Research on collaborative innovation optimization strategies for digitally enabled higher education ecosystems

Digitally enabled higher education involves the in-depth use of new-generation digital technology, which has subverted and innovated the traditional teaching mode, driven the development of high-quality teaching and learning, and improved teachers' teaching experience, and increased efficiency. Based on ecosystem theory, this paper constructs a higher education ecosystem with the government, enterprises, and universities as the core participating subjects. It considers the participating subjects' effort level and the ecosystem's overall benefits under the three scenarios of noncooperative research and development (R&D), cost sharing, and cooperative R&D. The results show that (1) the service innovation effort level of the three parties increases with increasing human resource level and technology maturity, and the government's benefit decreases with increasing cost of fulfilling social responsibility. (2) The government's cost subsidies to universities and enterprises can enhance the service innovation level of both parties and increase the optimal returns of the three parties and the ecosystem as a whole. (3) In the cooperative R&D game scenario, the effort level of the three parties and the total ecosystem returns are greater than those in the noncollaborative R&D scenario, and after determining the subsidy coefficients of the government, Pareto optimality of the three parties and the ecosystem as a whole can be achieved. The conclusions of this study can aid in understanding the dynamic evolution mechanism of digitally enabled higher education and provide a realistic decision-making reference for higher education ecosystem managers.

Effects of Cost Sharing on Ophthalmic Care Utilization in the Affordable Care Act Marketplace

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.

Association of State Insulin Out-of-Pocket Caps With Insulin Cost-Sharing and Use Among Commercially Insured Patients With Diabetes : A Pre-Post Study With a Control Group

BACKGROUND

Twenty-five states have implemented insulin out-of-pocket (OOP) cost caps, but their effectiveness is uncertain.

OBJECTIVE

To examine the effect of state insulin OOP caps on insulin use and OOP costs among commercially insured persons with diabetes.

DESIGN

Pre-post study with control group.

SETTING

Eight states implementing insulin OOP caps of $25 to $30, $50, or $100 in January 2021, and 17 control states.

PARTICIPANTS

Commercially insured persons with diabetes and insulin users younger than 65 years. Subgroups of particular interest included members from states with insulin OOP caps of $25 to $30, enrollees with health savings accounts (HSAs) that require high insulin OOP payments, and lower-income members.

MEASUREMENTS

Mean monthly 30-day insulin fills and OOP costs.

RESULTS

State insulin caps were not associated with changes in insulin use in the overall population (relative change in fills per month, 1.8% [95% CI, -3.2% to 6.9%]). Insulin users in intervention states saw a 17.4% (CI, -23.9% to -10.9%) relative reduction in insulin OOP costs, largely driven by reductions among HSA enrollees; there was no difference in OOP costs among nonaccount plan members. More generous ($25 to $30) state insulin OOP caps were associated with insulin OOP cost reductions of 40.0% (CI, -62.5% to -17.6%), again primarily driven by a larger reduction in the subgroup with HSA plans.

LIMITATIONS

Single national insurer; 9-month follow-up.

CONCLUSION

Insulin OOP caps were associated with reduced insulin OOP costs but no overall increases in insulin use. A proposed national insulin cap of $35 for commercially insured persons might lead to meaningful insulin OOP savings but have a limited effect on insulin use.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases.

The Impact of Prescription Drug Coverage on Disparities in Adherence and Medication Use: A Systematic Review

Prescription drug cost-sharing is a barrier to medication adherence, particularly for low-income and minority populations. In this systematic review, we examined the impact of prescription drug cost-sharing and policies to reduce cost-sharing on racial/ethnic and income disparities in medication utilization. We screened 2,145 titles and abstracts and identified 19 peer-reviewed papers that examined the interaction between cost-sharing and racial/ethnic and income disparities in medication adherence or utilization. We found weak but inconsistent evidence that lower cost-sharing is associated with reduced disparities in adherence and utilization, but studies consistently found that significant disparities remained even after adjusting for differences in cost-sharing across individuals. Study designs varied in their ability to measure the causal effect of policy or cost-sharing changes on disparities, and a wide range of policies were examined across studies. Further research is needed to identify the types of policies that are best suited to reduce disparities in medication adherence.

Evolution analysis of low-carbon cooperation of service providers based on Moran process in cloud manufacturing

Low-carbon cooperation among cloud manufacturing service providers is one way to achieve carbon peak and neutrality. Such cooperation is related to the benefits to service providers adopting low-carbon strategies and stochastic factors such as government low-carbon policies, providers' environmental awareness, and demanders' low-carbon preferences. Focusing on the evolutionary process of service providers' low-carbon strategy selection under uncertain factors, a stochastic evolutionary game model is constructed based on the Moran process, and the equilibrium conditions for low-carbon cooperation among providers are analyzed under benefit-dominated and stochastic factor-dominated situations. Through numerical simulation, the effects of the cloud platform's cost-sharing coefficient for low-carbon investment, matching growth rate, carbon trading price, and group size on providers' low-carbon strategy evolution are analyzed. The research results show that increasing the cloud platform's low-carbon cost-sharing, carbon trading price, and group size can promote low-carbon cooperation among service providers. With greater low-carbon investment costs and greater stochastic factor interference, the providers' enthusiasm for low-carbon cooperation decreases. This study fills the research gap in the low-carbon cooperation evolution of cloud manufacturing providers based on the stochastic evolutionary game and provides decision-making suggestions for governments and cloud platforms to encourage provider participation in low-carbon cooperation and for providers to adopt low-carbon strategies.

Cost sharing for oral lenvatinib among commercially insured patients

OBJECTIVE

To use a nationwide pharmaceutical claims database to evaluate cost-sharing trends for commercially insured patients with cancer who were prescribed lenvatinib (Lenvima).

STUDY DESIGN

IBM MarketScan databases were used to evaluate lenvatinib costs for patients with employer-based commercial insurance, and for patients 65 years and older, Medicare claims for fee-for-service plans.

METHODS

Patients were included if they had least 1 outpatient pharmaceutical claim for lenvatinib paid on a noncapitated basis from 2015 to 2019. Median and IQR costs were estimated and inflation adjusted to 2019 US$ for 30-day supplies and reported as total, insurance liability, coordination of benefits, and out-of-pocket costs.

RESULTS

A total of 685 patients had at least 1 pharmaceutical claim for lenvatinib, which included patients with thyroid (n = 251; 36.6%), renal cell (n = 202; 29.5%), hepatocellular (n = 160; 23.4%), and endometrial (n = 48; 7.0%) cancer. The median (IQR) number of prescriptions per patient was 3 (2-7), and the median (IQR) total days of supply was 90 (45-210) days. The median (IQR) 30-day cost of lenvatinib was $17,253 ($15,597-$18,120). Median (IQR) 30-day insurance liability was $16,847 ($15,000-$17,981). Median (IQR) 30-day coordination of benefits was $0 ($0-$0). Median (IQR) 30-day patient out-of-pocket cost was $32 ($0-$100). However, the maximum 30-day out-of-pocket cost in our patient cohort was $12,538.

CONCLUSIONS

In this cohort, insurance was liable for the majority of total lenvatinib drug costs, and 75% of patients paid $100 or less per month out of pocket. This information can be used by care teams to counsel insured patients. Health systems and drug manufacturers must identify patients with high out-of-pocket costs and provide convenient access to financial assistance programs so that patients are not forced to forgo the benefits of these drugs due to financial barriers. Value-based payment models and drug pricing reform are also needed to address underlying drivers of high drug costs.

Health Plan Switching and Health Care Utilization: A Randomized Clinical Trial

Importance

While the Patient Protection and Affordable Care Act (ACA) helped make health insurance premiums more affordable with premium tax credits, ACA marketplace enrollees continue to face barriers to care.

Objective

To investigate the effect of informational emails on plan switching and health care utilization.

