Breadth and Exclusivity of Hospital and Physician Networks in US Insurance Markets.
Breadth and Exclusivity of Hospital and Physician Networks in US Insurance Markets.
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美国保险市场中医院和医师网络的广度和排他性。
DOI：
10.1001/jamanetworkopen.2020.29419
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发表时间：
2020-12-01
影响因子：
13.8
通讯作者：
Polsky D
中科院分区：
文献类型：
--
作者：
Graves JA;Nshuti L;Everson J;Richards M;Buntin M;Nikpay S;Zhou Z;Polsky D
医疗保健网络的广度及其重叠程度在专业和保险市场内部和不同领域是如何变化的？在这项对1192个医疗保健网络的横断面研究中，大集团雇主网络比小集团雇主、市场、医疗保险优势和医疗补助管理的医疗网络更广泛。在许多州，较窄的网络与最广泛的网络相比，不同保险公司网络之间的重叠程度即使不是更多，也是一样多；保险、医生和医院市场集中度较低的地区，网络范围更窄，排他性更强。这些发现表明，计划网络的结构可能是决定美国医疗负担能力和连续性的一个因素，特别是考虑到个人更换保险计划的频率。本横断面研究量化了以雇主为基础、个人购买、医疗保险优势和医疗补助管理医疗计划的初级保健医生、心脏病科和普通急症护理医院网络的网络广度和排他性（即重叠）。人们对医疗保健网络的广度或不同保险公司网络重叠的程度知之甚少。量化以雇主为基础（大集团和小集团）、个人购买（市场）、医疗保险优势（MA）和医疗补助管理医疗（MMC）计划的初级保健医生（PCP）、心脏病学和普通急症护理医院网络的网络广度和排他性（即重叠）。这项横断面研究包括来自Vericred的1192个网络。分析单位是网络邮编-临床医生类型-市场，它从一个假设的患者的角度捕捉网络的属性，该患者在60分钟的车程内寻求网络内的临床医生或医院。参加私人保险计划。在给定的邮政编码（宽度）内，距离假设患者60分钟车程内的网络内医生和/或医院的百分比。每个网络中与其他保险公司网络重叠的医生和/或医院数量，表示为共享连接总数（独占性）的百分比。描述性统计（平均值，分位数）是根据整体和网络宽度类别进行的，如下：超小型（<10%），小型（10%-25%），中型（25%-40%），大型（40%-60%）和超大型（>60%）。通过Hirschman-Herfindahl指数，按保险类型、州和保险、医生和/或医院市场集中度对网络进行分析。在所有美国邮政编码网络的观察中，511143个大集团PCP网络中有415549个（81%）是大型或超大型网络，而202 702 MA网络中有138 485个（68%），318 082个小集团网络中有191 918个（60%），149 841个市场网络中有60 425个（40%），66 370 MMC网络中有21 781个（40%）。大集团雇主网络的覆盖面比所有其他网络计划更广（平均[SD] PCP广度：大集团雇主计划，57.3%[20.1]；小集团雇主计划，45.7%[21.4]；市场，36.4% [21.2]；MMC, 32.3% [19.3]； MA, 47.4%[18.3]）。MMC网络的排他性最低（pcp的平均[SD]重叠率为61.3%[10.5]，心脏病学为66.5%[9.8]，医院为60.2%[12.3]）。加州的网络最窄（平均[SD]宽度为42.4%[16.9]）和最排外（平均[SD]重叠47.7%[23.0]），内布拉斯加州的网络最宽（79.9%[16.6]）和最不排外（71.1%[14.6]）。保险公司和市场集中度的提高与更广泛和更少的排他性网络有关。初级保健和保险市场集中的市场在大集团商业计划中具有最广泛（中位数[四分位数间距{IQR}]， 75.0%[60.0%-83.1%]）和最不排外（中位数[IQR]， 63.7%[52.4%-73.7%]）的初级保健网络，而最不集中的市场具有最狭窄（中位数[IQR]， 54.6%[46.8%-67.6%]）和最排外（中位数[IQR]， 49.4%[41.9%-56.9%]）的网络。在本研究中，较窄的医疗保健网络与同一地理区域内的其他网络有较大程度的重叠，而较宽的网络与医生、医院和保险市场集中有关。这些结果表明，许多患者可以转向低成本的窄网络计划，而不会失去网络内的PCP访问，尽管未来的研究需要评估对护理质量和跨网络内医疗保健专业人员和窄网络计划的临床整合的影响。
How does the breadth of health care networks and the degree to which they overlap vary within and across specialties and insurance markets? In this cross-sectional study of 1192 health care networks, large-group employer networks were broader than small-group employer, marketplace, Medicare Advantage, and Medicaid managed care networks. In many states, narrower networks had as much, if not more, overlap across different insurers’ networks than the broadest networks; areas with less concentrated insurance, physician, and hospital markets had narrower and more exclusive networks. These findings suggest that the structure of plan networks may be a factor in determining care affordability and continuity in the United States, particularly given how frequently individuals change insurance plans. This cross-sectional study quantifies network breadth and exclusivity (ie, overlap) among primary care physician, cardiology, and general acute care hospital networks for employer-based, individually purchased, Medicare Advantage, and Medicaid managed care plans. Little is known about the breadth of health care networks or the degree to which different insurers’ networks overlap. To quantify network breadth and exclusivity (ie, overlap) among primary care physician (PCP), cardiology, and general acute care hospital networks for employer-based (large group and small group), individually purchased (marketplace), Medicare Advantage (MA), and Medicaid managed care (MMC) plans. This cross-sectional study included 1192 networks from Vericred. The analytic unit was the network–zip code–clinician type–market, which captured attributes of networks from the perspective of a hypothetical patient seeking access to in-network clinicians or hospitals within a 60-minute drive. Enrollment in a private insurance plan. Percentage of in-network physicians and/or hospitals within a 60-minute drive from a hypothetical patient in a given zip code (breadth). Number of physicians and/or hospitals within each network that overlapped with other insurers’ networks, expressed as a percentage of the total possible number of shared connections (exclusivity). Descriptive statistics (mean, quantiles) were produced overall and by network breadth category, as follows: extra-small (<10%), small (10%-25%), medium (25%-40%), large (40%-60%), and extra-large (>60%). Networks were analyzed by insurance type, state, and insurance, physician, and/or hospital market concentration level, as measured by the Hirschman-Herfindahl index. Across all US zip code–network observations, 415 549 of 511 143 large-group PCP networks (81%) were large or extra-large compared with 138 485 of 202 702 MA (68%), 191 918 of 318 082 small-group (60%), 60 425 of 149 841 marketplace (40%), and 21 781 of 66 370 MMC (40%) networks. Large-group employer networks had broader coverage than all other network plans (mean [SD] PCP breadth: large-group employer-based plans, 57.3% [20.1]; small-group employer-based plans, 45.7% [21.4]; marketplace, 36,4% [21.2]; MMC, 32.3% [19.3]; MA, 47.4% [18.3]). MMC networks were the least exclusive (a mean [SD] overlap of 61.3% [10.5] for PCPs, 66.5% [9.8] for cardiology, and 60.2% [12.3] for hospitals). Networks were narrowest (mean [SD] breadth 42.4% [16.9]) and most exclusive (mean [SD] overlap 47.7% [23.0]) in California and broadest (79.9% [16.6]) and least exclusive (71.1% [14.6]) in Nebraska. Rising levels of insurer and market concentration were associated with broader and less exclusive networks. Markets with concentrated primary care and insurance markets had the broadest (median [interquartile range {IQR}], 75.0% [60.0%-83.1%]) and least exclusive (median [IQR], 63.7% [52.4%-73.7%]) primary care networks among large-group commercial plans, while markets with least concentration had the narrowest (median [IQR], 54.6% [46.8%-67.6%]) and most exclusive (median [IQR], 49.4% [41.9%-56.9%]) networks. In this study, narrower health care networks had a relatively large degree of overlap with other networks in the same geographic area, while broader networks were associated with physician, hospital, and insurance market concentration. These results suggest that many patients could switch to a lower-cost, narrow network plan without losing in-network access to their PCP, although future research is needed to assess the implications for care quality and clinical integration across in-network health care professionals and facilities in narrow network plans.
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