The Out-of-Network Benefit: Problems and Policy Solutions

Kyanko, Kelly A.; Busch, Susan H.

doi:10.5034/inquiryjrnl_49.04.02

Cited by 17 publications

(17 citation statements)

References 9 publications

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“…However, beneficiaries are subject to increased cost sharing and balance billing—that is, a larger part of the bill is not covered by the insurer and thus must be paid directly by the patient—if they choose to seek care outside the network. 8 …”

Section: The Out-of-network Benefit Debatementioning

confidence: 99%

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Federal Parity Law Associated With Increased Probability Of Using Out-Of-Network Substance Use Disorder Treatment Services

McGinty

Busch²,

Stuart

et al. 2015

Health Affairs

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The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires commercial insurers providing group coverage for substance use disorder services to offer benefits for those services at a level equal to those for medical or surgical benefits. Unlike previous parity policies instituted for federal employees and in individual states, the law extends parity to out-of-network services. We conducted an interrupted time-series analysis using insurance claims from large self-insured employers to evaluate whether federal parity was associated with changes in out-of-network treatment for 525,620 users of substance use disorder services. Federal parity was associated with an increased probability of using out-of-network services, an increased average number of out-of-network outpatient visits, and increased average total spending on out-of-network services among users of those services. Our findings were broadly consistent with the contention of federal parity proponents that extending parity to out-of-network services would broaden access to substance use disorder care obtained outside of plan networks.

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Section: The Out-of-network Benefit Debatementioning

confidence: 99%

“…A potential downside of physician networks is that they may not include adequate numbers of specialty providers to meet enrollees’ health care needs. 8 …”

Section: The Out-of-network Benefit Debatementioning

confidence: 99%

Federal Parity Law Associated With Increased Probability Of Using Out-Of-Network Substance Use Disorder Treatment Services

McGinty

Busch²,

Stuart

et al. 2015

Health Affairs

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“…19 Therefore, services from many of these practices may only be accessible to those with the financial resources to pay out-of-pocket or to cover the out-of-network costs. 20,21 Consequently, these practices may be more likely to locate in wealthier communities.…”

Section: Introductionmentioning

confidence: 99%

Geographic Access to Specialty Mental Health Care Across High- and Low-Income US Communities

et al. 2017

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Importance With the future of the Affordable Care Act and Medicaid program unclear, it is critical to examine the geographic availability of specialty mental health (MH) treatment resources that serve low-income populations across local communities. Objective To examine the geographic availability of community-based specialty MH treatment resources and how these resources are distributed by community socioeconomic status (SES). Design Measures of MH specialty resource availability were derived for 31,836 zip-code tabulation areas (ZCTAs) using national data. Analyses examined the association between community SES (assessed by median household income quartiles) and resource availability using logistic regressions. Models controlled for ZCTA-level demographic characteristics and state indicators. Main Outcome Measures Dichotomous indicators for whether a ZCTA had any: (1) outpatient MH treatment facility (more than nine-tenths of which offer payment arrangements for low-income populations); (2) office-based practice of MH specialist physician(s); (3) office-based practice of non-physician MH practitioners (e.g., therapists); and (4) facility or office-based practice (i.e., any resource). Results More than four-tenths (42.5%) of communities in the highest income quartile had any community-based MH treatment resource versus 23.1% of communities in the lowest income quartile (Adjusted odds ratio [AOR]=1.74, 95% Confidence Interval [CI]=1.50,2.03). When examining the distribution of MH specialist providers, 25.3% of the highest income communities had any MH specialist physician practice versus 8.0% of the lowest income communities (AOR=3.04, 95% CI=2.53,3.66). Similarly, 35.1% of the highest income communities had any non-physician MH specialist practice versus 12.9% of the lowest income communities (AOR=2.77, 95% CI=2.35,3.26). In contrast, MH treatment facilities were less likely to be located in the highest versus lowest income communities (12.9% versus 16.5%, AOR=0.43, 95% CI=0.37,0.51). Over seven-tenths of the lowest income communities with any resource had an outpatient MH treatment facility. Conclusions and Relevance MH treatment facilities are more likely to be located in poorer communities, whereas office-based practices of MH specialist providers are more likely to be located in higher income communities. These findings indicate that MH treatment facilities constitute the backbone of the specialty MH treatment infrastructure in low-income communities. Policies are needed to support and expand available resources for this critical infrastructure.

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“…) and focused on privately insured individuals (Kyanko, Curry, and Busch ,b). The limited research focused on out‐of‐network ED care has acknowledged that it exists (Kyanko and Busch ), and that medical emergencies are a main contributor to out‐of‐network use overall (Kyanko, Curry, and Busch ,b). However, no research has examined factors associated with out‐of‐network ED use among Medicaid beneficiaries.…”

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confidence: 99%

Out‐of‐Network Emergency Department Use among Managed Medicaid Beneficiaries

Raven

Guzman

Chen

et al. 2016

Health Services Research

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There are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity.

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The Out-of-Network Benefit: Problems and Policy Solutions

Cited by 17 publications

References 9 publications

Federal Parity Law Associated With Increased Probability Of Using Out-Of-Network Substance Use Disorder Treatment Services

Federal Parity Law Associated With Increased Probability Of Using Out-Of-Network Substance Use Disorder Treatment Services

Geographic Access to Specialty Mental Health Care Across High- and Low-Income US Communities

Out‐of‐Network Emergency Department Use among Managed Medicaid Beneficiaries

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