Employer-sponsored Health Insurance Plans Research Articles

Benefit Design And Biosimilar Coverage In Medicare Part D: Evidence And Implications From Recent Reforms.

There is substantial disparity between Medicare Part D and employer-sponsored health insurance plans in the coverage of biosimilars and their reference biologics. These disparities may be due to design elements of Part D plans that encourage the adoption of more expensive biologic drugs. We undertook several analyses to illustrate the dynamics of benefit design incentives over time, compare formulary coverage in Part D plans with that of employer-sponsored plans, and study how the Bipartisan Budget Act of 2018 affected Part D formulary coverage. Using these analyses of Part D reforms enacted through the Bipartisan Budget Act, we discuss the implications of elements of the Inflation Reduction Act of 2022 that will be implemented in 2025. Biosimilar coverage increased by 23percentage points five quarters after the Bipartisan Budget Act was implemented. We predict that the Inflation Reduction Act will also have a positive effect on biosimilar coverage. Given ample evidence of a relationship between drug coverage and utilization, our results suggest that Medicare patients and the federal government could realize substantial savings if Part D formularies resembled those of employer-sponsored plans.

Out-of-pocket costs for diabetes medications in employer-sponsored health insurance plans.

Out-of-pocket costs of diabetes medications other than insulin can be quite high for individuals with employer-sponsored health insurance.

SUDs Cost Employer Health Insurance $35 Billion Per Year

SUDs Cost Employer Health Insurance $35 Billion Per Year

Assessment of Spending for Patients Initiating Dialysis Care

Despite a widespread belief that private insurers spend large amounts on health care for enrollees receiving dialysis, data limitations over the past decade have precluded a comprehensive analysis of the topic. To examine the amount and types of increases in health care spending for privately insured patients associated with initiating dialysis care. A cohort study covering calendar years 2012 to 2019 included patients with kidney failure who had employer-sponsored insurance for 12 months following dialysis initiation. Data analysis was performed from August 27, 2021, to August 18, 2022. The data cover the entirety of the US and were obtained from the Health Care Cost Institute. The data include all medical claims for enrollees in employer-sponsored health insurance plans offered by multiple major health care insurers within the US. Participants included patients younger than 65 years who were continuously enrolled in these plans in the 12 months before and after their first claim for dialysis care. Patients also had to have nonmissing documented key characteristics, such as sex, race and ethnicity, and health characteristics. A claim for dialysis care. Out-of-pocket, inpatient, outpatient, physician services, prescription medication, and total health care spending. The hypothesis tested was formulated before data collection. The sample included 309 800 enrollee-months, which was a balanced panel of 25 months for 12 392 enrollees. At baseline, 7534 patients (61%) were male, 5415 (44%) were aged 55 to 64 years, and patients had been enrolled with their insurer for a mean of 30 months (95% CI, 29.9-30.1 months). In the 12 months before initiating dialysis care, total monthly health care spending was $5025 per patient per month (95% CI, $4945-$5106). Dialysis care initiation was associated with an increase in total monthly spending of $14 685 (95% CI, $14 413-$14 957). This increase occurred across all spending categories (dialysis, nondialysis outpatient, inpatient, physician services, and prescription drugs). Monthly patient out-of-pocket spending increased by $170 (95% CI, $162-$178). These spending increases occurred abruptly, beginning about 2 months before dialysis initiation, and remained increased for the subsequent 12 months. In this cohort study, evidence that private insurers experience significant, sustained increases in spending when patients initiated dialysis was noted. The findings suggest that proposed policies aimed at limiting the amount dialysis facilities charge private insurers and the enrollees has the potential to reduce health care spending in this high-cost population.

896-P: Dapagliflozin Cost Offsets in Chronic Kidney Disease for Commercial U.S. Payers

