Effects of Cost Sharing on Ophthalmic Care Utilization in the Affordable Care Act Marketplace.
Ophthalmic Epidemiol
; 31(2): 159-168, 2024 Apr.
Article
em En
| MEDLINE
| ID: mdl-37042706
ABSTRACT
PURPOSE:
To determine the distribution and quantity of ophthalmic care consumed on Affordable Care Act (ACA) plans, the demographics of the population utilizing these services, and the relationship between ACA insurance coverage plan tier, cost sharing, and total cost of ophthalmic care consumed.METHODS:
This cross-sectional study analyzed ACA individual and small group market claims data from the Wakely Affordable Care Act (WACA) 2018 dataset, which contains detailed claims, enrollment, and premium data from Edge Servers for 3.9 million individual and small group market lives. We identified all enrollees with ophthalmology-specific billing, procedure, and national drug codes. We then analyzed the claims by plan type and calculated the total cost and out-of-pocket (OOP) cost.RESULTS:
Among 3.9 million enrollees in the WACA 2018 dataset, 538,169 (13.7%) had claims related to ophthalmology procedures, medications, and/or diagnoses. A total of $203 million was generated in ophthalmology-related claims, with $54 million in general services, $42 million in medications, $20 million in diagnostics and imaging, and $86 million in procedures. Average annual OOP costs were $116 per member, or 30.9% of the total cost, and were lowest for members with platinum plans (16% OOP) and income-driven cost sharing reduction (ICSR) subsidies (17% OOP). Despite stable ocular disease distribution across plan types, beneficiaries with silver ICSR subsidies consumed more total care than any other plan, higher than platinum plan enrollees and almost 1.5× the cost of bronze plan enrollees.CONCLUSIONS:
Ophthalmic care for enrollees on ACA plans generated substantial costs in 2018. Plans with higher OOP cost sharing may result in lower utilization of ophthalmic care.Palavras-chave
Texto completo:
1
Coleções:
01-internacional
Contexto em Saúde:
1_ASSA2030
Base de dados:
MEDLINE
Assunto principal:
Patient Protection and Affordable Care Act
/
Trocas de Seguro de Saúde
Tipo de estudo:
Health_economic_evaluation
/
Observational_studies
Aspecto:
Equity_inequality
Limite:
Humans
País/Região como assunto:
America do norte
Idioma:
En
Revista:
Ophthalmic Epidemiol
Ano de publicação:
2024
Tipo de documento:
Article