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This study compares Iterative Proportion Fitting (IPF) as a direct balancing method with five traditional propensity score modeling methods using 10-years of administrative and claims data from a regional health plan. Each method is assessed for internal and external covariate balancing between treated and controls, bias impact of control exclusions, and the design effect of the models. A scaled effect summary score (lower is better) shows that IPF performs better overall with a score of 0.09 while the propensity models have scores ranging from 0.12 to 0.31. All models show internal and external validity with average standardized covariate differences ranging between 0.0 and 0.2, while most models have design effects ranging between 1.0 and 5.6 suggesting modest variance inflation due to balancing. Four of the five propensity models exclude some control observations, and a Wilcoxon signed-rank test verifies that these exclusions were not random suggesting the existence of bias. This study demonstrates that IPF performs better than propensity score balancing methods primarily because IPF utilizes all observations which eliminates any control exclusion bias and reduces the external balancing effect due to perfect external treatment alignment among covariates.

Background When a patient in a provider network seeks services outside of their community, the community experiences a leakage. Leakage is undesirable as it typically leads to higher out-of-network cost for patient and increases barrier for care coordination, which is particularly problematic for Accountable Care Organization (ACO) as the in-network providers are financially responsible for quality of care and outcome. We aim to design a data-driven method to identify naturally occurring provider networks driven by diabetic patient choices, and understand the relationship among provider composition, patient composition, and service leakage pattern. By doing so, we learn the features of low service leakage provider networks that can be generalized to different patient population. Methods Data used for this study include de-identified healthcare insurance administrative data acquired from Capital District Physicians’ Health Plan (CDPHP) for diabetic patients who resided in four New York state counties (Albany, Rensselaer, Saratoga, and Schenectady) in 2014. We construct a healthcare provider network based on patients’ historical medical insurance claims. A community detection algorithm is used to identify naturally occurring communities of collaborating providers. For each detected community, a profile is built using several new key measures to elucidate stakeholders of our findings. Finally, import-export analysis is conducted to benchmark their leakage pattern and identify further leakage reduction opportunity. Results The design yields six major provider communities with diverse profiles. Some communities are geographically concentrated, while others tend to draw patients with certain diabetic co-morbidities. Providers from the same healthcare institution are likely to be assigned to the same community. While most communities have high within-community utilization and spending, at 85% and 86% respectively, leakage still persists. Hence, we utilize a metric from import-export analysis to detect leakage, gaining insight on how to minimize leakage. Conclusions We identify patient-driven provider organization by surfacing providers who share a large number of patients. By analyzing the import-export behavior of each identified community using a novel approach and profiling community patient and provider composition we understand the key features of having a balanced number of PCP and specialists and provider heterogeneity.

The Affordable Care Act creates state-based health exchanges that will begin acting as a market place for health insurance plans and consumers in 2014. This paper compares the financial protection offered by today's group and individual plans with the standards that will apply to insurance sold in state-based exchanges. Some states may apply these standards to all health insurance sold within the state. More than half of Americans who had individual insurance in 2010 were enrolled in plans that would not qualify as providing essential coverage under the rules of the exchanges in 2014. These people were enrolled in plans with an actuarial value below 60 percent, which means that the plans covered less than that proportion of the enrollees' health expenses. Many of today's individual health plans are below the \"bronze\" level, the lowest level of plan that can be sold through exchanges. In contrast, most group plans in 2010 had an actuarial benefit of 80-89 percent and would qualify as highly rated \"gold\" plans in the exchanges. To sell to ten million new buyers on the exchanges, insurers will need to redesign benefit packages. Combined with a ban on medical underwriting, the individual insurance market in a post-health reform world will sharply contrast with the market of past decades. [PUBLICATION ABSTRACT]

Our annual analysis of health benefits contains findings from interviews of 2,046 public and private employers surveyed during January-May 2010. Average annual premiums in 2010 were$5,049 for single coverage and $ 13,770 for family coverage-up 5 percent and 3 percent from 2009, respectively. Workers paid more toward premiums in 2010, and more workers are in consumer-directed plans and plans with high deductibles than in 2009. Thirty percent of firms reported that they reduced the scope of benefits or increased cost sharing because of the recession. Surprisingly, the percentage of firms offering health benefits in 2010 increased to 69 percent, up from 60 percent in 2009. The change was largely driven by a thirteen-percentage-point increase in the number of firms with three to nine workers that offered benefits (up from 46 percent in 2009 to 59 percent in 2010). The reason for this increase is unclear. [PUBLICATION ABSTRACT]

