Association Between Provider-Sponsored Health Plan Ownership and Health Insurance Marketplace Plan Quality.

BACKGROUND: Over 15.3 million Americans relied on the individual health insurance market for health coverage in 2021. Yet, little is known about the relationships between the organizational characteristics of individual market health insurers and quality of coverage, particularly with respect to clinical outcomes. OBJECTIVE: To examine variation in marketplace insurers' quality performance and investigate how performance varies by insurer organizational characteristics. DESIGN: Retrospective cohort study. PARTICIPANTS: 381 insurer products, representing 184 unique insurers in 50 states in 2019 and 2020. MAIN MEASURES: Marketplace plan clinical quality measures reported in the 2019-2020 CMS Plan Quality Rating System dataset and insurer-product organizational attributes identified from several data sources, including non-profit ownership, Blue Cross Blue Shield Association membership, Medicaid focus and whether or not the insurer product is vertically integrated with a provider organization. KEY RESULTS: Among the 381 insurer products in this study, 35% are part of a provider-sponsored health plan (PSHP) and 70% of these entities received four stars or above for overall quality performance. Overall, PSHPs exhibited higher quality than non-PSHPs for both clinical quality management (0.36 increased on a 5-point scale; 95% CI = 0.11 to 0.62; P = 0.005) and enrollee experience (0.27; 95% CI = 0.03 to 0.50; P = 0.03) summary indicators. Medicaid focused insurers were associated with lower performance on enrollee experience, plan administration, and various outcomes related to clinical quality. CONCLUSIONS: Provider-sponsored health plans in the health insurance marketplaces are associated with higher-quality care, as measured by CMS clinical quality measures.

Paid Maternity Leave in the United States: Associations with Maternal and Infant Health.

Objectives The United States is one of only three countries worldwide with no national policy guaranteeing paid leave to employed women who give birth. While maternity leave has been linked to improved maternal and child outcomes in international contexts, up-to-date research evidence in the U.S. context is needed to inform current policy debates on paid family leave. Methods Using data from Listening to Mothers III, a national survey of women ages 18-45 who gave birth in 2011-2012, we conducted multivariate logistic regression to predict the likelihood of outcomes related to infant health, maternal physical and mental health, and maternal health behaviors by the use and duration of paid maternity leave. Results Use of paid and unpaid leave varied significantly by race/ethnicity and household income. Women who took paid maternity leave experienced a 47% decrease in the odds of re-hospitalizing their infants (95% CI 0.3, 1.0) and a 51% decrease in the odds of being re-hospitalized themselves (95% CI 0.3, 0.9) at 21 months postpartum, compared to women taking unpaid or no leave. They also had 1.8 times the odds of doing well with exercise (95% CI 1.1, 3.0) and stress management (95% CI 1.1, 2.8), compared to women taking only unpaid leave. Conclusions for Practice Paid maternity leave significantly predicts lower odds of maternal and infant re-hospitalization and higher odds of doing well with exercise and stress management. Policies aimed at expanding access to paid maternity and family leave may contribute toward reducing socio-demographic disparities in paid leave use and its associated health benefits.

Impact of a workplace physical activity tracking program on biometric health outcomes.

Wellness programs are a popular strategy utilized by large U.S. employers. As mobile health applications and wearable tracking devices increase in prevalence, many employers now offer physical activity tracking applications. This longitudinal study evaluates the impact of engagement with a web-based, physical activity tracking program on changes in individuals' biometric outcomes in an employer population. The study population includes active employees and adult dependents continuously enrolled in an eligible health plan and who have completed at least two biometric screenings (n=36,882 person-years with 11,436 unique persons) between 2011 and 2014. Using difference-in-differences (DID) regression, we estimate the effect of participation in the physical activity tracking application on BMI, total cholesterol, and blood pressure. Participation was significantly associated with a reduction of 0.275 in BMI in the post-period, relative to the comparison group, representing a 1% change from baseline BMI. The program did not have a statistically significant impact on cholesterol or blood pressure. Sensitivity checks revealed slightly larger BMI reductions among participants with higher intensity of tracking activity and in the period following the employer's shift to an outcomes-based incentive design. Results are broadly consistent with the existing literature on changes in biometric outcomes from workplace initiatives promoting increased physical activity. Employers should have modest expectations about the potential health benefits of such programs, given current designs and implementation in real-world settings.

The effect of participation in an incentive-based wellness program on self-reported exercise.

