Out-of-Pocket Spending for Insulin, Diabetes-Related Supplies, and Other Health Care Services Among Privately Insured US Patients With Type 1 Diabetes.
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ABSTRACT:
SUBMITTER: Chua KP
PROVIDER: S-EPMC7265118 | biostudies-literature | 2020 Jul
REPOSITORIES: biostudies-literature
Publications
Out-of-Pocket Spending for Insulin, Diabetes-Related Supplies, and Other Health Care Services Among Privately Insured US Patients With Type 1 Diabetes.
Chua Kao-Ping KP Lee Joyce M JM Conti Rena M RM
JAMA internal medicine 20200701 7
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Project description:ImportancePrivately insured US children account for 40% of non-birth-related pediatric hospitalizations. However, there are no national data on the magnitude or correlates of out-of-pocket spending for these hospitalizations.ObjectiveTo estimate out-of-pocket spending for non-birth-related hospitalizations among privately insured children and identify factors associated with this spending.Design, setting, and participantsThis study is a cross-sectional analysis of the IBM MarketScan Commercial Database, which reports claims from 25 to 27 million privately insured enrollees annually. In the primary analysis, all non-birth-related hospitalizations of children 18 years and younger from 2017 through 2019 were included. In a secondary analysis focused on insurance benefit design, hospitalizations that could be linked to the IBM MarketScan Benefit Plan Design Database and were covered by plans with a family deductible and inpatient coinsurance requirements were analyzed.Main outcomes and measuresIn the primary analysis, factors associated with out-of-pocket spending per hospitalization (sum of deductibles, coinsurance, and copayments) were identified using a generalized linear model. In the secondary analysis, variation in out-of-pocket spending was assessed by level of deductible and inpatient coinsurance requirements.ResultsAmong 183 780 hospitalizations in the primary analysis, 93 186 (50.7%) were for female children, and the median (IQR) age of hospitalized children was 12 (4-16) years. A total of 145 108 hospitalizations (79.0%) were for children with a chronic condition and 44 282 (24.1%) were covered by a high-deductible health plan. Mean (SD) total spending per hospitalization was $28 425 ($74 715). Mean (SD) and median (IQR) out-of-pocket spending per hospitalization were $1313 ($1734) and $656 ($0-$2011), respectively. Out-of-pocket spending exceeded $3000 for 25 700 hospitalizations (14.0%). Factors associated with higher out-of-pocket spending included hospitalization in quarter 1 compared with quarter 4 (average marginal effect [AME], $637; 99% CI, $609-$665) and lack of chronic conditions compared with having a complex chronic condition (AME, $732; 99% CI, $696-$767). The secondary analysis included 72 165 hospitalizations. Among hospitalizations covered by the least generous plans (deductible of $3000 or more and coinsurance of 20% or more) and most generous plans (deductible less than $1000 and coinsurance of 1% to 19%), mean (SD) out-of-pocket spending was $1974 ($1999) and $826 ($798), respectively (AME, $1123; 99% CI, $1069-$1179).Conclusions and relevanceIn this cross-sectional study, out-of-pocket spending for non-birth-related pediatric hospitalizations were substantial, especially when they occurred early in the year, involved children without chronic conditions, or were covered by plans with high cost-sharing requirements.
| S-EPMC10043803 | biostudies-literature
Project description: Not available
| S-EPMC10407758 | biostudies-literature
Project description: Not available
| S-EPMC8783269 | biostudies-literature
Project description:While out-of-network or potential "surprise" billing has garnered increasing attention, particularly in emergency department and inpatient settings, few national studies have examined out-of-network care overall or in other settings. We examined out-of-network spending and use among two large nationwide populations with employer-sponsored insurance. In a primary sample of 27,883,040 people in data for 2008-16 from the Truven MarketScan Commercial Claims and Encounters Database, we found that the unadjusted share of total spending that occurred out of network decreased from 7.0 percent in 2008-10 to 6.1 percent in 2014-16, an adjusted average decline of 0.10 percentage points per year. Using a secondary sample of 13,093,209 people in the Health Care Cost Institute database provided qualitatively similar results, including when provider charges (upper bound for balance billing) were used in place of observed out-of-network prices. In subgroup analyses of the primary sample, the share of out-of-network spending was stable or declined among all segments of care except hospitalist services, pathologist services, and laboratory tests across the study period. Out-of-network use demonstrated comparable patterns. Prices were higher out of network than in network. Policy makers should focus their efforts on protecting consumers from balance billing or potential surprise billing in clinical scenarios where patients often have little choice over their provider.
