Trends and postoperative outcomes of thyroidectomy after expansion and rise of health insurance deductibles in the fiscal year.

BACKGROUND: The purpose of this study is to evaluate a relationship between expansion of High Deductible Health Plans (HDHPs) and the number of thyroid surgery cases with associated postoperative outcomes in the fiscal year. METHODS: Data from TriNetX was used to evaluate the trends in thyroid surgery from 2005 and 2021 between the end of the year (Quarter 4) and the beginning of the year (Quarter 1). Risk of postoperative outcomes were statistically interrogated. RESULTS: The average rate of thyroid surgery in cases/year between Quarter 4 and Quarter 1 was similar after expansion of HDHPs (152; 146; p = 0.64). There was no increased risk of postoperative complications. The rate of surgery decreased significantly for patients with Medicare after implementation of the revised American Thyroid Association (ATA) guidelines (Quarter 4: p = 0.03; Quarter 1: p = 0.02). CONCLUSIONS: Patients are less likely to delay thyroid surgery at the end of the year despite higher deductibles.

Non-warfarin oral anticoagulant copayments and adherence in atrial fibrillation: A population-based cohort study.

BACKGROUND: In patients with atrial fibrillation, incomplete adherence to anticoagulants increases risk of stroke. Non-warfarin oral anticoagulants (NOACs) are expensive; we evaluated whether higher copayments are associated with lower NOAC adherence. METHODS: Using a national claims database of commercially-insured patients, we performed a cohort study of patients with atrial fibrillation who newly initiated a NOAC from 2012 to 2018. Patients were stratified into low (<$35), medium ($35-$59), or high (≥$60) copayments and propensity-score weighted based on demographics, insurance characteristics, comorbidities, prior health care utilization, calendar year, and the NOAC received. Follow-up was 1 year, with censoring for switching to a different anticoagulant, undergoing an ablation procedure, disenrolling from the insurance plan, or death. The primary outcome was adherence, measured by proportion of days covered (PDC). Secondary outcomes included NOAC discontinuation (no refill for 30 days after the end of NOAC supply) and switching anticoagulants. We compared PDC using a Kruskal-Wallis test and rates of discontinuation and switching using Cox proportional hazards models. RESULTS: After weighting patients across the 3 copayment groups, the effective sample size was 17,558 patients, with balance across 50 clinical and demographic covariates (standardized differences <0.1). Mean age was 62 years, 29% of patients were female, and apixaban (43%), and rivaroxaban (38%) were the most common NOACs. Higher copayments were associated with lower adherence (P < .001), with a PDC of 0.82 (Interquartile range [IQR] 0.36-0.98) among those with high copayments, 0.85 (IQR 0.41-0.98) among those with medium copayments, and 0.88 (IQR 0.41-0.99) among those with low copayments. Compared to patients with low copayments, patients with high copayments had higher rates of discontinuation (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.08-1.19; P < .001). CONCLUSIONS: Among atrial fibrillation patients newly initiating NOACs, higher copayments in commercial insurance were associated with lower adherence and higher rates of discontinuation in the first year. Policies to lower or limit cost-sharing of important medications may lead to improved adherence and better outcomes among patients receiving NOACs.

Patient co-payments for women diagnosed with breast cancer in Australia.

PURPOSE: Among Australian women, breast cancer is the most commonly diagnosed cancer. The out-of-pocket cost to the patient is substantial. This study estimates the total patient co-payments for Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for women diagnosed with breast cancer and determined the distribution of these costs by Indigenous status, remoteness, and socioeconomic status. METHODS: Data on women diagnosed with breast cancer in Queensland between 01 July 2011 and 30 June 2012 were obtained from the Queensland Cancer Registry and linked with hospital and Emergency Department Admissions, and MBS and PBS records for the 3 years post-diagnosis. The data were then weighted to be representative of the Australian population. The co-payment charged for MBS services and PBS prescriptions was summed. We modelled the mean co-payment per patient during each 6-month time period for MBS services and PBS prescriptions. RESULTS: A total of 3079 women were diagnosed with breast cancer in Queensland during the 12-month study period, representing 15,335 Australian women after weighting. In the first 3 years post-diagnosis, the median co-payment for MBS services was AU$ 748 (IQR, AU$87-2121; maximum AU$32,249), and for PBS prescriptions was AU$ 835 (IQR, AU$480-1289; maximum AU$5390). There were significant differences in the co-payments for MBS services and PBS prescriptions by Indigenous status and socioeconomic disadvantage, but none for remoteness. CONCLUSIONS: Women incur high patient co-payments in the first 3 years post-diagnosis. These costs vary greatly by patient. Potential costs should be discussed with women throughout their treatment, to allow women greater choice in the most appropriate care for their situation.

