Abstract
Professional and social connections among physicians impact patient outcomes, but little is known about how characteristics of insurance plans are associated with physician patient-sharing network structure. We use information from commercially insured enrollees in the 2011 Massachusetts All Payer Claims Database to construct and examine the structure of the physician patient-sharing network using standard and novel social network measures. Using regression analysis, we examine the association of physician patient-sharing network measures with an indicator of whether a patient is enrolled in a health maintenance organization (HMO) or preferred provider organization (PPO), controlling for patient and insurer characteristics and observed health status. We find patients enrolled in HMOs see physicians who are more central and densely embedded in the patient-sharing network. We find HMO patients see PCPs who refer to specialists who are less globally central, even as these specialists are more locally central. Our analysis shows there are small but significant differences in physician patient-sharing network as experienced by patients with HMO versus PPO insurance. Understanding connections between physicians is essential and, similar to previous findings, our results suggest policy choices in the insurance and delivery system that change physician connectivity may have important implications for healthcare delivery, utilization and costs.
Similar content being viewed by others
References
Agha, L., Ericson, K. M., Geissler, K. H., & Rebitzer, J. B (2019) Team Formation and Performance: Evidence from Healthcare Referral Networks. National Bureau of Economic Research Working Paper. Cambridge, MA.
An, C., O’Malley, A. J., Rockmore, D. N., & Stock, C. D. (2018). Analysis of the U S patient referral network. Stat Med., 37(5), 847–866. https://doi.org/10.1002/sim.7565
Barnett, M. L. (2019). Improving Network Science in Health Services Research. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-019-05264-4
Barnett, M. L., Christakis, N. A., O’Malley, J., Onnela, J. P., Keating, N. L., & Landon, B. E. (2012a). Physician patient-sharing networks and the cost and intensity of care in US hospitals. Medical Care, 50(2), 152–160. https://doi.org/10.1097/MLR.0b013e31822dcef7
Barnett, M. L., Landon, B. E., O’Malley, A. J., Keating, N. L., & Christakis, N. A. (2011). Mapping physician networks with self-reported and administrative data. Health Services Research, 46(5), 1592–1609. https://doi.org/10.1111/j.1475-6773.2011.01262.x
Barnett, M. L., Song, Z., Bitton, A., Rose, S., & Landon, B. E. (2018). Gatekeeping and patterns of outpatient care post healthcare reform. Am J Manag Care, 24(10), e312–e318.
Barnett, M. L., Song, Z., & Landon, B. E. (2012b). Trends in physician referrals in the United States, 1999–2009. Archives of Internal Medicine, 172(2), 163–170. https://doi.org/10.1001/archinternmed.2011.722
Boccuti, C., & Neuman, T. (2017). Private Contracts Between Doctors and Medicare Patients: Key Questions and Implications of Proposed Policy Changes. Kaiser Family Foundation: Kaiser Family Foundation.
Bodenheimer, T., Lo, B., & Casalino, L. (1999). Primary care physicians should be coordinators, not gatekeepers. JAMA, 281(21), 2045–2049. https://doi.org/10.1001/jama.281.21.2045
Brunson, J. C., & Laubenbacher, R. C. (2018). Applications of network analysis to routinely collected health care data: a systematic review. Journal of the American Medical Informatics Association, 25(2), 210–221. https://doi.org/10.1093/jamia/ocx052
Center for Health Information and Analysis (2013) All-Payer Claims Database Introduction. www.mass.gov/chia/apcd. Accessed 5 October 2013 2013.
Center for Workforce Studies. (2011). 2011 State Physican Workforce Data Book. Association of American Medical Colleges: Association of American Medical Colleges.
Centers for Medicare and Medicaid Services (2014) National Plan and Provider Enumeration System. http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/DataDissemination.html. Accessed February 14, 2014.
Crosson, F. J. (2009). 21st-century health care–the case for integrated delivery systems. New England Journal of Medicine, 361(14), 1324–1325. https://doi.org/10.1056/NEJMp0906917
Csardi, G., & Nepusz, T. (2006). The igraph software package for complex network research. InterJournal Complex System, 1695, 66–68.