One in 7 adults have chronic kidney disease (CKD) , which is associated with high mortality and costly healthcare resource utilization (HCRU) . Data from a US employer-sponsored health insurance plan show rising per-member-per-year costs for treatment of cardiac and renal complications associated with CKD. A cost-offset model (COM) was deployed to quantify the predicted clinical and economic benefits of treatment with dapagliflozin. The COM used real-world cost and member count data from a US employer-sponsored commercial payer and the phase 3 DAPA-CKD (NCT03036150) clinical trial event rates for outcomes, including ≥ 50% decline in estimated glomerular filtration rate (eGFR) , end-stage kidney disease (ESKD) , and hospitalization for heart failure (HHF) . HCRU cost-offsets were calculated over a 3-year time horizon in a population of 130 members with CKD stages 2-4 who were modeled for treatment with either dapagliflozin plus standard of care (SOC) or SOC alone. Over a 3-year period, 9 instances of ≥ 50% decline in eGFR were estimated for treatment with dapagliflozin versus (vs.) 15 with SOC (6 fewer events; number needed to treat [NNT]: 20) , amounting to estimated cumulative cost-offsets of $0.57 million (M) . Similarly, 6 ESKD events were avoided with dapagliflozin vs. SOC (8 vs. 14; NNT: 24) , resulting in $1.92 M in cumulative cost-offsets. Dapagliflozin use also avoided 20 HHF events compared with SOC (13 vs. 33; NNT: 7) , totaling $0.79 M in cumulative cost-offsets. Overall, better clinical outcomes translated into total cumulative HCRU cost-offsets of $3.89 M (36.6% reduction in favor of dapagliflozin + SOC vs. treatment with SOC alone) . Results of our COM estimate that dapagliflozin greatly decreases HCRU costs in plan members with CKD by reducing cardiac and renal clinical events over a 3-year period. Modeling these outcomes for members with CKD with and without type 2 diabetes demonstrates that dapagliflozin can be a cost-effective way to reduce HCRU costs associated with CKD for commercial payers. Disclosure R.Chang: Employee; AstraZeneca, UnitedHealth Group. J.Huang: Employee; AstraZeneca. D.Reck: None. J.Hurst: Employee; AstraZeneca. K.Wolf khachatourian: Consultant; Bayer AG, Xcenda. M.H.Shannon: Consultant; Bayer AG, Speaker's Bureau; Bayer AG, Novo Nordisk A/S. Funding AstraZeneca

“How Could I Choose My Health Insurance Plan” Determinants of Employer-Sponsored Health Insurance Plan Selection: Application of Machine Learning Technique

“How Could I Choose My Health Insurance Plan” Determinants of Employer-Sponsored Health Insurance Plan Selection: Application of Machine Learning Technique

'How could I choose my health insurance plan' Determinants of employer-sponsored health insurance plan selection: application of machine learning technique

'How could I choose my health insurance plan' Determinants of employer-sponsored health insurance plan selection: application of machine learning technique

PIH20 The Impact of an Employer Benefit Exclusion for Erectile Dysfunction Treatments: US Employer Perspective

Erectile dysfunction (ED) negatively impacts the quality of life and work productivity. Providing male employees access to effective ED treatments could improve patient outcomes, yet several employer-sponsored health insurance (ESHI) plans exclude the treatments – especially penile prosthesis (PP). This analysis estimates the number of men suffering from ED who are covered by ESHI plans which exclude PP and estimates the financial impact of work productivity loss due to ED on employers.

An Analysis of a Commercial Database on the Use of Erectile Dysfunction Treatments for Men With Employer-Sponsored Health Insurance

ObjectiveTo investigate the annual erectile dysfunction (ED) prevalence among men enrolled in an employer-sponsored health insurance (ESHI) plan and evaluate ED treatment profiles among those with an ED diagnosis. MethodsA cross-sectional claims analysis was conducted using the IBM MarketScan Commercial Database, a nationally representative sample of US workers enrolled in ESHI plans. Patients aged 18-64 with at least one ED medical diagnosis claim and continuous enrollment in a given year between 2009 and 2017 were included. Among those with an ED diagnosis, utilization rates of the following ED treatments were determined: phosphodiesterase type 5 inhibitors (PDE5I), penile prosthesis implantation, other ED treatments (eg, vacuum pump, intraurethral suppositories), combination treatment, and no insurer-paid treatments. ResultsBetween 2009 and 2017, the annual prevalence of men with ESHI suffering from ED increased by 116%. However, in 2017, only 23% of men with an ED diagnosis received an ED therapy paid for by their ESHI plans. The proportion of men taking PDE5Is ranged from 18% in 2012 to 26% in 2015. The proportion of men with ED undergoing penile prosthesis implantation has declined in recent years (0.23% in 2009 to 0.11% in 2017). Similarly, the rate of men who received other ED treatments or combination treatment has decreased from 2009 to 2017 (0.94%-0.30% and 0.65%-0.19%, respectively). ConclusionED prevalence among men insured by an ESHI plan has notably increased, yet approximately three-quarters of these men had no claims for ED treatments, indicating substantial access gaps to treatment.

