BACKGROUND: As U.S. legislators are urged to combat ghost networks in behavioral health and address the provider data quality issue, it becomes important to better characterize the variation in data quality of provider directories to understand root causes and devise solutions. Therefore, this manuscript examines consistency of address, phone number, and specialty information for physician entries from 5 national health plan provider directories by insurer, physician specialty, and state.
METHODS: We included all physicians in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) found in ≥ 2 health insurer physician directories across 5 large national U.S. health insurers. We examined variation in consistency of address, phone number, and specialty information among physicians by insurer, physician specialty, and state.
RESULTS: Of 634,914 unique physicians in the PECOS database, 449,282 were found in ≥ 2 directories and included in our sample. Across insurers, consistency of address information varied from 16.5 to 27.9%, consistency of phone number information varied from 16.0 to 27.4%, and consistency of specialty information varied from 64.2 to 68.0%. General practice, family medicine, plastic surgery, and dermatology physicians had the highest consistency of addresses (37-42%) and phone numbers (37-43%), whereas anesthesiology, nuclear medicine, radiology, and emergency medicine had the lowest consistency of addresses (11-21%) and phone numbers (9-14%) across health insurer directories. There was marked variation in consistency of address, phone number, and specialty information by state.
CONCLUSIONS: In evaluating a large national sample of U.S. physicians, we found minimal variation in provider directory consistency by insurer, suggesting that this is a systemic problem that insurers have not solved, and considerable variation by physician specialty with higher quality data among more patient-facing specialties, suggesting that physicians may respond to incentives to improve data quality. These data highlight the importance of novel policy solutions that leverage technology targeting data quality to centralize provider directories so as not to not reinforce existing data quality issues or policy solutions to create national and state-level standards that target both insurers and physician groups to maximize quality of provider information.

BACKGROUND: Recent studies document the rising prevalence of common ownership by institutional investors in specific industries. Those investors offer products, such as mutual and index funds, to trade securities on behalf of others and often own shares of multiple firms in the same industry to diversify portfolios. However, at present, few studies focus on common ownership trends in health care.
OBJECTIVE: This paper examines institutional investors\' common ownership in the major insurers offering plans in the Medicare Part D stand-alone prescription drug plan (PDP) market between 2013 and 2020.
METHODS: Using data from the Securities and Exchange Commission (SEC) database and the Center for Research in Securities Prices, we compute the percentages of outstanding shares of each insurer owned by institutional investors. Data visualization and network analysis are employed to assess the trends in common ownership among major insurers.
RESULTS: We document a high prevalence of and substantial increase in shared institutional investors in the PDP market. From 2013 to 2020, the degree of common ownership increased by 7% on average, and the common ownership network became more connected. Common ownership also varies across the 34 PDP regions depending on their reliance on listed insurers, that are traded in the stock exchange, offering stand-alone PDPs.
CONCLUSIONS: High and rising common ownership in the Medicare Part D PDP market raises policy questions about potential effects on plan offerings, premiums, and quality for consumers.

Healthcare organizations increasingly engage in activities to identify and address social determinants of health (SDOH) among their patients to improve health outcomes and reduce costs. While several studies to date have focused on the evolving role of hospitals and physicians in these types of population health activities, much less is known about the role health insurers may play. We used data from the National Longitudinal Survey of Public Health Systems for the period 2006 to 2018 to examine trends in health insurer participation in population health activities and in the multi-sector collaborative networks that support these activities. We also used a difference-in-differences approach to examine the impact of Medicaid expansion on insurer participation in population health networks. Insurer participation increased in our study period both in the delivery of population health activities and in the integration into collaborative networks that support these activities. Insurers were most likely to participate in activities focusing on community health assessment and policy development. Results from our adjusted difference-in-differences models showed variation in association between insurer participation in population health networks and Medicaid expansion (Table 2). Population health networks in expansion states experienced significant increases insurer participation in assessment (4.48 percentage points, P < .05) and policy and planning (7.66 percentage points, P < .05) activities. Encouraging insurance coverage gains through policy mechanisms like Medicaid expansion may not only improve access to healthcare services but can also act as a driver of insurer integration into population health networks.