Employers are increasingly trying to promote healthy behaviors, including regular exercise, through wellness programs that offer financial incentives. However, there is limited evidence that these types of programs affect exercise habits within employee populations. In this study, we estimate the effect of participation in an incentive-based wellness program on self-reported exercise. Since 2008, the University of Minnesota's Fitness Rewards Program has offered a $20 monthly incentive to encourage fitness center utilization among its employees. Using 2006 to 2010 health risk assessments and university administrative files for 2972 employees, we conducted a retrospective cohort study utilizing propensity score methods to estimate the effect of participation in the Fitness Rewards Program on self-reported exercise days per week from 2008 to 2010. On average, participation in the program led to an increase of 0.59 vigorous exercise days per week (95% Confidence Interval: 0.42, 0.78) and 0.43 strength-building exercise days per week (95% Confidence Interval: 0.31, 0.58) in 2008 for participants relative to non-participants. Increases in exercise persisted through 2010. Employees reporting less frequent exercise prior to the program were least likely to participate in the program, but when they participated they had the largest increases in exercise compared to non-participants. Offering an incentive for fitness center utilization encourages higher levels of exercise. Future policies may want to concentrate on how to motivate participation among individuals who are less frequently physically active.

Is the medical loss ratio a good target measure for regulation in the individual market for health insurance?

Effective January 1, 2011, individual market health insurers must meet a minimum medical loss ratio (MLR) of 80%. This law aims to encourage 'productive' forms of competition by increasing the proportion of premium dollars spent on clinical benefits. To date, very little is known about the performance of firms in the individual health insurance market, including how MLRs are related to insurer and market characteristics. The MLR comprises one component of the price-cost margin, a traditional gauge of market power; the other component is percent of premiums spent on administrative expenses. We use data from the National Association of Insurance Commissioners (2001-2009) to evaluate whether the MLR is a good target measure for regulation by comparing the two components of the price-cost margin between markets that are more competitive versus those that are not, accounting for firm and market characteristics. We find that insurers with monopoly power have lower MLRs. Moreover, we find no evidence suggesting that insurers' administrative expenses are lower in more concentrated insurance markets. Thus, our results are largely consistent with the interpretation that the MLR could serve as a target measure of market power in regulating the individual market for health insurance but with notable limited ability to capture product and firm heterogeneity.

How has the Affordable Care Act's medical loss ratio regulation affected insurer behavior?

BACKGROUND: Starting in 2011, the Affordable Care Act stipulates that insurers meet the minimum medical loss ratio (MLR) standards or issue rebates. An MLR is the proportion of premium revenues spent on clinical benefits, and must be at least 80% in the individual and small-group markets. Although some insurers have issued rebates, it is unclear whether they also adjusted MLRs and their components in ways to move toward compliance. OBJECTIVE: To investigate early responses of individual and small-group insurers' MLR-related outcomes to the Affordable Care Act provisions. RESEARCH DESIGN: Descriptive and multivariate analyses using 2010-2011 data from the National Association of Insurance Commissioners and other sources. MEASURES: Outcomes include MLRs, MLR components (claims incurred, premiums earned, quality improvement expenses, and fraud detection/recovery expenses), and administrative expenses. RESULTS: In 2010, only 44.3% of individual market insurers reported MLRs of at least the stipulated level; by 2011, this percentage was 63.2%. Among small-group insurers, 74.9% had 2010 MLRs at or above the stipulated level, with little change in 2011. Individual insurers with 2010 MLRs >10 percentage points below the minimum exhibited the largest increases in MLRs, with changes occurring through increases in claims and indirectly through decreases in administrative expenses. CONCLUSIONS: Early responses to MLR regulation seem more pronounced in the individual versus small-group market, with insurers using both direct and indirect strategies for compliance. Because insurers learned of final MLR regulations only in late 2010, early responses may be limited and skewed more toward greater use of rebates than other adjustments.

The effect of consumer incentives on Medicaid beneficiaries' compliance with well-child visit guidelines.

The Affordable Care Act of 2010 recommends that consumer incentives be employed to increase the use of preventive care by Medicaid beneficiaries, but few evaluative studies exist. This study evaluates a Target gift card incentive employed by a Minnesota health plan serving Medicaid beneficiaries over the period 2002-2003. Lacking a contemporaneous control group, the proximity between the child's residence and the nearest Target store was used as the intervention variable. Using alternative specifications for the intervention variable, results of the difference-in-differences equations suggest that the incentive program significantly increased the likelihood that a Medicaid beneficiary would have a well-child visit.

