Narrow Networks Research Articles

Providers Paid Substantially Less By Marketplace Nongroup Insurers Than By Employer Small-Group Plans, 2021.

Numerous studies show that employer plans pay providers significantly more than Medicare, but less is known about prices in nongroup plans sold both on and off the Marketplaces established by the Affordable Care Act (ACA), where narrow networks and low-cost insurers are more prevalent. We estimated prices for three market segments (Marketplace nongroup, off-Marketplace nongroup, and employer small group) and three types of services (professional, outpatient hospital, and inpatient hospital) relative to a Medicare benchmark. We used 2021 claims data covering virtually all enrollment in ACA risk-adjusted plans. In aggregate, in 2021, Marketplace prices were 152percent of Medicare prices, whereas the prices paid in small-group employer plans were 179percent of Medicare prices. Comparing across market segments, relative to employer small-group plans, Marketplace professional prices were 6.9percent lower, inpatient prices were 13.3percent lower, and outpatient prices were 26.3percent lower. Off-Marketplace prices fell between Marketplace and employer small-group prices. The finding that nongroup prices were significantly lower than prices paid by employer small-group plans-more so than indicated by prior research-is important for understanding federal subsidies and affordability for nongroup coverage and evaluating policies such as a nongroup public option with prices capped at a percentage of Medicare prices.

Association Between Insurance Status and Nonelderly Penile Squamous Cell Carcinoma Survivorship: A National Retrospective Analysis

Background: Penile squamous cell carcinoma is an aggressive malignancy with significant physical and psychological impacts. Socioeconomic factors influence prognosis in genitourinary cancers, making the investigation of insurance status critical for reducing cancer burden and promoting health equity. Materials and Methods: Men diagnosed with primary penile squamous cell carcinoma from 2007 to 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) national database. Participants were categorized based on insurance status: privately insured, Medicaid, and uninsured. Pearson’s chi-squared test assessed the distribution of observed frequencies between the patient demographics, socioeconomic status, tumor characteristics, and surgical variables across the insurance groups. Overall and cancer-specific survival was estimated using a multivariate Cox hazards proportional model analysis. Results: The multivariate Cox hazards proportional model showed that, compared to privately insured patients, Medicaid patients had an increased risk for overall death (hazard ratio [HR] = HR 1.54; 95% CI, 1.12–2.07). For cancer-specific mortality, Medicaid patients had an increased risk of death compared to privately insured patients (HR 1.58; 95% CI, 1.11–2.25). Conclusions: Medicaid does not mitigate the differences caused by health insurance status due to health insurance disparities for overall or cancer-specific mortality. Lower Medicaid reimbursements and out-of-pocket costs lead to a narrow network of physicians, hospitals, and treatment modalities that compromise health equity. Increasing awareness of health insurance disparities and improving access to care via a clinician–community–governmental partnership can potentially lead to improved predictive outcomes.

Social network research and meat reduction – An overview of research directions and results from a study in Denmark

Reducing the current level of meat consumption would reap significant environmental benefits. However, a consumer transition towards more plant-rich eating is lagging, and the social sciences have had limited success in understanding behavioural change in this area. Here, we advocate a research agenda focussing on the role social networks could play in encouraging consumers to eat less meat. We present main research directions in social network theory and highlight the distinction between simple and complex behavioural domains of which food and eating practices are an example of the latter. To illustrate one way in which social network insights can contribute to meat reduction research, we then present results from a questionnaire-based study of Danish consumers. We examine the association between an individual's personal network and reduced meat consumption. In line with assumptions, we show that, for a complex domain such as food and eating practices, exposure from multiple network sources is central to behavioural adoption. However, multiple network exposure is predominantly important for the initial decision to eat less meat. A narrower network of personal contacts become more central during the implementation stage. We end by outlining future research directions for social network research regarding meat reduction.

Medicare Advantage plan characteristics associated with sorting their beneficiaries to providers that generate fewer avoidable hospital stays.

