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

• DOI: http://doi.org/10.1002/wmh3.309
• Date: 01 September 2019
• Published date: 01 September 2019
• Author: Simon F. Haeder

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doi: 10.1002/wmh3.309

© 2019 Policy Studies Organization

A Tale of Two Programs: Access to High Quality

Providers for Medicare Advantage and Affordable Care

Act Beneficiaries in New York State

Simon F. Haeder

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.

KEY WORDS: Affordable Care Act, medicare advantage, percutaneous coronary intervention,

provider networks

Introduction

The American health‐care system is a complex amalgam of private and public

entities. In many cases, federal or state governments shoulder some, if not all, of the

financial burden of a program but rely on private partners to provide services

(Haeder & Weimer, 2015a). Two major programs so structured are the Affordable

Care Act’s insurance marketplaces (Beland, Rocco, & Waddan, 2016)and Medicare

Advantage (Haeder, 2019; Kelly, 2016). Despite serving different primary clienteles,

both programs share many similarities, including regulatory oversight by the

federal government, public subsidies for beneficiaries, and service provision by

private entities. Importantly, both also generally rely on networks of providers to

connect beneficiaries to medical care. Yet despite these similarities, the programs

have been treated rather differently by policymakers. On the one hand, Repub-

licans have been excessively critical of the Affordable Care Act’s insurance mar-

ketplaces and the plans sold on them (Haeder & Weimer, 2015b). Criticism includes

a variety of issues, but is particularly centered on limited choices for beneficiaries in

terms of insurance plans and providers. At the same time, Republicans have been

overwhelmingly supportive of Medicare Advantage, and have repeatedly sought to

shift more Medicare beneficiaries into the program (Jindal, 2018, March 22).

Democrats, on the other hand, have been supportive of the Affordable Care Act,

and ambivalent, if not critical, of Medicare Advantage (Haeder, 2012; Kelly, 2016).

One of the major criticisms leveled at the Affordable Care Act’s insurance

marketplaces, and the policies sold on them, is the lack of consumer choice (Dafny,

Hendel, Marone, & Ody, 2017; Haeder, Weimer, & Mukamel, 2015a). A particular

focal point of such criticisms has been limitations on the number of in‐network

providers for ACA marketplace beneficiaries, a situation labeled as so‐called

narrow networks (Haeder, Weimer, & Mukamel, 2015b; Polsky & Weiner, 2015).

Republicans have been joined in this criticism by many consumer advocates

(Haeder, Weimer, & Mukamel, 2016). Yet no such criticism has been leveled at

Medicare Advantage, and we know surprisingly little about the experiences of

beneficiaries in accessing medical care (Haeder, 2019; Jacobson, Trilling, Neuman,

Damico, & Gold, 2016; Jacobson, Rae, Neuman, Orgera, & Boccuti, 2017).

This analysis answers important questions about Affordable Care Act in-

surance marketplace and Medicare Advantage plans with regard to the interaction

between patient choice and access, and the design of provider networks. While

under‐appreciated, the role of provider networks is crucial to consumers because

they serve as the pathway between health insurance coverage and health‐care ac-

cess (Haeder, Weimer, & Mukamel, 2019). First, how broad are provider networks

in both programs, and do these plans provide a minimum level of access? Second,

how do the quality of providers, operationalized here as risk‐adjusted mortality

rates, and networks interact? That is, do ACA and Medicare Advantage plans

disproportionately favor higher quality providers? To explore these questions, this

analysis utilized data on networks for providers of percutaneous coronary inter-

ventions (PCI or angioplasty with stent)in New York state.

Data and Methods

Since its introduction in the 1960s, coronary‐artery bypass grafting (CABG)has

been the preferred treatment choice for complex coronary artery disease (Serruys

et al., 2009). However, percutaneous coronary intervention (PCI), a less invasive

alternative treatment, has become an increasingly common response to many forms

of the disease. While significantly cheaper than CABG, PCI still carries a price tag in

excess of $25,000 for the immediate intervention (Aasa et al., 2010). Moreover,

follow‐up costs, such as re‐hospitalizations, medications, and revascularization, are

often costly as well (Magnuson et al., 2013).

Seeking to rein in costs and improve the quality of care, the New York State

Department of Health, with help from the New York State Cardiac Advisory

Committee, was one of the first entities in the United States to collect and publicize

data on patient outcomes of PCI (Mukamel & Mushlin, 1998). The most recent

quality report provides risk‐adjusted mortality rates for 136 cardiologists

Haeder: A Tale of Two Programs 213