Design, Setting, and Participants

This randomized clinical trial was conducted during the 2021 special enrollment period in California's Affordable Care Act marketplace among households that reported receiving unemployment insurance and were enrolled in non-silver-tier plans. The trial targeted 42 470 households that became temporarily eligible for cost-sharing reduction (CSR) silver plans that covered 94% of medical costs (CSR silver 94 plans) as a result of the 2021 American Rescue Plan Act.

Intervention

Households were randomized to either a no-email control group or to a treatment group receiving 2 informational emails encouraging households to switch to CSR plans.

Main Outcomes and Measures

The primary outcome was the switch rate to a CSR silver plan by July 31, 2021. Secondary outcomes include various measures of health care utilization in the second half of 2021 (July 1, 2021, to December 31, 2021). Health care utilization was measured by rates of practitioner visits, emergency department visits, hospitalizations, and prescription fills.

Results

Of the 42 470 households (head of household mean [SD], age, 41.4 [13.3] years; 51.7% male), 10 650 (25.1%) were in the control group and 31 820 (74.9%) were in the treatment group. The emails led to a statistically significant 3.1-percentage point (95% CI, 2.6-3.6 percentage points) increase in CSR silver 94 enrollment (a 74.8% relative increase) by July 31, 2021, and a 1.3-percentage point (95% CI, 0.2-2.4 percentage points) increase (a 2.3% relative increase) in practitioner visits by December 31, 2021. The emails had no detectable effect on prescription fills, emergency department visits, or hospitalizations.

Conclusions and Relevance

The results of this randomized clinical trial provide experimental evidence that, with access to more affordable health care, individuals are more likely to visit practitioners.

Trial Registration

ClinicalTrials.gov Identifier: NCT05891418.

The Reality of Cost Sharing in Japan

Financial pressure on younger generation is mounting in Japan, a super-ageing society with staggering economy. The revision on the co-insurance rate for 70-74 with "Standard" category was implemented to mitigate such pressure, seeking better balance across generations in sharing the burden of healthcare cost. It raised the rate from 10% to 20% over the period of five years from 2014 to 2018. This report examined how it changed the share of cost sharing (cost sharing as percentage to total healthcare expenditure), among the 70-74 with "Standard" category in Citizens Health Insurance programme in 44 prefectures. It specifically focused on change in the population's actual share of cost sharing (ASCS) that better reflect the genuine amount of payment actually made by the patients themselves. The average ASCS increased from 7.28% (2013) to 10.78% (2019), resulting wider gap from the statutory planned share of cost sharing (i.e., the statutory co-insurance rate of 10% in 2013, and 20% in 2019). Also found was increased variance among prefectural ASCS, which may suggest a possibility of un-designed effect by the revision, of encouraging a move towards ability and willingness to pay. In terms of cost containment effect, Japan needs to consider various non-conventional options, including review of the current use of healthcare resources. First and foremost, however, the true state of cost sharing should be recognized in terms of ASCS and shared more widely as a reality. Such effort is essential in discussion of how to keep embracing the country's life line, UHC.

Prescription Drug Dispensing and Patient Costs After Implementation of a No Behavioral Health Cost-Sharing Law

Importance

On January 1, 2022, New Mexico implemented a No Behavioral Cost-Sharing (NCS) law that eliminated cost-sharing for mental health and substance use disorder (MH/SUD) treatments in plans regulated by the state, potentially reducing a barrier to treatment for MH/SUDs among the commercially insured; however, the outcomes of the law are unknown.

Objective

To assess the association of implementation of the NCS with out-of-pocket spending for prescription for drugs primarily used to treat MH/SUDs and monthly volume of dispensed drugs.

Design, Settings, and Participants

This retrospective cohort study used a difference-in-differences research design to examine trends in outcomes for New Mexico state employees, a population affected by the NCS, compared with federal employees in New Mexico who were unaffected by NCS. Data were collected on prescription drugs for MH/SUDs dispensed per month between January 2021 and June 2022 for New Mexico patients with a New Mexico state employee health plan and New Mexico patients with a federal employee health plan. Data analysis occurred from December 2022 to January 2024.

Exposure

Enrollment in a state employee health plan or federal health plan.

Main Outcomes and Measures

The primary outcomes were mean patient out-of-pocket spending per dispensed MH/SUD prescription and the monthly volume of dispensed MH/SUD prescriptions per 1000 employees. A difference-in-differences estimation approach was used.

Results

The implementation of the NCS law was associated with a mean (SE) $6.37 ($0.30) reduction (corresponding to an 85.6% decrease) in mean out-of-pocket spending per dispensed MH/SUD medication (95% CI, -$7.00 to -$5.75). The association of implementation of NCS with the volume of prescriptions dispensed was not statistically significant.

Conclusions and Relevance

These findings suggest that the implementation of the New Mexico NCS law was successful in lowering out-of-pocket spending on prescription medications for MH/SUDs, but that there was no association of NCS with the volume of medications dispensed in the first 6 months after implementation. A key challenge is to identify policies that protect from high out-of-pocket spending while also promoting access to needed care.

Why Cost Sharing on Its Own Will Not Fix Health Care Costs

This Viewpoint describes issues with cost sharing for health care costs and suggests improvements to current cost sharing systems.

Effects of nurse visit copayment on primary care use: Do low-income households pay the price?

Nurses are increasingly providing primary care, yet the literature on cost-sharing has paid little attention to nurse visits. We employ a staggered difference-in-differences design to examine the effects of adopting a 10-euro copayment for nurse visits on the use of public primary care among Finnish adults. We find that the copayment reduced nurse visits by 9%-10% during a one-year follow-up. There is heterogeneity by income in absolute terms, but not in relative terms. The spillover effects on general practitioner (GP) use are negative but small, with varying statistical significance. We also analyze the subsequent nationwide abolition of the copayment. However, we refrain from drawing causal conclusions from this due to the lack of credibility in the parallel trends assumption. Overall, our analysis suggests that moderate copayments can create a greater barrier to access for low-income individuals. We also provide an example of using a pre-analysis plan for retrospective observational data.

Why higher copayments for opioids did not reduce use among Medicare beneficiaries

To examine whether higher cost-sharing deterred prescription opioid use. Medicare Part D claims from 2007 to 2016 for a 20% random sample of Medicare enrollees. We obtain estimates of the effect of cost-sharing on prescription opioid use using ordinary least squares and instrumental variables methods. In both, we exploit the variation (change) in cost-sharing within plans over time for a sample of beneficiaries who remain in the same plan. Focusing on changes in cost-sharing within a plan for a constant sample of beneficiaries mitigates potential bias from plan selection and using a constant set of weights derived from use in year (t) eliminates changes in the cost-sharing indexes due to (endogenous) consumer choice in year (t+1). Part D plans adopted benefit changes designed to reduce opioid use, including moving opioids to higher cost-sharing tiers. Increasing plan copayments for hydrocodone or oxycodone was associated with reductions in plan-paid claims and offsetting increases in cash claims. Widespread availability of low-cost generics combined with the anti-clawback provision in Part D mediated the effect of higher cost sharing to curb opioid use. As plans moved generic opioids to higher cost-sharing tiers, beneficiaries simply paid cash prices and aggregate use remained largely unchanged. The anti-clawback provision in Part D, intended to protect beneficiaries from price gouging, limited plans' ability to constrain opioid use through typical demand-side measures such as increased cost-sharing.

PERSPECTIVE: A Path to Value-Based Insurance Design for Mental Health Services

BACKGROUND

Aligning cost of mental health care with expected clinical and functional benefits of that care would incentivize the delivery of high value treatments and services. In turn, ineffective or untested care could still be offered but at costs high enough to offset the delivery of high value care.

