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.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE uniform health maintenance organization (HMO) benefit--Prime enrollment fee exemption for survivors of active duty deceased sponsors and medically retired uniformed services members and their dependents. Final rule.

This final rule creates an exception to the usual rule that TRICARE Prime enrollment fees are uniform for all retirees and their dependents and responds to public comments received to the proposed rule published in the Federal Register on June 7, 2013. Survivors of Active Duty Deceased Sponsors and Medically Retired Uniformed Services Members and their Dependents are part of the retiree group under TRICARE rules. In acknowledgment and appreciation of the sacrifices of these two beneficiary categories, the Secretary of Defense has elected to exercise his authority under the United States Code to exempt Active Duty Deceased Sponsors and Medically Retired Uniformed Services Members and their Dependents enrolled in TRICARE Prime from paying future increases to the TRICARE Prime annual enrollment fees. The Prime beneficiaries in these categories have made significant sacrifices for our country and are entitled to special recognition and benefits for their sacrifices. Therefore, the beneficiaries in these two TRICARE beneficiary categories who enrolled in TRICARE Prime prior to 10/1/2013, and those since that date, will have their annual enrollment fee frozen at the appropriate fiscal year rate: FY2011 rate $230 per single or $460 per family, FY2012 rate $260 or $520, FY2013 rate $269.38 or $538.56, or the FY2014 rate $273.84 or $547.68. The future beneficiaries added to these categories will have their fee frozen at the rate in effect at the time they are classified in either category and enroll in TRICARE Prime or, if not enrolling, at the rate in effect at the time of enrollment. The fee remains frozen as long as at least one family member remains enrolled in TRICARE Prime and there is not a break in enrollment. The fee charged for the dependent(s) of a Medically Retired Uniformed Services Member would not change if the dependent(s) was later re-classified a Survivor.

Oregon bets on coordinated care. Interview by Haydn Bush.

Gov. John Kitzhaber, M.D., describes his state's overhaul of Medicaid. It's an ambitious plan to control costs and improve quality through coordinated care organizations.

[An international comparison of physician control systems].

This study compares physicians' regulations set by the United Kingdom, the United States, Canada and Germany which have typical healthcare systems. Physicians' regulations are defined in this study as four aspects: physicians' training and qualifications, career pathways, payment methods and behavior regulations. Strict access rules, practicing with freedom, different training models between general and special practitioners, health services priced by negotiations and regulations by professional organizations are the common features of physicians' regulations in these four western countries. Three aspects--introducing contract mechanism, enhancing the roles of professional organizations and extending physicians' practice space should be taken into account in China's future reform of physicians' regulations.

Are Health Insurance Markets Competitive?

To gauge the competitiveness of the group health insurance industry, I investigate whether health insurers charge higher premiums, ceteris paribus, to more profitable firms. Such "direct price discrimination" is feasible only in imperfectly competitive settings. Using a proprietary national database of health plans offered by a sample of large, multisite firms from 1998­2005, I find firms with positive profit shocks subsequently face higher premium growth, even for the same health plans. Moreover, within a given firm, those sites located in concentrated insurance markets experience the greatest premium increases. The findings suggest health care insurers are exercising market power in an increasing number of geographic markets.

Out in the Cold: Health Plan Blamed For Major Prompt-Pay Mess.

Molina Healthcare of Texas isn't the only insurer to give physicians prompt-pay problems, and it won't be the last. Some of the practices trying to recover payments blame not just the health plan, but also the extended response time from the state regulator overseeing insurance products and conduct: the Texas Department of Insurance, which says it's hiring staff and making other changes to improve that response.

[A large network of integrated medical care: the example of Kaiser Permanente in California. First-hand report by a physician]. / Un grand réseau de soins médicaux intégrés: l'exemple de Kaiser Permanente en Californie. Témoignage d'un praticien.

The Kaiser Permanente (KP) system of integrated medical care is a unique model of medical organization in the USA which achieves the twin goals of economic efficiency and first-rate care. Organizationally, it is quite different from most health maintenance organizations (HMOs). The doctors remain independent, but in an exclusive marriage with the Kaiser Hospitals and the Kaiser insurance, both of which are non-profit. KP cares for over 8 million members. KP ensures continuity of patient care whether at home, as an outpatient, or when hospitalized, and promotes prevention among healthy members. The integration of all services produces very high indices measuring quality of care, as investigated by both the press and official government agencies at a surprising low cost. The system also was found to be more cost-effective than the National Health System in the United Kingdom.

Employee contributions: a primer on their use, historical trends and overall fit within benefits strategy.

This article focuses on the use of employee contributions as a strategic tool within employee health plans. While most employers require some form of employee contributions for health care, there is no clear "one-size-fits-all" solution. A myriad of strategies are in place, some active and some passive. This article reviews both common and emerging strategies and how they differ based on industry, employer size and region; discusses how employee contribution strategy fits within overall benefits strategy; and provides a strategic framework for approaching employee contributions in the future.

