Medicare advantage and dialysis facility choice.

OBJECTIVE: To compare the characteristics of dialysis facilities used by traditional Medicare (TM) and Medicare advantage (MA) enrollees with end-stage kidney disease (ESKD). DATA SOURCES: We used 20% TM claims and 100% MA encounter data from 2018 and publicly available data from the Centers for Medicare and Medicaid Services. STUDY DESIGN: We compared the characteristics of the dialysis facilities treating TM and MA patients in the same ZIP code, adjusting for patient characteristics. The outcome variables were facility ownership, distance to the facility, and several measures of facility quality. DATA COLLECTION/EXTRACTION: We identified point prevalent dialysis patients as of July 15, 2018. PRINCIPAL FINDINGS: Compared to TM patients in the same ZIP code, MA patients were 1.84 percentage points more likely to be treated at facilities owned by the largest two dialysis organizations and 1.85 percentage points less likely to be treated at an independently owned facility. MA patients went to further and lower quality facilities than TM patients in the same ZIP code. However, these differences in facility quality were modest. For example, while the mean dialysis facility mortality rate was 21.85, the difference in mortality rates at facilities treating MA and TM patients in the same ZIP code was 0.67 deaths per 100 patient-years. Similarly, MA patients went to facilities that were, on average, 0.15 miles further than TM patients in the same ZIP code. CONCLUSION: MA enrollees with ESKD were more likely than TM enrollees in the same ZIP code to use the dialysis facilities owned by the two largest chains, travel further for care, and receive care at lower quality facilities. While the magnitude of differences in facility distance and quality was modest, the direction of these results underscores the importance of monitoring dialysis network adequacy as ESKD MA enrollment continues to grow.

Access to Health Insurance and Utilization of Substance Use Disorder Treatment: Evidence from the Affordable Care Act Dependent Coverage Provision.

The relationship between insurance coverage and use of specialty substance use disorder (SUD) treatment is not well understood. In this study, we add to the literature by examining changes in admissions to SUD treatment following the implementation of a 2010 Affordable Care Act provision requiring health insurers to offer dependent coverage to young adult children of their beneficiaries under age 26. We use national administrative data on admissions to specialty SUD treatment and apply a difference-in-differences design to study effects of the expansion on the rate of treatment utilization among young adults and, among those in treatment, changes in insurance status and payment source. We find that admissions to treatment declined by 11% after the expansion. However, the share of young adults covered by private insurance increased by 5.4 percentage points and the share with private insurance as the payment source increased by 3.7 percentage points. This increase was largely offset by decreased payment from government sources. Copyright © 2017 John Wiley & Sons, Ltd.

Common and Costly Hospitalizations Among Insured Young Adults Since the Affordable Care Act.

PURPOSE: To describe the most prevalent and costly inpatient hospitalizations in a national cohort of privately insured young adults since the Affordable Care Act. METHODS: Cross-sectional study of a national administrative data set of privately insured young adult (18-30 years) beneficiaries hospitalized from January 2012 to June 2013. The most prevalent diagnosis categories for young adult hospitalizations are presented as percentages of all young adult hospitalizations by gender and age group (18-21, 22-25, and 26-30 years). Mean and median out-of-pocket costs by diagnosis category and gender are calculated based on deductible, copay and coinsurance payments. RESULTS: We analyzed 158,777 hospitalizations among 4.7 million young adult beneficiaries; young adults accounted for 18.3% of privately insured hospitalizations across all ages. Top diagnoses for young adult female hospitalizations were pregnancy related (71.9%) and mental illness (8.9%). Top diagnoses for young adult male hospitalizations were mental illness (39.3%) and injuries and poisoning (14.0%). Mean and median total out-of-pocket costs for any young adult hospitalization were $1,034 and $700, respectively (mean deductible payment = $411). The most expensive out-of-pocket hospitalizations were for dermatologic diseases (e.g., skin infections) with means of $1,306 for females and $1,287 for males. CONCLUSIONS: This study establishes a baseline for the ongoing assessment of the most common and costly hospitalizations among privately insured young adults in the United States under the Affordable Care Act. The substantial burden of potentially avoidable hospitalizations (e.g., mental health, injury, and poisonings) supports resource allocation to improve outpatient services, mental health access, and public health prevention strategies for young adults.