To examine whether certain Medicare Advantage (MA) plan characteristics are associated with driving beneficiaries to providers that generate fewer avoidable hospital stays. This paper primarily used 2018-2019 MA encounter data and traditional Medicare (TM) claims data for a nationally representative 20% sample of Medicare beneficiaries. For each plan design aspect-plan type, carrier, star rating, and network breadth-we estimated two adjusted Poisson regressions of avoidable hospital stays: one without clinician fixed effects and the other with. We calculated the difference between the coefficients to evaluate the extent to which patient sorting affected avoidable hospital stays relative to TM. Our sample included Medicare beneficiaries 65 years and older who were continuously enrolled in either MA or TM during 2018-2019. Beneficiaries in our sample had one or more chronic, ambulatory care-sensitive conditions. Patient sorting can be attributed to certain characteristics of plan design aspects. For plan type, HMOs account for 86%, with PPOs accounting for only 14%. For carriers, Humana and smaller carriers account for 89%. For star ratings, high-star contracts account for 94%, with other stars only accounting for 6%. By network design, narrow network plan-counties explained 20% of the patient sorting effect. While MA plans were found to be associated with driving beneficiaries to providers that generate fewer avoidable hospital stays, the effect is not homogeneous across the characteristics of MA plans. HMOs and high-star contracts are drivers of this MA phenomenon.

Mechanical Self-Organization of Particle Networks during Uniaxial Compression Yielding

Colloidal gels, sparse particle networks with large voids, are fundamental model systems of disordered porous materials. Unlike dense amorphous solids, they exhibit significant volumetric deformation while expelling solvents when subjected to external compression. Despite their importance in both natural and industrial settings, the relationship between their network microstructure and compressive yielding behavior has remained elusive. To address this problem, we employ confocal microscopy and a specially designed sample cell to observe the gravity-induced collapsing of colloidal gels at a single-particle level. The experimental insight gained is complemented by simulation results for gravitational collapse and homogeneous uniaxial compression. We find that, during compression, the microstructure of gels is uniquely determined solely by the local volume fraction. This relationship remains independent of the deformation strain history but is subtly influenced by the preparation history of the initial state. In contrast, compressive stress evolves as a unique function of local volume fraction, unaffected by both preparation and strain history, as long as the interparticle interaction remains identical. Moreover, we unveil that local yielding occurs in highly strained, narrow network domains, while highly stressed particles form chainlike structures to support the external stress. These findings suggest that colloidal gels undergoing compressive plastic deformation mechanically self-organize into a unique history-independent state to satisfy mechanical balance in a quasistatic condition, providing crucial microscopic insights into the compressive yielding behavior of particle network materials. Published by the American Physical Society 2024

Primary Care Physicians In Medicare Advantage Were Less Costly, Provided Similar Quality Versus Regional Average.

The use of many services is lower in Medicare Advantage (MA) compared with traditional Medicare, generating cost savings for insurers, whereas the quality of ambulatory services is higher. This study examined the role of selective contracting with providers in achieving these outcomes, focusing on primary care physicians. Assessing primary care physician costliness based on the gap between observed and predicted costs for their traditional Medicare patients, we found that the average primary care physician in MA networks was $433 less costly per patient (2.9percent of baseline) compared with the regional mean, with less costly primary care physicians included in more networks than more costly ones. Favorable selection of patients by MA primary care physicians contributed partially to this result. The quality measures of MA primary care physicians were similar to the regional mean. In contrast, primary care physicians excluded from all MA networks were $1,617 (13.8percent) costlier than the regional mean, with lower quality. Primary care physicians in narrow networks were $212 (1.4percent) less costly than those in wide networks, but their quality was slightly lower. These findings highlight the potential role of selective contracting in reducing costs in the MA program.

HOW MEDICARE ADVANTAGE IS SHAPING THE CARE OF OLDER ADULTS WITH SERIOUS ILLNESS

Abstract The Medicare Advantage (MA) program currently insures half of Medicare beneficiaries, and yet there are major gaps in our understanding of how it is impacting older adults, particularly those with serious illness and at the end of life. This population is particularly vulnerable to lapses in care quality in MA given their complex health care needs and challenges navigating MA cost-control mechanisms such as prior authorizations and narrow networks. I will present a framework to consider how MA is influencing care delivery and outcomes for older adults, a review of what we know about the impact of the dramatic growth of MA plans, and emerging data on the experience of older adults with serious illness in MA. This session will highlight best-practices regarding use of claims and population data to evaluate the MA program.

