Composition of buprenorphine prescribing networks in Medicaid and association with quality of care

INTRODUCTION

Despite Medicaid's outsized role in delivering and financing medications for opioid use disorder (MOUD), little is known about the extent to which buprenorphine prescriber networks vary across Medicaid health plans, and whether network characteristics affect quality of treatment received. In this observational cross-sectional study, we used 2018-2019 Medicaid claims in Oregon to assess network variation in the numbers and types of buprenorphine prescribers, as well as the association of prescriber and network characteristics with quality of care.

METHODS

We describe prescribers (MD/DOs and advanced practice providers) of OUD-approved buprenorphine formulations to patients with an OUD diagnosis, across networks. For each patient who initiated buprenorphine treatment during 2018, we assigned a "usual prescriber" and assessed four measures of quality in the 180d following initiation: 1) continuous receipt of buprenorphine; 2) receipt of any behavioral health counseling services; 3) receipt of any urine drug screen; and 4) receipt of any prescription for a benzodiazepine. We used multivariable linear regressions to examine the association of prescriber and network characteristics with quality of buprenorphine care following initiation.

RESULTS

We identified 645 providers who prescribed buprenorphine to 20,739 eligible Medicaid enrollees with an OUD diagnosis. The composition of buprenorphine prescriber networks varied in terms of licensing type, specialty, and panel size, with the majority of prescribers providing buprenorphine to small panels of patients. In the 180 days following initiation, a third of patients were maintained on buprenorphine; 69.9 % received behavioral health counseling; 88.4 % had a urine drug screen; and 11.3 % received a benzodiazepine prescription. In regression analyses, while no single network characteristic was associated with higher quality across all examined measures, each one unit increase in prescriber-to-enrollee ratio was associated with a 1.18 p.p. increase in the probability of continuous buprenorphine maintenance during the 180 days following initiation (95 % confidence interval = [0.21, 2.15], p = 0.017).

CONCLUSIONS

Medicaid plans may be able to leverage their networks to provide higher quality care. Our findings, which should be interpreted as descriptive only, suggest that higher prescriber-to-enrollee ratio is associated with increased buprenorphine maintenance. Future research should focus on isolating the causal relationships between MOUD prescribing network design and patient outcomes.

New Opportunities to Strengthen Medicaid Managed Care Network Adequacy Standards

This Viewpoint discusses new standards proposed by the Centers for Medicare & Medicaid Services for ensuring that Medicare managed care networks meet enrollees’ needs.

Psychiatrist Networks In Medicare Advantage Plans Are Substantially Narrower Than In Medicaid And ACA Markets

Medicare Advantage now covers twenty-eight million older adults, many of whom have mental health needs. Enrollees are often restricted to providers who participate in a health plan's network, which may present a barrier to care. We used a novel data set linking network service areas, plans, and providers to compare psychiatrist network breadth-the percentage of providers in a given area that are considered "in network" for a plan-across Medicare Advantage, Medicaid managed care, and Affordable Care Act plan markets. We found that nearly two-thirds of psychiatrist networks in Medicare Advantage were narrow (that is, they contained fewer than 25 percent of providers in a network's service area) compared with approximately 40 percent in Medicaid managed care and Affordable Care Act plan markets. We did not observe similar differences in network breadth for primary care physicians or other physician specialists across markets. Amid efforts to strengthen network adequacy, our findings suggest that psychiatrist networks in Medicare Advantage are particularly narrow, which may disadvantage enrollees as they attempt to obtain mental health services.

Characteristics of Specialty Mental Health Provider Networks in Oregon Medicaid

OBJECTIVE

Provider networks for mental health are narrower than for other medical specialties. Providers' influence on access to care is potentially greater in Medicaid because enrollees are generally limited to contracted providers, without out-of-network options for nonemergency mental health care. The authors used claims-based metrics to examine variation in specialty mental health provider networks.

METHODS

In a cross-sectional analysis of 2018 Oregon Medicaid claims data, claims from adults ages 18-64 years (N=100,515) with a psychiatric diagnosis were identified. In-network providers were identified as those associated with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a health plan (coordinated care organization [CCO]) during the study period. Specialty mental health providers were categorized as prescribers (psychiatrists and mental health nurse practitioners) and nonprescribers (therapists, counselors, clinical nurse specialists, psychologists, and social workers). Measures of network composition, provider-to-population ratio, continuity, and concentration of care were calculated at the CCO level; the correlation between these measures was estimated to describe the degree to which they capture unique dimensions of provider networks.