AIMS

The authors comment on Benson and Fendrick's paper on Value-Based Insurance Design (VBID) for mental health in the September 2023 special issue of this journal. The authors also present a preliminary framework of key ingredients needed to consider VBID for mental health treatments and services.

METHODS

The authors briefly review current and past efforts to contain costs and improve quality of mental health care, which include (for example) use of carve-out and carve-in programs, evaluation of cost sharing models, impact of accountable care organizations, and studying other benefit designs and impact of federal and state policies.

RESULTS

Using PTSD as an example, key ingredients of VBID for mental health services were identified and include the following: tools for case identification and monitoring progress over time at the population level; specific treatments and services with evidence of clinical effectiveness, cost-effectiveness, and health equity; and an approach to document the specific treatment or service was delivered (versus another treatment or service that may lack evidence).

DISCUSSION

The inability to afford mental health care is a top barrier to treatment seeking. People who do elect to spend time and money on mental health care are further disadvantaged by accessing care that is not well regulated and the quality at best is questionable. VBID could be an important lever for increasing access to and use of high value mental health care. Partnerships among the research, practice, and policy communities can help ensure research solutions meet needs of these two communities.

IMPLICATIONS FOR HEALTH CARE

VBID holds promise to make high value mental health care more affordable while discouraging low value treatments and services.

IMPLICATIONS FOR HEALTH POLICIES

While evidence gaps remain, these gaps can be filled concurrently with pursuit of VBID for mental health services.

IMPLICATIONS FOR FUTURE RESEARCH

This paper identifies important research opportunities to help make VBID a reality for mental health care.

The optimal co-insurance rate for outpatient drug expenses of Iranian health insured based on the data mining method

OBJECTIVE

A more equal allocation of healthcare funds for patients who must pay high costs of care ensures the welfare of society. This study aimed to estimate the optimal co-insurance for outpatient drug costs for health insurance.

SETTING

The research population includes outpatient prescription claims made by the Health Insurance Organization that outpatient prescriptions in a timely manner in 2016, 2017, 2018, and 2019 were utilized to calculate the optimal co-insurance. The study population was representative of the research sample.

DESIGN

At the secondary level of care, 11 features of outpatient claims were studied cross-sectionally and retrospectively using data mining. Optimal co-insurance was estimated using Westerhut and Folmer's utility model.

PARTICIPANTS

One hundred ninety-three thousand five hundred fifty-two individuals were created from 21 776 350 outpatient claims of health insurance. Because of cost-sharing, insured individuals in a low-income subsidy plan and those with refractory diseases were excluded.

RESULTS

Insureds were divided into three classes of low, middle, and high risk based on IQR and were separated to three clusters using the silhouette coefficient. For the first, second, and third clusters of the low-risk class, the optimal co-insurance estimates are 0.81, 0.76, and 0.84, respectively. It was equal to one for all middle-class clusters and 0.38, 0.45, and 0.42, respectively, for the high-risk class. The insurer's expenses were altered by $3,130,463, $3,451,194, and $ 1,069,859 profit for the first, second, and third clusters, respectively, when the optimal co-insurance strategy is used for the low-risk class. For middle risks, it was US$29,239,815, US$13,863,810, and US$ 14,573,432 while for high risks, US$4,722,099, US$ 6,339,317, and US$19,627,062, respectively.

CONCLUSIONS

These findings can improve vulnerable populations' access to costly medications, reduce resource waste, and help insurers distribute funds more efficiently.

Site of Ambulance Origination and Billing for Out-of-Network Services

Importance

The No Surprises Act implemented in 2022 aims to protect patients from surprise out-of-network (OON) bills, but it does not include ground ambulance services. Understanding ground ambulance OON and balance billing patterns from previous years could guide legislation aimed to protect patients following ground ambulance use.

Objective

To characterize OON billing from ground ambulance services by evaluating whether OON billing risk differs by the site of ambulance origination (home, hospital, nonhospital medical facility, or scene of incident).

Design, Setting, and Participants

Cross-sectional study of the Merative MarketScan dataset between January 1, 2015, and December 31, 2020, using claims-based data from employer-based private health insurance plans in the US. Participants included patients who utilized ground ambulances during the study period. Data were analyzed from June to December 2023.

Exposure

Medical encounter requiring ground ambulance transportation.

Main Outcomes and Measures

Ground ambulance OON billing prevalence was calcuated. Linear probability models adjusted for state-level mixed effects were fit to evaluate OON billing probability across ambulance origins. Secondary outcomes included the allowed payment, patient cost-sharing amounts, and potential balance bills for OON ambulances.

Results

Among 2 031 937 ground ambulance services (1 375 977 unique patients) meeting the inclusion and exclusion criteria, 1 072 791 (52.8%) rides transported men, and the mean (SD) patient age was 41 (18) years. Of all services, 1 113 676 (54.8%) were billed OON. OON billing probabilities for ambulances originating from home or scene were higher by 12.0 percentage points (PP) (95% CI, 11.8-12.2 PP; P < .001 for home; 95% CI, 11.7-12.2 PP; P < .001 for scene) vs those originating from hospitals. Mean (SD) total financial burden, including cost-sharing and potential balance bills per ambulance service, was $434.70 ($415.99) per service billed OON vs $132.21 ($244.92) per service billed in-network.

Conclusions and Relevance

In this cross-sectional study of over 2 million ground ambulance services, ambulances originating from home, the scene of an incident, and nonhospital medical facilities were more likely to result in OON bills. Legislation is needed to protect patients from surprise billing following use of ground ambulances, more than half of which resulted in OON billing. Future legislation should at minimum offer protections for these subsets of patients often calling for an ambulance in urgent or emergent situations.

Acute Diabetes Complications After Transition to a Value-Based Medication Benefit

Importance

The association of value-based medication benefits with diabetes health outcomes is uncertain.

Objective

To assess the association of a preventive drug list (PDL) value-based medication benefit with acute, preventable diabetes complications.

Design, Setting, and Participants

This cohort study used a controlled interrupted time series design and analyzed data from a large, national, commercial health plan from January 1, 2004, through June 30, 2017, for patients with diabetes aged 12 to 64 years enrolled through employers that adopted PDLs (intervention group) and matched and weighted members with diabetes whose employers did not adopt PDLs (control group). All participants were continuously enrolled and analyzed for 1 year before and after the index date. Subgroup analysis assessed patients with diabetes living in lower-income and higher-income neighborhoods. Data analysis was performed between August 19, 2020, and December 1, 2023.

Exposure

At the index date, intervention group members experienced employer-mandated enrollment in a PDL benefit that was added to their follow-up year health plan. This benefit reduced out-of-pocket costs for common cardiometabolic drugs, including noninsulin antidiabetic agents and insulin. Matched control group members continued to have cardiometabolic medications subject to deductibles or co-payments at follow-up.

Main Outcomes and Measures

The primary outcome was acute, preventable diabetes complications (eg, bacterial infections, neurovascular events, acute coronary disease, and diabetic ketoacidosis) measured as complication days per 1000 members per year. Intermediate measures included the proportion of days covered by and higher use (mean of 1 or more 30-day fills per month) of antidiabetic agents.

Results

The study 10 588 patients in the intervention group (55.2% male; mean [SD] age, 51.1 [10.1] years) and 690 075 patients in the control group (55.2% male; mean [SD] age, 51.1 [10.1] years) after matching and weighting. From baseline to follow-up, the proportion of days covered by noninsulin antidiabetic agents increased by 4.7% (95% CI, 3.2%-6.2%) in the PDL group and by 7.3% (95% CI, 5.1%-9.5%) among PDL members from lower-income areas compared with controls. Higher use of noninsulin antidiabetic agents increased by 11.3% (95% CI, 8.2%-14.5%) in the PDL group and by 15.2% (95% CI, 10.6%-19.8%) among members of the PDL group from lower-income areas compared with controls. The PDL group experienced an 8.4% relative reduction in complication days (95% CI, -13.9% to -2.8%; absolute reduction, -20.2 [95% CI, -34.3 to -6.2] per 1000 members per year) compared with controls from baseline to follow-up, while PDL members residing in lower-income areas had a 10.2% relative reduction (95% CI, -17.4% to -3.0%; absolute, -26.1 [95% CI, -45.8 to -6.5] per 1000 members per year).