Phase diagram of stochastic gradient descent in high-dimensional two-layer neural networks *

Despite the non-convex optimization landscape, over-parametrized shallow networks are able to achieve global convergence under gradient descent. The picture can be radically different for narrow networks, which tend to get stuck in badly-generalizing local minima. Here we investigate the cross-over between these two regimes in the high-dimensional setting, and in particular investigate the connection between the so-called mean-field/hydrodynamic regime and the seminal approach of Saad & Solla. Focusing on the case of Gaussian data, we study the interplay between the learning rate, the time scale, and the number of hidden units in the high-dimensional dynamics of stochastic gradient descent (SGD). Our work builds on a deterministic description of SGD in high-dimensions from statistical physics, which we extend and for which we provide rigorous convergence rates.

Supporting Low-Income Workers to Address Nutritional Needs

Summary Elevance Health set out to determine the impact of a custom, incremental social benefit program offered to low-income employees; the program featured access to a narrow network of providers plus access to in-kind nutritional support, with the goal of enhancing food security, quality of diet, and self-reported health. Elevance designed a retrospective longitudinal cohort study comparing responses to three surveys conducted through calendar year 2021 between employees enrolled in the social benefit (with an income of less than $42,500) and those who waived the benefit or marginally missed eligibility (income range $42,500–$62,500); this included 1,837 Elevance employees (1,583 in the treatment group and 254 in the control group). The survey outcomes included employees’ self-reported food security, financial security, quality of diet, and health status. Among the treatment group, 413 of 1,583 (26.1%), reported improvement in food security (concern that their food would run out before they got money to buy more), which was more than double the 12.6% who reported improvement among the 254 Elevance employees in the control group. There was less variation between groups when respondents assessed their health in general: 280 of 1,583 (17.7%) of the benefit group indicated improvement between the March and December 2021 surveys, whereas 37 of 254 (14.6%) in the control group reported improvement. Of note, 257 (16.2%) of the treatment group reported a decline in their overall health, whereas 41 (16.1%) of the control group reported a decline.

Study finds scant mental health care coverage for older adults

Amid heightened demand for mental health care, a new study finds that nearly two‐thirds of Medicare Advantage psychiatrist networks contain less than 25% of all psychiatrists in a given service area, according to new research published July 6 in Health Affairs. “This means that many people who have coverage through Medicare Advantage plans may not actually have access to psychiatrists, given how few are considered in‐network,” lead author Jane Zhu, M.D., assistant professor of medicine (general internal medicine and geriatrics) in the School of Medicine at Oregon Health & Science University, stated in an OHSU news release. Medicare Advantage, which covers 28 million Americans through private insurance plans backed by Medicare, has an even narrower network of psychiatrists available to patients than those covered by Medicaid managed care or by insurance plans in the Affordable Care Act. Insurance plans often contract with sets of providers — considered “in‐network” — to deliver services to their enrollees. The researchers built a nationwide data set of health plan networks, their service areas and their participating providers in 2019. The new study is the latest in a series of findings highlighting a lack of coverage and access to mental health care nationwide. Provider networks are one important lever of access, and Zhu noted that the new study likely understates the problem. That's because even if a psychiatrist is technically in‐network, Zhu said an overall national shortage of psychiatrists means that many are fully booked already and aren't accepting new patients. She said this may translate to higher out‐of‐pocket costs, delays in care or foregone treatment. For Zhu, these findings suggest that it's necessary for insurers to incentivize more psychiatrists and mental health professionals to accept health insurance, or to expand coverage of services delivered by other health care professionals such as psychologists, counselors or primary care physicians who provide mental health care.

Editor's Spotlight/Take 5: The Price-Quality Mismatch: Are Negotiated Prices for Total Joint Arthroplasty Associated With Hospital Quality in a Large California Health System?

Editor's Spotlight/Take 5: The Price-Quality Mismatch: Are Negotiated Prices for Total Joint Arthroplasty Associated With Hospital Quality in a Large California Health System?

Physician patient sharing relationships within insurance plan networks.