RESULTS

Across 15 CCOs, the number of prescribing providers per 1,000 patients was relatively stable. CCOs that expanded their networks did so by increasing the number of nonprescribing providers. Moderately negative correlations were found between the nonprescriber provider-to-population ratio and proportions of visits with prescribers as well as with usual provider continuity.

CONCLUSIONS

This analysis advances future research and policy applications by offering a more nuanced view of provider network measurement and describing empirical variation across networks.

Financial Toxicity in the Post-Health Reform Era

The Patient Protection and Affordable Care Act (ACA), enacted in March 2010, was comprehensive health care reform legislation aimed to improve health care access and quality of care and curb health care-related costs. This review focuses on key provisions of the ACA and their impact on financial toxicity. We will focus our review on cancer care, because this is the most commonly studied disease process in respect to financial toxicity. Patients with cancer face rising expenditures and financial burden, which in turn impact quality of life, compliance to treatment, and survival outcomes. Health insurance expansion include dependent-coverage expansion, Medicaid expansion, and establishment of the Marketplace. Coverage reform focused on reducing financial barriers by limiting cost sharing. Payment reforms included new innovative payment and delivery systems to focus on improving outcomes and reducing costs. Challenges remain as efforts to reduce costs have led to the expansion of insurance plans, such as high-deductible health plans, that may ultimately worsen financial toxicity in cancer and high out-of-pocket costs for further diagnostic testing and procedures. Further research is necessary to evaluate the long-term impacts of the ACA provisions-and threats to the ACA-on outcomes and the costs accrued by patients.

Health insurance literacy among head and neck cancer patients and their caregivers: A cross-sectional pilot study

Objective

Health insurance literacy interventions may reduce financial burden and its effects on cancer patients and their caregivers. However, little is known about the health insurance literacy levels of head and neck cancer (HNC) patients and their caregivers. We assessed the feasibility of screening for health insurance literacy in a pilot study and described the health insurance literacy levels of HNC patients and their caregivers.

Methods

We administered a survey that assessed demographics and subjective and objective health insurance literacy to HNC patients and their caregivers. Subjective health insurance literacy was measured through the Health Insurance Literacy Measure (score range: 0-84). Objective health insurance literacy was measured through correct answers to a previously developed 10-question knowledge test. Due to a small sample size, inferential statistics were not used; we instead descriptively reported findings.

Results

The pilot included 48 HNC patients and 13 caregivers. About 44.4% of patients and 30.8% of caregivers demonstrated low health insurance literacy (HILM ≤60). On the 10-item knowledge test, patients had an average of 6.8 (SD: 2.3) correct responses and caregivers had 7.8 (SD: 1.1) correct responses. Calculating out-of-pocket costs for out-of-network services was challenging; only 9.5% of patients and 0% of caregivers answered correctly.

Conclusion

Additional outreach strategies may be needed to supplement screening for health insurance literacy. Areas of focus for interventions include improving understanding of how to calculate financial responsibility for health care services and filing an appeal for health insurance claim denial.

Level of Evidence

IV.

The Impact of Narrow and Tiered Networks on Costs, Access, Quality, and Patient Steering: A Systematic Review

Health insurers use narrow and tiered networks to lower costs by contracting with, or favoring, selected providers. Little is known about the contemporary effects of narrow or tiered networks on key metrics. The purpose of this systematic review was to synthesize the evidence on how narrow and tiered networks impact cost, access, quality, and patient steering. We searched PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials databases for articles published from January 2000 to June 2020. Both narrow and tiered networks are associated with reduced overall health care costs for most cost-related measures. Evidence pertaining to access to care and quality measures were more limited to a narrow set of outcomes or were weak in internal validity, but generally concluded no systematic adverse effects on narrow or tiered networks. Narrow and tiered networks appear to reduce costs without affecting some quality measures. More research on quality outcomes is warranted.

Barriers to Equity in Pediatric Hearing Health Care: A Review of the Evidence

PURPOSE

We review the evidence regarding barriers to hearing health care for children who are deaf or hard of hearing.

BACKGROUND

There are considerable data to suggest that hearing health care disparities constitute a major factor in loss to follow-up or documentation for children going through the Early Hearing Detection and Intervention process. Families are affected by a combination of factors underlying these disparities, resulting in delayed care and suboptimal developmental outcomes for children who are deaf or hard of hearing.

CONCLUSIONS

To address the socioeconomic, cultural, and linguistic inequities seen in the diagnosis and management of childhood hearing loss, pediatric audiologists and speech-language pathologists have a responsibility to provide culturally responsive practice to their individual clients and their families, as well as advocate for substantive changes at the policy level that impact their clients' daily lives.