Conclusions and Relevance

In this cohort study, acute, preventable diabetes complication days decreased by 8.4% in the overall PDL group and by 10.2% among PDL members from lower-income areas compared with the control group. The results may support a strategy of incentivizing adoption of targeted cost-sharing reductions among commercially insured patients with diabetes and lower income to enhance health outcomes.

Expanding the Catalog of Patient and Caregiver Out-of-Pocket Costs: A Systematic Literature Review

Out-of-pocket (OOP) health care expenditures in the United States have increased significantly in the past 5 decades. Most research on OOP costs focuses on expenditures related to insurance and cost-sharing payments or on costs related to specific conditions or settings, and does not capture the full picture of the financial burden on patients and unpaid caregivers. The aim for this systematic literature review was to identify and categorize the multitude of OOP costs to patients and unpaid caregivers, aid in the development of a more comprehensive catalog of OOP costs, and highlight potential gaps in the literature. The authors found that OOP costs are multifarious and underestimated. Across 817 included articles, the authors identified 31 subcategories of OOP costs related to direct medical (eg, insurance premiums), direct nonmedical (eg, transportation), and indirect spending (eg, absenteeism). In addition, 42% of articles studied an expenditure that the authors did not label as "OOP." A holistic and comprehensive catalog of OOP costs can inform future research, interventions, and policies related to financial barriers to health care in the United States to ensure the full range of costs for patients and unpaid caregivers are acknowledged and addressed.

Estimating The Impact Of Out-Of-Pocket Cost Changes On Abandonment Of HIV Pre-Exposure Prophylaxis

Oral HIV pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV. Several different developments in the US either threaten to increase or promise to decrease PrEP out-of-pocket costs and access in the coming years. In a sample of 58,529 people with a new insurer-approved PrEP prescription, we estimated risk-adjusted percentages of patients who abandoned (did not fill) their initial prescription across six out-of-pocket cost categories. We then simulated the percentage of patients who would abandon PrEP under hypothetical changes to out-of-pocket costs, ranging from $0 to more than $500. PrEP abandonment rates of 5.5 percent at $0 rose to 42.6 percent at more than $500; even a small increase from $0 to $10 doubled the rate of abandonment. Conversely, abandonment rates that were 48.0 percent with out-of-pocket costs of more than $500 dropped to 7.3 percent when those costs were cut to $0. HIV diagnoses were two to three times higher among patients who abandoned PrEP prescriptions than among those who filled them. These results imply that recent legal challenges to the provision of PrEP with no cost sharing could substantially increase PrEP abandonment and HIV rates, upending progress on the HIV/AIDS epidemic.

Policy implications of heterogeneous demand reactions to changes in cost-sharing: Patient-level evidence from Austria

Cost-sharing is a prominent tool in many healthcare systems, both for raising revenue and steering patient behaviour. Although the effect of cost-sharing on demand for healthcare services has been heavily studied in the literature, researchers often apply a macro-perspective to these issues, opening the door for policy makers to the fallacy of assuming uniform demand reactions across a spectrum of different forms of treatments and diagnostic procedures. We use a simple classification system to categorize 11 such healthcare services along the dimensions of urgency and price to estimate patients' (anticipatory) demand reactions to a reduction in the co-insurance rate by a sickness fund in the Austrian social health insurance system. We use a two-stage study design combining matching and two-way fixed effects difference-in-differences estimation. Our results highlight how an overall joint estimate of an average increase in healthcare service utilization (0.8%) across all healthcare services can be driven by healthcare services that are deferrable (+1%), comparatively costly (+1.4%) or both (+1.6%) and for which patients also postponed their consumption until after the cost-sharing reduction. In contrast, we do not find a clear demand reaction for inexpensive or urgent services. The detailed analysis of the demand reaction for each individual healthcare service further illustrates their heterogeneity. We show that even comparatively minor changes to the costs borne by patients may already evoke tangible (anticipatory) demand reactions. Our findings help policy makers better understand the implications of heterogeneous demand reactions across healthcare services for using cost-sharing as a policy tool.

Contraceptive Use Among Traditional Medicare And Medicare Advantage Enrollees

Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.

Reimbursement to Pharmacies for Generic Drugs by Medicare Part D Sponsors

This study evaluates whether organizations that offer Medicare Part D plans (referred to as Part D sponsors) overpay pharmacies for generic drugs.

"You Have to Rob Peter to Pay Paul So Your Kid Can Breathe": Using Qualitative Methods to Characterize Trade-Offs and Economic Impact of Asthma Care Costs

BACKGROUND

Economic analyses often focus narrowly on individual patients' health care use, while overlooking the growing economic burden of out-of-pocket costs for health care on other family medical and household needs.

OBJECTIVE

The aim of this study was to explore intrafamilial trade-offs families make when paying for asthma care.

RESEARCH DESIGN

In 2018, we conducted telephone interviews with 59 commercially insured adults who had asthma and/or had a child with asthma. We analyzed data qualitatively via thematic content analysis.

PARTICIPANTS

Our purposive sample included participants with high-deductible and no/low-deductible health plans. We recruited participants through a national asthma advocacy organization and a large nonprofit regional health plan.

MEASURES

Our semistructured interview guide explored domains related to asthma adherence and cost burden, cost management strategies, and trade-offs.

RESULTS

Participants reported that they tried to prioritize paying for asthma care, even at the expense of their family's overall financial well-being. When facing conflicting demands, participants described making trade-offs between asthma care and other health and nonmedical needs based on several criteria: (1) short-term needs versus longer term financial health; (2) needs of children over adults; (3) acuity of the condition; (4) effectiveness of treatment; and (5) availability of lower cost alternatives.

CONCLUSIONS

Our findings suggest that cost-sharing for asthma care often has negative financial consequences for families that traditional, individually focused economic analyses are unlikely to capture. This work highlights the need for patient-centered research to evaluate the impact of health care costs at the family level, holistically measuring short-term and long-term family financial outcomes that extend beyond health care use alone.

Drug use and spending under a formulary informed by cost-effectiveness

BACKGROUND: The National Academy of Medicine has called for value-based drug formularies to address health plan prescription drug spending while maintaining access to high-value medicines. Thirty employer-sponsored plans implemented a "Value-Based Formulary-essentials" (VBF-e) program that uses cost-effectiveness evidence to inform cost-sharing and coverage exclusion. OBJECTIVE: To evaluate if the VBF-e was associated with changes in medication use and patient out-of-pocket spending and health plan spending on prescription drugs and other health care. METHODS: This was a cohort study using a difference-in-differences design from 2015 through 2019 with 1 year of follow-up after VBF-e implementation at Premera Blue Cross, the largest nonprofit health plan in the Pacific Northwest. The VBF-e exposure group was composed of all individuals aged younger than 65 years and enrolled at least 12 months prior to their employer group's VBF-e implementation date. The contemporaneous control group was composed of propensity score-matched individuals with the same inclusion criteria but their employer group that did not implement VBF-e. We prespecified the following outcomes: days of medication on hand overall and by VBF-e tier (high-value generic, brand, and specialty drugs were in tiers 1 to 3, respectively, and low-value drugs were in tier 4 or excluded from coverage); prescription drug spending; and other health care use (emergency department visits, hospital days, and outpatient visits). RESULTS: Comparing 12,111 exposed (mean age = 36.0; 49.8% female sex) participants with 24,222 control participants (mean age = 34.7; 49.6% female sex), VBF-e reduced use of low-value drugs by 0.3 days per member per month (PMPM) (95% CI = -0.5 to -0.1; 17% decrease) for tier 4 drugs and 0.4 days PMPM (95% CI = -0.5 to -0.4; 83% decrease) for excluded drugs. High-value specialty drug use increased by 0.1 days PMPM (95% CI = 0.0-0.1; 123% increase). Health plan spending decreased by $14 PMPM (95% CI = -26 to -4) and member out-of-pocket spending increased by $1 PMPM (95% CI = 1-2). Other health care use did not change significantly. CONCLUSIONS: An exclusion formulary informed by cost-effectiveness evidence reduced low-value drug use, increased high-value specialty drug use, reduced health plan spending, and increased member out-of-pocket spending without increasing acute care use. DISCLOSURES: This research was supported by a grant from the Patrick and Catherine Weldon Donaghue Medical Research Foundation's Greater Value Portfolio Program. Study Registration Number: NCT04904055.

