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

Date01 September 2019
Published date01 September 2019
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 Acts 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 aboveaverage 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 nonemergency 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
The American healthcare 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 Acts 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 Acts 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 Acts 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 innetwork
providers for ACA marketplace beneficiaries, a situation labeled as socalled
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
underappreciated, the role of provider networks is crucial to consumers because
they serve as the pathway between health insurance coverage and healthcare 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 riskadjusted 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, coronaryartery 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,
followup costs, such as rehospitalizations, 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 riskadjusted mortality rates for 136 cardiologists
Haeder: A Tale of Two Programs 213

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