Beyond average spending: distributional and seasonal commercial insurance trends, 2012-2021.

OBJECTIVES: The annual mean spending measures typically used to study longitudinal trends mask distributional and seasonal variation that is relevant to patients' perceptions of health care affordability and, in turn, provider collections. This study describes shifts in the distribution and seasonality of plan and patient out-of-pocket spending from 2012 through 2021. STUDY DESIGN: Analysis of multipayer commercial claims data. METHODS: Medical spending per enrollee was calculated by summing inpatient, outpatient, and professional services, which comprised plan payments and out-of-pocket payments (deductible, coinsurance, co-payment). To account for the long right tail of the spending distribution, enrollees were stratified by their decile of annual medical spending, and annual mean spending estimates were calculated overall and by decile. Mean spending estimates were also calculated by quarter-year. RESULTS: Inflation-adjusted medical spending grew most quickly among the highest decile of spenders, without proportional growth in their out-of-pocket expenses. Out-of-pocket spending increased for the majority of enrollees in our sample prior to the COVID-19 pandemic, in real dollars and as a share of total medical spending. Out-of-pocket spending was increasingly concentrated in the early months of the calendar year, driven by deductible spending, and was lower in 2020 and 2021, plausibly due to policies limiting cost sharing for COVID-19-related services. CONCLUSIONS: Insurance is working well to protect the highest spenders at the cost of reduced insurance generosity among spenders elsewhere in the distribution. The increasing cross-subsidization among enrollees through cost-sharing design-vs premiums-is a trend to watch among rising public concerns about underinsurance and medical debt.

Disparate Patient Advocacy When Facing Unaffordable and Problematic Medical Bills.

Importance: People in the US face high out-of-pocket medical expenses, yielding financial strain and debt. Objective: To understand how households respond to medical bills they disagree with or cannot afford. Design, Setting, and Participants: A retrospective cohort study was carried out using a survey fielded between August 14 and October 14, 2023. The study included a random sample of adult (aged ≥18 years) survey respondents from the Understanding America Study (UAS). Participant responses were weighted to be nationally representative. The analysis took place from November 3, 2023, through January 8, 2024. Main Outcomes and Measures: Respondents reported if their household received a medical bill that they could not afford or did not agree with in the prior 12 months, and if anyone contacted the billing office regarding their concerns. Those who did reach out were asked about their experience and those who did not were asked why. Results: The survey was sent to 1233 UAS panelists, of which 1135 completed the survey, a 92.1% cooperation rate. Overall, 1 in 5 of the 1135 respondents received a medical bill that they disagreed with or could not afford. Leading bill sources were physician offices (66 [34.6%]), emergency room or urgent care (22 [19.9%]), and hospitals (31 [15.3%]), and 136 respondents (61.5%) contacted the billing office to address their concern. A more extroverted and less agreeable personality increased likelihood of reaching out. Respondents without a college degree, lower financial literacy, and the uninsured were less likely to contact a billing office. Among those who did not reach out, 55 (86.1%) reported that they did not think it would make a difference. Of those who reached out, 37 (25.7%) achieved bill corrections, better understanding (16 [18.2%]), payment plans (18 [15.5%]), price drop (17 [15.2%]), financial assistance (10 [8.1%]), and/or bill cancellation (6 [7.3%]), while 32 (21.8%) said that the issue was unresolved and 23.8% reported no change. These outcomes aligned well with respondents' billing concerns with financial relief for 75.8% of respondents reaching out about an unaffordable bill, bill corrections for 73.7% of those who thought there was mistake, and a price drop for 61.8% of those who negotiated. Conclusions and Relevance: This cross-sectional survey of a representative sample of patients in the US found that most respondents who self-advocated achieved bill corrections and payment relief. Differences in self-advocacy may be exacerbating socioeconomic inequalities in medical debt burden, as those with less education, lower financial literacy, and the uninsured were less likely to self-advocate. Policies that streamline the administrative burden or shift it from patients to the billing clinician may counter these disparities.

Acceptability of Hospital-at-Home Care and Capacity for Caregiver Burden.