High-Deductible Health Plans and Prevention.

High-deductible health plans (HDHPs) are becoming more popular owing to their potential to curb rising health care costs. Relative to traditional health insurance plans, HDHPs involve higher out-of-pocket costs for consumers, which have been associated with lower utilization of health services. We focus specifically on the impact that HDHPs have on the use of preventive services. We critique the current evidence by discussing the benefits and drawbacks of the research designs used to examine this relationship. We also summarize the findings from the most methodologically sophisticated studies. We conclude that the balance of the evidence shows that HDHPs are reducing the use of some preventive service, especially screenings. However, it is not clear if HDHPs affect all preventive services. Additional research is needed to determine why variability in conclusions exists among studies. We describe an agenda for future research that can further inform public health decision makers on the impact of HDHPs on prevention.

The effect of cost-sharing design characteristics on use of health care recommended by the treating physician; a discrete choice experiment.

BACKGROUND: Cost-sharing programs are often too complex to be easily understood by the average insured individual. Consequently, it is often difficult to determine the amount of expenses in advance. This may preclude well-informed decisions of insured individuals to adhere to medical treatment advised by the treating physician. Preliminary research has showed that the uncertainty in these cost-sharing payments are affected by four design characteristics, i.e. 1) type of payments (copayments, coinsurances or deductibles), 2) rate of payments, 3) annual caps on cost-sharing and 4) moment that these payments must be made (directly at point of care or billed afterwards by the insurer). METHODS: An online discrete choice experiment was used to assess the extent to which design characteristics of cost-sharing programs affect the decision of individuals to adhere to recommended care (prescribed medications, ordered diagnostic tests and referrals to medical specialist care). Analyses were performed using mixed multinomial logits. RESULTS: The questionnaire was completed by 7921 members of a patient organization. Analyses showed that 1) cost-sharing programs that offer clear information in advance on actual expenses that are billed afterwards, stimulate adherence to care recommended by the treating physician; 2) the relative importance of the design characteristics differed between respondents who reported to have forgone health care due to cost-sharing and those who did not; 3) price-awareness among respondents was limited; 4) the utility derived from attributes and respondents' characteristics were positively correlated; 5) an optimized cost-sharing program revealed an adherence of more than 72.9% among those who reported to have forgone health care. CONCLUSIONS: The analyses revealed that less complex cost-sharing programs stimulate adherence to recommended care. If these programs are redesigned accordingly, individuals who had reported to have forgone a health service recommended by their treating physician due to cost-sharing, would be more likely to use this service. Such redesigned programs provide a policy option to reduce adverse health effects of cost-sharing in these groups. Considering the upcoming shift from volume-based to value-based health care provision, insights into the characteristics of a cost-sharing program that stimulates the use of recommended care may help to design value-based insurance plans.

The impact of change from copayment to coinsurance on medical care usage and expenditure in outpatient setting in older Koreans.

Patient cost-sharing change was implemented on August 1, 2007, for outpatient care in the clinic setting in Korea from copayment to coinsurance. This study aims to estimate the effect of the policy change on medical care usage and expenditure in older Koreans. By using national health insurance claims data from the Health Insurance Reimbursement Assessment Service, this study analyzed the entire 137 million claims for a total of approximately 4.1 million patients aged 60 to 69 years who had been diagnosed and/or treated for outpatient care in clinics from January 1, 2007, to December 31, 2008. Medical care usage was defined as the proportion of all beneficiaries in each group who visited clinics and the mean number of visit days per beneficiary. Medical care expenditure per visit day was expressed as total costs, reimbursed amount, and patient's out-of-pocket payment. Data on January through June of 2008 were analyzed as compared with the same months of 2007. Raw difference-in-difference and multiple regression analyses were performed. The interaction coefficients, which measured the impact of cost-sharing change, was -0.078 in model 1 and -0.039 in model 2 (P < .0001). In conclusion, a cost-sharing change from copayment to coinsurance reduced medical care usage and expenditure.

The Multi-Billion Dollar Drug-Sensitive Spending Opportunity.

Chronic diseases increase utilization and avoidable drug-sensitive spending, but little is done to optimize medication use and drive value. Value-based approaches to health care financing should shift focus to drug-sensitive spending to balance patient access and quality improvement with cost containment.

Impact of income-based deductibles on drug use and health care utilization among older adults.

