Eline M. van den Broek-Altenburg, PhD; and Adam J. Atherly, PhD
The authors used a discrete choice experiment to analyze patient preferences for attributes of provider choice, including wait time, breadth, travel time, continuity of care, and monthly premium.
Objectives: There is an ongoing policy discussion regarding an adequate breadth of provider networks. Health plans with “restricted networks” of providers have proved surprisingly popular on the Affordable Care Act health insurance exchanges because of a substantial gap in premiums between plans with open networks and closed networks. The objective of this paper is to assess which other attributes of the provider network matter to patients when choosing health insurance.
Study Design: We used a discrete choice experiment to analyze the effect of previously unobserved characteristics regarding provider networks on plan choice, including wait time, breadth, travel time, whether the plan covers care for their personal doctor, and monthly premium. Hypothetical plan options were offered to respondents of an online survey using Qualtrics software.
Methods: We used mixed multinomial logit models to estimate preference-based utilities for attributes of primary care provider networks and willingness to pay.
Results: Coverage of a personal doctor was the most important attribute, followed by premium, wait time to see a primary care provider, the breadth of the network, and travel time to the closest doctor covered by the plan. Respondents were willing to pay $95 per month to have a plan that covers care for their personal doctor, and they were willing to wait 6 days for an appointment to have a plan covering care for their personal doctor.
Conclusions: The results of this study provide new insights to federal and state legislators developing new models or standards on network adequacy and patient decision support tools.
Am J Manag Care. 2020;26(7):In Press
Takeaway Points- There is an ongoing policy discussion regarding an adequate breadth of provider networks.
- This is the first study to elicit patients’ preferences regarding provider choice and provider network adequacy.
- The results of this study provide new insights to federal and state legislators developing new models or standards on network adequacy and patient decision support tools.
Consumers may also not have appropriate information to make well-informed decisions, particularly regarding provider networks, or may not actively seek information. Indeed, the consumer-directed health care vision of consumers actively shopping is far removed from the reality of how most consumers currently choose health care providers.2 In addition, previous research has shown limited use of price information, which likely reflects the fact that most insured consumers have little or no financial incentive to compare provider prices because their out-of-pocket expenses stay constant across in-network providers.2 At the same time, consumers are not fully aware of the provider network configuration of their plan. The National Association of Insurance Commissioners recently drafted model legislation regarding out-of-network billing to reduce medical bills, but it remains a challenge to set exact minimum standards for qualified health plans (QHPs) in the marketplace.
One approach developed “T-shirt size” standards for the breadth of the provider network, which represents the percentage of providers covered by a plan compared with the total number of providers in the county. These standards categorize network size into 5 groups: extra-small (< 10%), small (10%-25%), medium (25%-40%), large (40%-60%), and extra-large (> 60%).3
The focus on network size, however, ignores other important aspects of network adequacy. Prior research suggests that patients heavily value having their personal doctor (ie, a doctor they have an existing relationship with) in the network and that coverage of an individual’s preferred provider is more important than overall network size.4-8 Higuera and colleagues, for example, found that if that a network covers their usual source of care, consumers show aversion only to the narrowest networks.4 Another attribute of provider networks that may matter is the maximum time and distance patients are willing to travel to the nearest provider covered by their insurance plan. Haeder and colleagues showed in a recent study that distances are relevant to consumers, especially those with limited resources and travel options.5 Drake measured the breadth of provider networks in terms of distance: the percentage of primary care providers (PCPs) covered by the network within a 15-mile radius of a given geography.6 He emphasized the importance of future research to learn which particular network characteristics (eg, high-reputation providers, distance) drive consumers’ sensitivity to network breadth. Indeed, these and other attributes, such as wait time to see a doctor or recommendations from family and friends, may be equally (or more) important. Certainly, for Medicaid enrollees, finding providers who will provide appointments in a timely manner has been an area of concern.
Despite the strong policy interest in network adequacy and regulatory efforts to mandate standards, there is surprisingly little published research on patient preferences for network design. An extensive literature addresses the relation between network breadth and premium pricing, such as a study by Dafny and colleagues that suggested that network breadth/valuation is not tightly linked to plan pricing.7 The authors concluded that this is likely due (at least in part) to the substantial uncertainty surrounding the first year of the marketplaces and perhaps the difficulty in assessing network breadth. Haeder and colleagues emphasized the need for information about provider networks and that accessing services for patients with acute conditions was particularly troubling.8 They concluded that effectively addressing issues of network adequacy requires more accurate provider information. Although current efforts to design network standards are intended to improve patient welfare, there is a lack of evidence about patient preferences for networks. A more complete picture of patients’ preferences regarding provider choice will help in formulating a better definition of network adequacy to maximize patient welfare.
METHODS
In this study, we used a discrete choice experiment (DCE) to assess which attributes of the provider network matter to patients when choosing a health insurance plan. Our conceptual model was based on health insurance demand theory, which emphasizes the role of expected utility in choice optimization. We created synthetic plan alternatives and had respondents from a nationally representative sample select their preferred options. This method allows us to study patient preferences for plan attributes that are not available in secondary data sets. We hypothesized that patients are willing to pay more for some of these attributes, such as continuing to see a personal doctor, than for the amount of provider choice.
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