This study surveys a representative US population about aspects of hospital-at-home care, including acceptability and willingness to perform caregiving tasks.

Deductible double jeopardy: patients may pay more out of pocket when pregnancy crosses 2 years.

OBJECTIVES: This study explores the concern that annual high-deductible commercial insurance plan design may yield higher out-of-pocket costs when an episode of maternity care spans 2 years, exposing patients to their cost-sharing limits twice during their episode of care. STUDY DESIGN: Cross-sectional study of Health Care Cost Institute commercial claims. METHODS: The study sample comprises 1,379,300 deliveries among high-deductible health plan enrollees in years 2012 through 2021. Patients' mean cost sharing is calculated across all service types for 3 time periods: (1) delivery hospitalization, (2) maternity episode from 40 weeks prior to delivery hospitalization through 12 weeks after discharge, and (3) extended period spanning 3 years from January of the year before delivery through December of the year after delivery. RESULTS: For each of the 3 episode measurements, mean out-of-pocket spending is highest among those who deliver in January and declines in each subsequent month until August and September (the delivery months with most pregnancy and postpartum periods within the same year), then flattens for the remainder of the year. Mean cost sharing for the maternity episode was $6308 in January and $4998 in December, a difference of $1310. Patients delivering in January also had mean out-of-pocket costs $1491 greater for delivery hospitalization and $1005 greater over the 3-year period than patients delivering in December. CONCLUSIONS: Higher out-of-pocket spending is observed when patients face their cost-sharing limits twice within an episode of maternity care, and this difference persists even when evaluating 3 calendar years of patients' out-of-pocket spending.

Financial assistance and payment plans for underinsured patients shopping for "shoppable" hospital services.

Recent price transparency laws are designed to better inform patients as they compare hospital options and "shop" for health care services. In addition to prices, underinsured patients seeking care need information on financial assistance, discounts, payment plans, and upfront payment requirements to compare the affordability of care across hospitals. Little is known about the availability of this information and the experience of prospective patients seeking it. We contacted a random sample of 10% of general short-term hospitals across the United States in this "secret shopper" telephone study to assess financial options and navigation challenges faced by underinsured patients in need of a non-emergency procedure. The administrative friction was substantial. Most hospitals have 3 siloed offices for (1) financial assistance, (2) payment plans and discounts, and (3) upfront payment requirements. All relevant offices were unreachable in 3 attempted calls at 18.1% of hospitals. Among hospitals with available information, the majority have financial options for patients: 86.7% of hospitals offer financial assistance and 97.0% of hospitals offer payment plans to underinsured patients for non-emergency care. The length and terms of payments plans varied widely for hospital-administered and third-party financing arrangements. Upfront payments were sometimes required, potentially posing barriers for patients without cash or credit access.

Prevalence of Medical Payment Products Promoted on US Hospitals' Websites.

This cross-sectional study examines the prevalence of hospital-promoted medical payment products (MPPs) by whether hospitals offered any MPP or an interest-bearing MPP.

Commercial Payments for COVID-19-Associated Inpatient Stays in 2020.

This cross-sectional study reports the allowed reimbursement amounts for inpatient COVID-19 care for different types of hospitals.

Insurers negotiate lower hospital prices for HIX than for commercial groups.

OBJECTIVES: This study investigates a sample of the pricing data released by hospitals under the price transparency law effective January 2021 to better understand the prices paid by health insurance exchange (HIX) plans relative to commercial group and Medicare Advantage plans. STUDY DESIGN: Cross-sectional analysis of hospital pricing data. METHODS: We compared allowed amounts for 25 common inpatient services and 56 common outpatient services across 22 hospital-insurer dyads, selected by the availability of plan-specific pricing data from the top 100 hospitals by bed counts and the top 100 hospitals by gross revenue based on 2017 CMS data. RESULTS: Insurers in our sample generally negotiated allowed amounts for their HIX plans that were lower than their commercial group rates and well above their Medicare Advantage contracts within the same hospital. CONCLUSIONS: Allowed amounts for HIX plans were generally lower than commercial group rates and higher than Medicare Advantage rates. Better information on HIX pricing is needed as the federal government and states consider additional ways to expand health care coverage, such as public options or expanded Medicaid or Medicare eligibility.

Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems.

Importance: Public and private payers continue to expand use of alternative payment models, aiming to use value-based payment to affect the care delivery of their contracted health system partners. In parallel, health systems and their employment of physicians continue to grow. However, the degree to which health system physician compensation reflects an orientation toward value, rather than volume, is unknown. Objective: To characterize primary care physician (PCP) and specialist compensation arrangements among US health system-affiliated physician organizations (POs) and measure the portion of total physician compensation based on quality and cost performance. Design Setting and Participants: This study was a cross-sectional mixed-methods analysis of in-depth multimodal data (compensation document review, interviews with 40 PO leaders, and surveys conducted between November 2017 and July 2019) from 31 POs affiliated with 22 purposefully selected health systems in 4 states. Data were analyzed from June 2019 to September 2020. Main Outcomes and Measures: The frequency of PCP and specialist compensation types and the percentage of compensation when included, including base compensation incentives, quality and cost performance incentives, and other financial incentives. The top 3 actions physicians could take to increase their compensation. The association between POs' percentage of revenue from fee-for-service and their physicians' volume-based compensation percentage. Results: Volume-based compensation was the most common base compensation incentive component for PCPs (26 POs [83.9%]; mean, 68.2% of compensation; median, 81.4%; range, 5.0%-100.0% when included) and specialists (29 POs [93.3%]; mean, 73.7% of compensation; median, 90.5%; range, 2.5%-100.0% when included). While quality and cost performance incentives were common (included by 83.9%-56.7% of POs for PCPs and specialists, respectively), the percentage of compensation based on quality and cost performance was modest (mean, 9.0% [median, 8.3%; range, 1.0%-25.0%] for PCPs and 5.3% [median, 4.5%; range, 0.5%-16.0%] for specialists when included). Increasing the volume of services was the most commonly cited action for physicians to increase compensation, reported as the top action by 22 POs (70.0%) for PCPs and specialists. We observed a very weak, nonsignificant association between the percentage of revenue of POs from fee for service and the PCP and specialist volume-based compensation percentage (r = 0.08; P = .78 and r = -0.04; P = .89, respectively). Conclusions and Relevance: The results of this cross-sectional study suggest that PCPs and specialists despite receiving value-based reimbursement incentives from payers, the compensation of health system PCPs and specialists was dominated by volume-based incentives designed to maximize health systems revenue.

Congress ends surprise billing: implications for payers, providers, and patients.

Compromise over ending surprise billing had consistently hit a deadlock as providers, payers, and patient groups found themselves at odds over mechanisms to resolve payment. The COVID-19 pandemic, however, accelerated legislative action on health care proposals, leading to the last-minute passage of the No Surprises Act at the end of 2020. The law marks a rare bipartisan success that promises to secure patient protections while also adding price transparency tools. Importantly, it creates an independent dispute resolution process that balances the demands of payers and providers in negotiating surprise billing. While the cost implications of this process will not be known until after implementation in 2022, it creates a template for states to emulate. Furthermore, it will reorient the relationships among payers and provider groups that have historically relied on out-of-network billing. This new competitive reality is an important step for consumer financial protection in health care.

Commercial and Medicare Advantage payment for anesthesiology services.