To quantify shared patient relationships between primary care physicians (PCPs) and cardiologists and oncologists and the degree to which those relationships were captured within insurance networks. Secondary analysis of Vericred data on physician networks, CareSet data on physicians' shared Medicare patients, and insurance plan attributes from Health Insurance Compare. Data validation exercises used data from Physician Compare and IQVIA. Cross-sectional study of the PCP-to-specialist in-network shared patient percentage (primary outcome). We also categorized networks by insurance market segment (Medicare Advantage [MA], Medicaid managed care, small-group or individually purchased), insurance plan type, and network breadth. We analyzed data on 219,982 PCPs, 29,400 cardiologists, and 22,745 oncologists who, in 2021, accepted MA (n=941 networks), Medicaid managed care (n=293), and individually-purchased (n=332) and small-group (n=501) plans. Networks captured, on average, 64.6% of PCP-cardiology shared patient ties, and 61.8% of PCP-oncologist ties. Less than half of in-network ties (44.5% and 38.9%, respectively) were among physicians with a common organizational affiliation. After adjustment for network breadth, we found no evidence of differences in the shared patient percentage across insurance market segments or networks of different types (p-value >0.05 for all comparisons). An exception was among national versus local and regional networks, where we found that national plans captured fewer shared patient ties, particularly among the narrowest networks (58.4% for national networksvs. 64.7% for local and regional networks for PCP-cardiology). Given recent trends toward narrower networks, our findings underscore the importance of incorporating additional and nuanced measures of network composition to aid plan selection (for patients) and to guide regulatory oversight.

Narrow Dialysis Networks In Medicare Advantage: Exposure By Race, Ethnicity, And Dual Eligibility.

The 21st Century Cures Act permitted people with end-stage renal disease (ESRD) to enroll in Medicare Advantage (MA) effective January 2021. It is imperative to understand the breadth of dialysis facility networks across MA contracts because most patients with ESRD need thrice-weekly dialysis to survive. In 2020 MA contracts' networks included a mean of 51percent of dialysis facilities in their service areas. MA contracts with plans in a single state, with not-for-profit status, and with higher proportions of dually eligible enrollees with ESRD were significantly more likely to include less than or equal to 25percent of dialysis facilities in their service area in network ("narrow networks") than contracts with plans in multiple states, with for-profit status, and with lower proportions of dually eligible enrollees with ESRD (by 12.9, 13.0, and 11.7percentage points, respectively). Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native people with ESRD were enrolled in contracts with narrow networks of dialysis facilities at markedly higher rates than non-Hispanic White people with ESRD. In contrast, Black people with ESRD were less likely to be enrolled in a narrow-network contract. Policy makers should monitor and address the adequacy of dialysis facility networks in MA contracts, as well as disparities in enrollment in narrow-network plans.

What Does a Provider Network Do? Evidence from Random Assignment in Medicaid Managed Care

Leveraging the random assignment of over 50,000 Medicaid enrollees in New York, I present causal evidence that narrower networks are a blunt instrument for reducing health care spending. While narrower networks constrain spending, they do so by generating hassle costs that reduce quantity, with modest effects on prices paid to providers. Enrollees assigned to narrower networks use fewer of both needed and unneeded services and are less satisfied with their plans. Using my causal estimates to construct counterfactuals, I identify an alternative assignment policy that reduces spending without harming satisfaction by matching consumers with narrower networks that include their providers. (JEL H51, H75, I13, I18, I38)

Achieving preeminent strength-ductility synergy of Mg–1Sb–1Mn alloy via trace co-addition of Sn and Zn

