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Objective: To develop and validate a measure of provider network restrictiveness in the Medicare Advantage (MA) population. Data Sources: Prescription 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 Design: A 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 Methods: Prescription drug event data were obtained for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017. Principal Findings: Health 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%). Multi-variable results confirmed these findings, and also indicated that increased provider supply was associated with less restrictive networks. Conclusions: We 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. KEYWORDS access/demand/utilization of services; managed care organizations (e.g., HMOs/PPOs/IPAs); Medicare; referrals and referral networks What is known on this topic * Provider networks are common in Medicare Advantage (MA). * Limited evidence exists on the association between MA network breadth and plan or market factors. * Existing measures of network breadth are limited and often incomplete. What this study adds * Using an off-the-shelf prediction algorithm and widely accessible claims data, this study develops an approach to measuring MA network restrictiveness based on prescription drug utilization. * This approach can be replicated by other researchers as well as regulators to better target regulation of provider networks., 1 | INTRODUCTION Provider networks concentrate utilization among certain providers and are common in health insurance, with substantial variation in insurance networks' coverage of nearby clinicians and hospitals. (1) Clinicians [...]

1 | INTRODUCTION As the opioid crisis re-intensifies, (1) the potential for fraudulent, wasteful, or abusive substance use disorder (SUD) treatment practices increases. Unethical SUD treatment practices include conducting or [...]

Medicare Advantage (MA) plans are increasingly enrolling veterans. Because MA plans receive full capitated payments regardless of whether or not veterans use Medicare services, the federal government can incur substantial duplicative, wasteful spending if veterans in MA plans predominantly seek care through the Veterans Health Administration (VHA) system. The recent growth of MA plans that disproportionately enroll veterans could further exacerbate such wasteful spending. Using national data, we found that veterans increasingly enrolled in MA between 2016 and 2022, including in a growing number of MA plans in which 20 percent or more of the enrollees were veterans. Notably, about one in five VHA enrollees in these high-veteran MA plans did not incur any Medicare services paid by MA within a given year—a rate 2.5 times that of VHA enrollees in other MA plans and 5.7 times that of the general MA population. Meanwhile, VHA enrollees in high-veteran MA plans were significantly more likely to receive VHA-funded care. In 2020, the Centers for Medicare and Medicaid Services paid more than $1.32 billion to MA plans for VHA enrollees who did not use any Medicare services, with 19.1 percent going to high-veteran MA plans.

Objective: To assess the prevalence of patient administrative tasks and whether they are associated with delayed and/or foregone care. Data Source: March 2019 Health Reform Monitoring Survey. Study Design: We assess the prevalence of five common patient administrative tasks--scheduling, obtaining information, prior authorizations, resolving billing issues, and resolving premium problems--and associated administrative burden, defined as delayed and/or foregone care. Using multivariate logistic models, we examined the association of demographic characteristics with odds of doing tasks and experiencing burdens. Our outcome variables were five common types of administrative tasks as well as composite measures of any task, any delayed care, any foregone care, and any burden (combined delayed/foregone), respectively. Data Collection: We developed and administered survey questions to a nationally representative sample of insured, nonelderly adults (n = 4155). Principal Findings: The survey completion rate was 62%. Seventy-three percent of respondents reported performing at least one administrative task in the past year. About one in three task-doers, or 24.4% of respondents overall, reported delayed or foregone care due to an administrative task: Adjusted for demographics, disability status had the strongest association with administrative tasks (adjusted odds ratio [OR] 2.91, p < 0.001) and burden (adjusted OR 1.66, p < 0.001). Being a woman was associated with doing administrative tasks (adjusted OR 2.19, p < 0.001). Being a college graduate was associated with performing an administrative task (adjusted OR 2.79, p < 0.001), while higher income was associated with fewer subsequent burdens (adjusted OR 0.55, p < 0.01). Conclusions: Patients frequently do administrative tasks that can create burdens resulting in delayed/foregone care. The prevalence of delayed/foregone care due to administrative tasks is comparable to similar estimates of cost-related barriers to care. Demographic disparities in burden warrant further attention. Enhancing measurement of patient administrative work and associated burdens may identify opportunities for assessing quality, value, and patient experience. KEYWORDS access/demand/utilization of services, health care costs, patient assessment/satisfaction, survey research and questionnaire design, 1 | INTRODUCTION Health spending in the United States is highest in the world, driven in part by administrative functions. (1) These include billing, documentation, scheduling, compliance, and other nonclinical [...]

Health is influenced by many factors outside the health system. This is often expressed by decomposing contributors to health into factors that sum to 100 percent. In this commentary, we assess the (few) strengths and (many) limitations of such decompositions. We conclude that they fail to be useful for policy guidance. We conclude by proposing an alternative approach to assessing how various factors affect health: evaluations of interventions. KEYWORDS delivery of health care, economics, policy, public health, quality of health care, 1 | INTRODUCTION Cultural, environmental, political, and economic conditions--the 'social determinants'--shape our lives in ways that affect health. (1,2) A large literature documents associations between social circumstances and health outcomes [...]