To measure and compare the scope of US insurers\' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories.
Cross sectional analysis.
PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B.
30 540 086 beneficiaries in traditional Medicare Part B.
Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules.
The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties.
PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.

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 (2.9 percent 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 (13.8 percent) costlier than the regional mean, with lower quality. Primary care physicians in narrow networks were $212 (1.4 percent) 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.

In health insurance markets with regulated competition, regulators face the challenge of preventing risk selection. This paper provides a framework for analyzing the scope (i.e., potential actions by insurers and consumers) and incentives for risk selection in such markets. Our approach consists of three steps. First, we describe four types of risk selection: (a) selection by consumers in and out of the market, (b) selection by consumers between high- and low-value plans, (c) selection by insurers via plan design, and (d) selection by insurers via other channels such as marketing, customer service, and supplementary insurance. In a second step, we develop a conceptual framework of how regulation and features of health insurance markets affect the scope and incentives for risk selection along these four dimensions. In a third step, we use this framework to compare nine health insurance markets with regulated competition in Australia, Europe, Israel, and the United States.

BACKGROUND: There is less attention to assessing how health services meet the expectations of private health insurance (PHI) actors, clients, insurers, and providers in developing countries. Interdependently, the expectations of each actor are stipulated during contract negotiations (duties, obligations, and privileges) in a PHI arrangement. Complementary service roles performed by each actor significantly contribute to achieving their expectations. This study assessed the role of PHI in meeting the expectations of clients, insurers, and providers in Kampala. Lessons from this study may inform possible reviews and improvements in Uganda\'s proposed National Health Insurance Scheme (NHIS) to ensure NHIS service responsiveness.
METHODS: This study employed a qualitative case-study design. Eight (8) focus group discussions (FGDs) with insured clients and nine (9) key informant interviews (KIIs) with insurer and provider liaison officers between October 2020 and February 2021 were conducted. Participants were purposively selected from eligible institutions. Thematic analysis was employed, and findings were presented using themes with corresponding anonymized narratives and quotes.
RESULTS: Client-Provider, Client-Insurer, and Provider-Insurer expectations were generally not met. Client-provider expectations: Although most facilities were clean with a conducive care environment, clients experienced low service care responsiveness characterized by long waiting times. Both clients and providers received inadequate feedback about services they received and delivered respectively, in addition to prompt care being received by a few clients. For client-insurer expectations, under unclear service packages, clients received low-quality medicines. Lastly, for provider-insurer expectations, delayed payments, selective periodic assessments, and inadequate orientation of clients on insurance plans were most reported. Weak coordination between the client-provider and insurer did not support delivery processes for responsive service.
CONCLUSIONS: Health care service responsiveness was generally low. There is a need to commit resources to support the setting up of clearer service package orientation programs, and efficient monitoring and feedback platforms. Uganda\'s proposed National Health Insurance Act may use these findings to: Inform its design initiatives focusing on operating under realistic expectations, investment in quality improvement systems and coordination, and efficient and accountable client care relationships.