In this study, a novel alloy designing concept, refining grain size and depressing intergranular deformation (inter-GD) simultaneously, is put forward to prepare the Mg alloy with preeminent strength-ductility synergy. A basic alloy, Mg–1Sb–1Mn (SM11), is extruded at 220 °C to attain ultrafine microstructure. Thereafter, the co-addition of Sn and Zn is conducted to inhibit the inter-GD which is the softening mechanism of the ultrafine-grained SM11 alloy. Compared with SM11 alloy, the tensile yield strength, ultimate tensile strength and compressive yield strength of Mg–1Sb–1Mn–1Sn-0.2Zn (SMTZ1110) alloy increases from 196 MPa, 245 MPa and 193 MPa–301 MPa, 361 MPa and 273 MPa MPa respectively, without the loss of tensile elongation. With the co-addition of Sn and Zn, the grain size is refined from 1.07 μm to 0.82 μm. The narrower network spacing of Mg3Sb2 in the as-cast SMTZ1110 alloy promotes particle-stimulation nucleation during extrusion, resulting in finer grains of the extruded SMTZ1110 alloy. The in-situ experiments unveil that the deformation mechanisms in the SM11 alloy are mixed inter-GD and intragranular deformation, while the deformation mechanisms of the SMTZ1110 alloy shift to the modes predominated by intragranular deformation. The transmission electron microscope results show the segregations of Sn and Zn which pin and stabilize grain boundaries and further depress the inter-GD. Under the combining effects of depressing inter-GD and fine-grain strengthening, the strength of the extruded SMTZ1110 alloy is significantly improved. This study provides new insight into the development of Mg alloy with an excellent balance between strength and ductility.

Hot corrosion behavior of APS YSZ coatings treated by laser micro glazing (LMG) under molten salts (V2O5 +Na2SO4)

In this study, yttria-stabilized zirconia (YSZ) coatings prepared by atmospheric plasma spraying (APS) were glazed by a nanosecond pulsed laser (laser micro glazing, LMG). The hot corrosion mechanism of as-sprayed, ground, and LMGed YSZ coatings was investigated at a temperature of 1100 ºC in V2O5 and Na2SO4 molten salts for 20 h. The results show that a dense LMGed layer with narrow network of segmented microcracks (sub-micron level) was formed after the LMG process. Compared to the single-time LMG, pores can be effectively eliminated after six-times laser irradiation. The hot corrosion behavior of YSZ coatings exposed to molten V2O5 +Na2SO4 demonstrates that pores in the single-time LMGed layer seriously affect its hot corrosion resistance. After multiple LMG, the volume fraction of the m-ZrO2 decreases from 53% to 27% with the disappearance of pores. The quantity of the corrosion products YVO4 was greatly reduced and the depth of the damaged area diminished from 37.073 µm to 20.918 µm, which shows a significant improvement in molten salts corrosion resistance.

Impact of a selective narrow network with comprehensive patient navigation on access, utilization, expenditures, and enrollee experiences.

To examine the effect of enrollee switching from a broad-network accountable care organization (ACO) health maintenance organization (HMO) to a "high performance" ACO-HMO with a selective narrow network and comprehensive patient navigation system on access, utilization, expenditures, and enrollee experiences. Secondary administrative data were obtained for 2016-2020, and primary interview and survey data in 2021. Fixed-effects instrumental variable analyses of administrative data and regression analyses of survey data. Outcomes included access, utilization, expenditures, and enrollee experience. Background information was gathered via interviews. We obtained medical expenditure/enrollment and access data on continuously enrolled members in a broad-network ACO-HMO (n=24,555), a subset of those who switched to a high-performance ACO-HMO in 2018 (n=7664); interviews of organizational leaders (n=13); and an enrollee survey (n=512). Health care effectiveness data and information Set (HEDIS) access measures were not different across plans. However, annual utilization dropped by 15.5 percentage points (95% CI: 18.1, 12.9) more in the high-performance ACO-HMO, with relative annual expenditures declining by $1251 (95% CI: $1461, $1042) per person per year. High-performance ACO-HMO enrollees were 10.1 percentage points (95% CI 0.001, 0.201) more likely to access primary care usually or always as soon as needed and 11.2 percentage points (95% CI 0.007, 0.217) more likely to access specialty care usually or always as soon as needed. Plan satisfaction was 7.1 percentage points (95% CI: -0.001, 0.138) higher in the high-performance ACO-HMO. Interviewees noted the comprehensive patient navigation system was designed to ensure patients remained in the narrow network to receive care. ACO and HMO contracts with selective narrow networks supported by comprehensive patient navigation can reduce expenditures and improve specialty access and patient satisfaction compared to broad-network plans that lack these features. Payers should consider implementing narrow networks with comprehensive support systems.