Ten Modifiable Health Risk Factors and Employees' Medical Costs-An Update.

To estimate the relationship between employees' health risks and health-care costs to inform health promotion program design. An observational study of person-level health-care claims and health risk assessment (HRA) data that used regression models to estimate the relationship between 10 modifiable risk factors and subsequent year 1 health-care costs. United States. The sample included active, full-time, adult employees continuously enrolled in employer-sponsored health insurance plans contributing to IBM MarketScan Research Databases who completed an HRA. Study criteria were met by 135 219 employees from 11 employers. Ten modifiable risk factors and individual sociodemographic and health characteristics were included in the models as independent variables. Five settings of health-care costs were outcomes in addition to total expenditures. After building the analytic file, we estimated generalized linear models and conducted postestimation bootstrapping. Health-care costs were significantly higher for employees at higher risk for blood glucose, obesity, stress, depression, and physical inactivity (all at P < .0001) than for those at lower risk. Similar cost differentials were found when specific health-care services were examined. Employers may achieve cost savings in the short run by implementing comprehensive health promotion programs that focus on decreasing multiple health risks.

Employee Choice and the Demand for Health Insurance Coverage: Evidence from Random Coefficients Models

Abstract This study examines the effects of deductibles, employee premium contributions, and the availability of tax-sheltered health savings accounts on employee selection into health insurance plans after passage of the Affordable Care Act, and particularly after implementation of the individual mandate. In doing so, a utility-based structural demand model is applied to market-level macro data from the Kaiser Family Foundation and the Health Research Educational Trust. Results from random coefficients models indicate that for an average consumer, price sensitivity for employer-sponsored health insurance plans varies by age, wage, health condition and gender. Employees who are older, obese, or female are less sensitive to deductibles and premiums than younger and healthier employees, or male employees. These findings suggest that high deductible health plans that combine a tax-sheltered account with higher deductibles will negatively impact the utility of older employees and females as compared to younger employees and males.

Ex-ante moral hazard: empirical evidence for private health insurance in Brazil

Abstract This paper explores the existence of ex-ante moral hazard in private health insurance in Brazil. Before the advent of illness, insured individuals have no incentives to seek preventive care if it is not previously contractible. The data set comprises longitudinal administrative records of health care utilization from a Brazilian employer-sponsored health insurance plan. The empirical strategy is based on an exogenous and anticipated shock in health insurance coverage not associated with health conditions. The results show an increase of up to 17% on medical visits and 22% on diagnostic tests due to the loss of health insurance. Medical visits start to increase five months before the individual leaves the health insurance pool, reaching its peak at two months prior to exit. For diagnostic tests, the increase was observed only in the last two months before the loss of health insurance coverage.

Political Economy of Reform under US Federalism: Adopting Single-Payer Health Coverage in New York State

The US remains the only high-income country that lacks a universal health financing system and instead relies on a fragmented system with the largest segment of the population receiving health insurance through private, voluntary employer-sponsored health insurance plans. While not “universal” in the sense of being mandatory and tax-financed, through a series of reforms, the US has managed to provide some form of health insurance coverage to 90% of the population. Yet, the high cost of this system, the insufficient coverage afforded to many, and continued concerns about equity have led to calls for a national health insurance program that can reduce costs across the board while providing high-quality coverage for all. Given the policy gridlock at the national level, the states have often sought to achieve universal health financing on their own, but these bills have met with little success so far. Why has the ideal of states as “laboratories of democracy” failed to produce policy change towards national health insurance? This article examines the prospects for the New York Health Act, a single-payer bill that would create a universal health financing plan for all New York State residents. Applying the Political Economy of Health Financing Framework, we analyze the politics of health reform in New York State and identify strategies to overcome opposition to this policy proposal. We find that while a clear political opportunity is in place, the prospects for adoption remain low given the power of symbolic politics and institutional inertia on the reform process.