Do minimum wage laws affect employer-sponsored insurance provision?

Employers may respond to minimum wage increases by adjusting their health benefits. We examine the impact of state minimum wage increases on employer health benefit offerings using the 2002-2020 Medical Expenditure Panel Survey - Insurance/Employer Component data. Our primary regression specifications are difference-in-differences models that estimate the relationship between within-state changes in employer-sponsored insurance and minimum wage laws over time. We find that a $1 increase in minimum wages is associated with a 0.92 percentage point (p.p.) decrease in the percentage of employers offering health insurance, largely driven by small employers and employers with a greater share of low-wage employees. A $1 increase is also associated with a 1.83 p.p. increase in the prevalence of plans with a deductible requirement, but we do not find consistent evidence that other benefit characteristics are affected. We find no consequent change in uninsurance, likely explained by an increase in Medicaid enrollment.

To be or not to be compliant? Hospitals' initial strategic responses to the federal price transparency rule.

OBJECTIVE: To understand US hospitals' initial strategic responses to the federal price transparency rule that took effect January 2021. DATA SOURCES AND STUDY SETTING: Primary interview data collected from 12 not-for-profit hospital organizations in six US metropolitan markets. All but one organization were multihospital systems; the 12 organizations represent a total of 81 hospitals. STUDY DESIGN: Exploratory, cross-sectional, qualitative interview study of a convenience sample of hospital organizations across six geographically and compliance diverse markets. DATA COLLECTION/EXTRACTION METHODS: In-depth, semi-structured, qualitative interviews with 16 key informants across sampled organizations between November 2021 and March 2022. Interviews solicited data about internal organizational factors and external market factors affecting strategic responses. Transcribed interviews were de-identified, coded, and analyzed using the constant comparative method. PRINCIPAL FINDINGS: Hospitals' strategic responses were influenced internally by the degree of the regulation's alignment with organizational values and goals, and task complexity vis-a-vis available resources. We found extensive variation in organizational capabilities to comply, and all but one organization relied on consultants and vendors to some degree. Key external factors driving strategic responses were hospitals' variable perceptions about how available price information would affect their competitive position, bottom line, and reputation. Organizations with more confidence in their interpretation of the environment, including how peers or purchasers would behave, and greater clarity in their own organization's position and goals, had more definitive initial strategic responses. In the first year, organizations' strategic responses skewed toward compliance, especially for the rule's consumer shopping requirements. CONCLUSIONS: A deeper understanding of the realities of operationalizing price transparency policy for hospitals is needed to improve its impact.

Evaluating the association between expanded coverage of direct-to-consumer telemedicine and downstream utilization and quality of care for urinary tract infections and sinusitis.

OBJECTIVE: To compare direct-to-consumer (DTC) telemedicine and in-person visits in rates of testing, follow-up health care use, and quality for urinary tract infections (UTIs) and sinusitis. DATA SOURCE: The Minnesota All Payer Claims Data provided 2008-2015 administrative claims data. STUDY DESIGN: Using a difference-in-differences approach, we compared episodes of care for UTIs and sinusitis among enrollees of health plans introducing coverage for DTC telemedicine relative to those without DTC telemedicine coverage. Primary outcomes included number of laboratory tests, antibiotics filled, office and outpatient visits, emergency department (ED) visits, and standardized spending, based on standardized prices of health services. DATA COLLECTION: The study sample included non-elderly enrollees of commercial health insurance plans. We constructed 30-day episodes of care initiated by a DTC telemedicine or in-person visit. PRINCIPAL FINDINGS: The UTI and sinusitis samples were comprised of 215,134 and 624,630 episodes of care, respectively. Following the introduction of coverage for DTC telemedicine, 15.7% of UTI episodes and 8.9% of sinusitis episodes were initiated with DTC telemedicine. Compared to episodes without coverage for DTC telemedicine, UTI episodes with coverage had 0.25 fewer lab tests (95% CI: -0.33, -0.18; p < 0.001), lower standardized spending for the first UTI visit (-$11.18 [95% CI: -$21.62, -$0.75]; p < 0.05), and no change in office and outpatient visits, ED visits, antibiotics filled, or standardized medical spending. Sinusitis episodes with coverage for DTC telemedicine had fewer antibiotics filled (-0.08 [95% CI: -0.14, -0.01]; p < 0.05) and a very small increase in ED visits (0.001 [95% CI: 0.001, 0.010]; p < 0.05), but no change in lab tests, office and outpatient visits, or standardized medical spending. CONCLUSIONS: Among commercially insured patients, coverage of DTC telemedicine was associated with reductions in antibiotics for sinusitis and laboratory tests for UTI without changes in downstream total office and outpatient visits or changes in ED visits.

