Medical Spending Among US Households With Children With a Mental Health Condition Between 2017 and 2021

This cross-sectional study examines US household medical spending for children with a mental health condition between 2017 and 2021.

Hospital Prices for Physician-Administered Drugs for Patients with Private Insurance

BACKGROUND

Hospitals can leverage their position between the ultimate buyers and sellers of drugs to retain a substantial share of insurer pharmaceutical expenditures.

METHODS

In this study, we used 2020-2021 national Blue Cross Blue Shield claims data regarding patients in the United States who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Markups of the reimbursement prices were measured in terms of amounts paid by Blue Cross Blue Shield plans to hospitals and physician practices relative to the amounts paid by these providers to drug manufacturers. Acquisition-price reductions in hospital payments to drug manufacturers were measured in terms of discounts under the federal 340B Drug Pricing Program. We estimated the percentage of Blue Cross Blue Shield drug spending that was received by drug manufacturers and the percentage retained by provider organizations.

RESULTS

The study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times (95% confidence interval [CI], 6.02 to 7.16) as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (95% CI, 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%.

CONCLUSIONS

This study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.).

Barriers primary care clinic leaders face to improving value in a consumer choice health plan design

Primary care clinics are a frequent focus of policy initiatives to improve the value of health care; yet, it is unclear whether they have the ability or incentive to take on the additional tasks that these initiatives ask of them. This paper reports on a qualitative study assessing barriers that clinic leaders face to reducing cost within a tiered cost-sharing commercial health insurance benefit design that gives both consumers and clinics a strong incentive to reduce cost. We conducted semi-structured interviews of clinical and operational leaders at a diverse set of 12 Minnesota primary care clinics and identified 6 barriers: insufficient information on drivers of cost; clinics controlling a portion of spending; patient preference for higher cost specialists; administrative challenges; limited resources; and misalignment of incentives. We discuss approaches to reducing these barriers and opportunities to implement them.

Changes in Employment in the US Health Care Workforce, 2016-2022

This study examines the rate of employment in US health care in the postpandemic period, through the end of 2022.

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

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

The impact of COVID-19 shelter-in-place policy responses on excess mortality

As a way of slowing COVID-19 transmission, many countries and U.S. states implemented shelter-in-place (SIP) policies. However, the effects of SIP policies on public health are a priori ambiguous. Using an event study approach and data from 43 countries and all U.S. states, we measure changes in excess deaths following the implementation of COVID-19 shelter-in-place (SIP) policies. We do not find that countries or U.S. states that implemented SIP policies earlier had lower excess deaths. We do not observe differences in excess deaths before and after the implementation of SIP policies, even when accounting for pre-SIP COVID-19 death rates.

Utilization and Spending on Mental Health Services Among Children and Youths With Commercial Insurance

This cross-sectional study examines telehealth, in-person, and overall pediatric mental health service utilization and spending rates from January 2019 through August 2022 among a US pediatric population with commercial insurance.

Telehealth and In-Person Mental Health Service Utilization and Spending, 2019 to 2022

This cohort study assesses trends in monthly telehealth vs in-person utilization and spending rates for mental health services among commercially insured US adults before and during the COVID-19 pandemic.

Association between hospital-physician vertical integration and medication adherence rates

OBJECTIVE

To test the association between vertical integration of primary care providers (PCPs) and adherence rates for anti-diabetics, renin angiotensin system antagonists (RASA), and statins.

DATA SOURCES

Medicare Part B outpatient fee-for-service claims and Medicare Part D event data from 2014 to 2017.

STUDY DESIGN

We estimated difference-in-differences regressions, comparing changes in adherence among patients with PCPs who converted from independent to integrated to changes among patients whose PCPs remained independent or integrated during the study period. To test for heterogenous impacts by patient demographics, we estimated triple difference regressions that included additional interaction terms by comorbidity rates, age group, and race/ethnicity.

EXTRACTION METHODS

We extracted Medicare claims for adults with continuous enrollment in Parts B and D during the study period.

PRINCIPAL FINDINGS

The proportion of patients who had a vertically integrated PCP increased by approximately 23% over the study period. Changes in adherence did not differ significantly between patients based on whether their PCP became integrated (Statins: 0.18, 95% CI -0.13, 0.49; RASA: -0.13, 95% CI -0.46, 0.19; Anti-Diabetics: -0.20, 95% CI -0.78, 0.38). Among patients with PCPs who became integrated, there were significant decreases in adherence for patients who were Black, Asian, Hispanic, or Native American, above 80 years old, and had greater comorbidities for all three classes.

CONCLUSIONS

While there were no average changes in adherence following vertical integration of PCPs, health equity worsened, with significant declines in adherence for Black, Asian, Hispanic, and Native American patients, patients over 80 years old, and patients with greater comorbidities. These findings suggest that integration may reduce clinicians' incentives to compete based on the quality of care delivered. Given the price increases associated with integration, integration may be a net welfare loss.

The effect of hospital discharge price increases on publicly reported measures of quality

OBJECTIVE

To determine if increases in hospital discharge prices are associated with improvements in clinical quality or patient experience.