Davis, K. (2007). Paying for care episodes and care coordination. New England Journal of Medicine, 356(11), 1166–1168. https://doi.org/10.1056/NEJMe078007
de Choudhury, M., Mason, W., Hofman, J., & Watts, D. J. Inferring relevant social networks from interpersonal communication. In Proceedings of the 19th International Conference on the World Wide Web (WWW-10), 2010 (pp. 301–310 (ACM))
DeCamp, M., & Lehmann, L. S. (2015). Guiding choice–ethically influencing referrals in ACOs. New England Journal of Medicine, 372(3), 205–207. https://doi.org/10.1056/NEJMp1412083
Decker, S. L. (2018). No Association Found Between The Medicaid Primary Care Fee Bump And Physician-Reported Participation In Medicaid. Health Aff (Millwood), 37(7), 1092–1098. https://doi.org/10.1377/hlthaff.2018.0078
Dugan, J. (2015). Trends in Managed Care Cost Containment: An Analysis of the Managed Care Backlash. Health Economics, 24(12), 1604–1618. https://doi.org/10.1002/hec.3115
DuGoff, E. H., Cho, J., Si, Y., & Pollack, C. E. (2018). Geographic Variations in Physician Relationships Over Time: Implications for Care Coordination. Med Care Res Rev, 75(5), 586–611. https://doi.org/10.1177/1077558717697016
Ericson, K., Geissler, K., & Lubin, B. (2019). The Impact of Partial-Year Enrollment on the Accuracy of Risk-Adjustment Systems: A Framework and Evidence. Am J Health Econ, 4(4), 454–478.
Forrest, C. B., & Reid, R. J. (1997). Passing the baton: HMOs’ influence on referrals to specialty care. Health Aff (Millwood), 16(6), 157–162.
Geissler, K. H., et al. (2020a). The association between patient sharing network structure and healthcare costs. PLoS ONE, 15(6), e0234990.
Geissler, K. H. (2020). Differences in referral patterns for rural primary care physicians from 2005 to 2016. Health Services Research, 55(1), 94–102.
Geissler, K. H., Lubin, B., & Marzilli Ericson, K. M. (2016). Access is not enough: Characteristics of physicians who treat Medicaid patients. Medical Care, 54(4), 350–358. https://doi.org/10.1097/MLR.0000000000000488
Geissler, K. H., Lubin, B., & Marzilli, K. M. (2020b). The role of organizational affiliations in physician patient-sharing relationships. Medical Care Research and Review, 77(2), 165–175.
Geissler, K. H., & Zeber, J. E. (2020). Primary care physician referral patterns for behavioral health diagnoses. Psychiatric Services (Washington, D. C.), 71(4), 389–392.
Jacobson, G., Rae, M., Neuman, T., Orgera, K., & Boccuti, C. (2017). Medicare Advantage: How Robust Are Plans’ Physician Networks. Kaiser Family Foundation.
Jacobson, G., Damico, A., & Neuman, T. (2018). A Dozen Facts About Medicare Advantage. Washington: DC.
Kaiser Family Foundation (2018). Total Medicaid Managed Care Enrollment. https://www.kff.org/medicaid/state-indicator/total-medicaid-mc-enrollment/. Accessed January 20 2018.
KFF (2019). State HMO Penetration Rate. https://www.kff.org/other/state-indicator/hmo-penetration-rate/. Accessed August 21 2019.
Kyanko, K. A., & Busch, S. H. (2012). The out-of-network benefit: problems and policy solutions. Inquiry, 49(4), 352–361. https://doi.org/10.5034/inquiryjrnl_49.04.02
Landon, B. E., Keating, N. L., Barnett, M. L., Onnela, J. P., Paul, S., O’Malley, A. J., et al. (2012). Variation in patient-sharing networks of physicians across the United States. JAMA, 308(3), 265–273. https://doi.org/10.1001/jama.2012.7615
Landon, B. E., Onnela, J. P., Keating, N. L., Barnett, M. L., Paul, S., O’Malley, A. J., et al. (2013). Using administrative data to identify naturally occurring networks of physicians. Medical Care, 51(8), 715–721. https://doi.org/10.1097/MLR.0b013e3182977991
Massachusetts Health Connector. (2014). Commonwealth of Massachusetts Notice of Benefit and Payment Parameters 2014: Risk Adjustment Methodology & Operation. Boston: MA.
McClellan, M., McKethan, A. N., Lewis, J. L., Roski, J., & Fisher, E. S. (2010). A national strategy to put accountable care into practice. Health Aff (Millwood), 29(5), 982–990. https://doi.org/10.1377/hlthaff.2010.0194
Mehrotra, A., Forrest, C. B., & Lin, C. Y. (2011). Dropping the baton: specialty referrals in the United States. Milbank Quarterly, 89(1), 39–68. https://doi.org/10.1111/j.1468-0009.2011.00619.x
Milstein, A., & Gilbertson, E. (2009). American medical home runs. Health Aff (Millwood), 28(5), 1317–1326. https://doi.org/10.1377/hlthaff.28.5.1317
Neprash, H. T., Zink, A., Gray, J., & Hempstead, K. (2018). Physicians’ Participation In Medicaid Increased Only Slightly Following Expansion. Health Aff (Millwood), 37(7), 1087–1091. https://doi.org/10.1377/hlthaff.2017.1085
Newman, M. (2010). Networks: An Introduction. New York: Oxford University Press.