Health Benefits In 2023: Premiums Increase With Inflation And Employer Coverage In The Wake Of Dobbs

In 2023 the average annual premium for employer-sponsored family health insurance coverage was $23,968-an increase of $1,505 (7 percent) from 2022. Both single and family premiums increased faster in 2023 than in 2022, in a period of generally high inflation throughout the US economy. On average, covered workers contributed 17 percent ($1,401) of the cost of single coverage and 29 percent ($6,575) of the cost of family coverage. When compared to employers' perceptions of the number of primary care providers in their networks, a smaller share of employers believed that their provider networks had a sufficient number of mental health and substance abuse providers to provide timely access to services. One-quarter of employers indicated that their employees had a "high" level of concern with the level of cost sharing required by their plans. When asked about abortion coverage in the wake of the Supreme Court Dobbs decision, almost a third of large employers reported that their largest plan covered abortion in most or all circumstances.

Incentive strategy of dual innovation balance in green manufacturing innovation ecosystem: Based on hierarchical structure of innovation subject

Exploratory innovation is a pivotal way to seize future opportunities in green manufacturing innovation ecosystems, and exploitative innovation is conducive to expanding existing markets and resources, so it is essential to discuss the balanced incentive strategy of dual innovation for the sustainable development of ecosystems. Based on the hierarchical structure, this paper divides the core subjects in the green manufacturing innovation ecosystem into the application layer, the support layer, and the scientific research layer, constructs the differential game model of the no-incentive scenario, the cost-sharing scenario, and the collaborative scenario, and discusses the incentive strategies of the three types of subjects and the ecosystem in the evolution process of the dual innovation balance. The conclusions are as follows: (1) The level of dual innovation balance effort of the three types of subjects decreases with the increase of resource costs and environmental construction costs and increases with the increase of innovation balance capacity; (2) Cost sharing from the application layer to the support layer and the scientific research layer can enhance the effort level of both, which in turn enhances the optimal benefits for the three types of subjects and the ecosystem as a whole; (3) In the collaborative scenario, the level of effort and total ecosystem benefits of the innovation balance of the three types of subjects are strictly better than in the no incentive scenario, and the Pareto-optimality of the three subjects and the ecosystem will be realized after the coefficients of the distribution of benefits among the three types of subjects are determined. Based on this, this paper puts forward specific suggestions for the optimization of the structural relationship of the innovation body hierarchy, the exploitation of green manufacturing resources, and the macro-planning of the management department.

Commercial Health Plan and Enrollee Out-of-Pocket Spending on Accelerated Approval Products in 2019

This cross-sectional study examines spending by health care plans and enrollees on products with accelerated approval.

Growth In Patient Cost Sharing For Hospitalizations With And Without Intensive Care Among Commercially Insured Patients

Intensive care units (ICUs) are increasingly used for hospital care, yet out-of-pocket spending for ICU hospitalizations remains poorly understood, particularly among the nearly half of the US population with commercial health insurance. Using 2008-19 MarketScan data, we compared 1,441,810 hospitalizations involving ICU services with 13,011,208 hospitalizations that did not involve ICU services. Average cost sharing, adjusted for patient and admission factors, increased from $1,137 per hospitalization in 2008 to $1,539 in 2019, or a 34 percent increase. This was driven by increasing deductibles, which rose by 163 percent. Across twenty clinical conditions whose hospitalizations commonly occurred in both ICU and non-ICU settings, ICU admission was associated with $155 higher cost sharing (13.0 percent higher) relative to cost sharing in non-ICU hospitalizations. Patients with high-deductible plans faced the highest cost sharing relative to those with other plan types. Patients who received out-of-network hospital care encountered higher cost sharing relative to those admitted to in-network hospitals with in-network clinicians.

Effect of no cost sharing for paediatric care on healthcare usage by household income levels: regression discontinuity design

OBJECTIVES

To investigate the impact of no cost sharing on paediatric care on usage and health outcomes, and whether the effect varies by household income levels.

DESIGN

Regression discontinuity design.

SETTING

Nationwide medical claims database in Japan.

PARTICIPANTS

Children aged younger than 20 years from April 2018 to March 2022.

EXPOSURE

Co-insurance rate that increases sharply from 0% to 30% at a certain age threshold (the threshold age varies between 6 and 20 years depending on region).

PRIMARY OUTCOME MEASURES

The outpatient care usage (outpatient visit days and healthcare spending for outpatient care) and inpatient care (experience of any hospitalisation and healthcare spending for inpatient care).

RESULTS

Of 244 549 children, 49 556 participants were in the bandwidth and thus included in our analyses. Results from the regression discontinuity analysis indicate that no cost sharing was associated with a significant increase in the number of outpatient visit days (+5.26 days; 95% CI, +4.89 to +5.82; p<0.01; estimated arc price elasticity, -0.45) and in outpatient healthcare spending (+US$369; 95% CI, +US$344 to +US$406; p<0.01; arc price elasticity, -0.55). We found no evidence that no cost sharing was associated with changes in inpatient care usage. Notably, the effect of no cost-sharing policy on outpatient healthcare usage was larger among children from high-income households (visit days +5.96 days; 95% CI, +4.88 to +7.64, spending +US$511; 95% CI, +US$440 to +US$627) compared with children from low-income households (visit days +2.64 days; 95% CI, +1.54 to +4.23, spending +US$154; 95% CI, +US$80 to +US$249).

CONCLUSIONS

No cost sharing for paediatric care was associated with a greater usage of outpatient care services, but did not affect inpatient care usage. The study found that this effect was more pronounced among children from high-income households, indicating that the no cost sharing disproportionately benefits high-income households and may contribute to larger disparities.

Internal incentives for carbon emission reduction in a capital-constrained supply chain: A financial perspective

Capital constraints hinder enterprises' carbon reduction efforts and affect the sustainability of the supply chain. To alleviate this limitation, the core enterprise considers offering two financial-based carbon reduction incentive mechanisms: cost-sharing mechanism (CS) and preferential financing mechanism (PF). In a supply chain with the dual sensitivity of market demand to price and carbon reduction, we model each incentive mechanism, discussing their impact, value, and selection strategies. The results show that neither party under CS pursues an excessively high share ratio. Only a below-threshold sharing ratio can promote the supplier's carbon reduction behavior and improve efficiency for both parties. Conversely, PF has a stable incentive effect on the supplier's carbon reduction behavior and can effectively increase the retailer's profits. However, a reasonable carbon reduction standard is needed to attract the supplier. In addition, as market demand becomes more sensitive to carbon reduction, the feasible range of CS narrows and that of PF expands. We compare players' preferences of PF and CS and find a Pareto region in which all players prefer PF to CS. Finally, we test the robustness of our findings by an extending model. Our study provides guidance for supply chain decisions facing dual pressures of financial constraints and carbon reduction.

Do discussions of financial burdens decrease long-term financial toxicity in adolescent and young adult cancer survivors?