Objective. To describe a new Veterans Health Administration (VHA) program to foster the learning health system paradigm by rigorously evaluating health care initiatives and to report key lessons learned in designing those evaluations.Principal Findings. The VHA's Quality Enhancement Research Initiative and its Health Services Research and Development Service are cooperating on several large, randomized program evaluations aimed at improving the care veterans receive and the efficiency with which it is delivered. The evaluations we describe involve collaborative design, outcomes assessment, and implementation science through partnerships between VHA operations and researchers. We review key factors to assess before committing to an evaluation. In addition to traditional design issues (such as ensuring adequate power and availability of data), these include others that are easily overlooked: the stability of intervention financing, means of controlling and commitment to adhering to randomized roll-out, degree of buy-in from key implementation staff, and feasibility of managing multiple veto points for interventions that span several programs, among others.Conclusions. Successful program implementation and rigorous evaluation require resources, specialized expertise, and careful planning. If the learning health system model is to be sustained, organizations will need dedicated programs to prioritize resources and continuously adapt evaluation designs.Key Words. Evaluation design and research, randomized program evaluation, health care organizations and systems, VA health care system, The United States spends over $3 trillion on health care, but less than 0.1 percent of that total on evaluating health care programs and policies (Bridgeland and Orszag 2013). A [...]

Objective. Veterans' utilization of Veterans Affairs (VA) health care is likely influenced by community factors external to the VA, including Medicaid eligibility and unemployment, although such factors are rarely considered in models predicting such utilization. We measured the sensitivity of VA utilization to changes in such community factors (hereafter, 'external determinants'), including the 2014 Medicaid expansion following the Affordable Care Act.Data Sources/Study Setting. We merged VA health care enrollment and utilization data with area-level data on Medicaid policy, unemployment, employer-sponsored insurance, housing prices, and non-VA physician availability (2008-2014).Study Design. For veterans aged 18-64 and >65, we estimated the sensitivity of annual individual VA health care utilization, measured by the cost ($) of care received, to changes in external determinants using longitudinal regression models controlling for individual fixed effects.Principal Findings. All external determinants were associated with small but significant changes in VA health care utilization. In states that expanded Medicaid in 2014, this expansion was associated with 9.1 percent ($826 million) reduction in VA utilization among those aged 18-64; sizable changes occurred in all services used (inpatient, outpatient, and prescription drugs).Conclusions. Changes in alternative insurance coverage and other external determinants may affect VA health care spending. Policy makers should consider these factors in allocating VA resources to meet local demand.Key Words. Veterans, health care utilization, economic conditions, unemployment, Medicaid, insurance coverage, The Department of Veterans Affairs (VA) must 'anticipate and proactively prepare for the needs' (Department of Veterans Affairs 2010) of veterans to provide timely and adequate health care services for [...]

Each of us augments our work as health researchers with a significant amount of writing for lay audiences in popular media, including The New York Times, The Washington Post, The [...]

One of HSR's ambitions, articulated last year, is to address structural racism at the journal. (1) Our motivating concern is that there may be parts of the health services research [...]

In the last issue of Health Services Research, I wrote an Editor's Desk editorial (1) about enhancing our authors' experience--one of my three high-priority goals for the journal. Another goal [...]

As | assumed Health Services Research (HSR) Editor-in-Chief duties from Andy Bindman earlier this year, I began to think about the journal's long-term agenda. With input from the editorial team [...]

Policy makers are increasingly investing in efforts to better integrate Medicare and Medicaid services for people who are eligible for both programs, including expanding Dual-Eligible Special Needs Plans (D-SNPs). In recent years, however, a potential threat to integration has emerged in the form of D-SNP “look-alike” plans, which are conventional Medicare Advantage plans that are marketed toward and primarily enroll dual eligibles but are not subject to federal regulations requiring integrated Medicaid services. To date, limited evidence exists documenting national enrollment trends in look-alike plans or the characteristics of dual eligibles in these plans. We found that look-alike plans experienced rapid enrollment growth among dual eligibles during the period 2013–20, increasing from 20,900 dual eligibles across four states to 220,860 dual eligibles across seventeen states, for an elevenfold increase. Nearly one-third of dual eligibles in look-alike plans were previously in integrated care programs. Compared with D-SNPs, look-alike plans were more likely to enroll dual eligibles who were older, Hispanic, and from disadvantaged communities. Our findings suggest that look-alike plans have the potential to compromise national efforts to integrate care delivery for dual eligibles, including vulnerable subgroups who may benefit the most from integrated coverage.