Changes in Emergency Department Use Among Young Adults After the Patient Protection and Affordable Care Act's Dependent Coverage Provision.

STUDY OBJECTIVE: Since September 2010, the Patient Protection and Affordable Care Act has allowed young adults to remain as dependents on their parents' private health plans until age 26 years. This insurance expansion could improve the efficiency of medical care delivery by reducing unnecessary emergency department (ED) use. We evaluated the effect of this provision on ED use among young adults. METHODS: We used a nationally representative ED visit database of more than 17 million visits from 2007 to 2011. Our analysis compared young adults aged 19 to 25 years (the age group targeted by the law) with slightly older adults aged 27 to 29 years (control group), before and after the implementation of the law. RESULTS: The quarterly ED-visit rate decreased by 1.6 per 1,000 population (95% confidence interval 1.2 to 2.1) among targeted young adults after the implementation of the provision, relative to a comparison group. The decrease was concentrated among women, weekday visits, nonurgent conditions, and conditions that can be treated in other settings. We found no effect among weekend visits or visits due to injuries or urgent conditions. The provision also changed the health insurance composition of ED visits; the fraction of privately insured young adults increased, whereas the fraction of those insured through Medicaid and those uninsured decreased. CONCLUSION: The Patient Protection and Affordable Care Act dependent coverage expansion was associated with a statistically significant yet modest decrease in ED use, concentrated in the types of ED visits that were likely to be responsive to changes to insurance status. In response to the law, young adults appeared to have altered their visit pattern to reflect a more efficient use of medical care.

Access to health insurance and the use of inpatient medical care: evidence from the Affordable Care Act young adult mandate.

The Affordable Care Act of 2010 expanded coverage to young adults by allowing them to remain on their parent's private health insurance until they turn 26 years old. While there is evidence on insurance effects, we know very little about use of general or specific forms of medical care. We study the implications of the expansion on inpatient hospitalizations. Given the prevalence of mental health needs for young adults, we also specifically study mental health related inpatient care. We find evidence that compared to those aged 27-29 years, treated young adults aged 19-25 years increased their inpatient visits by 3.5 percent while mental illness visits increased 9.0 percent. The prevalence of uninsurance among hospitalized young adults decreased by 12.5 percent; however, it does not appear that the intensity of inpatient treatment changed despite the change in reimbursement composition of patients.

Variation in charges for 10 common blood tests in California hospitals: a cross-sectional analysis.

OBJECTIVES: To determine the variation in charges for 10 common blood tests across California hospitals in 2011, and to analyse the hospital and market-level factors that may explain any observed variation. DESIGN, SETTING AND PARTICIPANTS: We conducted a cross-sectional analysis of the degree of charge variation between hospitals for 10 common blood tests using charge data reported by all non-federal California hospitals to the California Office of Statewide Health Planning and Development in 2011. OUTCOME MEASURES: Charges for 10 common blood tests at California hospitals during 2011. RESULTS: We found that charges for blood tests varied significantly between California hospitals. For example, charges for a lipid panel ranged from US$10 to US$10,169, a thousand-fold difference. Although government hospitals and teaching hospitals were found to charge significantly less than their counterparts for many blood tests, few other hospital characteristics and no market-level predictors significantly predicted charges for blood tests. Our models explained, at most, 21% of the variation between hospitals in charges for the blood test in question. CONCLUSIONS: These findings demonstrate the seemingly arbitrary nature of the charge setting process, making it difficult for patients to act as true consumers in this era of 'consumer-directed healthcare.'

A cross-sectional analysis of variation in charges and prices across California for percutaneous coronary intervention.

