1 Controlling Health Care Costs Through Limited Network Insurance Plans: Evidence from Massachusetts State Employees Jonathan Gruber, MIT and NBER Robin McKnight, Wellesley and NBER
3 Our Setting Massachusetts Group Insurance Commission (GIC) Offers health insurance for state employees and numerous municipalities. 6 of 11 plans are limited network plans. 3-month premium holiday for state employees in limited network plans in FY No corresponding change for municipalities that use GIC. Similar pre- premium holiday trends across groups.
4 GIC Background GIC insured 81,420 state employees and 109,343 dependents. 23 municipalities purchasing their insurance through the GIC, with 14,232 employees and 19,160 dependents. Municipalities may find the broader negotiating power of the GIC more attractive alternative to local purchasing options 10% of the municipalities in the state were enrolled in the GIC by 2012.
5 Table 1: GIC Plans Plan Enrollment in 2010 Type of Plan Limited Network Fallon Community Health Plan Direct Care 1% HMO Yes Fallon Community Health Plan Select Care 3% HMO No Harvard Pilgrim Independence 26% PPO No Harvard Pilgrim Primary Choice Plan 0% HMO Yes Health New England 6% HMO Yes Neighborhood Health Plan 1% HMO Yes Tufts Health Plan Navigator 31% PPO No Tufts Health Plan Spirit 0% HMO Yes Unicare Basic 17% Indemnity No Unicare Community Choice 6% PPO Yes Unicare Plus 9% PPO No
6 What Does Narrow Mean? No simple definition. Intended to exclude the most expensive providers, while still maintaining sufficient coverage. We create empirical measure of network breadth: Focus on counties in which plans operate. Consider all physicians for whom we see 5-10 claims. Ask how many of those physicians have in-network claims in each plan.
7 Table 2: Network Breadth Plan Physician Hospital Average Limited Network Plan Fallon Community Health Plan Direct Care Harvard Pilgrim Primary Choice Health New England Neighborhood Health Plan Tufts Spirit Unicare Community Choice Average Broad Network Plan Fallon Community Health Plan Select Care Harvard Pilgrim Independence Tufts Navigator Unicare Basic Unicare Plus
8 Premium Holiday FY 2012 open enrollment featured threemonth premium holiday 25% reduction in cost of limited network plans Savings from $268 for cheapest individual plan to $764 for family coverage Available to state employees, but not for municipalities
9 Data Complete set of (de-identified) claims and enrollment records for all GIC enrollees. Three years of data: fiscal years 2010, 2011, 2012 Premium holiday affects FY 2012 Restrict to continuously enrolled sample of active employees and their dependents: Ensures that the composition of our sample does not change over time. 479,196 annual observations on 159,732 enrollees. 86% obtained coverage through the state. 14% obtained coverage through one of 21 municipalities.
10 Table 3: Means Mean (Standard Deviation) Enrolled in Limited Network Plan (0.400) Savings from switching to limited network plan (as a share of employee contribution to broad network plan) 36.55% (9.64) Total expenses $4,811 (15,132) N 479,196
11 DD Around Policy Change Y imt = α + βstate m *POST t + γmuni m + τyear t + δx imt + ε imt where i indexes individuals m indexes municipalities (and state) t indexes years. β captures the change for state workers after the premium holiday, relative to before, and compared to the change over the same time period for municipal workers.
12 Interpretation: Marginal Compliers Our estimates of β are identified solely by the compliers that switch plans in response to financial incentives. Estimates are not a population average estimate of the impact of forcing all enrollees to enroll in a limited network But current policy conversations center around employee and exchange choice, which consider limited network plans as a choice option, not the mandated default.
