Document Type

Report

Publication Date

2019

Abstract

This report examines the necessary functionality of toolsets to analyze evaluation criteria for network adequacy of commercial health insurance plans in the private market. Following an initial report, the Idaho Department of Insurance (DOI) narrowed the scope of this report to encompass four specific criteria: 1) provider-to-member ratio, 2) provider-to-member ratio by specialization, 3) out-of-network to in-network usage ratio and 4) travel time/distance.

The first report in this study identified seven potential toolsets available to DOI to facilitate data collection and analysis of these criteria. These were: 1) ArcGIS, 2) QGIS, 3) Quest Analytics, 4) Optum GeoAccess, 5) Encompass, 5) Access Mod 5, 6) R and 7) External Quality Review Organizations (EQROs).

The scope of this report is limited to descriptions of toolset functionality necessary to collect and analyze data related to provider network evaluations. It is organized into two major sections. In the first section, the criteria selected by DOI are discussed, including a description of measurement and which of the identified toolsets (if any) are capable of facilitating data collection and analysis. In the second section, the focus is on a series of other factors identified by DOI, such as the urban/rural nature of the networks and health plan types. This section describes functionality requirements in order for toolsets to include these additional factors in network adequacy analyses.

Comments

This report was prepared by Idaho Policy Institute at Boise State University and commissioned by the Idaho Department of Insurance.

The project described was supported by Funding Opportunity Number PR-PRP-18-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

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