Assuntos
Acessibilidade aos Serviços de Saúde/economia , Neoplasias/economia , Organizações de Prestadores Preferenciais/economia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Medicaid/economia , Medicaid/estatística & dados numéricos , Medicare/economia , Neoplasias/terapia , Organizações de Prestadores Preferenciais/estatística & dados numéricos , Estados UnidosRESUMO
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.
Assuntos
Nefrologistas , Seguro de Saúde Baseado em Valor , Redução de Custos , Atenção à Saúde/economia , Técnica Delphi , Custos de Cuidados de Saúde , Humanos , Nefrologistas/economia , Visita a Consultório Médico , Educação de Pacientes como Assunto , Pacientes/psicologia , Organizações de Prestadores Preferenciais/economia , Organizações de Prestadores Preferenciais/estatística & dados numéricos , Prática Profissional , Melhoria de Qualidade , Autogestão , Estados Unidos , Dispositivos de Acesso VascularRESUMO
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.
Assuntos
Gastos em Saúde , Medicare Part C/economia , Médicos de Atenção Primária/economia , Organizações de Prestadores Preferenciais/economia , Atenção Primária à Saúde/economia , Idoso , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Medicare Part C/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Médicos de Atenção Primária/estatística & dados numéricos , Organizações de Prestadores Preferenciais/estatística & dados numéricos , Estudos Retrospectivos , População Rural , Estados Unidos , População UrbanaRESUMO
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.
Assuntos
Comportamento do Consumidor/estatística & dados numéricos , Dedutíveis e Cosseguros/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comportamento de Escolha , Comportamento do Consumidor/economia , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Países Baixos , Organizações de Prestadores Preferenciais/economia , Organizações de Prestadores Preferenciais/organização & administração , Organizações de Prestadores Preferenciais/estatística & dados numéricos , Varizes/economia , Varizes/terapia , Adulto JovemRESUMO
Much research has focused on differences in hospital prices paid by private (commercial) versus public (Medicare and Medicaid) health insurers. Far less is known about price differences across commercial payers-health maintenance organizations (HMOs) or preferred provider organizations (PPOs) versus other payers, such as casualty (automobile), workers' compensation, and travel insurers. We found that other insurers had far less negotiating power with hospitals than commercial HMO/PPO insurers did. In the period 2010-16, the median price paid by HMO/PPO insurers for hospital services in Florida increased from 1.9 times to 2.5 times the Medicare price, respectively, while the median price paid by other insurers increased from 2.8 times to 3.8 times the Medicare price. Commercial HMO/PPO insurers' prices were similar across major hospital systems, regardless of ownership, while other insurers' prices differed substantially across systems. In 2016 the twenty hospitals with the highest prices (7.8-14.1 times the Medicare rate) for other insurers in Florida were all affiliated with the Hospital Corporation of America. These hospitals generated 24 percent of their commercial net revenue (median) from other payers, despite treating a relatively small proportion of patients covered by these payers. Protecting patients with other insurance from high hospital prices requires efforts by policy makers, hospitals, and insurers.
Assuntos
Comércio/economia , Competição Econômica/estatística & dados numéricos , Seguradoras/economia , Seguro Saúde/economia , Comércio/estatística & dados numéricos , Florida , Gastos em Saúde , Sistemas Pré-Pagos de Saúde/economia , Humanos , Seguradoras/tendências , Organizações de Prestadores Preferenciais/economia , Setor Privado/economia , Indenização aos Trabalhadores/economiaRESUMO
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.
Assuntos
Controle de Acesso/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/estatística & dados numéricos , Organizações de Prestadores Preferenciais/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Especialização/estatística & dados numéricos , Adolescente , Adulto , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Feminino , Controle de Acesso/economia , Reforma dos Serviços de Saúde , Gastos em Saúde/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/economia , Humanos , Masculino , Massachusetts , Pessoa de Meia-Idade , Organizações de Prestadores Preferenciais/economia , Atenção Primária à Saúde/economia , Especialização/economia , Estados Unidos , Adulto JovemRESUMO
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.
Assuntos
Medicare Part C/economia , Medicare/economia , Benchmarking , Controle de Custos , Previsões , Sistemas Pré-Pagos de Saúde/economia , Sistemas Pré-Pagos de Saúde/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/tendências , Humanos , Medicare/estatística & dados numéricos , Medicare/tendências , Medicare Part C/estatística & dados numéricos , Medicare Part C/tendências , Organizações de Prestadores Preferenciais/economia , Organizações de Prestadores Preferenciais/estatística & dados numéricos , Organizações de Prestadores Preferenciais/tendências , Estados UnidosRESUMO
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.
Assuntos
Custos e Análise de Custo/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/estatística & dados numéricos , Benefícios do Seguro/estatística & dados numéricos , Organizações de Prestadores Preferenciais/estatística & dados numéricos , Adolescente , Adulto , Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , California , Custos e Análise de Custo/economia , Feminino , Planos de Assistência de Saúde para Empregados/economia , Planos de Assistência de Saúde para Empregados/estatística & dados numéricos , Gastos em Saúde/tendências , Sistemas Pré-Pagos de Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Organizações de Prestadores Preferenciais/economiaRESUMO
ISSUE: Privately insured consumers expect that if they pay premiums and use in-network providers, their insurer will cover the cost of medically necessary care beyond their cost-sharing. However, when obtaining care at emergency departments and in-network hospitals, patients treated by an out-of-network provider may receive an unexpected "balance bill" for an amount beyond what the insurer paid. With no explicit federal protections against balance billing, some states have stepped in to protect consumers from this costly and confusing practice. GOAL: To better understand the scope of state laws to protect consumers from balance billing. METHODS: Analysis of laws in all 50 states and the District of Columbia and interviews with officials in eight states. FINDINGS AND CONCLUSIONS: Most states do not have laws that directly protect consumers from balance billing by an out-of-network provider for care delivered in an emergency department or in-network hospital. Of the 21 states offering protections, only six have a comprehensive approach to safeguarding consumers in both settings, and gaps remain even in these states. Because a federal policy solution might prove difficult, states may be better positioned in the short term to protect consumers.