Association of Teaching Status and Mortality After Cancer Surgery

OBJECTIVE

To examine patient outcomes for nine cancer-specific procedures performed in teaching versus non-teaching hospitals.

SUMMARY BACKGROUND DATA

Few contemporary studies have evaluated patient outcomes in teaching versus non-teaching hospitals across a comprehensive set of cancer-specific procedures.

METHODS

Use of national Medicare data to compare 30-, 60-, and 90-day mortality rates in teaching and non-teaching hospitals for cancer-specific procedures. Risk-adjusted 30-day, all-cause, postoperative mortality overall and for each specific surgery, as well as overall 60- and 90-day mortality rates, were assessed.

RESULTS

The sample consisted of 159,421 total cancer surgeries at 3,151 hospitals. Overall thirty-day mortality rates, adjusted for procedure type, state, and invasiveness of procedure were 1.3% lower at major teaching hospitals (95%CI=-1.6% to -1.1%; p<0.001) relative to non-teaching hospitals. After accounting for patient characteristics, major teaching hospitals continued to demonstrate lower mortality rates compared with non-teaching hospitals (-1.0% difference [95%CI -1.2% to -0.7%]; p<0.001). Further adjustment for surgical volume as a mediator reduced the difference to -0.7% (95%CI -0.9% to -0.4%, p<0.001). Cancer surgeries for four of the nine disease sites (bladder, lung, colorectal and ovarian) followed this overall trend. Sixty- and ninety-day overall mortality rates, adjusted for procedure type, state, and invasiveness of procedure showed that major teaching hospitals had a 1.7% (95%CI -2.1% to -1.4%; p<0.001) and 2.0% (95%CI -2.4 to -1.6%, p<0.001) lower mortality relative to non-teaching hospitals. These trends persisted after adjusting for patient characteristics.

CONCLUSIONS

Among cancer-specific procedures for Medicare beneficiaries, major teaching hospital status was associated with lower 30-, 60-, and 90-day mortality rates overall and across four of the nine cancer types.

Access to Neurosurgery in the Era of Narrowing Insurance Networks: Statewide Analysis of Patient Protection and Affordable Care Act Marketplace Plans in Arizona

OBJECTIVE

The Patient Protection and Affordable Care Act (ACA) sought to expand access to health care for 46 million uninsured Americans. Increasing consumer coverage and ensuring affordability of care have raised concerns about ACA Marketplace plans with limited in-network physician coverage (narrow network plans). We assessed the neurosurgery coverage of ACA Marketplace plans in Arizona.

METHODS

The Health Insurance Marketplace website was used to identify ACA Marketplace plans in Arizona. Plan-specific details were examined to search for in-network neurosurgeons (2016-2019). Physician- and patient-level information was obtained using Intellimed health care databases, which provide specific neurosurgery diagnosis-related group information.

RESULTS

Although 5 insurance providers offered plans on the ACA Marketplace in Arizona, only 1 plan was available in 13 of 15 counties (87%). Evaluation of in-network coverage found that all in-network outpatient neurosurgery providers are in 5 of 15 counties (33%). Most of the other counties (9 of 10) have neurosurgery facilities, but do not have in-network access to neurosurgical care within the county (∼1.1 million people or 15% of the state population).

CONCLUSIONS

By narrowing the network of providers, insurance companies are attempting to maintain fiscal viability of their ACA Marketplace products. However, 10 of the 15 counties (67%) in Arizona do not have access to outpatient neurosurgical care through these plans despite the presence of neurosurgical facilities in most counties. Access to neurosurgical care requires consideration of network coverage in policies designed to expand coverage and coverage options for patients insured through the ACA Marketplace.

Do Narrow Networks Affect the Delivery of Outpatient Care in Neurosurgery?: A Statewide Analysis of Marketplace Plans in New Jersey

BACKGROUND

The aftermath of the Affordable Care Act (ACA) witnessed the rise of narrow networks, which feature fewer providers in exchange for lower premiums. Debate still continues on whether narrow networks provide adequate access to health care, especially in specialty care services such as neurosurgery. The objective of this article was to analyze the 2019 Marketplace plans' impact on delivering outpatient neurosurgical care in New Jersey.

METHODS

The 2019 Marketplace Public Use Files were queried for "silver" plans, identifying a total of 11 plans across 3 insurance companies. Online search engines were used to identify the number of in-network neurosurgeons within 20-25 miles of ZIP codes at the center of each county. The primary outcome was the number of neurosurgeon-deficient plans, defined as those having no in-network neurosurgeons within the assigned mile radius.

