Mixed signals: The inadequacy of provider-per-enrollee ratios for assessing network adequacy in California (and elsewhere)
Mixed signals: The inadequacy of provider-per-enrollee ratios for assessing network adequacy in California (and elsewhere)
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DOI：
10.1002/wmh3.466
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发表时间：
2021-07-21
影响因子：
4.1
通讯作者：
Mukamel, Dana B.
中科院分区：
文献类型：
--
作者：
Haeder, Simon F.;Weimer, David L.;Mukamel, Dana B.
医疗保险监管机构经常设定医疗保险计划的提供者=每个参保人的最低比率，以试图确保其提供者网络为参保人提供足够的医疗服务。然而，当每个提供商只参与一个单一网络时，特定于计划的比率才有明确的解释。基于网络数据，我们发现加州的内分泌科医生、妇产科医生、心脏病医生和儿科医生平均分别参与了、66、72和63个网络。网络中如此高的参与率使得在计划级别测量的提供商与参与者的比率作为接入指标毫无意义。我们建议放弃针对具体计划的比率，转而采用更有质量的方法，提供强有力的争议解决保护以及“警察巡逻”(例如，监管机构调查以评估预约的等待时间)和“火警”(例如，向消费者权益倡导组织投资资源)。
Health insurance regulators often set minimum ratios of provider = per-enrollee for health insurance plans to try to ensure that their provider networks offer enrollees adequate access to medical care. However, plan-specific ratios only have an unambiguous interpretation when each provider participates in only one single network. Based on network data, we show that endocrinologists, obstetrician-gynecologists, cardiologists, and pediatricians in California participate on average in 64, 66, 72, and 63 networks, respectively. Such high participation rates in networks make provider-per-enrollee ratios measured at the plan level meaningless as metrics for access. We recommend that plan-specific ratios be abandoned in favor of a more qualitative approach with strong dispute resolution protections as well as "police patrols" (e.g., regulator surveys to assess waiting times for appointments) and "fire alarms" (e.g., investing resources in consumer advocate organizations).