Value-based insurance design: aligning incentives to bridge the divide between quality improvement and cost containment.

Rising costs and suboptimal clinical quality have spawned efforts to redesign healthcare benefit packages. Momentum has gathered behind 2 trends; the first, represented by disease management initiatives and pay-for-performance programs, focuses on the quality of care, and uses tools to manage patient health. The second trend, represented by increased patient cost sharing and consumer-driven health plans, focuses on the cost of care and uses financial incentives to alter patient and provider behavior. These 2 trends create a conflict for the patient in that disease management programs--designed to improve patient self-management--aim to enhance compliance with specific clinical interventions, while rising copayments create financial barriers that discourage the use of these recommended services. When patients are required to pay more for their healthcare, they buy less, even if the intervention is potentially lifesaving. Thus, the challenge for purchasers is to devise benefit packages that incorporate a range of features that complement each other in the effective and efficient delivery of care while explicitly avoiding the unwanted negative clinical effects associated with increased cost sharing.

Economic profiling of physicians: does omission of pharmacy claims bias performance measurement?

OBJECTIVE: To investigate the degree to which the absence of prescriber identifying information and the absence of pharmacy claims might affect the validity of physicians' economic profiles. STUDY DESIGN: The study database consisted of 4 years of claims from a mixed-model health maintenance organization. Using the grouper of Episode Treatment Groups by Symmetry Health Data Systems, Inc, 2 episode databases were created, with and without pharmacy claims included. For each database, the responsibility for defined episodes was attributed to physicians within specialty (1) on the basis of combined professional and prescribing costs and (2) on the basis of professional costs alone. METHODS: Using the different databases and attribution rules, physicians were ranked within specialty on the economic profiling metric, and the various rankings were compared for consistency. Analyses were performed for cardiologists, family practitioners, general surgeons, and neurologists. RESULTS: The absence of prescriber identifying information appears to have only a small effect on physicians' economic profiles. The absence of pharmacy claims, on the other hand, may affect economic profile performance, but the effects differ by specialty and depend on pharmacy costs as a percentage of episode total costs for the specialty and the correlation of episode costs with and without pharmacy costs included. CONCLUSIONS: Physicians' economic profile rankings are not greatly affected by the presence or absence of prescriber identifying information in pharmacy claims. If pharmacy claims are missing altogether, however, valid economic profiling remains feasible for some clinical specialties but not for others.

Relationship of the use and costs of physician office visits and prescription drugs to travel distance and increases in member cost share.

BACKGROUND: The prescription drug benefit is commonly designed and managed as a stand-alone health insurance product without consideration of how the design of other medical benefits may impact its use. OBJECTIVE: To determine the effects of member cost (copayment/coinsurance) increases on the relationship between the use of physician office visits and the type/tier of prescription medication purchased in a commercially insured population. METHODS: Our research model utilized managed care organization member costshare levels that were changed as part of the annual benefit renewal process to estimate the price.quantity.expenditure relationship between cost sharing and use of physician office visits/prescription drugs by benefit tier. The price.quantity. expenditure relationship was measured across a benefit copayment price change to determine the effect of a price increase on utilization/expenditures. We included the distance from the member.s residence to the physician.s office as a proxy for the time cost of an office visit. The study sample included 44,828 members who were fully insured for the full 12 months of 2002, continued coverage for the full 12 months of 2003, and whose benefit renewal occurred on January 1, 2003. We hypothesize that a relationship exists between office visit use and its expenditures and prescription drug use and its expenditures based on out-of-pocket cost. Hypotheses were tested using a least squares dummy variable regression model across claims records for years 2002 and 2003, containing consecutive yearly records for the same members. The unit of analysis was the member. Demand was estimated by benefit category and copayment tier to provide the study variables, price elasticity of demand, cross-price elasticity of demand, and distance elasticity. Expenditure is net health plan cost after subtraction of member cost share (including copayments, coinsurance, and deductibles). The expenditure categories in this study were pharmacy, medical office visits, and total health care costs. RESULTS: Members with greater travel distance to a primary care physician (PCP) or specialty care physician (SCP) office experienced higher PCP and SCP visit utilization (distance elasticity = 0.164 and 0.202, respectively; P <0.01). Greater travel distance to a PCP was also associated with higher tier-1 prescription use (0.048, P <0.01) as well as higher total plan-paid (0.032, P <0.05) and PCP expenditures (0.141, P <0.01). Greater travel distance to an SCP was associated with higher use of drugs in all 3 pharmacy copayment tiers (0.085, 0.075, and 0.073 for tier 1, tier 2, and tier 3, respectively; P <0.01 for each tier). The price effects of an increase in tier-1 copayments were fewer PCP office visits (-0.118, P <0.01) but more SCP office visits (0.177, P <0.01); SCP visits were also higher with increased tier-3 copayments (0.118, P <0.01). Tier-2 prescription drug use decreased with higher office visit copayments (-0.105, P <0.05). Increased tier-1 copayments were associated with lower expenditures for PCP office visits (-0.146, P <0.05) but higher expenditures for SCP office visits (0.149, P <0.05). While increases in tier-2 copayments were associated with lower PCP (and -0.322, P <0.01) and SCP (-0.453, P <0.01) expenditures, increases in tier-3 copayments were associated with higher PCP (0.495, P <0.01) and SCP (0.197, P <0.05) expenditures. CONCLUSIONS: A relationship exists between physician office visits and prescription drug use based on member cost share and time factors. Increases in office visit copayments were associated with decreased use of drugs in the tier-2 pharmacy benefit category. Increases in tier-2 pharmacy benefit copayment levels were associated with lower PCP/SCP expenditures, but increases in tier-3 pharmacy benefit copayment levels were associated with higher PCP/SCP expenditures. The distance to a physician.s office was directly proportional to the number of office visits. Separation of the management of pharmacy and medical benefits may have significant cost implications for consumers, employers, and health plans. Therefore, optimal management of medical and pharmacy benefits may require a coordinated strategy and tactics.