DATA SOURCES

This study used Medicare cost report data and publicly available Medicare.gov Care Compare quality measures for approximately 3000 short-term care general hospitals between 2011 and 2018.

STUDY DESIGN

We separately regressed quality measure scores on a lag of case mix adjusted discharge price, hospital fixed effects, and year indicators. Clinical quality measures included 30-day readmission rates for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, hip and knee replacement, and pneumonia; risk-adjusted 30-day mortality rates for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, and stroke; and 90-day complication rate for hip and knee replacement. Patient experience measures included the summary star rating and 10 domain measures reported through the Hospital Consumer Assessment of Healthcare Providers and Systems survey. We tested for heterogeneous effects by hospital ownership, number of beds, the commercial share of overall discharges, and market concentration.

DATA COLLECTION/EXTRACTION METHODS

We linked hospitals identified in Medicare cost reports to Medicare.gov Care Compare quality measures. We excluded hospitals for which we could not identify a discharge price or that had an unrealistic price.

PRINCIPAL FINDINGS

There was no positive association between lagged discharge price and any clinical quality measure. For patient experience measures, a 2% increase in discharge price was not associated with overall patient satisfaction but was associated with small, statistically significant increases ranging from 0.01% to 0.02% (relative to mean scores) for seven of ten domain measures. There was a positive association for five of ten patient experience measures in competitive markets and one measure in both moderately concentrated and heavily concentrated markets.

CONCLUSIONS

We found no evidence that hospitals use higher prices to make investments in clinical quality; patient experience improved, but only negligibly.

The association of strained ICU capacity with hospital patient racial and ethnic composition and federal relief during the COVID-19 pandemic

OBJECTIVE

To identify the association between strained intensive care unit (ICU) capacity during the COVID-19 pandemic and hospital racial and ethnic patient composition, federal pandemic relief, and other hospital characteristics.

DATA SOURCES

We used government data on hospital capacity during the pandemic and Provider Relief Fund (PRF) allocations, Medicare claims and enrollment data, hospital cost reports, and Social Vulnerability Index data.

STUDY DESIGN

We conducted cross-sectional bivariate analyses relating strained capacity and PRF award per hospital bed with hospital patient composition and other characteristics, with and without adjustment for hospital referral region (HRR).

DATA COLLECTION

We linked PRF data to CMS Certification Numbers based on hospital name and location. We used measures of racial and ethnic composition generated from Medicare claims and enrollment data. Our sample period includes the weeks of September 18, 2020 through November 5, 2021, and we restricted our analysis to short-term, general hospitals with at least one intensive care unit (ICU) bed. We defined "ICU strain share" as the proportion of ICU days occurring while a given hospital had an ICU occupancy rate ≥ 90%.

PRINCIPAL FINDINGS

After adjusting for HRR, hospitals in the top tercile of Black patient shares had higher ICU strain shares than did hospitals in the bottom tercile (30% vs. 22%, p < 0.05) and received greater PRF amounts per bed ($118,864 vs. $92,407, p < 0.05). Having high versus low ICU occupancy relative to pre-pandemic capacity was associated with a modest increase in PRF amounts per bed after adjusting for HRR ($107,319 vs. $96,627, p < 0.05), but there were no statistically significant differences when comparing hospitals with high versus low ICU occupancy relative to contemporaneous capacity.

CONCLUSIONS

Hospitals with large Black patient shares experienced greater strain during the pandemic. Although these hospitals received more federal relief, funding was not targeted overall toward hospitals with high ICU occupancy rates.

If Patients Don't Use Available Health Service Pricing Information, Is Transparency Still Important?

The US health system is replete with health service pricing idiosyncrasies and opacity unrelated to quality. Online tools intended to make health care purchasing resemble consumerism by making prices transparent have had little if any effect on improving health care market functioning and changing patient behavior. Although price transparency is still in its infancy, it holds promise to be as useful to patient-consumers as it has been to large purchasers (eg, employers) of health services and policymakers. But even if price information is not routinely used by patients, transparency of such information still has ethical importance in a market in which patients pay increasingly high out-of-pocket costs.

Costs of Specialist Referrals From Employer-Sponsored Integrated Health Care Clinics Are Lower Than Those From Community Providers

BACKGROUND

There have been very few published studies of referral management among commercially insured populations and none on referral management from employer-sponsored health centers.

OBJECTIVE

Describe the referral management system of an integrated employer-sponsored health care system and compare specialist referral rates and costs of specialist visits between those initiated from employer-sponsored health clinics and those initiated from community providers.

DESIGN

Retrospective, comparative cohort study using multivariate analysis of medical claims comparing care initiated in employer-sponsored health clinics with propensity-matched controls having specialist referrals initiated by community providers.

PATIENTS

Adult patients (≥ 18 years) eligible for employer-sponsored clinical services incurring medical claims for specialist referrals between 12/1/2018 and 12/31/2020. The study cohort was comprised of 3129 receiving more than 75% of their care in the employer-sponsored clinic matched to a cohort of 3129 patients receiving care in the community.

INTERVENTION

Specialist referral management program implemented by Crossover Health employer-sponsored clinics.

MAIN MEASURES

Rates and costs of specialist referrals.

