The Journal of General Internal Medicine has just published a short research letter## that I wrote with Sih-Ting Cai, Jean Abraham and Coleman Drake. We were curious about what insurer characteristics were associated with better or worse care quality and care effectiveness ratings for ACA plans.
We used Center for Medicare and Medicaid Services (CMS) Quality Rating System (QRS) data to get four quality of care metrics:
- Are kids tested appropriately for pharyngitis?
- Are kids treated right for upper respiratory infections?
- Are antibiotics given to adults for acute bronchitis?
- Is imaging used appropriately for lower back pain.
We thought that there were a few notable charactersistics of insurers that could influence these ratings in a consistent manner. We used Robert Wood John Foundation Plan Participation Tracker and National Association of Insurance Commissioner data to identify each plan as having the following four binary attributes:
- Non-profit
- Member of Blue Cross/Blue Shield Association
- Medicaid Managed Care dominant entity
- Offers a PPO
I had fairly strong priors. I had thought that non-profits were more likely to have good quality ratings. I thought PPO plans would have weak control on their networks. I thought Blues would be notably better than Medicaid Managed Care entities. This was based on the assumption that there is both a premium-quality trade-off and that Medicaid Managed Care dominant entities are making a premium subsidy benchmark cream skimming and risk adjustment arbitrage play.
I was wrong.
Non-profits were a bit better on two metrics. PPOs were a bit worse on two metrics. Everyone was bad on back pain. None of this was shocking.
However, Blues and Medicaid were about the same.
That surprised me. I love doing research and having to update my priors.
We have more research in this general area. Some will be coming out soon(ish) and other chunks are still under review but this has been a fascinating line of poking at the data and changing my mind as to what the markets are doing.
## J Gen Intern Med DOI: 10.1007/s11606-020-06248-5
HinTN
Having an open mind and going where the data take you is such a quaint concept these days.
Well done, sir!
Hoppie
I haven’t before taken the opportunity to thank you for the informative posts. A lot to digest. Still, I expect you want to fix “imagining”.
Mart
We went on the ACA for a year between jobs. All the Drs & networks changed, but overall care seemed the same.
David Anderson
@Hoppie: I really don’t want to change “imagining” to “imaging” as I like the image of a radiologist conducting a seance to diagnosis a slipped disk… but I did make the change
StringOnAStick
Sab
@David Anderson: Shades of Dr Atlas
ETA bringing the same approach to epidemiology.
Nutmeg again (formerly MoxieM)
Really interesting. Thanks! so much to chew on.
Specifically in my case the LBP imaging–I more than qualify, having 10+ years of conservative Tx in my big fat file, but evidently not a candidate for surgery, either, per very very thorough Dx workup at Yale New Haven (for which I am super grateful).
But, yeah, echo comments above–back pain is a minefield–in my case, I can barely walk any more, nor stand, but am told I need to wait until I am further debilitated for any intervention… in a wheelchair and incontinent. It does seem like a high bar, but I keep at the problem, and at my PT.
Other informer readers, what sort of specialist is recommended for case management? –my PCP really isn’t up to it, and [stuff]–I’m always collecting info.
Butch
For what it’s worth, based on our experience with Blue Cross since I was laid off, I want to see Blue Cross burned to the ground. Deny everything just to see how you react, let you appeal, and then surprise, announce that their initial decision was correct. (State insurance commission personnel seem to regard their job as answering the phone and telling you there’s nothing they can do, so no help there.)
StringOnAStick
@Nutmeg again (formerly MoxieM): I’m so sorry to hear about your back issues being so debilitating. Have you considered seeing a neurosurgeon and letting them take over case management? Ortho surgeons are much more knife happy but neurosurgeons have better results from what I have read in the past.
L85NJGT
Human foibles are what they are – non-profit institutions don’t get some inherent virtue shield.
A former employee on their time at a non-profit Blue: “They’re not nice people over there….
My impressions of the local Blue is they are waiting for the glory days of employer provided insurance to return. Still focused on B2B rather than a consumer oriented business model. The in-house apps are junk, customer service is meh, etc.
Another Scott
Interesting. (I haven’t tried to read the article yet.)
It’s my understanding that there are various kinds of BC-BS operators (e.g. Anthem vs traditional). Did you see any significant differences between the types of BC-BS? Or is Anthem not BC-BS in your sorting?
https://www.forbes.com/sites/brucejapsen/2019/03/14/blue-cross-merger-takes-five-states-off-the-board-for-anthem/#2efb7cb631d3
Thanks.
Cheers,
Scott.
David Anderson
@Another Scott: Anthem was considered to be both BLUE and FOR Profit.
mskitty
Uh … ok, I have a dim feeling that antibiotics may not be considered generally appropriate for acute bronchitis. But if not, then, generally, what is?
Nutmeg again (formerly MoxieM)
@StringOnAStick: days late…. yes, thanks– it was a neurosurgeon who said I wasn’t bad enough for surgery. Evidently if it’s just back pain (and claudication, i.e, the can’t walk stuff) conservative surgeon won’t operate. so. pffft. coping, coping. looking for a 2nd opinion in maybe a different discipline, and then I’ll have to see. I really want a case manager!
Nutmeg again (formerly MoxieM)
@David Anderson: I’ve had both kinds of BC/BS. Yes the traditional one was better–but coverage type/level, and the state in which I had it (MA) were huge intervening factors. MA insurance tends toward the really good and comprehensive. I’ve had Anthem BC/BS out of CA (really bad!), and currently out of CT (not so awful). What I really notice are the dearth of choices for individual subscribers, and the high cost, in not-MA states, regardless of provider. Must be state-level regulation.