| S-EPMC8299541 | biostudies-literature
Project description:ImportancePatients may be unaware of which laboratory is processing their clinical tests, limiting their ability to choose an in-network laboratory. Out-of-network laboratory services could increase patients' out-of-pocket costs and their reluctance to obtain necessary tests.ObjectiveTo evaluate the frequency and cost of out-of-network bills for outpatient laboratory services compared with other services.Design, setting, and participantsThis retrospective cohort study of claims data from the Truven MarketScan Commercial Claims database evaluated claims from 3 946 210 individuals (30.5% of the total) in the MarketScan database who were continually enrolled in health maintenance organization plans, preferred provider organization plans, exclusive provider organization plans, or consumer-driven health plans/high-deductible health plans with at least 1 outpatient clinical laboratory service in 2018. Outpatient laboratory services occurred in independent laboratories, physician offices, and outpatient centers. Laboratory bills from January 1, 2010, to December 31, 2018, were studied.ExposuresReceipt and cost of outpatient laboratory service.Main outcomes and measuresThe primary outcome was the proportion of outpatient laboratory services billed as out of network. The secondary outcome was the total potential out-of-pocket cost associated with the out-of-network bill, the sum of observed cost sharing, and the potential balance bill.ResultsOf the 12 958 130 in the total sample, 30.5% (3 946 210) had a laboratory test, of whom 5.9% received an out-of-network laboratory test. In comparison, 7.1% of the total sample had an emergency department visit, of whom 4.9% had a service billed as out of network, and 1.6% had an inpatient anesthesiology service, of whom 3.4% had an out-of-network service. Observed out-of-pocket spending was $24.59 higher for an out-of-network laboratory service than an in-network laboratory service. In addition, patients with an out-of-network laboratory service may receive an additional balance bill from the laboratory service; the estimated mean balance bill was $80.63. For the most common laboratory services, the total potential out-of-pocket cost associated with an out-of-network bill ranged from $15.68 for venipuncture to $88.09 for lipid panel but was as high as $303.18 for a drug screening test.Conclusions and relevanceIn this cohort study, out-of-network laboratory services were 5 times more common than out-of-network emergency department visits and 34 times more common than out-of-network anesthesiology services. It is important for patients that consumer protections against out-of-network bills apply to laboratory services.
| S-EPMC8077039 | biostudies-literature
Project description:ObjectivesMany patients report financial stress following hospitalization for COVID-19. Although many COVID-19 survivors require extensive care after discharge, the degree to which this care contributes to financial stress is unclear. Using national data, we assessed out-of-pocket spending during the 180 days after discharge among patients hospitalized for COVID-19.Study designRetrospective cohort analysis of Optum's deidentified Clinformatics Data Mart, a national database of medical and pharmacy claims.MethodsAmong privately insured and Medicare Advantage patients hospitalized for COVID-19 between March and June 2020, we calculated median out-of-pocket spending during the 180 days after discharge. For comparison, we repeated this calculation among patients hospitalized for pneumonia.ResultsOf 7932 patients with COVID-19 included in analyses, 2061 (26.0%) had private insurance. Among privately insured and Medicare Advantage patients, median (25th-75th percentile) out-of-pocket spending after discharge was $287 ($59-$842) and $271 ($63-$783), respectively. Out-of-pocket spending exceeded $2000 for 10.9% and 9.3% of these patients, respectively. Among privately insured and Medicare Advantage patients hospitalized for pneumonia, median (25th-75th percentile) out-of-pocket spending after discharge was $276 ($62-$836) and $570 ($181-$1466). Out-of-pocket spending exceeded $2000 for 12.1% and 17.2% of these patients, respectively.ConclusionsFor most patients hospitalized for COVID-19, postdischarge care may not be a major source of financial stress. Although this is reassuring, our findings also suggest that a sizable minority of COVID-19 survivors have substantial out-of-pocket spending after discharge. These survivors could be particularly vulnerable to financial toxicity if they also receive bills for the hospitalization owing to the expiration of insurer cost-sharing waivers. Insurers should consider this possibility when deciding whether to reinstate cost-sharing waivers for COVID-19 hospitalizations.
| S-EPMC9826666 | biostudies-literature
Project description: Not available
| S-EPMC7838924 | biostudies-literature
Project description:ImportanceRising out-of-pocket costs of maternal health care for people with commercial insurance may affect use of health care and outcomes. There are stark racial and ethnic disparities in outcomes, but little is known about differences in spending.ObjectiveTo measure differences in out-of-pocket spending for maternity care by race and ethnicity.Design, setting, and participantsThis retrospective cross-sectional study used administrative data from Blue Cross Blue Shield of Massachusetts from January 1, 2018, through December 31, 2022, for pregnancies, deliveries, and 42-day postpartum care. Participants were continuously enrolled during pregnancy, delivery, and 42 days post partum (collectively termed maternity episode).ExposuresThe primary characteristic of interest was the birthing person's race and ethnicity.Main outcomes and measuresThe primary outcome was total out-of-pocket spending during the maternity episode. Out-of-pocket spending was measured separately for the pregnancy period, prenatal services, and delivery, by type of cost sharing, and as a percentage of the median household income in the patient's census tract (using American Community Survey data). Race and ethnicity were measured via self-report and imputation.ResultsThe analytic sample included 87 253 maternity episodes among 76 826 unique birthing persons (mean [SD] age, 32.4 [4.7] years; 99.8% female) between 2018 and 2022; among maternity episodes, 8572 birthing persons (9.8%) were Asian, 3331 (3.8%) were Black, 6872 (7.9%) were Hispanic, and 68 478 (78.5%) were White. Mean out-of-pocket spending for the maternity episode was highest among Black birthing people ($2398 [$426]), followed by Hispanic ($2300 [$572]), Asian ($2202 [$603]), and White ($2036 [$1547]) birthing people (P < .001). These differences remained statistically significant after adjusting for health and demographic characteristics. The differences were largest in the prenatal period and for coinsurance payments. Black (1003 [30.1%]) and Hispanic (2302 [33.5%]) birthing people were more likely than Asian (1569 [18.3%]) and White (12 600 [18.4%]) birthing people to be enrolled in plans with high coinsurance, but not plans with high deductibles (3317 [38.7%] for Asian, 1232 [37.0%] for Black, 2350 [34.2%] for Hispanic, and 24 515 [35.8%] for White birthing people).Conclusions and relevanceIn this study, differences in out-of-pocket maternity spending among the commercially insured were associated with differences in coinsurance rates. These costs could lead people to forgo needed health care or other basic needs that support health (eg, food or housing). Changes to health plan benefit design could improve equity in out-of-pocket maternity spending and its consequences.
