Background: Over 15.3 million Americans relied on the individual health insurance market for health coverage in 2021. Yet, little is known about the relationships between the organizational characteristics of individual market health insurers and quality of coverage, particularly with respect to clinical outcomes.
Objective: To examine variation in marketplace insurers' quality performance and investigate how performance varies by insurer organizational characteristics.
Design: Retrospective cohort study.
Participants: 381 insurer products, representing 184 unique insurers in 50 states in 2019 and 2020.
Main measures: Marketplace plan clinical quality measures reported in the 2019-2020 CMS Plan Quality Rating System dataset and insurer-product organizational attributes identified from several data sources, including non-profit ownership, Blue Cross Blue Shield Association membership, Medicaid focus and whether or not the insurer product is vertically integrated with a provider organization.
Key results: Among the 381 insurer products in this study, 35% are part of a provider-sponsored health plan (PSHP) and 70% of these entities received four stars or above for overall quality performance. Overall, PSHPs exhibited higher quality than non-PSHPs for both clinical quality management (0.36 increased on a 5-point scale; 95% CI = 0.11 to 0.62; P = 0.005) and enrollee experience (0.27; 95% CI = 0.03 to 0.50; P = 0.03) summary indicators. Medicaid focused insurers were associated with lower performance on enrollee experience, plan administration, and various outcomes related to clinical quality.
Conclusions: Provider-sponsored health plans in the health insurance marketplaces are associated with higher-quality care, as measured by CMS clinical quality measures.
Keywords: Affordable Care Act; health insurance; health insurance marketplace; health plan quality; provider-sponsored health plan.
© 2022. The Author(s) under exclusive licence to Society of General Internal Medicine.