O’Malley, A. J., Moen, E. L., Bynum, J. P. W., Austin, A. M., & Skinner, J. S. (2020). Modeling peer effect modification by network strength: The diffusion of implantable cardioverter defibrillators in the US hospital network. Statistics in Medicine. https://doi.org/10.1002/sim.8466
Ong, M. S., Olson, K. L., Cami, A., Liu, C., Tian, F., Selvam, N., et al. (2016). Provider Patient-Sharing Networks and Multiple-Provider Prescribing of Benzodiazepines. Journal of General Internal Medicine, 31(2), 164–171. https://doi.org/10.1007/s11606-015-3470-8
Oster, E. (2019). Unobservable Selection and Coefficient Stability: Theory and Evidence. Journal of Business & Economic Statistics, 37(2), 187–204.
Pollack, C. E., Weissman, G., Bekelman, J., Liao, K., & Armstrong, K. (2012). Physician social networks and variation in prostate cancer treatment in three cities. Health Services Research, 47(1 Pt 2), 380–403. https://doi.org/10.1111/j.1475-6773.2011.01331.x
Pollack, C. E., Weissman, G. E., Lemke, K. W., Hussey, P. S., & Weiner, J. P. (2013). Patient sharing among physicians and costs of care: a network analytic approach to care coordination using claims data. Journal of General Internal Medicine, 28(3), 459–465. https://doi.org/10.1007/s11606-012-2104-7
Polsky, D., Cidav, Z., & Swanson, A. (2016). Marketplace Plans With Narrow Physician Networks Feature Lower Monthly Premiums Than Plans With Larger Networks. Health Aff (Millwood), 35(10), 1842–1848. https://doi.org/10.1377/hlthaff.2016.0693
Rathi, V. K., & McWilliams, J. M. (2019). First-Year Report Cards From the Merit-Based Incentive Payment System (MIPS): What Will Be Learned and What Next? JAMA, 321(12), 1157–1158. https://doi.org/10.1001/jama.2019.1295
Rittenhouse, D. R., Shortell, S. M., & Fisher, E. S. (2009). Primary care and accountable care–two essential elements of delivery-system reform. New England Journal of Medicine, 361(24), 2301–2303. https://doi.org/10.1056/NEJMp0909327
Rosenthal, M. B., Li, Z., & Milstein, A. (2009). Do patients continue to see physicians who are removed from a PPO network? Am J Manag Care, 15(10), 713–719.
Shi, Y., Pollack, C. E., Soulos, P. R., Herrin, J., Christakis, N. A., Xu, X., et al. (2019). Association Between Degrees of Separation in Physician Networks and Surgeons’ Use of Perioperative Breast Magnetic Resonance Imaging. Medical Care, 57(6), 460–467. https://doi.org/10.1097/MLR.0000000000001123
Trogdon, J. G., Weir, W. H., Shai, S., Mucha, P. J., Kuo, T. M., Meyer, A. M., et al. (2019). Comparing Shared Patient Networks Across Payers. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-019-04978-9
Tushman, M., & Nadler, D. (1978). Information processing as an integrating concept in organizational design. Academy of Management Review, 3(3), 613–624.
Uddin, S., Hossain, L., & Kelaher, M. (2012). Effect of physician collaboration network on hospitalization cost and readmission rate. Eur J Public Health, 22(5), 629–633. https://doi.org/10.1093/eurpub/ckr153
Watts, D. J., & Strogatz, S. H. (1998). Collective dynamics of “small-world” networks. Nature, 393(6684), 440–442. https://doi.org/10.1038/30918
Zuvekas, S. H., & Cohen, J. W. (2010). Paying physicians by capitation: is the past now prologue? Health Aff (Millwood), 29(9), 1661–1666. https://doi.org/10.1377/hlthaff.2009.0361
Acknowledgements
Preliminary results from this study were presented at the non-archival Symposium on Statistical Challenges in Electronic Commerce Research, Workshop on Information in Networks and the Academy Health Annual Research Meeting.
Funding
This research was supported by a research grant from the National Institute for Health Care Management (NIHCM) and by the Agency for Healthcare Research and Quality (5R03HS025515).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
No conflicts of interest exist for the authors.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Geissler, K.H., Lubin, B. & Ericson, K.M.M. The association of insurance plan characteristics with physician patient-sharing network structure. Int J Health Econ Manag. 21, 189–201 (2021). https://doi.org/10.1007/s10754-021-09296-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10754-021-09296-4