{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T14:53:55Z","timestamp":1791212035626,"version":"4.1.0"},"reference-count":19,"publisher":"Oxford University Press (OUP)","issue":"10","license":[{"start":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T00:00:00Z","timestamp":1788998400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,10,5]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>The Affordable Care Act's (ACA) medical loss ratio (MLR) regulation requires individual market insurers to spend at least 80% of premium revenue on medical care and quality improvement, but evidence is limited on whether MLRs correspond to measured quality and how this differs by insurer organizational structure.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Using CMS MLR financial reports for ACA marketplace insurers (2015-2023) linked to Quality Rating System ratings (2020-2023), we compared provider-sponsored insurers owned by or operating as part of integrated delivery systems with traditional insurers on MLRs, spending components, and quality, using adjusted regressions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 2751 issuer-state-years, 581 (21.1%) were provider-sponsored. Provider-sponsored insurers had MLRs 5.8 percentage points higher than traditional insurers (95% CI, 2.0 to 9.7). Provider-sponsored insurers had higher overall quality ratings (0.65 stars; 95% CI, 0.36 to 0.94), despite reporting $5.5 lower quality improvement expenses per member per month (95% CI, \u22128.9 to \u22122.2). A 10 percentage point higher MLR was associated with 0.15 higher stars (95% CI, 0.09 to 0.21). Prior-year, but not current-year, quality improvement expenses were associated with higher subsequent ratings (0.04 stars per $10 per member per month; 95% CI, 0.02 to 0.07).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Organizational structure may shape MLR interpretation; direct quality measures may complement MLR regulation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/haschl\/qxag246","type":"journal-article","created":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T11:48:26Z","timestamp":1788954506000},"source":"Crossref","is-referenced-by-count":0,"title":["Provider-sponsored insurers, medical loss ratios, and quality ratings in ACA marketplaces"],"prefix":"10.1093","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3681-7202","authenticated-orcid":false,"given":"Lynn M","family":"Hua","sequence":"first","affiliation":[{"name":"Robinson College of Business, Georgia State University , Atlanta, GA 30303 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-7923-0155","authenticated-orcid":false,"given":"Hyein","family":"Cho","sequence":"additional","affiliation":[{"name":"Cornerstone Research , Boston, MA 02116 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,9,10]]},"reference":[{"key":"2026100510120941200_qxag246-B1"},{"key":"2026100510120941200_qxag246-B2","author":"McGough"},{"issue":"8","key":"2026100510120941200_qxag246-B3","doi-asserted-by":"publisher","first-page":"1321","DOI":"10.1377\/hlthaff.2020.00017","article-title":"Consolidation of providers into health systems increased substantially, 2016-18","volume":"39","author":"Furukawa","year":"2020","journal-title":"Health Aff 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