Physician patient sharing relationships within insurance plan networks

Area of Science:

• Health Services Research
• Health Economics
• Network Analysis

Background:

• Understanding patient referral patterns between primary care physicians (PCPs) and specialists is crucial for coordinated care.
• Insurance networks play a significant role in shaping these physician-specialist relationships and patient access to care.
• The degree to which insurance networks capture existing patient relationships is not well understood, especially with trends toward narrower networks.

Purpose of the Study:

• To quantify the shared patient relationships between PCPs and cardiologists/oncologists.
• To assess the extent to which these shared patient relationships are captured within various insurance networks.
• To analyze how network characteristics (e.g., market segment, plan type, breadth) influence the capture of these relationships.

Main Methods:

• Secondary analysis of Vericred, CareSet, and Health Insurance Compare data.
• Cross-sectional study design focusing on the PCP-to-specialist in-network shared patient percentage.
• Analysis included data from 219,982 PCPs, 29,400 cardiologists, and 22,745 oncologists across multiple insurance network types in 2021.

Main Results:

• Insurance networks captured an average of 64.6% of PCP-cardiology and 61.8% of PCP-oncology shared patient ties.
• Less than half of in-network ties involved physicians with a common organizational affiliation.
• National plans captured fewer shared patient ties than local/regional plans, particularly within narrow networks.

Conclusions:

• Insurance networks capture a majority, but not all, of shared PCP-specialist patient relationships.
• Network breadth and type, especially national vs. local/regional and narrow networks, affect relationship capture.
• Nuanced measures of network composition are essential for patient plan selection and regulatory oversight, given trends toward narrower networks.