PURPOSE

This study aims to evaluate the associations between patient-provider cost discussions with patient-reported out-of-pocket (OOP) spending and long-term financial toxicity (FT) among adolescent and young adult (AYA; 15-39 years old) cancer survivors.

METHODS

Using a cross-sectional survey, we assessed the themes and quality of patient discussions with providers about financial needs and general survivorship preparation, quantified patients' levels of FT, and evaluated patient-reported OOP spending. We determined the association between cancer treatment cost discussion and FT using multivariable analysis. In a subset of survivors (n = 18), we conducted qualitative interviews and used thematic analysis to characterize responses.

RESULTS

Two hundred forty-seven AYA survivors completed the survey at a mean of 7 years post treatment and with a median COST score of 13. 70% of AYA survivors did not recall having any cost discussion about their cancer treatment with a provider. Having any cost discussion with a provider was associated with decreased FT (β = 3.00; p = 0.02) but not associated with reduced OOP spending (χ2 = 3.77; p = 0.44). In a second adjusted model, with OOP spending included as a covariate, OOP spending was a significant predictor of FT (β =  - 1.40; p = 0.002). Key qualitative themes included survivors' frustration about the lack of communication related to financial issues throughout treatment and in survivorship, feeling unprepared, and reluctance to seek help.

CONCLUSION

AYA patients are not fully informed about the costs of cancer care and FT; the dearth of cost discussions between patients and providers may represent a missed opportunity to reduce costs.

Availability of off-marketplace plans with lower premiums for higher-income families

OBJECTIVES

Families with incomes above 400% of the federal poverty level were ineligible for marketplace premium tax credits before 2021 and may again be after 2025. Current laws temporarily removed this income cap, but because credits cap out-of-pocket premiums for a reference plan as a share of income, some higher-income families still receive zero tax credits. We quantified (1) premium differences between on- and off-marketplace plans and (2) the association between these premium differences and state decisions to finance cost-sharing reductions (CSRs) for lower-income families.

STUDY DESIGN

We created a comprehensive database of on- and off-marketplace plans in each county (including both federal and state-based marketplaces).

METHODS

By county and metal level, we compared on- and off-marketplace (1) plan premiums in 2020 and (2) growth rates in the numbers of plans. We contrasted outcomes for states by how insurers were instructed to finance CSRs.

RESULTS

In 2020, 89% of the US population lived in counties where some plans were offered exclusively off-marketplace. In these counties, for a 45-year-old choosing among silver plans in 2020 and who did not qualify for premium subsidies, premiums for the lowest-cost off-marketplace plans averaged 11.3% less than premiums for the lowest-cost on-marketplace plans. In contrast, for bronze and gold plans, the lowest-cost off-marketplace plans were, on average, more expensive. Silver plan premiums were 6.1% higher off-marketplace than on-marketplace in states that loaded CSRs on all silver plans, and 13.5% lower in states that loaded CSRs only on on-marketplace silver plans.

CONCLUSIONS

Higher-income individuals and families may consider purchasing Affordable Care Act-compliant silver plans off-marketplace and thereby reduce their premiums. State and federal policy makers should consider the impact of their decisions on the choice between on- and off-marketplace plans.

Designing a Value-Based Formulary for a Commercial Health Plan: A Simulated Case Study of Diabetes Medications

OBJECTIVES

The healthcare expenditure for managing diabetes with glucose-lowering medications has been substantial in the United States. We simulated a novel, value-based formulary (VBF) design for a commercial health plan and modeled possible changes in spending and utilization of antidiabetic agents.

METHODS

We designed a 4-tier VBF with exclusions in consultation with health plan stakeholders. The formulary information included covered drugs, tiers, thresholds, and cost sharing amounts. The value of 22 diabetes mellitus drugs was determined primarily in terms of incremental cost-effectiveness ratios. Using pharmacy claims database (2019-2020), we identified 40 150 beneficiaries who were on the included diabetes mellitus medicines. We simulated future health plan spending and out-of-pocket costs with 3 VBF designs, using published own price elasticity estimates.

RESULTS

The average age of the cohort is 55 years (51% female). Compared with the current formulary, the proposed VBF design with exclusions is estimated to reduce total annual health plan spending by 33.2% (current: $33 956 211; VBF: $22 682 576), saving $281 in annual spending per member (current: $846; VBF: $565) and $100 in annual out-of-pocket spending per member (current: $119; VBF: $19). Implementing the full VBF with new cost shares, along with exclusions, has the potential to achieve the greatest savings, compared with the 2 intermediate VBF designs (ie, VBF with prior cost sharing and VBF without exclusions). Sensitivity analyses using various price elasticity values showed declines in all spending outcomes.

CONCLUSION

Designing a VBF with exclusions in a US employer-based health plan has the potential to reduce health plan and patient spending.

The Associations of Prescription Drug Insurance and Cost-Sharing With Drug Use, Health Services Use, and Health: A Systematic Review of Canadian Studies

OBJECTIVES

In Canada, public insurance for physician and hospital services, without cost-sharing, is provided to all residents. Outpatient prescription drug coverage, however, is provided through a patchwork system of public and private plans, often with substantial cost-sharing, which leaves many underinsured or uninsured.

METHODS

We conducted a systematic review to examine the association of drug insurance and cost-sharing with drug use, health services use, and health in Canada. We searched 4 electronic databases, 2 grey literature databases, 5 specialty journals, and 2 working paper repositories. At least 2 reviewers independently screened articles for inclusion, extracted characteristics, and assessed risk of bias.

RESULTS

The expansion of drug insurance was associated with increases in drug use, individuals who reported drug insurance generally reported higher drug use, and increases in and higher levels of drug cost-sharing were associated with lower drug use. Although a number of studies found statistically significant associations between drug insurance or cost-sharing and health services use, the magnitudes of these associations were generally fairly small. Among 5 studies that examined the association of drug insurance and cost-sharing with health outcomes, 1 found a statistically significant and clinically meaningful association. We did not find that socioeconomic status or sex were effect modifiers; there was some evidence that health modified the association between drug insurance and cost-sharing and drug use.

CONCLUSIONS

Increased cost-sharing is likely to reduce drug use. Universal pharmacare without cost-sharing may reduce inequities because it would likely increase drug use among lower-income populations relative to higher-income populations.

Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period?

BACKGROUND/OBJECTIVE

In recent years, 2 circumstances changed provider-patient interactions in primary care: the substitution of virtual (eg, video) for in-person visits and the COVID-19 pandemic. We studied whether access to care might affect patient fulfillment of ancillary services orders for ambulatory diagnosis and management of incident neck or back pain (NBP) and incident urinary tract infection (UTI) for virtual versus in-person visits.

METHODS

Data were extracted from the electronic health records of 3 Kaiser Permanente Regions to identify incident NBP and UTI visits from January 2016 through June 2021. Visit modes were classified as virtual (Internet-mediated synchronous chats, telephone visits, or video visits) or in-person. Periods were classified as prepandemic [before the beginning of the national emergency (April 2020)] or recovery (after June 2020). Percentages of patient fulfillment of ancillary services orders were measured for 5 service classes each for NBP and UTI. Differences in percentages of fulfillments were compared between modes within periods and between periods within the mode to assess the possible impact of 3 moderators: distance from residence to primary care clinic, high deductible health plan (HDHP) enrollment, and prior use of a mail-order pharmacy program.

RESULTS

For diagnostic radiology, laboratory, and pharmacy services, percentages of fulfilled orders were generally >70-80%. Given an incident NBP or UTI visit, longer distance to the clinic and higher cost-sharing due to HDHP enrollment did not significantly suppress patients' fulfillment of ancillary services orders. Prior use of mail-order prescriptions significantly promoted medication order fulfillments on virtual NBP visits compared with in-person NBP visits in the prepandemic period (5.9% vs. 2.0%, P=0.01) and in the recovery period (5.2% vs. 1.6%, P=0.02).