BACKGROUND: Income-based deductibles are present in several provincial public drug plans in Canada and have been the subject of extensive debate. We studied the impact of such deductibles in British Columbia's Fair PharmaCare plan on drug and health care utilization among older adults. METHODS: We used a quasi-experimental regression discontinuity design to compare the impact of deductibles in BC's PharmaCare plan between older community-dwelling adults registered for the plan who were born in 1928 through 1939 (no deductible) and those born in 1940 through 1951 (deductible equivalent to 2% of household income). We used 1.2 million person-years of data between 2003 and 2015 to study public drug plan expenditures, overall drug use, and physician and hospital resource utilization in these 2 groups. RESULTS: The income-based deductible led to a 28.6% decrease in person-years in which public drug plan benefits were received (95% confidence interval [CI] -29.7% to -27.5%) and to a reduction in the per capita extent of annual benefits by $205.59 (95% CI -$247.81 to -$163.37). Despite this difference in public subsidy, we found no difference in the number of drugs received or in total drug spending once privately paid amounts were accounted for (p = 0.4 and 0.8, respectively). Further, we found only small or nonexistent changes in health care resource utilization at the 1939 threshold. INTERPRETATION: A modest income-based deductible had a considerable impact on the extent of public subsidy for prescription drugs. However, it had only a trivial impact on overall access to medicines and use of other health services. Unlike copayments, modest income-based deductibles may safely reduce public spending on drugs for some population groups.

An Econometric Model of Healthcare Demand With Nonlinear Pricing.

From 2004 to 2012, the German social health insurance levied a co-payment for the first doctor visit in a calendar quarter. We develop a new model for estimating the effect of such a co-payment on the individual number of visits per quarter. The model combines a one-time increase in the otherwise constant hazard rate determining the timing of doctor visits with a difference-in-differences strategy to identify the reform effect. An extended version of the model accounts for a mismatch between reporting period and calendar quarter. Using data from the German Socio-Economic Panel, we do not find an effect of the co-payment on demand for doctor visits. Copyright © 2016 John Wiley & Sons, Ltd.

Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage? Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March--June 2017.

Issue: After Congress's failure to repeal and replace the Affordable Care Act, some policy leaders are calling for bipartisan approaches to address weaknesses in the law's coverage expansions. To do this, policymakers will need data about trends in insurance coverage, reasons why people remain uninsured, and consumer perceptions of affordability. Goal: To examine U.S. trends in insurance coverage and the demographics of the remaining uninsured population, as well as affordability and satisfaction among adults with marketplace and Medicaid coverage. Methods: Analysis of the Commonwealth Fund Affordable Care Act Tracking Survey, March­June 2017 Findings and Conclusions: The uninsured rate among 19-to-64-year-old adults was 14 percent in 2017, or an estimated 27 million people, statistically unchanged from one year earlier. Uninsured rates ticked up significantly in three subgroups: 35-to-49-year-olds, adults with incomes of 400 percent of poverty or more (about $48,000 for an individual), and adults living in states that had not expanded Medicaid. Half of uninsured adults, or an estimated 13 million, are likely eligible for marketplace subsidies or the Medicaid expansion in their state. Four of 10 uninsured adults are unaware of the marketplaces. Adults in marketplace plans with incomes below 250 percent of poverty are much more likely to view their premiums as easy to afford compared with people with higher incomes. Policies to improve coverage include a federal commitment to supporting the marketplaces and the 2018 open enrollment period, expansion of Medicaid in 19 remaining states, and enhanced subsidies for people with incomes of 250 percent of poverty or more.

Reductions in Diagnostic Imaging With High Deductible Health Plans.

BACKGROUND: Diagnostic imaging utilization grew rapidly over the past 2 decades. It remains unclear whether patient cost-sharing is an effective policy lever to reduce imaging utilization and spending. MATERIALS AND METHODS: Using 2010 commercial insurance claims data of >21 million individuals, we compared diagnostic imaging utilization and standardized payments between High Deductible Health Plan (HDHP) and non-HDHP enrollees. Negative binomial models were used to estimate associations between HDHP enrollment and utilization, and were repeated for standardized payments. A Hurdle model were used to estimate associations between HDHP enrollment and whether an enrollee had diagnostic imaging, and then the magnitude of associations for enrollees with imaging. Models with interaction terms were used to estimate associations between HDHP enrollment and imaging by risk score tercile. All models included controls for patient age, sex, geographic location, and health status. RESULTS: HDHP enrollment was associated with a 7.5% decrease in the number of imaging studies and a 10.2% decrease in standardized imaging payments. HDHP enrollees were 1.8% points less likely to use imaging; once an enrollee had at least 1 imaging study, differences in utilization and associated payments were small. Associations between HDHP and utilization were largest in the lowest (least sick) risk score tercile. CONCLUSIONS: Increased patient cost-sharing may contribute to reductions in diagnostic imaging utilization and spending. However, increased cost-sharing may not encourage patients to differentiate between high-value and low-value diagnostic imaging services; better patient awareness and education may be a crucial part of any reductions in diagnostic imaging utilization.

