Variation in network adequacy standards in Medicaid managed care.
Variation in network adequacy standards in Medicaid managed care.
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DOI：
10.37765/ajmc.2022.89156
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发表时间：
2022-06
影响因子：
3.2
通讯作者：
McConnell, K. John
中科院分区：
文献类型：
--
作者：
Zhu, Jane M.;Polsky, Daniel;Johnstone, Cameron;McConnell, K. John
描述具有管理式医疗安排的州医疗补助计划所使用的网络充足性标准的类型和广度。医疗补助提供者网络报告、管理式医疗计划合同、访问监控审查计划、医疗补助服务手册、质量策略审查以及州法规和法规的文件分析。我们分析了 2017 年至 2020 年的 52 份主要文件，代表了 40 个实行医疗补助管理医疗的州中的 39 个州。我们对网络充足性标准、提供商类型的标准差异、及时访问标准、非定量网络访问标准以及监控或执行计划进行了描述性分析。大多数 (89.7%) 的州采用时间和距离标准来衡量网络充足性，并按人口规模或地理位置进行分层。初级保健提供者的时间和距离标准为 15-90 分钟（农村地区平均 44.7 分钟，城市地区 28.9 分钟）到心脏病专家的 30-135 分钟（农村地区平均 72.1 分钟，城市地区 40.4 分钟）。大多数州还使用及时访问或预约可用性标准。相对较少的州采用其他定量标准，例如提供者与参与者的比率，或在合规性较差的情况下提供详细的执行计划。大多数州使用旅行时间和距离来考虑当地情况和地理位置，但医疗补助计划之间存在很大差异。一些州没有公布其网络充足性法规，或者尽管有联邦要求，仍依赖定性标准。为了使网络充足性有意义，各国必须平衡灵活性和问责制之间的紧张关系，并确保法规得到相应的监督和执行。医疗补助管理式医疗网络充分性标准在不同地区和专业之间表现出显着的异质性，可能会导致医疗保健的获取和质量存在巨大差异。
To describe the types and breadth of network adequacy standards used by state Medicaid programs with managed care arrangements. Document analysis of Medicaid provider network reports, managed care plan contracts, access monitoring review plans, Medicaid services manuals, quality strategy reviews, and state statutes and regulations. We analyzed 52 primary documents from 2017–2020, representing 39 out of the 40 states with Medicaid managed care. We conducted descriptive analyses of network adequacy standards, variation in standards by type of provider, timely access standards, non-quantitative network access standards, and monitoring or enforcement plans. A majority (89.7%) of states applied time and distance standards for network adequacy, stratified by population size or geography. Time and distance standards ranged from 15–90 minutes for a primary care provider (mean, 44.7 minutes in rural areas, 28.9 minutes in urban areas) to 30–135 minutes for a cardiologist (mean, 72.1 minutes in rural areas, 40.4 minutes in urban areas). Most states also used timely access or appointment availability standards. Relatively few states applied other quantitative standards like provider-to-enrollee ratios or provided detailed enforcement plans in cases of poor compliance. Most states use travel time and distance to account for local contexts and geographies, but there is considerable variation across Medicaid programs. Several states do not publicize their network adequacy regulations, or rely on qualitative standards despite federal requirements. For network adequacy to be meaningful, states must balance the tension between flexibility and accountability and ensure that regulations are monitored and enforced accordingly. Medicaid managed care network adequacy standards exhibit significant heterogeneity across regions and specialties, potentially creating large variations in health care access and quality.
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影响因子：
4.8
作者：
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通讯作者：
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影响因子：
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通讯作者：
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影响因子：
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作者：
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