CONCLUSIONS

Distance to the clinic or HDHP enrollment had minimal impact on the fulfillment of diagnostic or prescribed medication services associated with incident NBP or UTI visits delivered virtually or in-person; however, prior use of mail-order pharmacy option promoted fulfillment of prescribed medication orders associated with NBP visits.

Exploring the effectiveness of demand-side retail pharmaceutical expenditure reforms : Cross-country evidence from weighted-average least squares estimation

Increasing expenditures on retail pharmaceuticals bring a critical challenge to the financial stability of healthcare systems worldwide. Policy makers have reacted by introducing a range of measures to control the growth of public pharmaceutical expenditure (PPE). Using panel data on European and non-European OECD member countries from 1990 to 2015, we evaluate the effectiveness of six types of demand-side expenditure control measures including physician-level behaviour measures, system-level price-control measures and substitution measures, alongside a proxy for cost-sharing and add a new dimension to the existing empirical evidence hitherto based on national-level and meta-studies. We use the weighted-average least squares regression framework adapted for estimation with panel-corrected standard errors. Our empirical analysis suggests that direct patient cost-sharing and some-but not all-demand-side measures successfully dampened PPE growth in the past. Cost-sharing schemes stand out as a powerful mechanism to curb PPE growth, but bear a high risk of adverse effects. Other demand-side measures are more limited in effect, though may be more equitable. Due to limitations inherent in the study approach and the data, the results are only explorative.

Coordinating a three-level contract farming supply chain with option contracts considering risk-averse farmer and retailer

We considered a three-level contract farming supply chain comprising a risk-averse farmer, a risk-neutral supplier, and a risk-averse retailer. The farmer plants and grows fresh agricultural products with yield uncertainty, the supplier is the leader of the supply chain and the designer of the contracts, and the retailer sells processed products with random demand. Under CVaR criterion, this paper discusses three option contracts between the supplier and the retailer, as well as wholesale price contracts or replenishment cost-sharing contracts between the supplier and the farmer. Results show that when the farmer is risk-neutral, option contracts with or without replenishment cost-sharing contracts can maximize the total profit and increase the profits of all members simultaneously. When the farmer and the retailer are risk-averse, only option contracts with replenishment cost-sharing contracts can ensure supply chain full coordination and Pareto improvement by adjusting the option parameters and making the farmer's sharing ratio equal to his risk aversion coefficient. Moreover, through numerical analysis, we discovered that the interval of the Pareto improvement decreases with the retailer's risk aversion coefficient and the quantity loss rate, and increases with the farmer's risk aversion coefficient. The supplier will not be able to increase his own profits when the loss rate is excessively large. Therefore, the leader should consider the risk aversion degree of all parties and the quantity loss rate of fresh agricultural products before choosing contracts.

"Internet+ Recycling" Platform Participation Selection Strategy in a Two-Echelon Remanufacturing Closed-Loop Supply Chain

Compared with traditional offline recycling channel, recycling through the "Internet+ recycling" platform has increasingly attracted the academic and practical intention in the past decade because of its accessibility and convenience. To promote the recycling initiatives and construct sustainable operations, how to stimulate supply chain stakeholders participating in the online recycling becomes a challenge issue. This paper considers one supplier, one manufacturer, and one third-party recycler (3PR) in a two-echelon remanufacturing closed-loop supply chain with an "Internet+ recycling" platform, in which consumers can access the online recycling platform and make an appointment for recycling without a physical visit. The manufacturer has three choices: either do not participate or participate with one of two strategies: cost-sharing (CS) or active promotion (AP) strategy. We develop a Stackelberg game model to study the motivation of the manufacturer to participate in the "Internet+ recycling" platform and the influence mechanism of key factors. The key findings include the following: (1) compared with the case without the "Internet+ recycling" platform, when the proportion of cost sharing for the 3PR is low, strategy CS contributes to the improvement of the 3PR's performance; (2) in the presence of two participation strategies, when the disassembly rate is low enough, the manufacturer prefers strategy AP; otherwise, he selects strategy CS; and (3) a high proportion of cost sharing for the manufacturer or low promotion effort cost can increase the whole profit of the closed-loop supply chain.

Green Agricultural Products Supply Chain Subsidy Scheme with Green Traceability and Data-Driven Marketing of the Platform

Government subsidies have played an important role in the development of green agriculture. In addition, the Internet platform is becoming a new channel to realize green traceability and promote the sale of agricultural products. In this context, we consider a two-level green agricultural products supply chain (GAPSC) consisting of one supplier and one Internet platform. The supplier makes green R&D investments to produce green agricultural products along with conventional agricultural products, and the platform implements green traceability and data-driven marketing. The differential game models are established under four government subsidy scenarios: no subsidy (NS), consumer subsidy (CS), supplier subsidy (SS), and supplier subsidy with green traceability cost-sharing (TSS). Then, the optimal feedback strategies under each subsidy scenario are derived using Bellman's continuous dynamic programming theory. The comparative static analyses of key parameters are given, and the comparisons among different subsidy scenarios are conducted. Numerical examples are employed to obtain more management insights. The results show that the CS strategy is effective only if the competition intensity between two types of products is below a certain threshold. Compared to the NS scenario, the SS strategy can always improve the supplier's green R&D level, the greenness level, market demand for green agricultural products, and the system's utility. The TSS strategy can build on the SS strategy to further enhance the green traceability level of the platform and the greenness level and demand for green agricultural products due to the advantage of the cost-sharing mechanism. Accordingly, a win-win situation for both parties can be realized under the TSS strategy. However, the positive effect of the cost-sharing mechanism will be weakened as the supplier subsidy increases. Moreover, compared to three other scenarios, the increase in the environmental concern of the platform has a more significant negative impact on the TSS strategy.

The Impact of Sharing Drug Rebates at the Point of Sale on Out-of-Pocket Payments for Enrollees in Employer-Sponsored Insurance

OBJECTIVES

This study aimed to estimate the impact of sharing drug rebates at the point of sale on out-of-pocket spending by linking estimated rebates to administrative claims data for employer-sponsored insurance enrollees in 2018.

METHODS

We applied the drug rebate rate to the retail price of each brand name drug fill, allocated the reductions to out-of-pocket spending based on cost-sharing provisions, and aggregated each individual's out-of-pocket spending across drug fills. We assumed that generic drugs have no rebates for employer-sponsored insurance. We assessed the impact of sharing rebates at the point of sale on out-of-pocket spending overall, for the therapeutic classes and specific drugs with the highest average out-of-pocket spending per user, and by health plan type.

RESULTS

Across 4 simulations with different assumptions about the degree of cross-fill effects, we found that 10.4% to 12.2% of enrollees in our sample would have realized savings on out-of-pocket spending if rebates were shared to the point of sale. Among those with savings, approximately half would save $50 or less, and 10% would save > $500 annually. We calculated that a premium increase of $1.06 to $1.41 per member per month among the continuously enrolled, insured population would be sufficient to finance the out-of-pocket savings in our sample.

CONCLUSIONS

Our study suggests that, for a small percentage of enrollees, sharing drug rebates at the point of sale would likely improve the affordability of high-priced brand name drugs, especially drugs that face significant competition.

Cost Sharing and Cost Shifting Mechanisms under a per Diem Payment System in a County of China

Cost sharing and cost shifting mechanisms are of vital importance in a prospective payment system. This paper employed the difference-in-differences method to estimate the impacts of a per diem system with inverted-U-shape rates on medical costs and the length of stay based on data from a health insurance institution. The supply side cost sharing mechanism worked so that the new payment system significantly reduced medical costs by 17.59 percent while the average length of stay varied little. After further analyzing the mechanism, we found that heterogeneous effects emerged mainly due to the special rates design. The reform decreased the cases that incurred relatively high medical costs and lengths of stay. However, cost shifting existed so that physicians could be motivated to provide unnecessary services to the patients who should have been discharged before the average length of stay. Therefore, payment rates in the per diem system require a sophisticated design to constrain its distortion to medical service provision even though medical expenditures were successfully contained.