Colorectal Cancer Screening in a Nationwide High-deductible Health Plan Before and After the Affordable Care Act.

BACKGROUND: Little is known about the effect of the Affordable Care Act's (ACA) elimination of out-of-pocket costs for preventive services. This policy likely reduced out-of-pocket colonoscopy costs most for high-deductible health plan (HDHP) members. OBJECTIVES: Determine the ACA's impact on colorectal cancer screening among HDHP members. RESEARCH DESIGN: Pre-post with comparison group, constructed before and after the ACA. SUBJECTS: We studied 2003-2012 administrative claims data of a large national health insurer. HDHP members had 1 year of low-deductible (≤$500) plan enrollment followed by 1 year of HDHP (≥$1000) enrollment after an employer-mandated switch; HDHP enrollment occurred fully after the ACA for 21,605 members and fully before the ACA for 106,609 members. We propensity score-matched contemporaneous low-deductible (≤$500) control group members to both the before-ACA and after-ACA HDHP groups. We examined the 1-year impact of the HDHP switch separately in the before-ACA and after-ACA study cohorts, then compared these changes to estimate ACA effects. MEASURES: Overall colorectal cancer screening, colonoscopy, and fecal-occult blood testing annual rates. RESULTS: Before the ACA, colorectal cancer screening tests declined by 37/10,000 (-71, -4) among HDHP members versus controls; after the ACA, HDHP members experienced a nonsignificant increase in screening [+52/10,000 (-19,124)]. Corresponding changes in colonoscopy were -55/10,000 (-81, -29) before and +20/10,000 (-38, 78) after the ACA. Thus, the ACA was associated with increased colorectal cancer screening rates [+89/10,000 (11, 168); relative: +9.1% (0.5-17.8)] and screening colonoscopies [+75/10,000 (12-139); relative: +16.4% (2.5-30.3)] among HDHP members. CONCLUSION: The ACA was associated with improved colorectal cancer screening among HDHP members.

Does Full Insurance Increase the Demand for Health Care?

We estimate the causal impact of having full health insurance on healthcare expenditures. We take advantage of a unique quasi-experimental setup in which deductibles and co-payments were zero in a managed care plan and nonzero in regular insurance, until a policy change forced all individuals with an active plan to cover a minimum amount of their expenses. Using panel data and a nonlinear difference-in-differences strategy, we find a demand elasticity of about -0.14 comparing full insurance with the cost-sharing model and a significant upward shift in the likelihood to generate costs. Copyright © 2015 John Wiley & Sons, Ltd.

Health Insurance, Health Savings Accounts and Healthcare Utilization.

Assuming symmetric information, we show that a high-deductible health plan (HDHP) combined with a tax-favored health savings account (HSA) induces more savings and less treatment compared with a full coverage plan under reasonable risk preferences. Furthermore, a higher tax subsidy increases savings in any case but decreases medical utilization if and only if treatment expenses are above the deductible. A larger deductible increases savings but does not necessarily decrease healthcare utilization. Whether an HDHP/HSA combination is preferred over a full coverage contract depends on absolute risk aversion. A higher tax advantage increases the attractiveness of an HDHP/HSA combination, whereas the effects of changes in the deductible are ambiguous. The paper shows that a potential regulator needs to carefully set the size of the deductible as only in a certain corridor of the probability of sickness, its effect on aggregate healthcare costs are unambiguously favorable.

How Will the Affordable Care Act's Cost-Sharing Reductions Affect Consumers' Out-of-Pocket Costs in 2016?

Health insurers selling plans in the Affordable Care Act's market­places are required to reduce cost-sharing in silver plans for low- and moderate-income people earning between 100 percent and 250 percent of the federal pov­erty level. In 2016, as many as 7 million Americans may have plans with these cost-sharing reductions. In the largest markets in the 38 states using the federal website for marketplace enrollment, the cost-sharing reductions substantially lower projected out-of-pocket costs for people who qualify for them. However, the degree to which consumers' out-of-pocket spending will fall varies by plan and how much health care they use. This is because insurers use deductibles, out-of-pocket limits, and copayments in different combinations to lower cost-sharing for eligible enrollees. In 2017, marketplace insurers will have the option of offering standard plans, which may help simplify consumers' choices and lead to more equal cost-sharing.