KEY RESULTS

The relative rate of specialist referrals was 22% lower among patients receiving care in employers-sponsored health clinics (35.1%) than among patients receiving care in the community (45%, p <0.001). The total per-user per-month cost for patients in the study cohort was $372 (SD $894), compared to $401 (SD $947) for the community cohort, a difference of $29 (p<0.001) and a relative reduction of 7.2%. The lower costs can be attributed, in part, to lower specialist care costs ($63 (SD $140) vs $76 (SD $213) (p<0.001).

CONCLUSIONS

Employer-sponsored health clinics can provide effective integrated care and may be able to reduce avoidable specialist utilization. Standardized referral management and care navigation may drive lower specialist spend, when referrals are needed.

Variation in prices for an evidence-based pediatric preventive service

OBJECTIVE

To examine variation in prices paid by private medical insurers for fluoride varnish applications in medical settings, a newly reimbursed service that few children receive.

DATA SOURCES

Private-insurance medical claims from Connecticut, Maine, New Hampshire, and Rhode Island (2016-2018).

STUDY DESIGN

We examined prices paid for fluoride varnish by private insurers and compared these to prices paid by Medicaid.

DATA COLLECTION/EXTRACTION METHODS

Private claims for fluoride varnish during medical visits for children aged 1-5 years. State Medicaid rates for fluoride varnish were obtained from the American Academy of Pediatrics.

PRINCIPAL FINDINGS

Prices paid for fluoride varnish by private insurers varied within and across states, ranging from less than $5 to $50. Median prices closely followed Medicaid rates in three of the four states. In states covering a package of fluoride varnish plus additional preventive oral health services during medical visits, combined Medicaid rates were nearly double the median price paid by private insurers.

CONCLUSIONS

Fluoride varnish is a recommended service, but few children receive it. Price variation may contribute to the low uptake of this service. Ensuring sufficient Medicaid and private insurance rates could increase fluoride varnish applications in medical settings and improve oral health.

The impact of the COVID-19 pandemic and policy response on health care utilization: Evidence from county-level medical claims and cellphone data

The COVID-19 pandemic has forced federal, state, and local policymakers to respond by legislating, enacting, and enforcing social distancing policies. However, the impact of these policies on healthcare utilization in the United States has been largely unexplored. We examine the impact of county-level shelter in place ordinances on healthcare utilization using two unique datasets-employer-sponsored insurance for over 6 million people in the US and cell phone location data. We find that introduction of these policies was associated with reductions in the use of preventive care, elective care, and the number of weekly visits to physician offices, hospitals and other health care-related industries. However, controlling for county-level exposure to the COVID-19 pandemic as a way to account for the endogenous nature of policy implementation reduces the impact of these policies. Our results imply that while social distancing policies do lead to reductions in healthcare utilization, much of these reductions would have occurred even in the absence of these policies.

Paying patients to use lower-priced providers

OBJECTIVE

Many employers have introduced rewards programs as a new benefit design in which employees are paid $25-$500 if they receive care from lower-priced providers. Our goal was to assess the impact of the rewards program on procedure prices and choice of provider and how these outcomes vary by length of exposure to the program and patient population.

STUDY SETTING

A total of 87 employers from across the nation with 563,000 employees and dependents who have introduced the rewards program in 2017 and 2018.

STUDY DESIGN

Difference-in-difference analysis comparing changes in average prices and market share of lower-priced providers among employers who introduced the reward program to those that did not.

DATA COLLECTION METHODS

We used claims data for 3.9 million enrollees of a large health plan.

PRINCIPAL FINDINGS

Introduction of the program was associated with a 1.3% reduction in prices during the first year and a 3.7% reduction in the second year of access. Use of the program and price reductions are concentrated among magnetic resonance imaging (MRI) services, for which 30% of patients engaged with the program, 5.6% of patients received an incentive payment in the first year, and 7.8% received an incentive payment in the second year. MRI prices were 3.7% and 6.5% lower in the first and second years, respectively. We did not observe differential impacts related to enrollment in a consumer-directed health plan or the degree of market-level price variation. We also did not observe a change in utilization.

CONCLUSIONS

The introduction of financial incentives to reward patients from receiving care from lower-priced providers is associated with modest price reductions, and savings are concentrated among MRI services.

Dental Fluoride Varnish Application During Medical Visits Among Children Who Are Privately Insured

This cross-sectional study examines fluoride varnish application rates during well-child medical visits and identify characteristics associated with fluoride varnish receipt.

Trends in visits to substance use disorder treatment facilities in 2020

OBJECTIVE

To describe weekly changes in the number of substance use disorder treatment (SUDT) facility visits in 2020 compared to 2019 using cell phone location data.

METHODS

We calculated the percentage weekly change in visits to SUDT facilities from the week of January 5 through the week of October 11, 2020, relative to the week of January 6 through the week of October 13, 2019. We stratified facilities by county COVID-19 incidence per 10,000 residents in each week and by 2018 fatal drug overdose rate. Finally, we conducted a multivariable linear regression analysis examining percent change in visits per week as a function of county-level COVID-19 tercile, a series of calendar month indicators, and the interaction of county-level COVID-19 tercile and month. We repeated the regression analysis replacing COVID-19 tercile with overdose tercile.