The effectiveness of a health promotion program after 3 years: evidence from the University of Minnesota.

BACKGROUND: Health promotion programs for the workplace are often sold to employers with the promise that they will pay for themselves with lowered health care expenditures and reduced absenteeism. In a recent review of the literature, it was noted that analysts often caution not to expect a positive return on investment until the third year of operation. OBJECTIVE: This study investigates whether a positive return on investment was generated in the third year for the health promotion program used by the University of Minnesota. It further investigates what it is about the third year that would explain such a phenomenon. MEASURES: The study uses health care expenditure data and absenteeism data from 2004 to 2008 to investigate the effect of the University's lifestyle and disease management programs. It also investigates the effectiveness of participation in Minnesota's 10,000 Steps walking program and Miavita self-help programs. RESEARCH DESIGN: A differences-in-differences equations approach is used to address potential selection bias. Possible regression to the mean is dealt with by using only those who were eligible to participate as control observations. Propensity score weighting was used to balance the sample on observable characteristics and reduce bias due to omitted variables. RESULTS: The study finds that a 1.76 return on investment occurs in the third year of operation that is generated solely by the effect of disease management program participation in reducing health care expenditures. However, neither of the explanations for a third-year effect we tested seemed to be able to explain this phenomenon.

Taking the Pulse of Hospitals' Response to the New Price Transparency Rule.

As of January 1, 2021, most U.S. hospitals are required to publish pricing information on their website to promote more informed decision making by consumers regarding their care. In a nationally representative sample of 470 hospitals, we analyzed whether hospitals met price transparency information reporting requirements and the extent to which complete reporting was associated with ownership status, bed size category, system affiliation, and location in a metropolitan area. Fewer than one quarter of sampled hospitals met the price transparency information requirements of the new rule, which include five types of standard charges in machine-readable form and the consumer-shoppable display of 300 shoppable services. Our analyses of hospital reporting by organizational and market attributes revealed limited differences, with some exceptions for nonprofit and system-member hospitals demonstrating greater responsiveness with respect to the consumer-shoppable aspects of the rule.

How do health insurance loading fees vary by group size?: implications for Healthcare reform.

The health insurance loading fee represents the portion of the premium above the expected amount of medical care expenditures paid by the insurance company. The size of the loading fees and how they vary by employer group size have important implications for health policy given the recent passage of the Patient Protection and Affordable Care Act. Despite their policy relevance, there is surprisingly little empirical evidence on the magnitude and the determinants of health insurance loading fees. This paper provides estimates of the loading fees by firm size using data from the confidential Medical Expenditure Panel Survey Household Component-Insurance Component Linked File. Overall, we find an inverse relationship between employer group size and loading fees. Firms of up to 100 employees face similar loading fees of approximately 34%. Loads decline with firm size and are estimated to be on average 15% for firms with more than 100 employees, but less than 10,000 employees, and 4% for firms with more than 10,000 workers.

What factors influence participation in an exercise-focused, employer-based wellness program?

Following the recent introduction of an incentive-based, exercise-focused wellness program at a large public university, this paper investigates the factors that influence employees' behavior with respect to participation and regular exercise. Results suggest that an employee's probability of signing up for the program is related to her exercise behavior prior to the program's inception, the time cost of exercise, taste for fitness center exercise, and attitudes about the benefits and barriers of exercise. Employees who are older, male, and were regular fitness center exercisers prior to the program's inception are more likely to be regular exercisers.

Using a Social Capital Framework to Explore a Broker's Role in Small Employer Wellness Program Uptake and Implementation.

PURPOSE: Small employers, while motivated to implement wellness programs, often lack knowledge and resources to do so. As a result, these firms rely on external decision-making support from insurance brokers. The objective of this study was to analyze brokers' familiarity with wellness programs and to characterize their role and interactions with small employers. DESIGN: Using a newly developed common interview guide (20 questions), protocol and analysis plan, 20 interviews were conducted with health insurance brokers in Illinois, Minnesota, North Carolina and Washington in 2016 and 2017. In addition to exploring patterns of broker interactions and familiarity by segment, we propose a framework to conceptualize the broker-client relationship using social capital theory and the RE-AIM model. METHODS: Interviews were transcribed, summarized and a common codebook was established using DeDoose. Themes were identified following multi-rater coding and structured within the framework. RESULTS: Participating brokers reported having a high to moderate familiarity with wellness programs (65%) and a majority (80%) indicated that they have previously advised their small business clients on the availability and features of them. Further, we find that brokers may help eliminate barriers to resources and act as a connector to wellness opportunities within their professional network. CONCLUSION: New initiatives to promote small employer wellness programs can benefit from examining the influence of brokers on the decision-making process. When engaged and supported with resources, brokers may be effective champions for employer wellness programs.