Americans' Experiences with ACA Marketplace Coverage: Affordability and Provider Network Satisfaction: Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February--April 2016.

For people with low and moderate incomes, the Affordable Care Act's tax credits have made premium costs roughly comparable to those paid by people with job-based health insurance. For those with higher incomes, the tax credits phase out, meaning that adults in marketplace plans on average have higher premium costs than those in employer plans. The law's cost-sharing reductions are reducing deductibles. Lower-income adults in marketplace plans were less likely than higher-income adults to report having deductibles of $1,000 or more. Majorities of new marketplace enrollees and those who have changed plans since they initially obtained marketplace coverage are satisfied with the doctors participating in their plans. Overall, the majority of marketplace enrollees expressed confidence in their ability to afford care if they were to become seriously ill. This issue brief explores these and other findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February--April 2016.

Changes in Consumer Cost-Sharing for Health Plans Sold in the ACA's Insurance Marketplaces, 2015 to 2016.

This brief examines changes in consumer health plan cost-sharing--deductibles, copayments, coinsurance, and out-of-pocket limits--for coverage offered in the Affordable Care Act's marketplaces between 2015 and 2016. Three of seven measures studied rose moderately in 2016, an increase attributable in part to a shift in the mix of plans offered in the marketplaces, from plans with higher actuarial value (platinum and gold plans) to those that have less generous coverage (bronze and silver plans). Nearly 60 percent of enrollees in marketplace plans receive cost-sharing reductions as part of income-based assistance. For enrollees without cost-sharing reductions, average copayments, deductibles, and out-of-pocket limits remain considerably higher under bronze and silver plans than under employer-based plans; cost-sharing is similar in gold plans and employer plans. Marketplace plans are more likely than employer-based plans to impose a deductible for prescription drugs but no less likely to do so for primary care visits.

The effectiveness of interventions to reduce the household economic burden of illness and injury: a systematic review.

OBJECTIVE: To determine the nature, scope and effectiveness of interventions to reduce the household economic burden of illness or injury. METHODS: We systematically reviewed reports published on or before 31 January 2014 that we found in the CENTRAL, CINAHL, Econlit, Embase, MEDLINE, PreMEDLINE and PsycINFO databases. We extracted data from prospective controlled trials and assessed the risk of bias. We narratively synthesized evidence. FINDINGS: Nine of the 4330 studies checked met our inclusion criteria ­ seven had evaluated changes to existing health-insurance programmes and two had evaluated different modes of delivering information. The only interventions found to reduce out-of-pocket expenditure significantly were those that eliminated or substantially reduced co-payments for a given patient population. However, the reductions only represented marginal changes in the total expenditures of patients. We found no studies that had been effective in addressing broader household economic impacts ­ such as catastrophic health expenditure ­ in the disease populations investigated. CONCLUSION: In general, interventions designed to reduce the complex household economic burden of illness and injury appear to have had little impact on household economies. We only found a few relevant studies using rigorous study designs that were conducted in defined patient populations. The studies were limited in the range of interventions tested and they evaluated only a narrow range of household economic outcomes. There is a need for method development to advance the measurement of the household economic consequences of illness and injury and facilitate the development of innovative interventions to supplement the strategies based on health insurance.

Healthcare Demand in the Presence of Discrete Price Changes.

Deductibles in health insurance generate nonlinear budget sets and dynamic incentives. Using detailed individual health expenditure data from a Swiss health insurer, we estimate the response in healthcare demand to the discrete price increase generated by resetting the deductible at the start of each calendar year. We find that for individuals with high deductibles, healthcare demand drops by 27%. The decrease is most pronounced for inpatient care and prescription drugs. By contrast, for individuals with low deductibles, there is no significant change in healthcare demand (except for prescription drugs). Overall our results suggest that healthy individuals respond much stronger to the price change.

How High is America's Health Care Cost Burden? Findings from the Commonwealth Fund Health Care Affordability Tracking Survey, July-August 2015.

One-quarter of privately insured working-age adults have high health care cost burdens relative to their incomes in 2015, according to the Commonwealth Fund Health Care Affordability Index, a comprehensive measure of consumer health care costs. This figure, which is based on a nationally representative sample of people with private insurance who are mainly covered by employer plans, is statistically unchanged from 2014. When looking specifically at adults with low incomes, more than half have high cost burdens. In addition, when privately insured adults were asked how they rated their affordability, greater shares reported their premiums and deductible costs were difficult or impossible to afford than the Index would suggest. Health plan deductibles and copayments had negative effects on many people's willingness to get needed health care or fill prescriptions. In addition, many consumers are confused about which services are free to them and which count toward their deductible.