A National Analysis of the Extent and Value of Medicare Advantage Physician Networks

医疗保险优势医生网络的范围和价值的全国分析

• 批准号: 10395554
• 负责人: Austin B. Frakt
• 金额: $ 42.98万
• 依托单位: HARVARD SCHOOL OF PUBLIC HEALTH
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-05-01 至 2024-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10395554
• 关键词: Accountability; Address; Affect; Caring; Clinical; Cost Analysis; Cost Control; Cost Sharing; Data; Dimensions; Directories; Drug Prescriptions; Enrollment; Event; Exhibits; Goals; Government; Health; Hospitals; Information Networks; Knowledge; Longitudinal Studies; Measures; Mediating; Medicare; Modeling; Outcome; Patients; Pharmaceutical Preparations; Physicians; Primary Care Physician; Privatization; Process; Provider; Quality of Care; Readability; Reporting; Research Personnel; Risk; Specialist; Time; United States Centers for Medicare and Medicaid Services; Variant; Work; base; beneficiary; care costs; care delivery; care outcomes; cost; experience; innovation; medical specialties; patient oriented; programs; welfare

About one-third of Medicare beneficiaries now rely on Medicare Advantage (MA), the private alternative to traditional Medicare, almost twice as many as did a decade ago. A mainstay of how MA manages costs and quality is through restricting access to specific networks of covered physicians and hospitals. However, we know little about how these limitations actually affect the quality or beneficiary cost of care. This lack of information has two major implications: consumers don’t know what they are buying in MA (in terms of the quality of care they will receive) and policymakers can’t effectively regulate MA markets to optimize access, quality, or costs. The lack of information is driven primarily by the fact that we have little, reliable data about the networks MA provides its patients. Circumventing these challenges, our team has pioneered an innovative approach to characterize the composition of MA physician networks and access on a national scale and over time. This project would apply this approach to high- cost specialists, as well as determine relationships between access and plan quality and costs for beneficiaries. Our broad goal is to understand MA plans’ care delivery though their networks and the resulting impact on quality and costs for MA patients. We previously exploited Part D, the Medicare prescription drug data, to infer networks from prescription events for primary care physicians. The enabling principle is that physicians who prescribe more for enrollees in a plan are more likely to be in-network for that plan than physicians who prescribe less. Though it would be preferable to rely on plan directories for network information, our prior work shows that plan-reported networks have substantial errors. Moreover, they do not capture which physicians are accessible and accepting patients. While there are recently released MA claims data available, they are limited to just three years and are of unknown accuracy. Thus, our approach remains the only known, reliable way to assess MA networks. The proposed project is crucial at this time because the extent to which MA, through establishment of networks, influences the quality of care is unknown to policymakers. Moreover, no specific guidance currently exists as to what beneficiaries gain or give up in exchange for narrower or broader networks in MA. As there are likely tradeoffs across dimensions of quality, premiums, and cost sharing, the findings of this study will be critical for beneficiaries (informing how they choose plans), as well as policymakers, suggesting where greater regulatory scrutiny around network adequacy and quality may be needed.

大约三分之一的 Medicare 受益人现在依赖 Medicare Advantage (MA)，即私人医疗保险 传统医疗保险的替代方案，几乎是十年前的两倍。的中流砥柱 MA 如何管理成本和质量是通过限制对所覆盖的特定网络的访问 医生和医院。然而，我们对这些限制实际上如何影响我们知之甚少。 护理质量或受益人费用。信息的缺乏有两个主要影响： 消费者不知道他们在马萨诸塞州购买什么（就护理质量而言，他们会 接收），政策制定者无法有效监管 MA 市场以优化准入、质量或 成本。信息缺乏的主要原因是我们几乎没有可靠的数据 关于 MA 为其患者提供的网络。为了克服这些挑战，我们的团队 开创了一种创新方法来描述 MA 医生网络的组成 并随着时间的推移在全国范围内进行访问。该项目将把这种方法应用于高 成本专家，以及确定访问和计划质量与成本之间的关系 对于受益人。 我们的总体目标是了解 MA 计划通过其网络和 由此对 MA 患者的质量和成本产生影响。我们之前利用了 D 部分， 医疗保险处方药数据，从初级保健处方事件推断网络 医生。授权原则是，为计划中的参与者开出更多处方的医生 与处方较少的医生相比，更有可能参与该计划的网络内。虽然它 最好依靠计划目录来获取网络信息，我们之前的工作表明 计划报告的网络存在重大错误。此外，他们没有捕获哪些医生 易于接受并接受患者。虽然最近发布了 MA 索赔数据 虽然可用，但其有效期仅限三年，且准确性未知。因此，我们的方法 仍然是评估 MA 网络的唯一已知、可靠的方法。 拟议的项目此时至关重要，因为 MA 通过的程度 政策制定者不知道网络的建立对护理质量的影响。而且， 目前没有关于受益人获得或放弃什么来换取什么的具体指导 MA 中更窄或更宽的网络。由于质量维度之间可能存在权衡， 保费和费用分摊，这项研究的结果对于受益人至关重要（告知 他们如何选择计划）以及政策制定者，建议在哪些方面加强监管审查 可能需要围绕网络充足性和质量。