Thermal Decrepitation and Thermally-Induced Cracking of Limestone Used in Quicklime Production

To produce quicklime, high calcium carbonate rocks, including limestone, are burned in industrial kilns at 1100–1450 °C. As a consequence of the high temperatures, the carbonate rock can break and decrepitate into fine material, causing operational problems and material losses. In the present paper, an industrial case study on thermal decrepitation was performed on Boda Limestone from the Jutjärn quarry in Dalarna, Sweden. We analyzed 80 limestone samples for thermal decrepitation; furthermore, the correlation with chemical composition was statistically analyzed. The experiments were complemented by a detailed analysis of thermally-induced cracking at a range of temperatures (ambient, 500 °C, 800 °C, and 1150 °C) for two limestone samples with similar chemical compositions but with very different decrepitation behaviors. Decrepitation was analyzed by an in-house method, the chemical composition by XRF, and the thermally-induced cracking was investigated by SEM and image analysis. No strong correlation was found between thermal decrepitation and the chemical composition of the limestone. For the sample with low thermal decrepitation, a dense narrow network of fractures was found after full calcination; however, this network was not observed in the sample with high thermal decrepitation. A plausible explanation for the different decrepitation behaviors is that this fracture network releases internal stress and stabilizes the calcined rock. The obtained results can help in predicting limestone thermal decrepitation, enabling increased resource efficiency in quicklime production.

In COVID-19, antigen size lower or larger than 70 kDa modulates the sepsis and memory B cells

This review pretends to shed light on the immune processes occurring in the coronavirus disease 2019 (COVID-19) from a perspective based on the antigens size, lower or larger than 70 kDa. This cutoff size point explains the host type of immune response against the antigenic proteins of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which may lead to the development of the memory B cells or, conversely, the immune suppression, apoptosis, viral escape, and sepsis. Here, based on previous experimental work and the review of related literature, the following is proposed: antigens < 70 kDa can access the germinal center through the follicular conduits, where the activated B cells can present the processed antigen to specific naive CD4+ T cells that, in interaction with the major histocompatibility complex class II (MHC-II), trigger the immune response T helper type 2 (Th2). Conversely, antigens > 70 kDa cannot circulate through the narrow follicular conduits network and might be captured within the subcapsular sinus by the macrophages and dendritic follicular cells. Then, these cognate antigens are presented, via complement receptors, to the B cells that acquire and present them through the MHC-II to the specific naive CD4+ T cells, triggering the immune response Th1. The sustained infected cells lysis can overfeed high levels of unassembled viral proteins < 70 kDa, which can lead to a strong and persistent B cell receptor (BCR) activation, enhancing the Th2 immune response, releasing interleukin-10 (IL-10) and transforming growth factor-beta (TGF-β) that may lead to the immune paralysis, apoptosis, sepsis, and death. Finally, it is suggested that the polymerization of the viral antigens < 70 kDa into an antigenic polymer > 70 kDa could shift the immune response type from Th2 to Th1, developing the memory B cells and immunoglobulin G2 (IgG2) production, and avoiding the sepsis.

Present in class yet absent in science: The individual and societal impact of inequitable science instruction and challenge to improve science instruction

AbstractCurrent science instruction does not educate K‐12 students equitably and creates short‐ and long‐term impacts on individual students and society. While students may be present in class, they may not have access to quality science learning experiences. The goals of this paper are to show how science instruction may not be reaching its aim of equitable access and to offer recommendations for creating a new baseline standard for equitable science instruction. Though not exhaustive, this paper identifies groups of students who are marginalized in current‐day science instruction—the racially minoritized, those with physical and cognitive differences, and those in urban or rural communities. First, this paper challenges the neutrality of science by highlighting systemic yet negative outcomes that disproportionately impact minoritized populations in everyday life because of the narrow network of people who define and solve problems. Second, this paper identifies examples where science instruction is not of its highest quality for the highlighted groups. Third, we present a synthesis of research‐informed solutions proposed to improve both the quality of science instruction and its equitable access for the highlighted groups, creating a new baseline standard for equitable science instruction. An elevated baseline would address the existing disparities in who has access to quality science instruction and consequently reduce the gatekeeper effect of who defines and solves societal problems that perpetuate intergenerational inequities.