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Objective: To quantify shared patient relationships between primary care physicians (PCPs) and cardiologists and oncologists and the degree to which those relationships were captured within insurance networks. Data Sources: Secondary analysis of Vericred data on physician networks, CareSet data on physicians' shared Medicare patients, and insurance plan attributes from Health Insurance Compare. Data validation exercises used data from Physician Compare and IQVIA. Study Design: Cross-sectional study of the PCP-to-specialist in-network shared patient percentage (primary outcome). We also categorized networks by insurance market segment (Medicare Advantage [MA], Medicaid managed care, small-group or individually purchased), insurance plan type, and network breadth. Data Extraction: We analyzed data on 219,982 PCPs, 29,400 cardiologists, and 22,745 oncologists who, in 2021, accepted MA (n = 941 networks), Medicaid managed care (n = 293), and individually-purchased (n = 332) and small-group (n = 501) plans. Principal Findings: Networks captured, on average, 64.6% of PCP-cardiology shared patient ties, and 61.8% of PCP-oncologist ties. Less than half of in-network ties (44.5% and 38.9%, respectively) were among physicians with a common organizational affiliation. After adjustment for network breadth, we found no evidence of differences in the shared patient percentage across insurance market segments or networks of different types (p-value >0.05 for all comparisons). An exception was among national versus local and regional networks, where we found that national plans captured fewer shared patient ties, particularly among the narrowest networks (58.4% for national networksvs. 64.7% for local and regional networks for PCP-cardiology). Conclusions: Given recent trends toward narrower networks, our findings underscore the importance of incorporating additional and nuanced measures of network composition to aid plan selection (for patients) and to guide regulatory oversight. KEY WORDS health policy, insurance, insurance benefits, managed care programs, provider networks What is known on this topic * Enrollment in private insurance plans is expected to grow, and private plans are increasingly limiting the number of in-network providers and/or limiting coverage of out-of-network care. * Interspecialty communication among physicians is an important determinant of care quality, spending, and the experience of care for both physicians and patients. * Health services research on provider networks focuses almost exclusively on the breadth of networks, but not on their composition or quality. What this study adds * We develop a novel measure of the degree to which insurance plan networks capture interspecialty relationships among primary care physicians and specialists in oncology and cardiology. * We investigate variation in this measure across insurance market segments, plan types, and network breadth sizes. * In 2021, private insurance networks captured approximately two-thirds of patient-sharing relationships. We find substantial variation in the degree to which narrow network plans capture these relationships., 1 | INTRODUCTION The majority of insured people in the US are covered by private health plans. With few exceptions, these plans require receipt of care from in-network clinicians to [...]

Objective: To compare the characteristics of dialysis facilities used by traditional Medicare (TM) and Medicare advantage (MA) enrollees with end-stage kidney disease (ESKD). Data Sources: We used 20% TM claims and 100% MA encounter data from 2018 and publicly available data from the Centers for Medicare and Medicaid Services. Study Design: We compared the characteristics of the dialysis facilities treating TM and MA patients in the same ZIP code, adjusting for patient characteristics. The outcome variables were facility ownership, distance to the facility, and several measures of facility quality. Data Collection/Extraction: We identified point prevalent dialysis patients as of July 15, 2018. Principal Findings: Compared to TM patients in the same ZIP code, MA patients were 1.84 percentage points more likely to be treated at facilities owned by the largest two dialysis organizations and 1.85 percentage points less likely to be treated at an independently owned facility. MA patients went to further and lower quality facilities than TM patients in the same ZIP code. However, these differences in facility quality were modest. For example, while the mean dialysis facility mortality rate was 21.85, the difference in mortality rates at facilities treating MA and TM patients in the same ZIP code was 0.67 deaths per 100 patient-years. Similarly, MA patients went to facilities that were, on average, 0.15 miles further than TM patients in the same ZIP code. Conclusion: MA enrollees with ESKD were more likely than TM enrollees in the same ZIP code to use the dialysis facilities owned by the two largest chains, travel further for care, and receive care at lower quality facilities. While the magnitude of differences in facility distance and quality was modest, the direction of these results underscores the importance of monitoring dialysis network adequacy as ESKD MA enrollment continues to grow. KEYWORDS chronic disease, health care financing/insurance/premiums, health policy/politics/law/regulation, managed care organizations (e.g., HMOs/PPOs/IPAs), Medicare, ownership/governance (for-prof it/N FP/public/chains/systems) What is known on this topic * Medicare advantage (MA) enrollment among beneficiaries with end-stage kidney disease (ESKD) is expected to grow because of recent policy changes. * Most ESKD patients are treated with dialysis. Two large dialysis organizations that control about 75% of the outpatient dialysis market charge high prices to MA plans * The impact of the concentrated dialysis market on how MA plans form dialysis provider networks, and where MA patients are treated is unknown. What this study adds * In 2018, MA patients were more likely than TM patients in the same ZIP code to be treated at facilities owned by the two largest dialysis organizations. * There were substantial differences in the ownership of the treating facility across MA carriers, suggesting preferred relationships between large providers and carriers. * Compared to TM patients in the same ZIP code, MA patients go to further and lower-quality facilities, though these differences were modest., 1 | INTRODUCTION About half a million people in the United States with end-stage kidney disease (ESKD), a condition characterized by permanent and irreversible kidney damage, rely on regular dialysis [...]