RESULTS

Beginning the eleventh week of 2020, the number of visits to SUDT facilities declined substantially, reaching a nadir of 48% of 2019 visits in early July. In contrast to January, there were significantly fewer visits in 2020 compared to 2019 in all subsequent months (p < 0.01 in all months). Multivariable regression results found that facilities in the tercile of counties experiencing the most COVID-19 cases had a significantly greater reduction in the number of SUDT visits in 2020 for the months of June through August than facilities in counties with the fewest COVID-19 rates (p < 0.05). The study found no statistically significant difference in the change in the number of visits by facilities in counties with historically different overdose rates.

DISCUSSION

Our findings support the hypothesis that a reduction has occurred in the average weekly number of visits to SUDT facilities. The size of the effect differs based on the number of COVID-19 cases but not on historical overdose rate.

Telehealth Use Among Safety-Net Organizations in California During the COVID-19 Pandemic

This study describes trends in use of in-person, telephone, and video primary care and behavioral health visits to California Federally Qualified Health Centers from 2019 to August 2020 before and during the coronavirus disease 2019 (COVID-19) pandemic.

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

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

Reference-Based Benefits for Colonoscopy and Arthroscopy: Large Differences in Patient Payments Across Procedures but Similar Behavioral Responses

This study examines how reference-based benefits (RBB) affect patient out-of-pocket payments across outpatient procedures. The California Public Employees' Retirement System (CalPERS) implemented RBB asymmetrically for outpatient procedures in 2012, only applying RBB to outpatient procedures performed in a hospital outpatient department (HOPD), and not applying RBB to outpatient procedures performed in a lower cost ambulatory surgery center. Using claims data (2009-2013) on arthroscopy and colonoscopy services, we found that for colonoscopy, CalPERS patients paid an average of 63.9% (p < .01) more for HOPDs than ambulatory surgery centers in 2012. For arthroscopy, no statistically different cost sharing was found on average. However, high-priced HOPDs were 17.3% and 17.9% less likely to be chosen by CalPERS patients in 2012 for colonoscopy and arthroscopy, respectively. These magnitudes increased in 2013 to 25.2% and 24.2% less, respectively. Overall, responsiveness to RBB with regard to the most expensive HOPDs was similar despite varying cost sharing by procedure.

Physician and Patient Adjustment to Reference Pricing for Drugs

IMPORTANCE

Reference pricing has been shown to reduce drug spending in Europe and has been adopted by some employers and labor unions in the United States. Its association with patient cost sharing depends on whether and how quickly physicians adjust their prescribing patterns to favor the least costly alternatives within each therapeutic class.

OBJECTIVE

To examine whether the implementation of reference pricing is associated with physicians and patients shifting to lower-cost drugs, thereby reducing consumer cost sharing and the prices paid by employers.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation included employees of Catholic organizations who purchased health insurance through the Reta Trust and a random sample of employees of public sector organizations who purchased insurance through the California Public Employees' Retirement System (CalPERS) as a comparison group between July 1, 2010, and December 31, 2017. Data analysis was performed from January 1, 2019, to September 1, 2019.

EXPOSURES

The Reta Trust implemented reference pricing in July 2013; CalPERS did not adopt reference pricing during the study period.

MAIN OUTCOMES AND MEASURES

Probability that the drug prescribed was the least costly alternative within its therapeutic class, price paid per prescription, and patient cost sharing per prescription. Multivariable, difference-in-differences regression analysis of drug insurance claims was performed for patients before and after implementation of reference pricing, adjusted for patient characteristics, each drug's therapeutic class, and the month and year of the prescription.

RESULTS

During the study period, a total of 1.2 million prescriptions were submitted by 34 319 individuals covered by Reta Trust and 2.1 million prescriptions were submitted by 738 159 individuals covered by CalPERS. In the first 2.5 years after implementation of reference pricing, the percentage of prescriptions made for the low-priced drug within each therapeutic class increased by 5.1 percentage points (95% CI, 1.8 to 8.4 percentage points), patient cost sharing increased by 10.3% (95% CI, -1.6% to -23.6%; this difference was not statistically significant), and prices paid decreased by 19.1% (95% CI, -30.2% to -6.2%) for Reta Trust patients compared with CalPERS patients. During the subsequent 2-year postimplementation period, the percentage of prescriptions made for the low-priced drug increased an additional 6.2 percentage points (95% CI, 2.3 to 10.1 percentage points), patient cost sharing decreased by 21.3% (95% CI, -31.2% to -9.9%), and prices paid increased by 7.2% (95% CI, -12.6% to 31.4%; this difference was not statistically significant). Relative to the change experienced by the CalPERS population, during the study period, the share of prescriptions for lower-priced drugs increased by 6.3 percentage points (8.9% relative increase), the mean prescription drug price decreased by $9.5 (12.1% relative decrease), and the mean patient cost sharing decreased by $1.8 (4.3% relative decrease).

CONCLUSIONS AND RELEVANCE

In this study, reference pricing was associated with a combination of lower prices paid by employers and lower cost sharing by employees but with a time lag in prescribing habits by physicians.