Abstract 178: Predicting Employee Health and Cost: Application of Machine Learning on Employee Health Claims Data, Insights, and Possibilities

Background: Self-insured employers, which are majority in US, face an increasing financial burden as health care costs have increased relative to savings. By applying machine learning (ML) techniques, we may decrease unnecessary hospitalizations by identifying low risk patients, who are on the path to become high risk, and eventually high cost. In this complex simulation, we applied and compared several ML techniques on data gathered from medical insurance claims. Methods: The analysis was limited to employees and their spouses only. We identified about 8000 employees and spouses who were covered by employer sponsored health insurance plan between 2011 and 2016. De-identified data were used to predict high cost claimants. High cost was defined as annual spending of over $10,000 in medical claims. We utilized and compared methods namely: bootstrapped random forest, gradient boosted tree, neural networks, Naïve Bayes classifier, and logistic regression with LASSO. Variables in the model included yearly inpatient and ER visits, CCS categories, CPT codes, and demographic information. Results: The mean (SD) age of eligible population was 49.7 (11.0) years. Approximately, the employee to spouse ratio each year was 3.5:1. Results show that bootstrapped random forest performed better than other techniques (AUROC: 80.33%). All other algorithms also performed extremely well. Future progress of these models will be oriented towards including employee health fair data and also strategies to avoid over fitting. Conclusion: Healthcare is way behind other industries in successfully using ML to improve processes and disrupt one industry that is admittedly in need of positive disruption. Models allowing successful preventive actions will both increase revenue and lower costs. Application of modern ML techniques can identify high cost claimants earlier. Our approach is one of the first applications of significant recent advances in ML algorithms and computer technologies, opening new opportunities for the future analysis of high healthcare costs.

Out of Pocket Costs and Health Insurance Take-Up Rates.

Over the first ten years of this century, the share of the US population covered by employer-sponsored health insurance plans experienced a significant decline. A decrease in the take-up rate accounts for about a quarter of this decline. Usually, the increasing share of the premium that is paid by workers is used to explain the decline in the take-up rate. However, in recent years the increase in copayments, deductible and coinsurance rate has far outpaced the increase in worker contribution. In this study we analyze the impact of out-of-pocket (OOP) costs, which consist of both workers' contribution toward the premium and expected expenditures, on the take-up rate for firms that offer multiple plan types. Using data from the Employer Health Benefits Survey we estimated a pooled ordinary least squares and a fixed effects model. Since we have information about different types of health insurance plans offered by the firm, we derive the cross-price elasticity of coverage. Our fixed effects estimations suggest that workers respond to an increase in the out-of-pocket contributions for Health Maintenance Organization (HMO) plans by switching to PPO plans without impacting the overall take-up rate, while workers respond to increases in the out-of-pocket contribution for Preferred Provider Organization (PPO) plans by switching to HMO plans or dropping out of the group coverage. In general, we found that the estimated elasticities are too small to explain the overall drop in take-up rates even in light of the large increases in required worker contributions and expected expenditures. Still, we highlight the growing importance of expected expenditures in explaining take-up rates.

A Kinked Health Insurance Market: Employer-Sponsored Insurance under the Cadillac Tax

The Affordable Care Act imposes a 40 percent excise tax on high-cost “Cadillac” health insurance plans in excess of defined thresholds beginning in 2020. Using economic theory and a microsimulation model, we predict how employers will respond to the Cadillac tax by adjusting wages and health insurance benefits. In its first year, 13.34 percent of individual and 16.73 percent of family employer-sponsored health insurance plan holders will be affected by the Cadillac tax; these percentages will increase to 35.33 and 42.01 percent, respectively, by 2025. Over 99 percent of those affected will reduce their health insurance benefits to the thresholds. Effectively, the Cadillac tax will impose a hard cap on health insurance benefits, causing a clustering of benefits at the thresholds and a sharp reduction in the variance of benefits. Revenue from the Cadillac tax through 2025 will total $204 billion, all but $42 million of which will stem from “indirect” revenues—health insurance benefits shifted into taxable wages. This shift will increase wage growth and decrease benefit growth for those affected by the Cadillac tax. We simulate a cap on the tax exclusion of employer-sponsored insurance premiums and conduct sensitivity analyses with linear regression metamodeling.

Financing of employer sponsored health insurance plans before and after health reform: What consumers don’t know won’t hurt them?

