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 |
REPOSITORIES: biostudies-literature
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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: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
Project description:ImportanceAlthough surprise medical bills are receiving considerable attention from lawmakers and the news media, to date there has been little systematic study of the incidence and financial consequences of out-of-network billing.ObjectiveTo examine out-of-network billing among privately insured patients with an inpatient admission or emergency department (ED) visit at in-network hospitals.Design, setting, and participantsA retrospective analysis using data from the Clinformatics Data Mart database (Optum), which includes health insurance claims for individuals from all 50 US states receiving private health insurance from a large commercial insurer was conducted of all inpatient admissions (n = 5 457 981) and ED visits (n = 13 579 006) at in-network hospitals between January 1, 2010, and December 31, 2016. Data were collected and analyzed in March 2019.ExposuresReceipt of a bill for care from at least 1 out-of-network physician or medical transport service associated with patient admission or ED visit.Main outcomes and measuresThe incidence of out-of-network billing and the potential amount of patients' financial liability associated with out-of-network bills from the admission or visit.ResultsOf 5 457 981 inpatient admissions and 13 579 006 ED admissions between 2010 and 2016, the percentage of ED visits with an out-of-network bill increased from 32.3% to 42.8% (P < .001) during the study period, and the mean (SD) potential financial responsibility for these bills increased from $220 ($420) to $628 ($865) (P < .001; all dollar values in 2018 US$). Similarly, the percentage of inpatient admissions with an out-of-network bill increased from 26.3% to 42.0% (P < .001), and the mean (SD) potential financial responsibility increased from $804 ($2456) to $2040 ($4967) (P < .001).Conclusions and relevanceOut-of-network billing appears to have become common for privately insured patients even when they seek treatment at in-network hospitals. The mean amounts billed appear to be sufficiently large that they may create financial strain for a substantial proportion of patients.
| S-EPMC6692693 | biostudies-literature
Project description:Millions of low-income Americans will gain health insurance through Medicaid under the Affordable Care Act. This study assesses the impact of previous Medicaid expansions on mental health services utilization and out-of-pocket spending.Secondary data from the 1998-2011 Medical Expenditure Panel Survey Household Component merged with National Health Interview Survey and state Medicaid eligibility rules data.Instrumental variables regression models were used to estimate the impact of expanded Medicaid eligibility on health insurance coverage, mental health services utilization, and out-of-pocket spending for mental health services.Person-year files were constructed including adults ages 21-64 under 300 percent of the Federal Poverty Level.Medicaid expansions significantly increased health insurance coverage and reduced out-of-pocket spending on mental health services for low-income adults. Effects of expanded Medicaid eligibility on out-of-pocket spending were strongest for adults with psychological distress. Expanding Medicaid eligibility did not significantly increase the use of mental health services.Previous Medicaid eligibility expansions did not substantially increase mental health service utilization, but they did reduce out-of-pocket mental health care spending.
| S-EPMC4693850 | biostudies-literature
Project description:Inpatient and skilled nursing facility (SNF) cost sharing in Medicare Advantage (MA) plans may reduce unnecessary use of these services. However, large out-of-pocket expenses potentially limit access to care and encourage beneficiaries at high risk of needing inpatient and postacute care to avoid or leave MA plans. In 2011 new federal regulations restricted inpatient and skilled nursing facility cost sharing and mandated limits on out-of-pocket spending in MA plans. After these regulations, MA members in plans with low premiums averaged $1,758 in expected out-of-pocket spending for an episode of seven hospital days and twenty skilled nursing facility days. Among members with the same low-premium plan in 2010 and 2011, 36 percent of members belonged to plans that added an out-of-pocket spending limit in 2011. However, these members also had a $293 increase in average cost sharing for an inpatient and skilled nursing facility episode, possibly to offset plans' expenses in financing out-of-pocket limits. Some MA beneficiaries may still have difficulty affording acute and postacute care despite greater regulation of cost sharing.
| S-EPMC4681704 | biostudies-literature
Project description:Previous research has shown relatively high use of out-of-network mental health providers, although direct comparisons with rates among general health providers are not available. We aimed to (1) estimate the proportion of privately insured adults using an out-of-network mental health provider in the past 12 months; (2) compare rates of out-of-network mental health provider use with out-of-network general medical use; (3) determine reasons for out-of-network mental health care use.A nationally representative sample of privately insured US adults was surveyed using the internet in February 2011. Screener questions identified if the participant had used either a general medical physician or a mental health professional within the past 12 months. Respondents using either type of out-of-network provider completed a 10-minute survey on details of their out-of-network care experiences.Eighteen percent of individuals who used a mental health provider reported at least 1 contact with an out-of-network mental health provider, compared to 6.8% who used a general health provider (P<0.01). The most common reasons for choosing an out-of-network mental health provider were the physician was recommended (26.1%), continuity with a previously known provider (23.7%), and the perceived skill of the provider (19.3%).Out-of-network provider use is more likely in mental health care than general health care. Most respondents chose an out-of-network mental health provider based on perceived provider quality or continuing care with a previously known provider rather than issues related to the availability of an in-network provider, convenient location, or appointment wait time.