OBJECTIVES: Anesthesiology services are a focal point of policy making to address surprise medical billing. However, allowed amounts and charges for anesthesiology services have been understudied due to the specialty's unique conversion factor (CF) unit of payment and complex provider structures involving anesthesiologists and certified registered nurse anesthetists (CRNAs). This study compares payments for common outpatient anesthesiology services by commercial health plans, Medicare Advantage (MA), and traditional Medicare. STUDY DESIGN: Analysis of 2016-2017 claims from Health Care Cost Institute. METHODS: We derived allowed amount and charge CFs for commercial and MA claims using the base units assigned to each procedure code, time units, and modifiers. We computed the ratio of the allowed amount and charge CFs relative to the traditional Medicare CF. We described these payment measures by provider structure and network status. RESULTS: Mean in-network commercial allowed amount CFs for anesthesiology services ($70) are 314% of the traditional Medicare rate ($22), whereas mean commercial charge CFs ($148) are 659% of the Medicare rate. Commercial payments vary widely and are higher to anesthesiologists than to CRNAs and higher out of network than in network. MA plan payments align with traditional Medicare with payment parity between anesthesiologists and CRNAs, both in network and out of network. CONCLUSIONS: Common payment measures for anesthesia services-commercial allowed amounts, charges, or traditional Medicare-are highly divergent. MA plans' relatively low payments likely reflect the cost-containing influence of competition with traditional Medicare and MA's prohibition on balance billing. Out-of-network benchmarks for anesthesia services, such as the "qualifying payment amount" used in the No Surprises Act as a guidepost for arbitrators, may benefit from considering commercial payment differences across independent anesthesiologist, independent CRNA, or anesthesiologist-CRNA dyad provider structures.

Policies to address surprise billing can affect health insurance premiums.

OBJECTIVES: To quantify the proportion of health plan spending on services for which surprise billing is common-provided by radiologists, anesthesiologists, pathologists, emergency physicians, emergency ground ambulances, and emergency outpatient facilities-and estimate the potential impact of proposed policies to address surprise billing on health insurance premiums. STUDY DESIGN: Analysis of 2017 commercial claims data from the Health Care Cost Institute, comprising 568.5 million claims from 44.8 million covered lives in 3 large US insurers: UnitedHealthcare, Aetna, and Humana. METHODS: We calculate the share of total health plan claims spending attributable to ancillary and emergency services. Next, we estimate the premium impact of proposed federal policies to address surprise billing, which, by removing provider leverage stemming from the ability to surprise-bill, could reduce in- and out-of-network payments for these services, in turn affecting premiums. Specifically, we model the premium impact of reducing payment for these services (1) by 15% and (2) to 150% of traditional Medicare payment rates. RESULTS: More than 10% of health plan spending is attributable to ancillary and emergency services that commonly surprise-bill. Reducing payment for these services by 15% would reduce premiums by 1.6% ($67 per member per year), and reducing average payment to 150% of traditional Medicare rates-the high end of payments to other specialists-would reduce premiums by 5.1% ($212 per member per year). These savings would reduce aggregate premiums for the nation's commercially insured population by approximately $12 billion and $38 billion, respectively. CONCLUSIONS: Addressing surprise billing could substantially affect commercial insurance premiums.

Integrating Department of Defense and Department of Veterans Affairs Purchased Care: Preliminary Feasibility Assessment.

The U.S. Department of Defense (DoD) and U.S. Department of Veterans Affairs (VA) health systems provide services through a mix of direct care, delivered at government facilities, and purchased care, provided through the private sector, mainly by community-based providers who have entered into contracts with third-party administrators (TPAs). In the interest of expanding DoD-VA resource sharing that may lead to greater efficiencies and cost savings, the DoD/VA Joint Executive Committee is exploring options to integrate DoD and VA's purchased care programs. This preliminary feasibility assessment examined how an integrated approach to purchasing care could affect access, quality, and costs for beneficiaries, DoD, and VA and identified general legislative, policy, and contractual challenges to implementing an integrated purchased care program. An integrated approach to purchasing care is feasible under current legal and regulatory authorities, but policy changes may be needed-and the practicality of such an approach depends on the contract and network design. For example, legal/regulatory changes in how contracts are established would be required to achieve any real savings to the government. There are also differences in the populations served by TRICARE (DoD health care) and VA, particularly in terms of age and geographic location. Implementation would be further complicated by contractual differences in the TPA contracts for VA and DoD as they relate to network standards, provider payments, network participation requirements, and reporting requirements and incentive structures. As a result, there are significant uncertainties with respect to increased efficiency or cost savings for the government.

Identification of Alternative Physician Assistant Recertification Models: An Analysis of the Landscape and Evidence Surrounding Approaches to Recertification in the Health Professions.