Objective: Examine whether Medicare Advantage (MA) coverage is associated with more efficient prescribing of Part B drugs than traditional Medicare (TM) coverage. Data Sources: Twenty percent sample of 2016 outpatient and carrier TM claims and MA encounter records and Master Beneficiary Summary File data. Study Design: We analyzed whether MA enrollees compared to TM enrollees more often received the low-cost Part B drug in four clinical scenarios where multiple similarly effective drugs exist: (1) anti-VEGF agents to treat macular degeneration, (2) bone resorption inhibitors for osteoporosis, (3) bone resorption inhibitors for malignant neoplasms, and (4) intravenous iron for iron deficiency anemia. We then estimated differences in spending if TM prescribing aligned with MA prescribing. Finally, using linear probability models, we examined whether differences in MA and TM prescribing patterns were attributable to differences in the hospitals and clinician practices who treat MA and TM enrollees or differences in how these hospitals and clinician practices treat their MA versus TM patients. Data Collection/Extraction Methods: Not applicable. Principal Findings: In all cases, a larger share of MA enrollees received the low-cost drug compared to TM enrollees, ranging from 8 percentage points higher for anemia to 16 percentage points higher for macular degeneration in the unadjusted analysis. Results were similar in regression analyses controlling for enrollee characteristics and market factors (5-13 percentage points). If TM prescribing matched MA prescribing, we estimated savings ranging from 6% to 20% of TM spending for each scenario. Differences in prescribing patterns were driven both by MA enrollees receiving treatment at more efficient hospitals and clinician practices and hospitals and clinician practices more often prescribing low-cost drugs to their MA patients. Conclusions: Our findings show MA enrollees were more likely than TM enrollees to receive low-cost Part B drugs in four clinical scenarios where multiple similarly or equally effective treatment options exist. KEYWORDS drug costs, Medicare, Medicare Part B/economics, Medicare Part C, prescription drugs, reimbursement mechanisms What Is known on this topic * The current traditional Medicare reimbursement system for Part B drugs incentivizes clinician practices and hospital outpatient departments to prescribe more expensive drugs. * Medicare Advantage insurers have a financial incentive to reduce spending on medical services, but it is unknown whether Medicare Advantage coverage reduces wasteful spending on Part B drugs. * There is limited research on whether Medicare Advantage coverage is associated with more efficient or higher quality treatment, and the existing studies have mixed results. What this study adds * Medicare Advantage coverage was associated with more efficient prescribing of Part B drugs in four scenarios where multiple similarly effective treatments were available. * Medicare Advantage enrollees received treatment at hospitals and clinician practices that favored prescribing lower cost Part B drugs. * In addition, within hospitals and clinician practices, Medicare Advantage enrollees more often received low-cost drugs than traditional Medicare enrollees., 1 | INTRODUCTION Medicare spending on Part B drugs (i.e., clinician-administered injections and infusions) grew 9.6% annually from 2009 to 2017, which is more than double the 4.4% annual increase [...]

Objective: To examine how plan premiums are associated with physician network breadth, hospital network breadth, and hospital network quality on the Affordable Care Act's Health Insurance Marketplaces in all 50 states and the DC in 2016. Data Sources: Data on plan premiums and characteristics came from 2016 Robert Wood Johnson Foundation Health Insurance Exchange (HIX) Compare. Provider network information was obtained from Vericred. Hospital characteristics were obtained from CMS Hospital Compare and the American Hospital Association (AHA) survey. Study Design: We analyzed how plan premiums were associated with variations in physician network breadth, hospital network breadth, and hospital network quality using ordinary least square regressions with state-rating area fixed effects and carrier fixed effects. Principal Findings: Plan premiums were positively associated with physician network breadth and hospital network breadth. We find the following statistically significant results: a one standard deviation increase in physician network breadth was linked to a premium increase of 2,8 percent or $101 per year; a one standard deviation increase in hospital network breadth was linked to a premium increase of 2.4 percent or $86 per year. There was no significant association between premiums and hospital network quality, as measured by hospital star ratings and the inclusion of teaching hospitals or the top-20 hospitals nationwide. Conclusions: Physician network breadth and hospital network breadth contributed positively to plan premiums. The roles of the two types of provider network breadth are quantitatively similar. Premiums appear to be insensitive to hospital network quality. KEYWORDS Affordable Care Act (ACA) Health Insurance Marketplace, hedonic pricing, narrow network, network quality, plan premium, 1 | INTRODUCTION Plans with restricted provider networks--plans where the providers available to beneficiaries are restricted through a narrow provider network paired with plan benefits that either only cover in-network [...]

Objective: To compare access at community health centers (CHCs) vs private offices (non-CHCs) under the Affordable Care Act. Data Source: Ten state primary care audit conducted in 2012/2013 and 2016. Study Design: CHCs and non-CHCs were called. We calculated difference in differences comparing CHCs vs non-CHCs by caller insurance type. Principal Findings: In both rounds, Medicaid and uninsured callers had higher appointment rates at CHC than non-CHCs. CHC appointment rates significantly increased between 2012/2013 and 2016 for both employer-sponsored and Medicaid callers, with no significant wait time changes. Appointment rates increased (13.5% points, P < 0.001) and wait times decreased (-5.7 days, P = 0.017) at CHCs relative to non-CHCs for employer-sponsored insurance. Conclusion: Appointment availability at CHCs improved after ACA implementation, without increased wait times. KEYWORDS access, Affordable Care Act, community health centers, 1 | INTRODUCTION Community health centers (CHCs) specialize in delivering care to populations that are predominantly low income and enrolled in Medicaid or uninsured. (1) Expanded access to CHCs has [...]