Health care lobbying in the United States.

PURPOSE: To assess the relative political influence of different organizations, we examined the efforts of health care organizations to influence policy decisions by lobbying lawmakers. METHODS: We reviewed reports filed by lobbyists from 1997 to 2000, as required by the Lobbying Disclosure Act, to characterize health care lobbying at the federal level in the United States. RESULTS: Health care lobbying expenditures totaled 237 million dollars in 2000. These expenditures accounted for 15% of all federal lobbying and were larger than the lobbying expenditures of every other sector, including agriculture, communications, and defense. A total of 1192 organizations were involved in health care lobbying. Pharmaceutical and health product companies spent the most (96 million dollars), followed by physicians and other health professionals (46 million dollars). Disease advocacy and public health organizations spent 12 million dollars. From 1997 to 2000, lobbying expenditures by physicians and other health professionals grew more slowly than lobbying by other organizations (10% vs. 26%). CONCLUSION: Although policy decisions are influenced by many factors, our findings may indicate a limited political influence of disease advocacy and public health organizations and a declining political influence of physicians and other health professionals.

Canaries in a coal mine: California physician groups and competition.

Health care organizations may compete by developing organized processes to improve quality and increase efficiency, or may focus on growing to increase negotiating leverage and on controlling costs through withholding appropriate care and avoiding sick patients. This paper describes key ways in which public and private policy decisions create incentives that influence the competitive focus of physician groups in California, a state in which physician groups and health maintenance organizations are prevalent. These policies do not manage competition in optimal ways: They reward groups for market leverage and controlling costs while failing to fully reward quality and efficiency.

Physician organization in California: crisis and opportunity.

Many of the 250 physician organizations that provide care to California's sixteen million health maintenance organization enrollees are in a state of crisis, squeezed between constrained revenues, rising practice costs, and consumer sentiment that favors unconstrained choice over integrated delivery. Medical groups and independent practice associations are retrenching to their core geographic areas, reducing capitation for drug benefits and hospital services, and abandoning dreams of displacing health plans. Consolidation is accelerating in some areas, as medical groups join with hospitals to extract higher payment rates from insurers and employers. The conjunction of consumerism and premium inflation creates new opportunities for organizations that truly can manage health care, but the challenges roiling California's medical groups may preclude meaningful efforts to seize the initiative.

Does a fixed-dollar premium contribution lower spending?

In a multiple-option health benefits program, the employer's premium contribution determines the incentives facing employees and participating health plans. Advocates of managed contribution argue that a fixed-dollar contribution policy will result in lower health spending by encouraging cost-conscious choices by employees and price competition among plans. The University of California (UC), which adopted a fixed-dollar contribution policy in 1994, provides a useful case study for assessing this claim. This DataWatch documents the effect of this policy on health maintenance organization (HMO) premiums and per employee health spending in the UC health benefits program.

Consumers versus managed care: the new class actions.

The plaintiffs in pending consumer class-action lawsuits against health maintenance organizations (HMOs) should fail in their claims for damages for fraud under federal anti-racketeering legislation. Although HMOs have regularly failed to disclose their business methods and have not strictly honored their contractual coverage promises, the circumstances in which they introduced cost controls into a market sadly lacking them suggest motives not deserving punitive sanctions. Courts could easily find that HMOs violated the Employee Retirement Income Security Act (ERISA), however. Injunctive relief compelling more extensive disclosures and clearer contracts might well legitimize HMOs' methods and generally improve the performance of the health care marketplace.