A National Analysis of the Extent and Value of Medicare Advantage Physician Networks

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As the share of Medicare beneficiaries enrolled in Medicare Advantage (MA) plans continues to expand, a growing priority for policymakers is to learn more about the provider networks these plans offer. Unlike traditional Medicare, MA plans use restricted provider networks to manage care utilization and spending and to lower premium costs. Because of a lack of publicly available data, little is known about MA networks, including their size, how well they meet adequacy requirements, and how they vary by location. This project will attempt to fill this knowledge gap using an innovative analytical approach. The Harvard research team will use Medicare prescription drug claims submitted for members of MA plans that provide a drug benefit (about 90% of plans) to identify members' primary care physicians (based on which primary care physicians are their primary prescribers). The team will then use that information to estimate the size of MA networks, using standards recently applied by University of Pennsylvania researchers to analyze plan networks in the health insurance exchanges. Project staff will also examine variation in MA plan primary care networks and how that variation relates to market characteristics (e.g., urban or rural location, high or low provider density). The analysis will also compare the inferred networks to federal requirements for provider choice and determine whether plans continue to meet these standards over time. (The Centers for Medicare and Medicaid Services (CMS) applies network standards only when a plan enters a market.) The study's findings will inform policymakers about the breadth of MA plans' physician networks, an unexplored issue that is critical to the functioning of the MA program. This information should be of interest to federal regulators and policymakers, journalists, and researchers.

Grant Details

Grantee Organization:
President and Fellows of Harvard College
Principal Investigator:
Austin Frakt, Ph.D.
Award Amount:
$223,451.00
Approval Date:
July 11, 2017

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