Increasing Divergence in Drug Prices Between the United States and Germany After Implementation of Comparative Effectiveness Analysis and Collective Price Negotiations

BACKGROUND

Payers and purchasers in the United States seek to moderate drug prices and align them with the incremental clinical benefit offered by individual medications; some policymakers have proposed linking U.S. prices to an index of prices paid in other nations. The German health care system resembles that of the United States in featuring multiple private payers but differs in featuring a highly coordinated process of comparative clinical assessment and price negotiations for drugs.

OBJECTIVES

To (a) measure trends in prices paid for physician-administered drugs in Germany before and after the mandate for comparative effectiveness assessment and price negotiations in 2011 and (b) compare them with price trends for the same drugs in the United States.

METHODS

This study observed trends in the prices paid for 80 physician-administered drugs, which account for approximately half of Medicare Part B drug spending. Quarterly data covering 2004-2018 were obtained for Germany from the Lauer-Taxe database, which contains net prices paid by all German payers. U.S. data were obtained from the Centers for Medicare & Medicaid Services, which publishes net prices paid by private U.S. payers and the Medicare Part B program. These data contain the net prices actually paid after accounting for all discounts and rebates, not merely the manufacturer's list price. Statistical analyses were conducted with multivariable difference-in-differences regression methods.

RESULTS

Before implementation in Germany of comparative effectiveness analysis and collective price negotiations, net U.S. prices for physician-administered drugs averaged 29.2% higher (95% CI = 26.6%-31.7) than those in Germany. After implementation of comparative effectiveness assessments and price negotiations in 2011, the divergence between U.S. and German prices increased another 28.9% (95% CI = 23.7%-34.3%).

CONCLUSIONS

Commercial health insurers and Medicare pay significantly higher net prices for physician-administered drugs than do insurers in Germany, with the divergence growing after the mandate in Germany that new drugs be subject to comparative effectiveness assessment and collective price negotiations. The experience of Germany may be of special value for the current U.S. debate over pharmaceutical pricing reform, given the demographic, economic, and health system similarities between the 2 nations.

DISCLOSURES

This study was supported by the Commonwealth Fund, New York. The sponsor had no role in the study design, conduct, interpretation, or writing up of results. Whaley reports a grant from the National Institute on Aging, unrelated to this work. The other authors have no potential conflicts of interest to report.

The Association Between Provider Price and Complication Rates for Outpatient Surgical Services

BACKGROUND

Wide variations exist in price and quality for health-care services, but the link between price and quality remains uncertain.

OBJECTIVE

This paper used claims data from a large commercially insured population to assess the association between both procedure- and provider-level prices and complication rates for three common outpatient surgical services.

DESIGN

This is a retrospective cohort study.

SETTING

The study used medical claims data from commercial health plans between 2009 and 2013 for three outpatient surgical services-joint arthroscopy, cataract surgery, and colonoscopy.

MAIN MEASURES

For each procedure, price was assessed as the sum of patient, employer, and insurer spending. Complications were identified using existing algorithms specific to each service. Multivariate regressions were used to risk-adjust prices and complication rates. Provider-level price and complication rates were compared by calculating standardized differences that compared provider risk-adjusted price and complication rates with other providers within the same geographic market. The association between provider-level risk-adjusted price and complication rates was estimated using a linear regression.

KEY RESULTS

Across the three services, there was an inverse association between both procedure- and provider-level prices and complication rates. For joint arthroscopy, cataract surgery, and colonoscopy, a one standard deviation increase in procedure-level price was associated with 1.06 (95% CI 1.05-1.08), 1.14 (95% CI 1.11-1.16), and 1.07 (95% CI 1.06-1.07) odds increases in the rate of procedural complications, respectively. A one standard deviation increase in risk-adjusted provider price was associated with 0.09 (95% CI 0.07 to 0.11), 0.02 (95% CI 0.003 to 0.05), and 0.32 (95% CI 0.29 to 0.34) standard deviation increases in the rate of provider risk-adjusted complication rates, respectively.

LIMITATIONS

Results may be due to unobserved factors. Only three surgical services were examined, and the results may not generalize to other services and procedures. Quality measurements did not include patient satisfaction or experience measures.

CONCLUSIONS

For three common outpatient surgical services, procedure- and provider-level prices are associated with modest increased rates of complication rates.

Reference Pricing Changes The 'Choice Architecture' Of Health Care For Consumers

Reference pricing in health insurance creates incentives for patients to select for nonemergency services providers that charge relatively low prices and still offer high quality of care. It changes the "choice architecture" by offering standard coverage if the patient chooses cost-effective providers but requires considerable consumer cost sharing if more expensive alternatives are selected. The short-term impact of reference pricing has been to shift patient volumes from hospital-based to freestanding surgical, diagnostic, imaging, and laboratory facilities. This article summarizes reference pricing's impacts to date on patient choice, provider prices, surgical complications, and employer spending and estimates its potential impacts if expanded to more services and a broader population. Reference pricing induces consumers to select lower-price alternatives for all of the forms of care studied, leading to significant reductions in prices paid and spending incurred by insurers and employers. The impact on consumer cost sharing is mixed, with some studies finding higher copayments and some lower. We conclude with a discussion of the incentives created for providers to redesign their clinical processes and for efficient providers to expand into price-sensitive markets. Over time, reference pricing may increase pressures for price competition and lead to further cost-reducing innovations in health care products and processes.