This paper studies the potential impact on consumers of regulatory arbitrage based on financing of employment-based health insurance plans in the United States. Consumers enrolled in self-insured health plans, for which employers are financially responsible for medical claims, make up a majority of Americans with employer-sponsored health coverage. Unlike their fully insured counterparts, self-insured plans are not subject to state health insurance regulation. They are also exempt from certain provisions in the Patient Protection and Affordable Care Act (ACA). Employers who offer health plans can thus avoid certain insurance regulations and consumer protections by electing to self-insure. This research explores the impact of self-insurance on consumer welfare and how that is expected to change under the ACA. We describe the major consumer concerns regarding self-insurance – firm financial solvency, benefit generosity and stability, claims adjudication and recourse options – and present qualitative and quantitative evidence on their importance. We find a substantial degree of similarity between self-insured and fully insured plans with regard to benefit generosity and stability, at least with respect to available measures. In addition, we find no evidence that enrollees in self-insured plans face higher denial rates. While the ACA will not directly affect claims adjudication, it will improve recourse options for consumers with all plans and narrow the regulatory differences that existed between financing types. Policymakers must work to ensure the transparency of recourse options for enrollees in self and fully insured plans. In terms of financial solvency, while stop loss coverage is more common among smaller versus larger self-insured firms and such coverage typically commences at lower attachment points for smaller firms, roughly one-fourth of self-insured firms with fewer than 200 employees do not have such coverage. The ability of small firms without stop loss coverage to manage the risks associated with health care claims is uncertain, as are the consequences of health care expenditure-related risk for the overall financial solvency of the firm. Further, the financial security of firms who purchase stop loss coverage, and – by extension, the solvency of health plan benefits provided to employees – depends critically on the reliability of the stop loss insurer. State insurance commissioners may want to carefully consider the adequacy and appropriateness of their regulatory oversight of stop loss insurers in light of the potential move among smaller employers into the self-insured and stop loss marketplace.

Delayed and Denied: Toward an Effective ERISA Remedy for Improper Processing of Healthcare Claims

The healthcare reform effort culminating in the Patient Protection and Affordable Care Act (PPACA) has focused, to date, on the plight of the uninsured and on barriers to insurance such as pre-existing condition exclusions. Reform efforts focus less often, however, on threats to healthcare benefits for people who do have health insurance. When insured individuals suffer a serious illness, does their insurance live up to its promise? One overlooked threat to the insured concerns administration of employer-sponsored health insurance plans. Specifically, participants' benefits are threatened by the lack of consequences when administrators of such plans improperly process claims for healthcare benefits by delaying the decision, failing to conduct a complete review, or simply denying the claim incorrectly.

Antimigraine medication use and associated health care costs in employed patients

Migraine is under diagnosed and suboptimally treated in the majority of patients, and also associated with decreased productivity in employees. The objective of this retrospective study is to assess the antimigraine medication use and associated resource utilization in employed patients. Patients with primary diagnosis of migraine or receiving antimigraine prescription drugs were identified from an employer-sponsored health insurance plan in 2010. Medical utilization and health care costs were determined for the year of 2010. Generalized linear regression was applied to evaluate the association between health care costs and the use of antimigraine medications by controlling covariates. Of 465 patients meeting the study criteria, nearly 30% that had migraine diagnosis were prescribed antimigraine medications, and 20% that had migraine diagnosis were not prescribed antimigraine medications. The remaining 50% were prescribed antimigraine medications but did not have migraine diagnosis. Patients with antimigraine medication prescriptions showed lower frequency of emergency department visits than those without antimigraine medication prescriptions. Regression models indicated an increase in migraine-related health care costs by 86% but decreases in all-cause medical costs and total health care costs by 42 and 26%, respectively, in the antimigraine medication use group after adjusting for covariates. Employed patients experienced inadequate pharmacotherapy for migraine treatment. After controlling for covariates, antimigraine prescription drug use was associated with lower total medical utilization and health care costs. Further studies should investigate patient self-reported care and needs to manage headache and develop effective intervention to improve patient quality of life and productivity.

Healthcare Reforms in the US: A Multi-Billion Opportunity for Indian Firms

The US health care industry is a complex entity with significant contrasts. Despite its leadership position in health care spending and medical research, over 45 million of the US population continue to be uninsured and cannot afford even basic medical care. To understand this paradox, one needs to take a look at the history of health care in the US. As early as in the 1920's, US hospitals evolved into modern scientific institutions and along with this development came the beginning of health insurance, as a prepaid hospital plan, for covering sickness. This model was quickly embraced by the large workforce based organizations such as the auto and the railroad companies and employer sponsored health insurance plans became the de facto health benefit operating model in the US. During the 1960's, as medical research began to cover a range of illnesses, cost of medical care increased, thereby making health insurance also unaffordable to the public. To address this, the US government created the Medicare and Medicaid social programs in 1965. Medicare extended health coverage to almost all Americans aged 65 or older and Medicaid provided access to health care services for low income and poor persons and people with disabilities.