UNASSIGNED: Fluoride varnish reduces children\'s tooth decay, yet few clinicians provide it. Most state Medicaid programs have covered this service during medical visits for children aged 1 to 5 years, but private insurers began covering it only in 2015 due to the Patient Protection and Affordable Care Act (ACA) mandate that they cover a set of recommended preventive services without cost-sharing. Evidence on clinicians\' behavior change postmandate is limited.
UNASSIGNED: To examine monthly changes in fluoride varnish applications among pediatric clinicians following the ACA mandate.
UNASSIGNED: Using all-payer claims data from Massachusetts, this cohort study applied an interrupted time-series approach with linear regression models comparing changes in monthly clinician-level outcomes before and after the mandate. Participants included clinicians who billed at least 5 well-child visits for patients aged 1 to 5 years and were observed at least once premandate. Adjusted for clinician fixed effects, models were assessed overall and separately for clinicians categorized by their monthly share of well-child visits paid by private insurers before the mandate: mostly private (>66% of visits paid by private insurers), mostly public (<33% of visits paid by private insurers), or mixed (33%-66% of visits paid by private insurers) insurance types. Analysis was performed from June 1, 2022, to July 31, 2023.
UNASSIGNED: Preenactment and postenactment of the ACA mandate for private insurers to cover fluoride varnish applications without cost-sharing.
UNASSIGNED: Clinician-month measures of whether fluoride varnish was provided during at least 1 well-child visit and the share of such visits, analyzed separately for clinicians who did and did not apply fluoride varnish premandate.
UNASSIGNED: The sample included 2405 clinicians, with 107 841 clinician-months. Premandate, 10.48% of the visits included fluoride varnish applications. Two years postmandate, the likelihood of ever applying fluoride varnish was 13.64 (95% CI, 10.97-16.32) percentage points higher. For clinicians providing fluoride varnish premandate, the share of visits with fluoride varnish increased by 9.22 (95% CI, 5.41-13.02) percentage points. This increase was observed in clinicians who treated children with insurance that was mostly mixed and mostly private; no substantial change was observed among those treating children with mostly public insurance.
UNASSIGNED: In this cohort study of pediatric primary care clinicians, an association between the ACA mandate and an increase in fluoride varnish application was observed, especially among clinicians primarily treating privately insured patients and those applying it premandate. However, application remains infrequent, suggesting persistent barriers.

This paper presents a contingent claim model designed to assess an insurer\'s equity within the framework of carbon trading regulations imposed on borrowing firms while also considering the integration of green lending. The development of this model is particularly relevant for regions with established carbon trading markets, with a specific focus on the post-period following the 2015 Paris Agreement concerning climate change. We focus on shareholders and policyholders to optimize equity and ensure maximum protection. Strict caps in cap-and-trade harm interest margins, reducing guaranteed rates for equity maximization and compromising policyholder protection. Government intervention through sustainable production carbon trading hinders win-win outcomes. Green subsidies can improve insurer margins, but achieving win-win solutions remains challenging. A collective approach is needed to share sustainable production and finance benefits among diverse economic sectors.

In a healthcare system based on managed competition, health insurers are intended to be the prudent buyers of care on behalf of their enrollees. Equally, citizens are expected to be critical consumers when choosing a health insurance policy. The choice of a health insurance policy may be related to trust in the health insurer, as enrollees must believe that the health insurer will make the right choices for them when it comes to purchasing care. This study aims to investigate how enrollees\' trust in health insurers is associated with their choice of a health insurance policy in the Netherlands. We will focus on the switching behaviour of enrollees and the choice of a policy with restrictive conditions. In February 2022, a questionnaire was sent to a representative sample regarding gender and age of the adult Dutch population. In total 1,125 enrollees responded, a response rate of 56%. Respondents were asked about the choices they made in choosing health insurance. Trust in health insurers was measured using the Health Insurer Trust Scale (HITS), a validated multiple item scale. Descriptive statistics, a paired t-test and logistic regression models were conducted to analyse the results. Of all respondents, 35% indicated that they agree, or completely agree, with the statement that they trust health insurers completely. In addition, trust in enrollees\' own insurer is slightly higher than trust in other insurers (36.29 vs. 33.59, p<0.001). Furthermore, we found no significant associations between trust in health insurers, and whether enrollees have either switched health insurers or have chosen a policy with restrictive conditions. This study showed that enrollees\' trust in health insurance in the Netherlands is relatively low and that trust in their own insurer is slightly higher than trust in other insurers. Furthermore, this study does not show a relationship between trust in health insurers and, either switching health insurers, or choosing a policy with restrictive conditions. Nevertheless, attention for increasing the trust in health insurers might still be important, as low trust may have negative consequences for other elements of the functioning of the healthcare system.