13 Percent Figure 1, Panel A: Financial Incentives 55 Monthly Savings from Switching Fiscal Year Municipalities State
14 Percent Figure 1, Panel B: Enrollment 35 Enrollment in Limited Network Plans Fiscal Year Municipalities State
15 Table 4: First Stage Independent Variable Differences-in- Differences State Employees * Post ** (0.0036) Full price variation Savings from Limited Network Plan ** (0.0002) Number of Observations 479, ,196
16 Table 5: Heterogeneity by Health Sample Differences-in- Differences Full Sample 0.116** (0.004) Chronically ill (N=132,727) Not chronically ill (N=346,469) 0.104** (0.003) 0.121** (0.004) Full price variation ** (0.0002) ** (0.0002) ** (0.0002)
18 Table 5: Heterogeneity by Primary Care Inclusion in Network Sample Differences-in- Differences Full Sample 0.116** (0.004) Can keep PCP and insurer (N=187,656) Can keep PCP, different insurer (N=76,125) PCP not in a limited network plan (N=43,197) 0.168** (0.006) 0.127** (0.010) 0.101** (0.002) Full price variation ** (0.0002) ** (0.0003) ** (0.0006) ** (0.0002)
19 2010q1 2010q2 2010q3 2010q4 2011q1 2011q2 2011q3 2011q4 2012q1 2012q2 2012q3 2012q4 Figure 2: Spending 1500 Total Spending Per Capita Fiscal Year Municipality State
22 Table 8: Type of Physician Total Spending (GLM) Primary Care 0.030** (0.015) Specialists ** (0.013) Other (0.077) Old Providers ** (0.011) New Providers 0.056** (0.013) Any Visits (OLS) Primary Care vs. Specialists (0.005) (0.007) (0.0046) Old vs. New Providers (0.003) 0.016** (0.007) Number of Visits (OLS) 0.040* (0.023) ** (0.069) * (0.015) ** (0.042) 0.051* (0.028) Cost per Visit (OLS) 1.95 (2.09) (3.54) 18.87** (6.38) (1.83) 7.13** (1.40) N 479, , ,196 Varies
23 Table 9a: Access Type of Service Mean of dep. variable DD Coefficient Office Visits 9.82 (9.45) Primary Care 8.19 (10.69) Specialists (10.11) Other Office Visits 9.88 (15.59) Old Providers 9.49 (10.27) New Providers (12.82) Inpatient Hospitalization (26.81) Outpatient Hospitalization (13.00) Emergency Room (25.13) (0.131) ** (0.278) (0.183) (0.447) ** (0.147) 0.857** (0.377) 4.538** (2.149) ** (0.333) ** (0.729)
24 Table 9b: Access Measure of Hospital Quality Mean of dep variable DD Coefficient 30-Day Mortality Rate, AMI (1.24) 30-Day Mortality Rate, Heart Failure (1.28) 30-Day Mortality Rate, Pneumonia (1.50) 30-Day Readmission Rate, AMI (1.25) 30-Day Readmission Rate, Heart Failure (1.46) 30-Day Readmission Rate, Pneumonia (1.27) 30-Day Readmission Rate, Hip or Knee Surgery 5.51 (0.68) 30-Day Readmission Rate, All Cause (1.05) (0.040) (0.078) (0.112) (0.067) (0.041) (0.050) (0.018) (0.039)
25 Heterogeneity by Enrollee Type Overall spending effects similar for those with and without chronic illness. No evidence of reduced physician access for chronically ill, with primary care increasing. Largest declines in spending for those who are able to keep their PCP when they switch. Declines in spending occur broadly across the diagnosis spectrum.
26 Table 10b: Heterogenity by Network Spending Measure Breadth (1) PCP in limited plan, same insurer Total Spending ** (0.024) Office Visits (0.015) Primary Care 0.032** (0.010) Specialist * (0.021) Other office visits (0.159) Old Providers (0.017) New Providers 0.086** (0.025) PCP in limited plan, different insurer ** (0.055) ** (0.019) (0.036) ** (0.027) (0.149) ** (0.022) (0.086) PCP Not in limited network plan (0.045) (0.053) (0.065) (0.072) (0.225) * (0.097) (0.069) N 187,656 76,125 43,197
27 Table 10b: Heterogenity by Network Spending Measure Breadth (2) PCP in limited plan, same insurer Total Spending ** (0.024) Inpatient Hospitalization ** (0.133) Outpatient Hospitalization ** (0.036) Emergency Room (0.074) Labs & X-rays (0.082) Drugs (0.024) Other (0.038) PCP in limited plan, different insurer ** (0.055) (0.179) ** (0.086) ** (0.086) (0.140) (0.056) (0.175) PCP Not in limited network plan (0.045) Insufficient data 0.171** (0.085) Insufficient data (0.120) (0.064) * (0.104) N 187,656 76,125 43,197
28 Conclusions (1) Patients are very price sensitive in their decisions to switch to limited network plans, with a price elasticity above one. There is modest adverse selection associated with such price incentives Large premium differential between broad and limited network plans is driven not simply by selection, but by real reductions in spending among those induced to switch plans. Rather, the reduction arises from less spending on specialists and hospital care.
29 Conclusions (2) The fact that primary care use is rising, while emergency room and hospital spending is falling, suggests that the move to limited network plans is not adversely impacting health, although we are unable to demonstrate health effects with any certainty. Effects for both more and less healthy. But driven by those who keep their primary care doc. Suggests that savings come from downstream restrictions
30 Conclusions (3) Fiscally beneficial to MA? Yes! Employer premium contribution was 1.2% percent lower than it would have been if all of marginal enrollees had stayed in broad plans 2.8% savings from switching to limited network plans among marginal switchers 1.6% loss from premium holiday Suggests long run benefits much larger, given high inertia
31 Conclusions (4) Most important caveat to our results is that they apply to one particular example, May not be able to extrapolate them to other limited network plans, such as those on state exchanges. An important goal for future work should be to extend this analysis to those other examples. Should be very feasible given that the tax credits available under the ACA provide distinctly nonlinear price differentials across health insurance options
NBER WORKING PAPER SERIES CONTROLLING HEALTH CARE COSTS THROUGH LIMITED NETWORK INSURANCE PLANS: EVIDENCE FROM MASSACHUSETTS STATE EMPLOYEES Jonathan Gruber Robin McKnight Working Paper 20462 http://www.nber.org/papers/w20462
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