RESULTS

Of all individuals who purchased an insurance plan, 73% (185,797/255,246) opted for a silver plan. Out of 111 active neurosurgeons in New Jersey, 25% (28/111) did not participate in any of the silver plans. Analysis showed 8 plans as neurosurgeon-deficient in Sussex and Warren. Meanwhile, most of the silver plans provided access to >5 neurosurgeons within 20-25 miles of most (17/21) county centers.

CONCLUSIONS

In more densely populated states such as New Jersey, the impact of narrow networks on neurosurgical coverage is less apparent. However, frustrations regarding access to care still exist because nearly 25% of neurosurgeons do not participate in the standard ACA insurance product. Furthermore, guidelines that define network adequacy in neurosurgery remain elusive, which calls for more robust parameters to monitor and ensure adequate access to health care.

Quality Regulation? Access to High-Quality Specialists for Medicare Advantage Beneficiaries in California

Medicare Advantage enrollment has seen tremendous growth over the past decade. However, we know comparatively little about the experience of beneficiaries in the program. Our knowledge of Medicare Advantage provider networks is particularly limited. This article is one of the first major assessments of the issue. It seeks to answer 3 important questions. First, are Medicare Advantage plan networks made up of higher quality providers? Second, how significant are the network restrictions imposed by Medicare Advantage plans with regard to access to higher quality providers? And finally, how much provider choice are Medicare Advantage beneficiaries left with? To assess these questions, I utilize geospatial data and individual provider quality measures for cardiologists, endocrinologists, and obstetricians and gynecologists from California. I find that Medicare Advantage beneficiaries generally do well in large metropolitan areas compared to traditional Medicare. However, there are concerns for those in micropolitan and rural areas, and even those in standard metropolitan areas, at times. Crucially, the connection between provider quality and networks can only be fully understood when connected to assessments of provider access. These findings also raise questions about how we think about provider networks and the adequacy of current approaches to network regulation.

ROLE OF CANCER HISTORY AND GENDER IN MAJOR HEALTH INSURANCE TRANSITIONS: A LONGITUDINAL NATIONALLY REPRESENTATIVE STUDY

PURPOSE –

To examine associations by gender between cancer history and major health insurance transitions (gains and losses), and relationships between insurance transitions and access to care.

METHODOLOGY –

Longitudinal 2008-2013 Medical Expenditure Panel Survey data pooled yielding 2,223 cancer survivors and 50,692 individuals with no cancer history ages 18-63 years upon survey entry, with gender-specific sub-analyses. Access-to-care implications of insurance loss or gain were compared by cancer history and gender.

FINDINGS –

Initially uninsured cancer survivors were significantly more likely to gain insurance coverage than individuals with no cancer history (RR: 1.25; 95% CI: 1.08-1.44). Females in particular were significantly more likely to gain insurance (unmarried RR: 1.16; 95% CI: 1.06-1.28; married RR: 1.09; 95% CI: 1.02-1.16). Significantly higher rates of difficulty accessing needed medical care and prescription medications were reported by those remaining uninsured, those who lost insurance, and women in general. Remaining uninsured, losing insurance, and male gender were associated with lack of a usual source of care.

RESEARCH IMPLICATIONS –

Additional outreach to disadvantaged populations is needed to improve access to affordable insurance and medical care. Future longitudinal studies should assess whether major Affordable Care Act (ACA) provisions enacted after the 2008-2013 study period (or those of ACA's replacement) are addressing these important issues.

ORIGINALITY –

Loss of health insurance coverage can reduce health care access resulting in poor health outcomes. Cancer survivors may be particularly at risk of insurance coverage gaps due to the long-term chronic disease trajectory. This study is novel in exploring associations between cancer history by gender and health insurance transitions, both gains and losses, in a national non-elderly adult sample.

