A Tale of Two Programs: Access to High Quality Providers for Medicare Advantage and Affordable Care Act Beneficiaries in New York State

Abstract

Medicare Advantage and the Affordable Care Act's insurance marketplaces provide coverage to millions of beneficiaries. This paper assesses network design and access to percutaneous coronary intervention (PCI or angioplasty with stent) in New York for both programs. A specific focus is on access to higher quality providers. The findings indicate that both programs significantly restricted access and choice as compared to an unconstrained network. However, network design only rarely created areas devoid of any providers. In terms of access to quality, both programs tended to have slightly worse mean and median quality ratings than the overall physician supply. Findings with regard to access to above‐average providers were mixed. With respect to access to the highest quality providers, both ACA and Medicare Advantage plans generally fared slightly worse than unrestricted networks. In micropolitan and rural areas, access issues became apparent. Network regulation may do little to address these concerns. However, adding non‐emergency medical transportation benefits to insurance coverage may prove to be desirable going forward.

Going the Extra Mile? How Provider Network Design Increases Consumer Travel Distance, Particularly for Rural Consumers

“…While we include an analysis of access to the three closest providers, we also do not fully incorporate network breadth into our analyses. Other analyses that have done so indicate analogous findings to ours with regard to access (Haeder , 2019c(Haeder , 2019dHaeder, Weimer, and Mukamel 2019a). We also cannot connect our network data to actual utilization data.…”

“…Recent scholarly attention on provider networks has largely focused on their effects on premiums (Dafny et al 2017;Polsky, Cidav, and Swanson 2016) as well as on their narrowness (Giovannelli, Lucia, and Corlette 2015;Mukamel 2015a, 2015b;Polsky and Weiner 2015). Several studies have even begun to explore the relationship between provider quality and network design (Haeder, Weimer, and Mukamel 2015a;Haeder , 2019cHaeder , 2020Yasaitis, Bekelman, and Polsky 2017). While premiums and the number of in-network providers are important to consumers, insurers can impose another potentially challenging barrier to consumer access through decisions about which providers to include in their networks.…”

Quality Advantage? Provider Quality and Networks in Medicare Advantage

“…These costs are expected to balloon to $215 billion annually by 2035 (American Heart Association, 2017). While percutaneous coronary interventions (PCI) have increased in significance (Haeder, 2019b), two common procedures conducted for patients with heart disease are coronary artery bypass graft (CABG) surgery and heart valve surgery.…”

“…The actual quality of providers in Medicare Advantage networks has been understudied (Haeder, 2019a(Haeder, , 2019b; and, CMS does not include quality measures in its regulations of Medicare Advantage plans (Haeder, Weimer, & Mukamel, 2019b). Thus, this study aims to answer two important questions about the potential role provider networks play in restricting access for Medicare Advantage beneficiaries.…”

Inadequate in the Best of Times: Reevaluating Provider Networks in Light of the Coronavirus Pandemic

“…This, of course, particularly applies to Medicare beneficiaries, who are trading a virtually open network with almost unconstrained choice of providers in traditional Medicare, for one that is highly regulated and restricted by the insurance carrier in Medicare Advantage. A number of recent papers assessing provider networks for a variety of specialties and procedures raise significant concerns about the potential effects for the health of Americans and offer important insights for the potential impact of the coronavirus epidemic for Medicare Advantage (Haeder, 2019a, 2019b, 2020) and Affordable Care Act marketplace beneficiaries (Haeder, 2019b; Haeder et al, 2020a; Haeder, Weimer, & Mukamel, 2019a, 2020b) as well as commercial plans (Haeder et al, 2019a, 2020a, 2020b).…”