| S-EPMC4707657 | biostudies-literature
Project description:Importance:The Affordable Care Act (ACA) was associated with a reduced number of Americans who reported being unable to afford medical care, but changes in actual health spending by households are not known. Objectives:To estimate changes in household spending on health care nationwide after implementation of the ACA. Design, Setting, and Participants:Population-based data from the Medical Expenditure Panel Survey from January 1, 2012, through December 31, 2015, and multivariable regression were used to examine changes in out-of-pocket spending, premium contributions, and total health spending (out-of-pocket plus premiums) after the ACA's coverage expansions on January 1, 2014. The study population included a nationally representative sample of US adults aged 18 to 64 years (n = 83 431). In addition, changes were assessed in the likelihood of exceeding affordability thresholds for each outcome and spending changes for income subgroups defined under the ACA to determine program eligibility at 138% or less, 139% to 250%, 251% to 400%, and greater than 400% of the federal poverty level (FPL). Exposure:Implementation of the ACA's major insurance programs on January 1, 2014. Main Outcomes and Measures:Mean individual-level out-of-pocket spending and premium payments and the percentage of persons experiencing high-burden spending, defined as more than 10% of family income for out-of-pocket expenses, more than 9.5% for premium payments, and more than 19.5% for out-of-pocket plus premium payments. Results:In this nationally representative survey of 83 431 adults (weighted frequency, 49.1% men and 50.9% women; median age, 40.3 years; interquartile range, 28.6-52.4 years), ACA implementation was associated with an 11.9% decrease (95% CI, -17.1% to -6.4%; P < .001) in mean out-of-pocket spending in the full sample, a 21.4% decrease (95% CI, -30.1% to -11.5%; P < .001) in the lowest-income group (≤138% of the FPL), an 18.5% decrease (95% CI, -27.0% to -9.0%; P < .001) in the low-income group (139%-250% of the FPL), and a 12.8% decrease (95% CI, -22.1% to -2.4%; P = .02) in the middle-income group (251%-400% of the FPL). Mean premium spending increased in the full sample (12.1%; 95% CI, 1.9%-23.3%) and the higher-income group (22.9%; 95% CI, 5.5%-43.1%). Combined out-of-pocket plus premium spending decreased in the lowest-income group only (-16.0%; 95% CI, -27.6% to -2.6%). The odds of household out-of-pocket spending exceeding 10% of family income decreased in the full sample (odds ratio [OR], 0.80; 95% CI, 0.70-0.90) and in the lowest-income group (OR, 0.80; 95% CI, 0.67-0.97). The odds of high-burden premium spending increased in the middle-income group (OR, 1.28; 95% CI, 1.03-1.59). Conclusions and Relevance:Implementation of the ACA was associated with reduced out-of-pocket spending, particularly for low-income persons. However, many of these individuals continue to experience high-burden out-of-pocket and premium spending. Repeal or substantial reversal of the ACA would especially harm poor and low-income Americans.
| S-EPMC5885918 | biostudies-literature
Project description:ObjectiveTo characterize physician health system membership in four states between 2012 and 2016 and to compare primary care quality and cost between in-system providers and non-system providers for the commercially insured population.Data sourcesPhysician membership in health systems was obtained from a unique longitudinal database on health systems and matched at the provider level to 2014 all-payer claims data from Colorado, Massachusetts, Oregon, and Utah.Study designUsing an observational study design, we compared physicians in health systems to non-system physicians located in the same state and geography on average cost of care (risk-adjusted using the Johns Hopkins' Adjusted Clinical Grouper), five HEDIS quality measures, one measure of developmental screening, and two Prevention Quality Indicator Measures.Data collection/extraction methodsPatients in commercial health plans were attributed to a primary care physician accounting for the plurality of office visits. A cohort for each quality measure was constructed based on appropriate measure specifications.Principal findingsThe share of physicians in health systems increased steadily from 2012 to 2016 and ranged from 48% in Colorado to 63% in Utah in 2016. Compared to physicians not in a system, system physicians performed similarly on most HEDIS quality metrics compared to non-system physicians. Patients attributed to in-system physicians had about 40% higher rates (P < .05) of Ambulatory Care Sensitive Admissions (measured in admissions per 100 000:921.33 in-system vs 674.61 not-in-system for acute composite; 2540.91 in-system vs 1972.17 for chronic composite In-system providers were associated with $29 (P < .05) higher average per member per month costs (453.37 vs 432.93). Overall, differences in performance by system membership were relatively small compared to differences across states and geography.ConclusionA growing share of physicians is part of a health system from 2012 to 2016. Providers in health systems are not delivering primary care more efficiently than non-system providers for the commercially insured.
| S-EPMC7720710 | biostudies-literature
Project description:Medical care for children with cancer is complex and expensive, and represents a large financial burden for families around the world. We estimated the medical cost of cancer care for children under the age of 18, using administrative records of the universe of children with private insurance in Chile in the period 2007-2018, based on a sample of 3853 observations. We analyzed total cost and out-of-pocket spending by patients' characteristics, type of cancer, and by service. Children with cancer had high annual medical costs, USD 32,287 on average for 2018. Costs were higher for the younger children in the sample. The vast majority of the cost was driven by inpatient hospital care for all types of cancer. The average total cost increased 20% in real terms over the period of study, while out-of-pocket expenses increased almost 29%. Private insurance beneficiaries faced a significant economic burden associated with medical treatment of a child with cancer. Interventions that reduce hospitalizations, as well as systemwide reforms that incorporate maximum out-of-pocket payments and prevent catastrophic expenditures, can contribute to alleviating the financial burden of childhood cancer.
| S-EPMC8267683 | biostudies-literature
Project description:Among privately insured children, the proportion of inflation-adjusted total health care spending accounted for by orphan drugs increased from 4.0 percent to 6.6 percent between 2013 and 2018. This increase was largely driven by price growth. Mean annual out-of-pocket spending for orphan drugs rose from $486 to $866 and was higher for children than adults.
| S-EPMC7968887 | biostudies-literature