Sih-Ting Cai, Coleman Drake, Jean Abraham and I published a new paper in the Journal of General Internal Medicine where we look at 2019 and 2020 Plan Quality Rating System (QRS) scores for insurers on the ACA individual health insurance markets. Our primary question is whether or not Provider Sponsored Health Plans (PSHPs) have different quality scores than other forms of organization.
Going into this paper, our hypothesis is that organizations like Kaiser or UPMC (my former employer) or Geissenger have different financial incentives than entities that only sell insurance and not clinical care as well. We thought that PSHPs can internalize any gains from quality easier, thus making high scoring quality easier/cheaper to achieve and justify, so we thought that the would see PSHPs have higher global quality scores.
And that is basically what we found:
PSHPs had higher mean scores than non-PSHPs. We then intergogated the data a bit more as the figure above is non-exclusive, so we assessed the incremenetal contribution of different characteristics associated with global quality ratings:
For clinical quality management, PSHPs and non-profit organizations were associated with higher star ratings by 0.36 (95% CI = 0.11 to 0.62; P = 0.005) and 0.30 (95% CI = 0.10 to 0.51; P = 0.004), respectively. Also, PSHPs (95% CI = 0.03 to 0.50; P = 0.03) and PPOs (95% CI = 0.05 to 0.47; P = 0.02) exhibited positive associations with enrollee experience, whereas Medicaid-focused organizations were negatively associated with this outcome. Finally, non-profit insurer products were associated with a 0.24 (95% CI = 0.05 to 0.42; P = 0.01) higher rating with respect to plan administration.
We dive deeper into the subdomains. Typically PSHPs will have higher average scores than non-PSHPs on Behavioral Health, Diabetes and CVD care.
Organizational structures matter. This writing team has looked at quality ratings for behavioral health, and quality of care ratings. In those papers, we found that non-profits tended to have higher quality scores than other insurers and insurers that were primarily Medicaid Managed Care entities had lower quality scores. This new work adds to this literature as Medicaid Managed Care entities have lower quality scores for the newly examined domains over two years of data.
From a policy perspective, the ACA market does not pay for quality. Insurers have no incentive to invest in quality improvement or patient experience unless there is an immediate and large cost-saving return on investment. People churn in and out. The marginal buyer in the ACA is only buying on premium and has almost no utilization. People who are likely to care about quality are likely to have high utilization. Unless there is damn good risk adjustment, caring about quality can be a money sink and a negative attribute to insurers when they design plans. This is very different than Medicare Advantage where plans have direct financial incentives to score highly on quality ratings. If we think that the quality ratings are relevant information and a desired attribute of insurance plans in the ACA marketplace, the current price linked subsidy system does not encourage quality and should be changed.
Love the policy deep dive. With all your research I wonder what is the 80/20 changes that make the most difference?
Feels a bit weird to bleg on this thread, but my son, who just turned 26, is having a terrible time navigating the ACA signup process in NC. He’s currently unemployed while working to finish up his schooling (we are helping support him together with his fiance) but when he puts in “no income” on the ACA signup system, he is getting offered really expensive, terrible plans at very high monthly costs ($200-$500/mo; $8k deductible). I’m wondering if the system is thinking he should be on Medicare due to the lack of income, but since NC didn’t expand Medicare, that isn’t an option for him. Can that really be right?
If so, what is he supposed to do to get signed up? If that isn’t it, why is a young man in decent health getting such terrible options?
I’m trying to convince him that it isn’t the case that “the ACA is terrible and stupid,” but his lived experience is not inconsistent with that.
@drlemur: He might try finding a federally qualified health center (FQHC) at findahealthcenter.hrsa.gov. Many have insurance navigators who can help him get enrolled in insurance, even if he doesn’t get his health care there. He can call the ones nearby and ask if they have insurance/benefits navigators. And he can get health care there on a sliding fee scale, if that is a need.
Has he tried putting in minimal income? Enough to be just above the threshold for Medicare in NC (fuck the sociopathic republicans in non-expansion states BTW). He might then qualify for the subsidies.
@drlemur: e-mail me at the balloon juice e-mail
It makes me so angry. The ACA included medicaid expansion so it would be seamless from Medicare to subsidized insurance policies and some GOP governors and legislators decided to make their own people suffer so they could blame Obama and the Democrats. Their cruelty in the service of gaining power is disgusting.
@MomSense: that was my first suggestion too. It made him uncomfortable to “lie” about his income — he worried that somehow he’d lose his coverage later if they found out he was actually unemployed instead of minimally employed.
@narya — thanks for the suggestion and I’ll pass along the link. His current doctor had said there might be somebody in the office who could potentially assist him and I was hoping it would get him to one of the navigators.
Part of the reason I posted the comment/question here is that I was dismayed and slightly surprised at how thoroughly the sociopaths had screwed up the sign-up system. I had thought there might be issues and encouraged him to start working through this process a month ago. But it was even worse than I expected.
Insurers are interested in money, making it keeping it, having it. Paying it out, losing it, are not in their areas of interest. Making money are why they are in business. Paying it out is not. Why should healthcare insurers be any different? An HMO type of business is in business for healthcare, and sure they are going to be trying to make money, to stay in business and be profitable but they do that by providing healthcare – this is better. But. That motive for profit is always going to be there. Now even a totally government healthcare system has to not be run at a loss, at least on a continuing basis. BTW I now use a government healthcare system, the VA. Money is always an issue but it is not the first issue when a patient walks in the door. And this makes it better. It still may be crap healthcare, that is an issue that always has to be watched and fixed but it still is better overall because if a doc thinks I need something, I get it. It takes effort and process to get there, like any other complicated concept but it is possible.
Adding insurance into the mix adds an entire level of complication and cost to the system and in this case that insurance is most often only willing to pay the least amount possible, which often means less than effective healthcare, if for no other reason that people don’t want their insurance cost to increase. When every step is about money, the concept of healthcare is not in the room.
@drlemur: As long as he can make a good faith estimate of ~$13,000 in income for 2022 he will be eligible for subsidies. Note it is a good faith estimate.
David is right. It’s really not a lie. They are asking for an estimate. Also once he gets a job he will log in and update his information. Please encourage him to sign up.
I messaged him and hopefully he’ll follow through. Maybe “spoke to experts” and the specific advice to estimate next year’s income at $13k will help.
He’s planning to be enrolled as a full-time student in the Fall and will have access to healthcare through the university. He’s currently taking community college classes and does not seem to have healthcare access through that. As a younger person who doesn’t want to deal with paperwork hassles, he is very tempted to live uninsured in the interim, despite our advice (and covid).
His situation can’t be that unusual, though. I was weirded out by how easily the system failed for him. Any unemployed, part-time student, etc., is going to have the same experience of trying to be completely honest and having the whole thing fall apart. Is this happening in every state that didn’t expand Medicare? I try to follow this stuff, but this implication did not come through for me.
I have a subsidy difficulty I’m trying to sort out right now. I am struggling to afford insurance for just two months, at a premium of about 1150 per month. Right now between jobs but hopeful that a job offer may be forthcoming soon. HOWEVER, I’m very concerned that my annual income if I get the job will eliminate my subsidy, and I’ll end up paying over $2000 out of pocket for just two months of coverage, even after the cap
(edited to add: I just ended up emailing you the details, apologies in advance)
@drlemur: Pedant alert:
MediCARE is for the over 65 crowd; MedicAID is for poor and disabled people.
My nemonic device is We care for the elderly and give aid to the poor.
@Betsy: I will reply tonight.
@David Anderson: Thank you. That’s very kind.