Association of Reference Pricing for Diagnostic Laboratory Testing With Changes in Patient Choices, Prices, and Total Spending for Diagnostic Tests

IMPORTANCE

Prices for laboratory and other clinical services vary widely. Employers and insurers increasingly are adopting "reference pricing" policies to create incentives for patients to select lower-priced facilities.

OBJECTIVE

To measure the association between implementation of reference pricing and patient choice of laboratory, test prices, patient out-of-pocket spending, and insurer spending.

DESIGN, SETTING, AND PARTICIPANTS

We conducted an observational study of changes in laboratory pricing and selection by employees of a large national grocery firm (n = 30 415) before and after the firm implemented a reference pricing policy for laboratory services and compared the findings with changes over the same period for policy holders of a large national insurer that did not implement reference pricing (n = 181 831). The grocery firm established a maximum payment limit at the 60th percentile of the distribution of prices for each laboratory test in each region. Employees were provided with data on prices at all laboratories through a mobile digital platform. Patients selecting a laboratory that charged more than the payment limit were required to pay the full difference themselves. A total of 2.13 million claims were analyzed for 285 types of in vitro diagnostic tests between 2010 and 2013.

MAIN OUTCOMES AND MEASURES

Patient choice of laboratory, price paid per test, patient out-of-pocket costs, and employer spending.

RESULTS

Compared with trends in prices paid by insurance policy holders not subject to reference pricing, and after adjusting for characteristics of tests and patients, implementation of reference pricing was associated with a 31.9% reduction (95% CI, 20.6%-41.6%) in average price paid per test by the third year of the program. In these 3 years, total spending on laboratory tests declined by $2.57 million (95% CI, $1.59-$3.35 million). Out-of-pocket costs by patients declined by $1.05 million (95% CI, $0.73-$1.37 million). Spending by the employer declined by $1.70 million (95% CI, $0.92-$2.48 million).

CONCLUSIONS AND RELEVANCE

When combined with access to price information, reference pricing was associated with patient choice of lower-cost laboratories and reductions in prices and payments by both employer and employees.

Functional Limitations, Medication Support, and Responses to Drug Costs among Medicare Beneficiaries

OBJECTIVE

Standard Medicare Part D prescription drug benefits include substantial and complex cost-sharing. Many beneficiaries also have functional limitations that could affect self-care capabilities, including managing medications, but also have varying levels of social support to help with these activities. We examined the associations between drug cost responses, functional limitations, and social support.

DATA SOURCES AND STUDY SETTING

We conducted telephone interviews in a stratified random sample of community-dwelling Medicare Advantage beneficiaries (N = 1,201, response rate = 70.0%). Participants reported their functional status (i.e., difficulty with activities of daily living) and social support (i.e., receiving help with medications). Drug cost responses included cost-reducing behaviors, cost-related non-adherence, and financial stress.

STUDY DESIGN

We used multivariate logistic regression to assess associations among functional status, help with medications, and drug cost responses, adjusting for patient characteristics.

PRINCIPAL FINDINGS

Respondents with multiple limitations who did not receive help with their medications were more likely to report cost-related non-adherence (OR = 3.2, 95% CI: 1.2-8.5) and financial stress (OR = 2.4, 95% CI: 1.3-4.5) compared to subjects with fewer limitations and no help; however, those with multiple limitations and with medication help had similar odds of unfavorable cost responses as those with fewer limitations.

CONCLUSION

The majority of beneficiaries with functional limitations did not receive help with medications. Support with medication management for beneficiaries who have functional limitations could improve adherence and outcomes.

Association of Reference Payment for Colonoscopy With Consumer Choices, Insurer Spending, and Procedural Complications

IMPORTANCE

Regulatory limits on consumer cost sharing permit wide variation in the prices charged for screening and diagnostic tests such as colonoscopy. Employers are experimenting with reference payment initiatives that offer full insurance coverage at low-priced facilities but require substantial cost sharing if patients select high-priced alternatives.

OBJECTIVE

To ascertain the effect of reference payment on facility choice, insurer spending, consumer cost sharing, and procedural complications for colonoscopy.

DESIGN, SETTING, AND PARTICIPANTS

The California Public Employees' Retirement System (CalPERS) implemented reference payment in January 2012. We obtained data on 21 644 CalPERS enrollees who underwent colonoscopy in the 3 years prior to implementation and on 13 551 patients in the 2 years after implementation. Control group data were obtained on 258 616 Anthem Blue Cross enrollees who underwent colonoscopy and who were not subject to reference payment initiatives during this 5-year period.

MAIN OUTCOMES AND MEASURES

Consumer choice of facility, price paid per procedure, total insurer spending, consumer cost sharing, and procedural complications.

EXPOSURES

Choices, prices, and complications were compared for CalPERS and Anthem patients before and after implementation of reference payments, using difference-in-difference multivariable regressions to adjust for patient demographic characteristics and comorbidities, procedure indications, and geographic location.

