Measuring restrictiveness of Medicare Advantage networks: A claims-based approach.
Measuring restrictiveness of Medicare Advantage networks: A claims-based approach.
复制标题
衡量医疗保险优势网络的限制性：基于索赔的方法。
DOI：
10.1111/1475-6773.14255
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发表时间：
2024
影响因子：
3.4
通讯作者：
Garrido,MelissaM
中科院分区：
文献类型：
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作者：
Feyman,Yevgeniy;Pizer,StevenD;Shafer,PaulR;Frakt,AustinB;Garrido,MelissaM
目的开发和验证医疗保险优势（MA）人群中提供者网络限制性的测量方法。数据来源：医疗保险和医疗补助服务中心D部分登记者的处方药事件数据和受益人信息，沿着处方者标识符;地区卫生资源文件中的地理变量。研究设计一个预测模型被用来预测唯一数量的初级保健提供者，在没有网络限制的情况下，该模型在传统医疗保险（TM）受益人身上进行了训练和验证。评估了伪泊松和随机森林模型。观察与预期（O/E）比率计算为MA受益人看到的独特提供者数量除以基于TM预测模型的预期数量。使用多变量线性模型评估网络限制性与计划和市场因素之间的关系。数据收集/提取方法从2011年至2017年参加处方药覆盖的20%随机样本受益人中获得处方药事件数据。主要发现健康维护组织计划更具限制性（O/E= 55.5%; 95% CI 55.3%-55.7%）（67.2%; 95% CI 66.7%-67.8%）或首选提供商组织计划（74.7%; 95% CI 74.3%-75.1%），农村地区（31.6%; 95% CI 29.0%-34.2%）比大都市地区（61.5%; 95% CI 61.3%-61.7%）有更多的限制性网络。多变量的结果证实了这些发现，也表明，供应商的供应增加与限制较少的networks.ConclusionsWe开发了一种方法估计供应商网络的限制性MA索赔数据。我们的结果验证了该方法，为更广泛的应用提供了信心（例如，用于其他市场和专业）和用于调节。
ObjectiveTo develop and validate a measure of provider network restrictiveness in the Medicare Advantage (MA) population.Data SourcesPrescription drug event data and beneficiary information for Part D enrollees from the Center for Medicare and Medicaid Services, along with prescriber identifiers; geographic variables from the Area Health Resources Files.Study DesignA prediction model was used to predict the unique number of primary care providers that would have been seen by MA beneficiaries absent network restrictions. The model was trained and validated on Traditional Medicare (TM) beneficiaries. A pseudo‐Poisson and a random forest model were evaluated. An observed‐to‐expected (O/E) ratio was calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based the TM prediction model. Multivariable linear models were used to assess the relationship between network restrictiveness and plan and market factors.Data Collection/Extraction MethodsPrescription drug event data were obtained for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017.Principal FindingsHealth Maintenance Organization plans were more restrictive (O/E= 55.5%; 95% CI 55.3%–55.7%) than Health Maintenance Organization‐Point of Service plans (67.2%; 95% CI 66.7%–67.8%) or Preferred Provider Organization plans (74.7%; 95% CI 74.3%–75.1%), and rural areas had more restrictive networks (31.6%; 95% CI 29.0%–34.2%) than metropolitan areas (61.5%; 95% CI 61.3%–61.7%). Multivariable results confirmed these findings, and also indicated that increased provider supply was associated with less restrictive networks.ConclusionsWe developed a means of estimating provider network restrictiveness in MA from claims data. Our results validate the approach, providing confidence for wider application (e.g., for other markets and specialties) and use for regulation.