| S-EPMC11871542 | biostudies-literature
Project description:BackgroundIn recent years, the issue of out-of-network billing for privately insured patients has been highlighted as a source of unexpected out-of-pocket charges for patients, even in the setting of an in-network primary surgeon. The Congress recently passed the No Surprises Act to curtail these practices. However, the new law contains exceptions, and its regulatory system has yet to be established. As one of the most frequently performed major surgical procedures, hysterectomy represents a significant exposure to out-of-network bills among nonelderly females in the United States.ObjectiveTo describe the extent and nature of out-of-network bills at the time of hysterectomy among privately insured patients in the context of the recently passed No Surprises Act.Study designWe performed a retrospective cohort study of women aged 18 to 64 years who underwent simple hysterectomy from 2008 to 2018 with an in-network primary surgeon in the IBM Watson Marketscan claims database, which includes data from over 350 different payers. We identified out-of-network claims for facility or professional services and analyzed the frequency, size, and source of the payments. We used multivariable logistic regression to assess for patient, procedure, and facility characteristics associated with the risk of out-of-network claims.ResultsWe identified 585,223 hysterectomy cases meeting all the inclusion criteria, and they were evenly split between inpatient (49.6%) and outpatient (50.4%) procedures. Overall, 8.8% of cases included at least 1 out-of-network claim, with median out-of-network expenditures of $553 for inpatient procedures and $438 for outpatient procedures. Compared with professional out-of-network claims, facility out-of-network claims were less common (2.3% vs 7.4%) but far greater in the amount billed (median $8,307 vs $400 inpatient, $3,281 vs $407 outpatient). Among the professional claims, those from midlevel surgical assistants were most frequently out-of-network when present (13.8% inpatient; 20.0% outpatient), whereas out-of-network claims from anesthesia were most common overall and largest (median $890 inpatient, $1,021 outpatient) when present. In a multivariable model, older age, increasing comorbidity, and complications during the stay were associated with higher odds of any out-of-network claim. In contrast, the risk of facility out-of-network claims was more strongly associated with the facility region and the surgical approach, with the highest odds for cases in the North Central region and those using robotic approach.ConclusionOut-of-network bills for privately insured patients at the time of hysterectomy occurred in 8.8% of cases. Approximately one-quarter of these included out-of-network facility claims tended to have higher payments than out-of-network professional claims and may not be prevented by the No Surprises Act. Gynecologic surgeons should be aware of the potential out-of-network charges for ancillary services at the time of surgery, particularly the network status of the facility, to provide maximal transparency and financial protection to our patients.
| S-EPMC10150992 | biostudies-literature
Project description:We use insurance claims data covering 28% of individuals with employer-sponsored health insurance in the United States to study the variation in health spending on the privately insured, examine the structure of insurer-hospital contracts, and analyze the variation in hospital prices across the nation. Health spending per privately insured beneficiary differs by a factor of three across geographic areas and has a very low correlation with Medicare spending. For the privately insured, half of the spending variation is driven by price variation across regions, and half is driven by quantity variation. Prices vary substantially across regions, across hospitals within regions, and even within hospitals. For example, even for a nearly homogeneous service such as lower-limb magnetic resonance imaging, about a fifth of the total case-level price variation occurs within a hospital in the cross section. Hospital market structure is strongly associated with price levels and contract structure. Prices at monopoly hospitals are 12% higher than those in markets with four or more rivals. Monopoly hospitals also have contracts that load more risk on insurers (e.g., they have more cases with prices set as a share of their charges). In concentrated insurer markets the opposite occurs-hospitals have lower prices and bear more financial risk. Examining the 366 mergers and acquisitions that occurred between 2007 and 2011, we find that prices increased by over 6% when the merging hospitals were geographically close (e.g., 5 miles or less apart), but not when the hospitals were geographically distant (e.g., over 25 miles apart).
| S-EPMC7517591 | biostudies-literature