Author: United States. Congress. House. Committee on Commerce. Subcommittee on Health and the Environment
Publisher:
ISBN:
Category : Medical
Languages : en
Pages : 120

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Author: Michael Bilirakis
Publisher: DIANE Publishing
ISBN: 0788185535
Category : Managed care plans (Medical care)
Languages : en
Pages : 115

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A hearing on the important issue of establishing provider-sponsored networks, called PSNs, in the Medicare program. Although all sides agree that PSNs should be able to participate as Medicare risk contractors, there is a fundamental disagreement on how they should be regulated, particularly in regard to solvency standards. Testimony from the following organizations: Amer. Acad. of Actuaries; Amer. Medical Assoc.; Health Insur. Assoc. of Amer.; Blue Cross & Blue Shield; Amer. Medical Group Assoc.; Amer. Hospital Assoc.; various insurers; Amer. Assoc. of Health Plans; & the Premier Inst.

Author: United States. Congress. House. Committee on Commerce. Subcommittee on Health and the Environment
Publisher:
ISBN:
Category : Medical
Languages : en
Pages : 120

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Author: James Cosgrove
Publisher:
ISBN: 9781457870644
Category :
Languages : en
Pages : 50

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Medicare Advantage Organizations (MAOs) contract with a network of providers to manage health care delivery to their enrollees. MAOs can initiate or terminate contracts with providers at any time for any reason. Recently, some MAOs have been narrowing their provider networks, prompting concerns about ensuring enrollee access to care and CMS's oversight of MAO compliance with network adequacy criteria. This report examines (1) how the Centers for Medicare & Medicaid Services (CMS) defines network adequacy and how its criteria compares with other programs; (2) how and when CMS applies its criteria; and (3) the extent to which CMS conducts ongoing monitoring of MAO networks; and (4) how CMS ensures that MAOs inform beneficiaries about terminations. Tables. This is a print on demand report.

Author:
Publisher:
ISBN:
Category : Health insurance
Languages : en
Pages : 12

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Author: Yevgeniy Feyman
Publisher:
ISBN:
Category :
Languages : en
Pages : 0

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As is common in the private insurance market, insurers offering Medicare Advantage (MA) plans typically restrict the network of providers from which patients can seek care. Existing work evaluating the breadth of these provider networks relies on provider directories and typically measures breadth as the fraction of providers in-network within some geography. However, well-documented errors prevalent in provider directories and data identifying provider locations can lead to errors with this approach. We use Medicare prescription drug event data from 2011 to 2017 to identify interactions between MA beneficiaries and providers, creating a predictive model that estimates counterfactual utilization to measure the degree to which networks restrict the number of providers seen by patients. We detail the construction, tuning, and estimation of this model for one high-prescribing specialty (primary care). A random forest model outperformed other choices. Our estimates indicate that, as theory predicts, preferred provider organizations (PPOs) are less restrictive than health maintenance organizations (HMOs), that issuers with higher market share impose more restrictive networks, and that increased provider supply is associated with less restrictive networks. These results help validate our methodological approach, providing justification for application more generally.We also provide guidance on how our approach can be replicated for other markets and/or specialties.

Author: Patrick Kimuyu
Publisher: GRIN Verlag
ISBN: 3668627614
Category : Medical
Languages : en
Pages : 19

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Seminar paper from the year 2018 in the subject Medicine - Medical Frontiers and Special Areas, grade: 1, Egerton University, language: English, abstract: This paper will provide a comprehensive overview of managed care, primarily on the advantages and disadvantages of managed care organizations. Over the decades, the United States’ healthcare system has been experiencing challenges. In general, the cost and quality of care has always been considered as the most critical factors that influence healthcare sustainability in the United States and the world, as a whole. As a result, a series of value-based payment reforms have been introduced. For instance, the Affordable Care Act (ACA) of 2010 introduced payment and delivery system reforms. From a critical perspective, the reforms introduced by the ACA have addressed the long-standing problems which have been posing enormous hindrances to the development of the U.S. healthcare system. Above all, it has enhanced managed care through consolidating care, as well as, addressing the problem of unsustainable costs and uneven quality of care. However, managed care seems to exhibit some drawbacks too.

Author: United States. Congress. House. Committee on Commerce
Publisher:
ISBN:
Category :
Languages : en
Pages :

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Author: Peter Reid Kongstvedt
Publisher: Jones & Bartlett Publishers
ISBN: 1284087115
Category : Business & Economics
Languages : en
Pages : 418

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Author: United States Government Accountability Office
Publisher: Createspace Independent Publishing Platform
ISBN: 9781977956422
Category :
Languages : en
Pages : 50

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MAOs contract with a network of providers to manage health care delivery to their enrollees. MAOs can initiate or terminate contracts with providers at any time for any reason. Recently, some MAOs have been narrowing their provider networks, prompting concerns about ensuring enrollee access to care and CMS's oversight of MAO compliance with network adequacy criteria. GAO was asked to review how CMS ensures adequate access to care for MA enrollees. This report examines (1) how CMS defines network adequacy and how its criteria compares with other programs, (2) how and when CMS applies its criteria, (3) the extent to which CMS conducts ongoing monitoring of MAO networks, and (4) how CMS ensures that MAOs inform beneficiaries about terminations. GAO reviewed CMS and other guidance on network adequacy, federal regulations, and standards for internal control. GAO also interviewed CMS officials and representatives of medical associations and beneficiary advocacy groups, and analyzed CMS data on oversight of MAO provider networks for contract years 2013 through 2015.