7 million) of enrollees. (2) Rural enrollment in Health Maintenance Organization (HMO) plans (including point-of-service, or POS, plans), Preferred Provider Organization (PP0) plans, and other pre-paid plans (including Medicare Cost and Program of All-Inclusive Care for the Elderly Plans) all increased by 5-13 percent. (3) Enrollment in private fee-for-service (PFFS) plans continued to decline (decreasing nationally by 15.8 percent and 12.1 percent in rural counties over the period March 2014-2015). Only eight states showed an increase in PFFS plan enrollment. Five states experienced decreases of 50 percent or more. (4) The five states with the highest percentages of rural beneficiaries enrolled in a Medicare Advantage plan are Minnesota (51.8 percent), Hawaii (39.4 percent), Pennsylvania (36.2 percent), Wisconsin (35.5 percent), and New York (31.5 percent).