Health professional recertification is intended to be a mechanism for demonstration and fostering of professional knowledge and competence. Recertification requirements vary among health professions and are evolving over time. RAND Corporation researchers assessed the landscape of recertification requirements for physician assistants (PAs), advanced practice nurses (APNs), and physicians in the United States and other countries through an environmental scan, reviewed the literature regarding the impact of recertification requirements on patients and health professionals, and conducted semi-structured interviews with certifying organization representatives. Recertification requirements vary, including continuing education, exams or assessments, and other activities. Closed-book exams are most common in the United States. PA recertification currently requires a high-stakes closed-book exam; a pilot of a longitudinal assessment with smaller, regularly spaced batches of questions is planned. Many allopathic physician specialty boards are transitioning from recertification exams to longitudinal assessments; most osteopathic specialty boards require recertification exams. An exam is required for certified registered nurse anesthetist recertification, but not for other APNs. Evidence regarding the effects of recertification requirements on health professionals and patients for PAs, APNs, and professionals outside the United States is limited. The evidence mainly focuses on U.S. allopathic physicians. Physicians have mixed opinions about trade-offs between burden and professional benefit, and some, but not all, studies find associations between recertification and indicators of better care. Major themes reflected in interviews with certifying organizations included a desire to balance evaluative and educational goals, the tension felt between public responsibility and health professional preferences, and burden and applicability to practice.

Prevalence And Characteristics Of Surprise Out-Of-Network Bills From Professionals In Ambulatory Surgery Centers.

Patients treated at in-network facilities can involuntarily receive services from out-of-network providers, which may result in "surprise bills." While several studies report the surprise billing prevalence in emergency department and inpatient settings, none document the prevalence in ambulatory surgery centers (ASCs). The extent to which health plans pay a portion or all of out-of-network providers' bills in these situations is also unexplored. We analyzed 4.2 million ASC-based episodes of care in 2014-17, involving 3.3 million patients enrolled in UnitedHealth Group, Humana, and Aetna commercial plans. One in ten ASC episodes involved out-of-network ancillary providers at in-network ASC facilities. Insurers paid providers' full billed charges in 24 percent of the cases, leaving no balance to bill patients. After we accounted for insurer payment, we found that there were potential surprise bills in 8 percent of the episodes at in-network ASCs. The average balance per episode increased by 81 percent, from $819 in 2014 to $1,483 in 2017. Anesthesiologists (44 percent), certified registered nurse anesthetists (25 percent), and independent laboratories (10 percent) generated most potential surprise bills. There is a need for federal policy to expand protection from surprise bills to patients enrolled in all commercial insurance plans.

Influence of out-of-network payment standards on insurer-provider bargaining: California's experience.

OBJECTIVES: To examine the early effects of California's recent policy addressing surprise medical billing (AB-72) on the dynamics among physician, hospital, and insurer stakeholders and to identify the influences of the policy's novel out-of-network (OON) payment standard on provider-payer bargaining. This study can inform current policy formation, given that current federal proposals include a payment standard like that in AB-72. STUDY DESIGN: Case study of the implementation of AB-72 and stakeholders' perspectives, experiences, and responses in the first 6 to 12 months after policy implementation. METHODS: Semistructured interviews were conducted with 28 individuals representing policy experts, representatives of advocacy organizations and state-level professional associations, and current executives of physician practice groups, hospitals, and health benefits companies. Related documentation was collected and analyzed, including bill text, rulemaking guidance, testimony before the California Senate Committee on Health, and advocacy letters. Qualitative analysis techniques, such as process tracing and explanation building, were employed to identify key themes. RESULTS: AB-72 is effectively protecting patients from surprise medical bills. However, stakeholders report that an OON payment standard set at payer-specific local average commercial negotiated rates has changed the negotiation dynamics between hospital-based physicians and payers. Interviewees report that leverage has shifted in favor of payers, and payers have an incentive to lower or cancel contracts with rates higher than their average as a means of suppressing OON prices. Physicians reported that this experience of decreased leverage is exacerbating provider consolidation. CONCLUSIONS: California's experience demonstrates that OON payment standards can influence the payer-provider bargaining landscape, affecting network breadth and negotiated rates.