Reductions in out-of-pocket prices and forward-looking moral hazard in health care demand

Little is known about how patients dynamically respond to a forthcoming reduction in health care out-of-pocket prices. Using a kinked Donut Regression Discontinuity design with kinks entering and exiting the donut, we evaluate a Swedish cost-sharing policy, where primary care out-of-pocket prices were eliminated at age 85. We find evidence of forward-looking moral hazard with older adults delaying primary care visits up to four months before the out-of-pocket elimination and shifting these visits until shortly after. These health care delays are driven by non-urgent care: non-physician visits, planned visits and follow up visits. We find no evidence of severe negative health effects in the short-term as a result of the delay. Contrary to our finding of forward-looking behavior with respect to out-of-pocket prices, we do not find evidence of typical moral hazard, as we do not find a persistent increase in primary health care use after the copayment elimination.

The impact of cost-sharing on prescription drug demand: evidence from a double-difference regression kink design

Pharmaceuticals represent the third-largest expenditure item in health care spending in the OECD countries, and cost growth is around 5% per year in many OECD countries. One possible way to contain the rise in pharmaceutical spending is the use of cost-sharing schemes that makes insured individuals directly bear parts of the cost of a drug. This study estimates the price sensitivity of demand for prescription drugs using data on all prescription drug purchases from a random sample of 400,000 Swedes followed from 2010 to 2013. We use a regression kink design (RKD) by exploiting the kinked Swedish cost-sharing scheme to assess the price elasticity. Further, since the cost-sharing scheme has changed over time, we also use a double-difference RKD to account for potential confounding nonlinearities around the kink. Our results indicate that the standard RKD results are biased and exaggerate the price sensitivity. Our preferred double-difference RKD specifications show no or minor price sensitivity (95% CI price elasticity from - 0.12 to 0.02). The results are similar in several sub-group analyses across age groups, sexes, and income quartiles.

Value-Based Insurance Design: Clinically Nuanced Consumer Cost Sharing to Increase the Use of High-Value Medications

Consumer cost sharing is widely employed by payers in the United States in an effort to control spending. Most cost-sharing strategies set patient contributions on the basis of costs incurred by payers and often do not consider medical necessity as a coverage criterion. Available evidence suggests that increases in cost sharing worsen health disparities and adversely affect patient-centered outcomes, particularly among economically vulnerable individuals, people of color, and those with chronic conditions. A key question has been how to better engage consumers while balancing appropriate access to essential services with increasing fiscal pressures. Value-based insurance design (VBID) is a promising approach designed to improve desired clinical and financial outcomes, in which out-of-pocket costs are based on the potential for clinical benefit, taking into consideration the patient's clinical condition. For more than two decades, broad multistakeholder support and multiple federal policy initiatives have led to the implementation of VBID programs that enhance access to vital preventive and chronic disease medications for millions of Americans. A robust evidence base shows that when financial barriers to essential medications are reduced, increased adherence results, leading to improved patient-centered outcomes, reduced health care disparities, and in some (but not most) instances, lower total medical expenditures.

Factors Associated with Willingness to Pay for Cost-Sharing under Universal Health Coverage Scheme in Yogyakarta, Indonesia: A Cross-Sectional Survey

BACKGROUND

National Health Insurance (NHI) in Indonesia requires an appropriate cost-sharing policy, particularly for diseases that require the largest financing. This study examined factors that influence willingness to pay (WTP) for cost-sharing under the universal health coverage scheme among patients with catastrophic illnesses in Yogyakarta, Indonesia.

METHODS

This was a cross-sectional study using structured questionnaires through direct interviews. The factors related to the WTP for cost-sharing under the NHI scheme in Indonesia were identified by a bivariable logistic regression analysis.

RESULTS

Two out of every five (41.2%) participants had willingness to pay for cost-sharing. Sex [AOR = 0.69 (0.51, 0.92)], education [AOR = 1.54 (0.67, 3.55)], family size [AOR = 1.71 (1.07, 2.73)], occupation [AOR = 1.35 (0.88, 2.07)], individual income [AOR = 1.50 (0.87, 2.61)], household income [AOR = 1.47 (0.90, 2.39)], place of treatment [AOR = 2.54 (1.44, 4.45)], a health insurance plan [AOR = 1.22 (0.87, 1.71)], and whether someone receives an inpatient or outpatient service [AOR = 0.23 (0.10, 0.51)] were found to affect the WTP for a cost-sharing scheme with p < 0.05.

CONCLUSION

Healthcare (place of treatment, health insurance plan, and whether someone receives an inpatient or outpatient service) and individual socioeconomic (sex, educational, family size, occupational, income) factors were significantly related to the WTP for cost-sharing.

Pharmacy switching in response to preferred pharmacy networks in Medicare Part D

OBJECTIVE

To evaluate the effects of preferred pharmacy networks-a tool that Medicare Part D plans have recently adopted to steer patients to lower cost pharmacies-on the use of preferred pharmacies and factors underlying beneficiaries' decisions on whether to switch to preferred pharmacies.

DATA SOURCES

Medicare claims data were collected for a nationally representative 20% sample of beneficiaries during 2010-2016 and merged with annual Part D pharmacy network files.

STUDY DESIGN

We examined preferred networks' impact on pharmacy choice by estimating a difference-in-differences model comparing preferred pharmacies' claim share before and after implementation among unsubsidized and subsidized beneficiaries. Additionally, we evaluated the factors affecting whether a beneficiary switched from mainly using nonpreferred to preferred pharmacies.

DATA COLLECTION/EXTRACTION METHODS

We examined stand-alone drug plans that adopted a preferred network during 2011-2016. Our main sample included beneficiaries 65 years and older who stayed in their plan in both the first year of implementation and the year before and whose cost-sharing subsidy status and ZIP code remained unchanged during the 2-year period.

PRINCIPAL FINDINGS

Unsubsidized Part D beneficiaries faced an average difference of $129 per year in out-of-pocket spending between using nonpreferred and preferred pharmacies, while subsidized beneficiaries were insulated from these cost differences. The implementation of preferred networks resulted in a 3.7-percentage point (95% CI: 3.3, 4.2) increase in preferred pharmacies' claim share in the first year among the unsubsidized. Existing relationships with preferred pharmacies, the size of financial incentives, proximity to preferred pharmacies, and urban residence were positively associated with beneficiaries' decisions to switch to these pharmacies.

CONCLUSIONS

Preferred pharmacy networks caused a moderate shift on average towards preferred pharmacies among unsubsidized beneficiaries, although stronger financial incentives correlated with more switching. Researchers and policymakers should better understand plans' cost-sharing strategies and assess whether communities have equitable access to preferred pharmacies.

Tiered cost sharing and health care demand

In this paper, I study tiered cost sharing, an innovative incentive structure designed to steer patients toward low-cost providers using large out-of-pocket price differentials. Using administrative data from New Hampshire, where two large insurers utilize tiered pricing programs, I estimate the effects of tiering on choices and spending for common gastrointestinal endoscopic procedures. I first conduct a difference-in-differences analysis using the rollout of one insurer's tiered option. I then develop and estimate a demand model to explicitly compare the tiered design with other common plans. Both the reduced form and structural models imply that the tiered plans are associated with 4.5%-6.3% less in mean per-episode spending than high-deductible and coinsurance-based plans, and do not affect the likelihood of seeking care. I find evidence that the savings is in part due to a salience or "simple pricing" effect whereby patients respond to tiered out-of-pocket prices but not to traditional deductibles or coinsurance rates.