Assuntos
Contas a Pagar e a Receber , Defesa do Consumidor/economia , Defesa do Consumidor/legislação & jurisprudência , Dedutíveis e Cosseguros/economia , Dedutíveis e Cosseguros/legislação & jurisprudência , Honorários e Preços/legislação & jurisprudência , Seguro Saúde/economia , Seguro Saúde/legislação & jurisprudência , Serviços Médicos de Emergência/economia , Serviços Médicos de Emergência/legislação & jurisprudência , Sistemas Pré-Pagos de Saúde/economia , Sistemas Pré-Pagos de Saúde/legislação & jurisprudência , Humanos , Organizações de Prestadores Preferenciais/economia , Organizações de Prestadores Preferenciais/legislação & jurisprudência , Governo Estadual , Estados UnidosRESUMO
The new health insurance exchanges are the core of the Affordable Care Act's (ACA) insurance reforms, but insurance markets beyond the exchanges also are affected by the reforms. This issue brief compares the markets for individual coverage on and off of the exchanges, using insurers' most recent projections for ACA-compliant policies. In 2016, insurers expect that less than one-fifth of ACA-compliant coverage will be sold outside of the exchanges. Insurers that sell mostly through exchanges devote a greater portion of their premium dollars to medical care than do insurers selling only off of the exchanges, because exchange insurers project lower administrative costs and lower profit margins. Premium increases on exchange plans are less than those for off-exchange plans, in large part because exchange enrollment is projected to shift to closed-network plans. Finally, initial concerns that insurers might seek to segregate higher-risk subscribers on the exchanges have not been realized.
Assuntos
Trocas de Seguro de Saúde/economia , Seguro Saúde/economia , Aquisição Baseada em Valor/economia , Trocas de Seguro de Saúde/tendências , Sistemas Pré-Pagos de Saúde/economia , Humanos , Seleção Tendenciosa de Seguro , Patient Protection and Affordable Care Act , Organizações de Prestadores Preferenciais/economia , Setor Privado , Risco , Estados UnidosRESUMO
Clinical studies show that fewer than 25% of people who visit a dentist regularly are screened for oral cancer, and that the majority of oral cancers present at an advanced stage, when cure rates are already abysmal. This study explores the current status of oral cancer screening coverage among a variety of insurance providers in New York City. The study focuses on determining the coverage and frequency of the cluster of salient CDT (dental) codes surrounding oral cancer screenings.
Assuntos
Cobertura do Seguro , Seguro Odontológico , Programas de Rastreamento/economia , Neoplasias Bucais/diagnóstico , Codificação Clínica , Citodiagnóstico/economia , Técnica Direta de Fluorescência para Anticorpo/economia , Testes Genéticos/economia , Humanos , Formulário de Reclamação de Seguro , Neoplasias Bucais/economia , Cidade de Nova Iorque , Organizações de Prestadores Preferenciais/economia , Saliva/química , Abandono do Hábito de Fumar/economiaRESUMO
Concentration among physician groups has been steadily increasing, which may affect prices for physician services. We assessed the relationship in 2010 between physician competition and prices paid by private preferred provider organizations for fifteen common, high-cost procedures to understand whether higher concentration of physician practices and accompanying increased market power were associated with higher prices for services. Using county-level measures of the concentration of physician practices and county average prices, and statistically controlling for a range of other regional characteristics, we found that physician practice concentration and prices were significantly associated for twelve of the fifteen procedures we studied. For these procedures, counties with the highest average physician concentrations had prices 8-26 percent higher than prices in the lowest counties. We concluded that physician competition is frequently associated with prices. Policies that would influence physician practice organization should take this into consideration.
Assuntos
Competição Econômica , Custos de Cuidados de Saúde/estatística & dados numéricos , Seguro Saúde , Organizações de Prestadores Preferenciais/economia , Procedimentos Cirúrgicos Operatórios , Competição Econômica/economia , Competição Econômica/estatística & dados numéricos , Humanos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Médicos , Procedimentos Cirúrgicos Operatórios/economia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricosRESUMO
BACKGROUND: Although consumers purchasing health plans in the new Health Insurance Marketplace will be provided information on the cost and quality of participating health plans, it is unclear whether the state-wide plan quality averages that will be reported will accurately represent quality at the pricing region level where care will be received. OBJECTIVES: To evaluate whether currently reported state-wide health plan quality scores accurately represent quality within pricing regions established for the Health Insurance Marketplace. RESEARCH DESIGN: Observational, historical cohort study using health plan administrative and pharmacy data. SUBJECTS: A total of 5.2 million members enrolled in the preferred provider organization health plans of 1 large commercial California insurer in 2012. MEASURES: State-wide and pricing region performance on each of the 17 Healthcare Effectiveness Data and Information Set (HEDIS) measures. RESULTS: Across the 17 measures assessed in each of the 19 pricing regions, scores were statistically different (P<0.05) than the overall plan rate for 176 (54%). Variations in scores across regions were observed for each measure ranging from 6.4-percentage points for engagement in treatment for people with dependence of alcohol or other drugs to 47.2-percentage points for appropriate testing for pharyngitis among children. CONCLUSIONS: Quality scores in California vary greatly across geographic regions. Statewide averages may misrepresent the quality of care that consumers are likely to receive within a geographic area making difficult assessments about the value of the health care.