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: 10602542
• 负责人: Austin B. Frakt
• 金额: $ 54.35万
• 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 2025-01-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10602542
• 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; Marketing; Measures; Mediating; Medicare; Modeling; Outcome; Patients; Pharmaceutical Preparations; Physicians; Policy Maker; Primary Care Physician; Privatization; Process; Provider; Quality of Care; Readability; Recommendation; Reporting; Research Personnel; Specialist; Time; United States Centers for Medicare and Medicaid Services; Variant; Work; access restrictions; beneficiary; care costs; care delivery; cost; experience; innovation; medical specialties; patient oriented; programs; risk selection; 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.

大约三分之一的医疗保险受益人现在依靠医疗保险优势（MA），私人 传统医疗保险的替代品，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 护理质量或受益人成本。这种信息的缺乏有两个主要影响： 消费者不知道他们在MA购买的是什么（就医疗质量而言，他们将 政策制定者无法有效地监管并购市场，以优化准入、质量或 成本信息的缺乏主要是由于我们几乎没有可靠的数据 MA为病人提供的网络。为了规避这些挑战，我们的团队 开创了一种创新的方法来表征MA医生网络的组成 以及在全国范围内的普及。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和成本之间的关系 为受益人。 我们的广泛目标是了解MA计划通过其网络提供的护理， 从而影响MA患者的质量和成本。我们之前利用了Part D， 医疗保险处方药数据，从初级保健处方事件中推断网络 医生授权原则是，在计划中为登记者开更多处方的医生 更有可能是在网络上的计划比医生谁开少。虽然它 最好是依靠网络信息的计划目录，我们以前的工作表明， 计划报告的网络具有实质性错误。此外，他们没有捕捉到哪些医生 是可以接近和接受病人的。虽然最近公布的MA索赔数据 这些数据仅限于三年，准确性未知。因此，我们的方法 仍然是唯一已知的，可靠的方法来评估MA网络。 拟议的项目在这个时候是至关重要的，因为在多大程度上， 政策制定者不了解建立网络对护理质量的影响。此外，委员会认为， 目前没有具体的指导方针，以受益人获得或放弃什么，以换取 更窄或更宽的MA网络。由于在质量的各个方面可能存在权衡， 保险费和费用分摊，这项研究的结果将是至关重要的受益人（通知 他们如何选择计划），以及政策制定者，建议在哪里加强监管审查 可能需要围绕网络的充分性和质量。

项目成果

Use of High-Risk Medications Among Older Adults Enrolled in Medicare Advantage Plans vs Traditional Medicare.

• DOI: 10.1001/jamanetworkopen.2023.20583
• 发表时间: 2023-06-01
• 期刊: JAMA NETWORK OPEN
• 影响因子: 13.8
• 作者: Figueroa, Jose F.;Dai, Dannie;Feyman, Yevgeniy;Garrido, Melissa M.;Tsai, Thomas C.;Orav, E. John;Frakt, Austin B.
• 通讯作者: Frakt, Austin B.

Measuring restrictiveness of Medicare Advantage networks: A claims-based approach.

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
• 发表时间: 2024
• 期刊: Health services research
• 影响因子: 3.4
• 作者: Feyman,Yevgeniy;Pizer,StevenD;Shafer,PaulR;Frakt,AustinB;Garrido,MelissaM
• 通讯作者: Garrido,MelissaM

Rapid Enrollment Growth In 'Look-Alike' Dual-Eligible Special Needs Plans: A Threat To Integrated Care.

“相似”双重资格特殊需求计划的注册人数快速增长：对综合护理的威胁。

• DOI: 10.1377/hlthaff.2023.00103
• 发表时间: 2023
• 期刊: Health affairs (Project Hope)
• 作者: Ma,Yanlei;Frakt,AustinB;Roberts,EricT;Johnston,KentonJ;Phelan,Jessica;Figueroa,JoséF
• 通讯作者: Figueroa,JoséF