Insurance Clearance for Early-Phase Oncology Clinical Trials Following the Affordable Care Act

Purpose: The Affordable Care Act (ACA) required that private insurance plans allow clinical trial participation and cover standard-of-care costs, but the impact of this provision has not been well-characterized. We assessed rates of insurance clearance for trial participation within our large early-phase clinical trials program, before and after implementation of the requirement.Experimental Design: We analyzed the departmental database for the Clinical Center for Targeted Therapy (CCTT) at MD Anderson Cancer Center (Houston, TX). Among patients referred for sponsored trials, we described rates of insurance clearance and prolonged time to clearance (at least 14 days) from July 2012 to June 2013 (baseline), July 2013-December 2013 (following CCTT staffing changes in July 2103), and January 2014-June 2015 (following implementation of the ACA). We used multivariable logistic regression models to compare rates across these time periods.Results: We identified 2,404 referrals for insurance clearance. Among privately insured patients, insurance clearance rates were higher for those referred from January 2014 to June 2015 than for those referred from July 2012 to June 2013 (OR, 4.72; 95% CI, 2.96-7.51). There was no association between referral period and clearance rates for Medicare/Medicaid patients (P = 0.25). Referral from January 2014 to June 2015 was associated with lower rates of prolonged clearance among both privately insured (OR 0.57; 95% CI, 0.38-0.86) and Medicare/Medicaid patients (OR 0.39; 95% CI, 0.19-0.83).Conclusions: Within our large early-phase clinical trials program, insurance clearance rates among privately insured patients improved following implementation of the ACA's requirement for coverage of standard-of-care costs. Clin Cancer Res; 23(15); 4155-62. ©2017 AACR.

Relation Between Narrow Networks and Providers of Cancer Care

Purpose Health insurers offer plans covering a narrow subset of providers in an attempt to lower premiums and compete for consumers. However, narrow networks may limit access to high-quality providers, particularly those caring for patients with cancer. Methods We examined provider networks offered on the 2014 individual health insurance exchanges, assessing oncologist supply and network participation in areas that do and do not contain one of 69 National Cancer Institute (NCI)-Designated Cancer Centers. We characterized a network's inclusion of oncologists affiliated with NCI-Designated Cancer Centers relative to oncologists excluded from the network within the same region and assessed the relationship between this relative inclusion and each network's breadth. We repeated these analyses among networks offered in the same regions as the subset of 27 NCI-Designated Cancer Centers identified as National Comprehensive Cancer Network (NCCN) Cancer Centers. Results In regions containing NCI-Designated Cancer Centers, there were 13.7 oncologists per 100,000 residents and 4.9 (standard deviation [SD], 2.8) networks covering a mean of 39.4% (SD, 26.2%) of those oncologists, compared with 8.8 oncologists per 100,000 residents and 3.2 (SD, 2.1) networks covering on average 49.9% (SD, 26.8%) of the area's oncologists ( P < .001 for all comparisons). There was a strongly significant correlation ( r = 0.4; P < .001) between a network's breadth and its relative inclusion of oncologists associated with NCI-Designated Cancer Centers; this relationship held when considering only affiliation with NCCN Cancer Centers. Conclusion Narrower provider networks are more likely to exclude oncologists affiliated with NCI-Designated or NCCN Cancer Centers. Health insurers, state regulators, and federal lawmakers should offer ways for consumers to learn whether providers of cancer care with particular affiliations are in or out of narrow provider networks.

Inequality and the health-care system in the USA

Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10-15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.

Access to Accredited Cancer Hospitals Within Federal Exchange Plans Under the Affordable Care Act

Purpose The Affordable Care Act expanded access to health insurance in the United States, but concerns have arisen about access to specialized cancer care within narrow provider networks. To characterize the scope and potential impact of this problem, we assessed rates of inclusion of Commission on Cancer (CoC) -accredited hospitals and National Cancer Institute (NCI) -designated cancer centers within federal exchange networks. Methods We downloaded publicly available machine-readable network data and public use files for individual federal exchange plans from the Centers for Medicare and Medicaid Services for the 2016 enrollment year. We linked this information to National Provider Identifier data, identified a set of distinct provider networks, and assessed the rates of inclusion of CoC-accredited hospitals and NCI-designated centers. We measured variation in these rates according to geography, plan type, and metal level. Results Of 4,058 unique individual plans, network data were available for 3,637 (90%); hospital information was available for 3,531 (87%). Provider lists for these plans reduced into 295 unique networks for analysis. Ninety-five percent of networks included at least one CoC-accredited hospital, but just 41% of networks included NCI-designated centers. States and counties each varied substantially in the proportion of networks listed that included NCI-designated centers (range, 0% to 100%). The proportion of networks that included NCI-designated centers also varied by plan type (range, 31% for health maintenance organizations to 49% for preferred provider organizations; P = .04) but not by metal level. Conclusion A large majority of federal exchange networks contain CoC-accredited hospitals, but most do not contain NCI-designated cancer centers. These results will inform policy regarding access to cancer care, and they reinforce the importance of promoting access to clinical trials and specialized care through community sites.