This paper presents findings about weight management programs at the workplace, and employers' and employees' views about these programs. Data are from a survey of 505 randomly selected public and private employers with fifty or more employees, and a survey of 1,352 households with employer-based insurance. The majority of employers with 5,000 or more workers offer programs such as on-site exercise facilities, nutritional counseling, and health risk appraisals, whereas sizable minorities of smaller employers offer them. Employers and employees view weight management programs as appropriate and effective. Employers want programs to pay for themselves, whereas employees are willing to pay higher premiums for them. [PUBLICATION ABSTRACT]

Objectives. There is a debate regarding the effect of cost sharing on immunization, particularly as the Affordable Care Act will eliminate cost sharing for recommended vaccines. This study estimates changes in immunization rates and spending associated with extending first-dollar coverage to privately insured children for four childhood vaccines. Methods. We used the 2008 National Immunization Survey and peer-reviewed literature to generate estimates of immunization status for each vaccine by age group and insurance type. We used the Truven Health Analytics 2006 MarketScan Commercial Claims and Encounters Database of line-item medical claims to estimate changes in immunization rates that would result from eliminating cost sharing, and we used the Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey to determine the prevalence of coverage for patients with first-dollar coverage, patients who face office visit cost sharing, and patients who face cost sharing for all vaccine cost components. We assumed that once cost sharing is removed, coverage rates in plans that impose cost sharing will rise to the level of plans that do not. Results. We estimate that immunization rates would increase modestly and result in additional direct spending of $26.0 million to insurers/employers. Further, these payers would have an additional $11.0 million in spending associated with eliminating cost sharing for children already receiving immunizations. Conclusions. The effects of eliminating cost sharing for vaccines vary by vaccine. Overall, immunization rates will rise modestly given high insurance coverage for vaccinations, and these increases would be more substantial for those currently facing cost sharing. However, in addition to the removal of cost sharing for immunizations, these findings suggest other strategies to consider to further increase immunization rates.

This paper examines recent trends in the design and organization of coverage for mental health care using data from a Henry J. Kaiser Family Foundation and Health Research and Educational Trust (KFF/HRET) national employer survey. Legislation and changes in the delivery of mental health services have altered how mental health insurance is bought and sold. However, our findings reveal that mental health coverage is still typically not offered at a level equivalent to coverage for other medical conditions. We attempt to synthesize these data with prior research as a foundation for informed debates. [PUBLICATION ABSTRACT]

Using data from a special supplement to the 2006 Kaiser/HRET Employer Health Benefits Survey, this study examines the state of employer-sponsored insurance substance abuse benefits in 2006 and how benefits compare to coverage for medical-surgical services. In 2006, 88 percent of insured workers had some coverage for substance abuse services. Current substance abuse benefits, however, do not provide the same protection afforded under medical-surgical benefits. Instead, substance abuse benefits are characterized by higher cost sharing and annual limits and lifetime limits on inpatient and outpatient care. These limits generally do not exist for other medical conditions and have increased since 1990. Adapted from the source document.

National statistics on the cost and provisions of collectively bargained health plans show them to have similar single premiums, but lower family premiums, compared to employer-based plans not subject to collective bargaining. Union members contribute 4 percent and 6 percent of the cost of their premiums for single and family coverage, respectively, versus 18 percent and 29 percent for workers in employer-based plans. Cost sharing in collectively bargained plans is considerably less than in employer-based plans; coverage for prescription drugs is similar.

Based on data from a 1999 national survey of 1,939 randomly selected employers, this paper examines the policies that affect the percentage of workers eligible for and enrolled in a firm's health plan. In 1994, 14 percent of employees worked for a firm offering cash-back payments, but fewer than 1 percent worked for a firm with income-related premiums or deductibles. The strongest determinants of eligibility rates are the waiting time for new employees before they are deemed eligible, and eligibility standards for part-time workers. The primary determinants of the take-up rate are lowest monthly employee contribution for single coverage, and the percentage of the workforce earning less than $20,000 per year.