Quality Varies Across Health Insurance Marketplace Pricing Regions. Academic Article uri icon

Overview

abstract

  • BACKGROUND: Although consumers purchasing health plans in the new Health Insurance Marketplace will be provided information on the cost and quality of participating health plans, it is unclear whether the state-wide plan quality averages that will be reported will accurately represent quality at the pricing region level where care will be received. OBJECTIVES: To evaluate whether currently reported state-wide health plan quality scores accurately represent quality within pricing regions established for the Health Insurance Marketplace. RESEARCH DESIGN: Observational, historical cohort study using health plan administrative and pharmacy data. SUBJECTS: A total of 5.2 million members enrolled in the preferred provider organization health plans of 1 large commercial California insurer in 2012. MEASURES: State-wide and pricing region performance on each of the 17 Healthcare Effectiveness Data and Information Set (HEDIS) measures. RESULTS: Across the 17 measures assessed in each of the 19 pricing regions, scores were statistically different (P<0.05) than the overall plan rate for 176 (54%). Variations in scores across regions were observed for each measure ranging from 6.4-percentage points for engagement in treatment for people with dependence of alcohol or other drugs to 47.2-percentage points for appropriate testing for pharyngitis among children. CONCLUSIONS: Quality scores in California vary greatly across geographic regions. Statewide averages may misrepresent the quality of care that consumers are likely to receive within a geographic area making difficult assessments about the value of the health care.

publication date

  • July 1, 2015

Research

keywords

  • Health Insurance Exchanges
  • Preferred Provider Organizations
  • Quality Indicators, Health Care
  • State Health Plans

Identity

Scopus Document Identifier

  • 84933527617

Digital Object Identifier (DOI)

  • 10.1097/MLR.0000000000000367

PubMed ID

  • 26067884

Additional Document Info

volume

  • 53

issue

  • 7