RESULTS

Utilization of low-priced facilities for CalPERS members increased from 68.6% in 2009 to 90.5% in 2013. After adjusting for patient demographic characteristics, comorbidities, and other factors, the implementation of reference payment increased use of low-priced facilities by 17.6 percentage points (95% CI, 11.8 to 23.4; P < .001). The mean price paid for colonoscopy for the CalPERS population increased from $1587 (95% CI, $1555-$1618) in 2009 to $1716 (95% CI, $1678-$1753) in 2011 and then decreased to $1508 (95% CI, $1469-$1548) in 2013 for patients subject to reference payment. After adjustment for other relevant factors, reference payment was responsible for a 21.0% (95% CI, -26.0% to -15.6%, P < .001) reduction in the price. Reference payment was associated with a small but statistically insignificant decline in procedural complications, from 2.1% in 2009 to 2.0% in 2013 (P = .47). In the first 2 years after implementation, CalPERS saved $7.0 million (28%) on spending for the procedure.

CONCLUSIONS AND RELEVANCE

Implementation of reference payment for colonoscopy was associated with reduced spending and no change in complications.

Consumer Choice Between Hospital-Based and Freestanding Facilities for Arthroscopy: Impact on Prices, Spending, and Surgical Complications

BACKGROUND

Hospital-based outpatient departments traditionally charge higher prices for ambulatory procedures, compared with freestanding surgery centers. Under emerging reference-based benefit designs, insurers establish a contribution limit that they will pay, requiring the patient to pay the difference between that contribution limit and the actual price charged by the facility. The purpose of this study was to evaluate the impact of reference-based benefits on consumer choices, facility prices, employer spending, and surgical outcomes for orthopaedic procedures performed at ambulatory surgery centers.

METHODS

We obtained data on 3962 patients covered by the California Public Employees' Retirement System (CalPERS) who underwent arthroscopy of the knee or shoulder in the three years prior to the implementation of reference-based benefits in January 2012 and on 2505 patients covered by CalPERS who underwent arthroscopy in the two years after implementation. Control group data were obtained on 57,791 patients who underwent arthroscopy and were not subject to reference-based benefits. The impact of reference-based benefits on consumer choices between hospital-based and freestanding facilities, facility prices, employer spending, and surgical complications was assessed with use of difference-in-differences multivariable regressions to adjust for patient demographic characteristics, comorbidities, and geographic location.

RESULTS

By the second year of the program, the shift to reference-based benefits was associated with an increase in the utilization of freestanding ambulatory surgery centers by 14.3 percentage points (95% confidence interval, 8.1 to 20.5 percentage points) for knee arthroscopy and by 9.9 percentage points (95% confidence interval, 3.2 to 16.7 percentage points) for shoulder arthroscopy and a corresponding decrease in the use of hospital-based facilities. The mean price paid by CalPERS fell by 17.6% (95% confidence interval, -24.9% to -9.6%) for knee procedures and by 17.0% (95% confidence interval, -29.3% to -2.5%) for shoulder procedures. The shift to reference-based benefits was not associated with a change in the rate of surgical complications. In the first two years after the implementation of reference-based benefits, CalPERS saved $2.3 million (13%) on these two orthopaedic procedures.

CONCLUSIONS

Reference-based benefits increase consumer sensitivity to price differences between freestanding and hospital-based surgical facilities.

CLINICAL RELEVANCE

This study shows that the implementation of reference-based benefits does not result in a significant increase in measured complication rates for those subject to reference-based benefits.

Accountable Care Organizations in California: Market Forces at Work?

Accountable care organizations (ACOs), one of the most recent and promising health care delivery innovations, encourage care coordination among providers. While ACOs hold promise for decreasing costs by reducing unnecessary procedures, improving resource use as a result of economies of scale and scope, ACOs also raise concerns about provider market power. This study examines the market-level competition factors that are associated with ACO participation and the number of ACOs. Using data from California, we find that higher levels of preexisting managed care leads to higher ACO entry and enrollment growth, while hospital concentration leads to fewer ACOs and lower enrollment. We find interesting results for physician market power - markets with concentrated physician markets have a smaller share of individuals in commercial ACOs but a larger number of commercial ACO organizations. This finding implies smaller ACOs in these markets.

Reference-based benefit design changes consumers' choices and employers' payments for ambulatory surgery

Some employers are using reference-based benefit (RBB) designs, also known as "reference-based pricing," to encourage patients to select lower-price ambulatory surgery centers instead of expensive hospital outpatient departments. This article analyzes the impact of such benefit designs for cataract removal surgery from the period 2009-13, using data on 2,347 surgical patients covered by the California Public Employees Retirement System (CalPERS), in comparison to 14,867 patients enrolled in non-CalPERS Anthem Blue Cross plans, which are not covered by RBB. After adjusting for changes in patient case-mix and other factors, the shift to RBB was associated with an increase in ambulatory surgery center use by 8.6 percentage points compared to trends among Anthem enrollees. Total employer and employee payments per procedure, after adjusting for changes in case-mix severity and market factors, declined by 19.7 percent compared with Anthem enrollees not subject to RBB. Consumer cost-sharing requirements increased for CalPERS patients who continued to use hospital outpatient departments but who were not exempted from RBB because of geographic or clinical factors. Reference-based benefits for cataract surgery saved CalPERS $1.3 million in the two years after implementation.