Obesity Impacts Swelling of Ankle and Foot Joints in Early Rheumatoid Arthritis Patients.

OBJECTIVE: The evaluation of disease activity in obese rheumatoid arthritis (RA) patients presents challenges particularly in the clinical assessment of swollen joints. This study examines the effect of obesity on the American College of Rheumatology (ACR) core set measures used in assessing RA disease activity with specific focus on the swollen joint count (SJC). METHODS: We examined a cross-sectional cohort of 323 early seropositive RA patients (symptom duration ≤15 months). Patients were biologic-naive with equal to or more than 6/44 SJC and equal to or more than 9/44 tender joint count. The ACR core set measures, components of Disease Activity Score (DAS) 44/erythrocyte sedimentation rate (ESR), DAS28/ESR4 item, Clinical Disease Activity Index (CDAI), and body mass index (BMI) were collected. Disease activity measures were compared between BMI categories. Multivariable linear regression models assessed the relationship between high BMI (≥30 kg/m) and lower-extremity (LE) SJC and SJC44 while accounting for other ACR measures. RESULTS: Disease Activity Score 44/ESR4 item, Health Assessment Questionnaire Disability Index, physician global, and SJC44 differed across BMI categories (p < 0.05). Of the SJC44, metacarpophalangeal joints and LE joints (knees, ankles, metatarsophalangeal joints) were associated with increased swelling in all BMI groups (P < 0.05). Obesity was significantly associated with LE SJC after adjusting for ACR core set measures. CONCLUSIONS: There is a direct association between increased BMI and increased swelling of LE joints in RA patients. Increases in DAS44-measured disease activity are higher in obese RA patients because of increased LE swollen joints. Disease Activity Score 28 and Clinical Disease Activity Index, which emphasize upper-extremity joint assessment, are not significantly influenced by obesity.

Association between type of health insurance and children's oral health, NHANES 2011-2014.

OBJECTIVES: To examine the association between type of health insurance (public, uninsured, private, or other) and oral health outcomes for children in the United States using nationally representative surveillance data. METHODS: Using the National Health and Nutrition Examination Survey (2011/12-2013/14), logistic regression models were used to estimate the odds of any dental caries and any untreated caries by type of health insurance (public, uninsured, private, and other) for children aged 2-19 years, with adjustment for relevant individual and socioeconomic characteristics. RESULTS: Among 6,057 children, the odds of having any dental caries or untreated caries was not significantly different for publicly insured and uninsured children compared to privately insured children, when adjusting for family income and education. Children in families with income to poverty ratios <200 percent had greater odds of caries and untreated caries relative to children in families with income to poverty ratios ≥400 percent. Children with less educated parents also experienced greater odds of caries and untreated caries. CONCLUSIONS: Oral health outcomes, after adjusting for covariates, were similar for children with public and private health insurance. However, children in low-income families and with less educated parents had greater odds of untreated caries and dental caries, suggesting that initiatives focused on publicly insured populations may miss other vulnerable children of low socioeconomic status.

Supporting Veterans in Massachusetts: An Assessment of Needs, Well-Being, and Available Resources.

Massachusetts is home to approximately 380,000 of the nation's more than 21 million veterans, but there has been little research on the resources available to this population at the state level. There are numerous resources available to veterans and other military-affiliated groups in Massachusetts, but there are still pockets of unmet need in the areas of education, employment, health care, housing, financial, and legal services-particularly for newer veterans and current National Guard/reserve members. Although Massachusetts veterans fare better overall than their peers in other states, they lag behind other Massachusetts residents in terms of health and financial status. Massachusetts veterans and National Guard/reserve members who need support and services face such barriers as a lack of knowledge about how to access services, a lack of awareness about eligibility, and geographic distance from service providers. As the veteran population changes both nationally and in Massachusetts, it will be important for public- and private-sector providers serving Massachusetts veterans and service members to continue addressing unmet needs while ensuring that resources are responsive to shifts in these populations. A better understanding of the unique needs of Massachusetts veterans can help inform investments in initiatives that target these populations and guide efforts to remedy barriers to accessing available support services and other resources.