BACKGROUND: Though past studies have shown wide variation in aggregate hospital price indices and specific procedures, few have documented or explained such variation for distinct and common episodes of care. OBJECTIVES: We sought to examine the variability in charges for percutaneous coronary intervention (PCI) with a drug-eluting stent and without major complications (MS-DRG-247), and determine whether hospital and market characteristics influenced these charges. METHODS: We conducted a cross-sectional analysis of adults admitted to California hospitals in 2011 for MS-DRG-247 using patient discharge data from the California Office of Statewide Health Planning and Development. We used a two-part linear regression model to first estimate hospital-specific charges adjusted for patient characteristics, and then examine whether the between-hospital variation in those estimated charges was explained by hospital and market characteristics. RESULTS: Adjusted charges for the average California patient admitted for uncomplicated PCI ranged from $22,047 to $165,386 (median: $88,350) depending on which hospital the patient visited. Hospitals in areas with the highest cost of living, those in rural areas, and those with more Medicare patients had higher charges, while government-owned hospitals charged less. Overall, our model explained 43% of the variation in adjusted charges. Estimated discounted prices paid by private insurers ranged from $3,421 to $80,903 (median: $28,571). CONCLUSIONS: Charges and estimated discounted prices vary widely between hospitals for the average California patient undergoing PCI without major complications, a common and relatively homogeneous episode of care. Though observable hospital characteristics account for some of this variation, the majority remains unexplained.

Variation in charges for emergency department visits across California.

STUDY OBJECTIVE: Previous studies have shown that charges for inpatient and clinic procedures vary substantially; however, there are scant data on variation in charges for emergency department (ED) visits. Outpatient ED visits are typically billed with current procedural terminology-coded levels to standardize the intensity of services received, providing an ideal element on which to evaluate charge variation. Thus, we seek to analyze the variation in charges for each level of ED visits and examine whether hospital- and market-level factors could help predict these charges. METHODS: Using 2011 charge data provided by every nonfederal California hospital to the Office of Statewide Health Planning and Development, we analyzed the variability in charges for each level of ED visits and used linear regression to assess whether hospital and market characteristics could explain the variation in charges. RESULTS: Charges for each ED visit level varied widely; for example, charges for a level 4 visit ranged from $275 to $6,662. Government hospitals charged significantly less than nonprofit hospitals, whereas hospitals that paid higher wages, served higher proportions of Medicare and Medicaid patients, and were located in areas with high costs of living charged more. Overall, our models explained only 30% to 41% of the between-hospital variation in charges for each level of ED visits. CONCLUSION: Our findings of extensive charge variation in ED visits add to the literature in demonstrating the lack of systematic charge setting in the US health care system. These widely varying charges affect the hospital bills of millions of uninsured patients and insured patients seeking care out of network and continue to play a role in many aspects of health care financing.

Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study.

OBJECTIVE: To examine the between-hospital variation of charges and discounted prices for uncomplicated vaginal and caesarean section deliveries, and to determine the institutional and market-level characteristics that influence adjusted charges. DESIGN, SETTING AND PARTICIPANTS: Using data from the California Office of Statewide Health Planning and Development (OSHPD), we conducted a cross-sectional study of all privately insured patients admitted to California hospitals in 2011 for uncomplicated vaginal delivery (diagnosis-related group (DRG) 775) or uncomplicated caesarean section (DRG 766). OUTCOME MEASURES: Hospital charges and discounted prices adjusted for each patient's clinical and demographic characteristics. RESULTS: We analysed 76 766 vaginal deliveries and 32 660 caesarean sections in California in 2011. After adjusting for patient demographic and clinical characteristics, we found that the average California woman could be charged as little as US$3296 or as much as US$37 227 for a vaginal delivery, and US$8312-US$70 908 for a caesarean section depending on which hospital she was admitted to. The discounted prices were, on an average, 37% of the charges. We found that hospitals in markets with middling competition had significantly lower adjusted charges for vaginal deliveries, while hospitals with higher wage indices and casemixes, as well as for-profit hospitals, had higher adjusted charges. Hospitals in markets with higher uninsurance rates charged significantly less for caesarean sections, while for-profit hospitals and hospitals with higher wage indices charged more. However, the institutional and market-level factors included in our models explained only 35-36% of the between-hospital variation in charges. CONCLUSIONS: These results indicate that charges and discounted prices for two common, relatively homogeneous diagnosis groups-uncomplicated vaginal delivery and caesarean section-vary widely between hospitals and are not well explained by observable patient or hospital characteristics.