Same Game, Different Names: Cream-Skimming in the Post-ACA Individual Health Insurance Market.

One of the Affordable Care Act's (ACA) signature reforms was creating centralized Health Insurance Marketplaces to offer comprehensive coverage in the form of comprehensive insurance complying with the ACA's coverage standards. Yet, even after the ACA's implementation, millions of people were covered through noncompliant plans, primarily in the form of continued enrollment in "grandmothered" and "grandfathered" plans that predated ACA's full implementation and were allowed under federal and state regulations. Newly proposed and enacted federal legislation may grow the noncompliant segment in future years, and the employment losses of 2020 may grow reliance on individual market coverage further. These factors make it important to understand how the noncompliant segment affects the compliant segment, including the Marketplaces. We show, first, that the noncompliant segment of the individual insurance market substantially outperformed the compliant segment, charging lower premiums but with vastly lower costs, suggesting that insurers have a strong incentive to enter the noncompliant segment. We show, next, that state's decisions to allow grandmothered plans is associated with stronger financial performance of the noncompliant market, but weaker performance of the compliant segment, as noncompliant plans attract lower-cost enrollees. This finding indicates important linkages between the noncompliant and compliant segments and highlights the role state policy can play in the individual insurance market. Taken together, our results point to substantial cream-skimming, with noncompliant plans enrolling the healthiest enrollees, resulting in higher average claims cost in the compliant segment.

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.

Rural-Urban Differences In Individual-Market Health Plan Affordability After Subsidy Payment Cuts.

This article investigates changes in the affordability of individual health plans (Marketplace plans) that were compliant with the Affordable Care Act following the termination of cost-sharing reduction subsidy payments in 2017. We examined how states' and insurers' responses to these cuts affected enrollees differently depending on whether they lived in rural or urban geographic areas and were or were not eligible for Advance Premium Tax Credits. Using data for 2014-19 from the Health Insurance Exchange Compare database and other sources, we found that subsidy-eligible enrollees in rural markets gained access to Marketplace plans that were more affordable than those available to their urban counterparts, after the cuts affected premiums in 2018. Average minimum net monthly premiums for subsidized enrollees in majority-rural geographic rating areas decreased from $288 in 2017 to $162 in 2019, while those of their urban counterparts decreased from $275 to $180. In contrast, rural enrollees without subsidies faced the least affordable premiums for Marketplace plans.

The impact of Medicaid expansion on employer provision of health insurance.

Using the 2010-2015 Medical Expenditure Panel Survey-Insurance Component, this study investigates the effect of the Affordable Care Act's Medicaid eligibility expansion on four employer-sponsored insurance (ESI) outcomes: offers of health insurance, eligibility, take-up, and the out-of-pocket premium paid by employees for single coverage. Using a difference-in-differences identification strategy, we cannot reject the hypothesis of a zero effect of the Medicaid eligibility expansion on an establishment's probability of offering ESI, the percentage of an establishment's workforce that takes up coverage, or the out-of-pocket premium for single coverage. We find some evidence suggestive of an inverse relationship between the expansion of Medicaid and the percentage of an establishment's workers eligible for ESI. In line with other employer- and individual-level studies of the effect of the ACA on employment-related outcomes, we find that employer provision of health insurance was largely unaffected by the Medicaid expansions.

Plan Choice And Affordability In The Individual And Small-Group Markets: Policy And Performance-Past And Present.

The individual and small-group health insurance markets have experienced considerable changes since the passage of the Affordable Care Act in 2010, affecting access, choice, and affordability for enrollees in these markets. We examined how health plan access, choice, and affordability varied between the individual on-Marketplace, individual off-Marketplace, and small-group markets in 2018. We found relatively similar outcomes across the three markets with respect to deductibles and out-of-pocket spending maximums. However, the small-group market maintained greater plan choice and lower premiums-outcomes that appear to be associated with higher insurer participation. States may consider a variety of policy proposals such as reinsurance or the introduction of a public option to increase insurer participation and improve the plan choices offered in the individual market.