Association between availability of health service prices and payments for these services

IMPORTANCE

Recent governmental and private initiatives have sought to reduce health care costs by making health care prices more transparent.

OBJECTIVE

To determine whether the use of an employer-sponsored private price transparency platform was associated with lower claims payments for 3 common medical services.

DESIGN

Payments for clinical services provided were compared between patients who searched a pricing website before using the service with patients who had not researched prior to receiving this service. Multivariable generalized linear model regressions with propensity score adjustment controlled for demographic, geographic, and procedure differences. To test for selection bias, payments for individuals who used the platform to search for services (searchers) were compared with those who did not use the platform to search for services (nonsearchers) in the period before the platform was available. The exposure was the use of the price transparency platform to search for laboratory tests, advanced imaging services, or clinician office visits before receiving care for that service.

SETTING AND PARTICIPANTS

Medical claims from 2010-2013 of 502,949 patients who were insured in the United States by 18 employers who provided a price transparency platform to their employees.

MAIN OUTCOMES AND MEASURES

The primary outcome was total claims payments (the sum of employer and employee spending for each claim) for laboratory tests, advanced imaging services, and clinician office visits.

RESULTS

Following access to the platform, 5.9% of 2,988,663 laboratory test claims, 6.9% of 76,768 advanced imaging claims, and 26.8% of 2,653,227 clinician office visit claims were associated with a prior search on the price transparency platform. Before having access to the price transparency platform, searchers had higher claims payments than nonsearchers for laboratory tests (4.11%; 95% CI, 1.87%-6.41%), higher payments for advanced imaging services (5.57%; 95% CI, 1.83%-9.44%), and no difference in payments for clinician office visits (0.26%; 95% CI; 0.53%-0.005%). Following access to the price transparency platform, relative claim payments for searchers were lower for searchers than nonsearchers by 13.93% (95% CI, 10.28%-17.43%) for laboratory tests, 13.15% (95% CI, 9.49%-16.66%) for advanced imaging, and 1.02% (95% CI, 0.57%-1.47%) for clinician office visits. The absolute payment differences were $3.45 (95% CI, $1.78-$5.12) for laboratory tests, $124.74 (95% CI, $83.06-$166.42) for advanced imaging services, and $1.18 (95% CI, $0.66-$1.70) for clinician office visits.

CONCLUSIONS AND RELEVANCE

Use of price transparency information was associated with lower total claims payments for common medical services. The magnitude of the difference was largest for advanced imaging services and smallest for clinical office visits. Patient access to pricing information before obtaining clinical services may result in lower overall payments made for clinical care.

Validation of a clinical decision aid to discontinue in-hospital cardiac arrest resuscitations

CONTEXT

Most patients undergoing in-hospital cardiac resuscitation do not survive to hospital discharge. In a previous study, we developed a clinical decision aid for identifying all patients undergoing resuscitation who survived to hospital discharge.

OBJECTIVE

To validate our previously derived clinical decision aid.

DESIGN, SETTING, AND PARTICIPANTS

Data from a large registry of in-hospital resuscitations at a community teaching hospital in Georgia were analyzed to determine whether patients would be predicted to survive to hospital discharge (ie, whether their arrest was witnessed or their initial cardiac rhythm was either ventricular tachycardia or ventricular fibrillation or they regained a pulse during the first 10 minutes of chest compressions). Data from 2181 in-hospital cardiac resuscitation attempts in 1987-1996 involving 1884 pulseless patients were analyzed.

MAIN OUTCOME MEASURE

Comparison of predictions based on the decision aid with whether patients were actually discharged alive from the hospital.

RESULTS

For 327 resuscitations (15.0%), the patient survived to hospital discharge. For 324 of these resuscitations, the patients were predicted to survive to hospital discharge (sensitivity = 99.1%, 95% confidence interval, 97.1%-99.8%). In 269 resuscitations, patients did not satisfy the decision aid and were predicted to have no chance of being discharged from the hospital. Only 3 of these patients (1.1%) were discharged from the hospital (negative predictive value = 98.9%), none of whom were able to live independently following discharge from the hospital.

CONCLUSION

This decision aid can be used to help physicians identify patients who are extremely unlikely to benefit from continued resuscitative efforts.

Autonomy and satisfaction among mammographers

This article reports results of a study assessing the relationship between decision autonomy and task satisfaction in Texas mammographers. As hypothesized, the results indicate a positive correlation between autonomy and satisfaction. The authors also found that no independent variable (age, years of experience, employment status, position or type of imaging facility) had predictive value for mammographers' autonomy and task satisfaction.

Survey of interest in multicredentialed R.T.s

Kentucky radiologic technologists were surveyed regarding their interest in and need for additional education to acquire credentials in advanced imaging areas. The survey results indicated that technologists are interested in pursuing advanced programs of study that would produce multicompetent practitioners. The results also indicated that radiology managers prefer to hire multicompetent individuals.