Patient Cost-sharing Research Articles

Implications of the initial braidwood v. Becerra ruling for colorectal cancer outcomes: a modeling study.

The Affordable Care Act (ACA) eliminated patient cost-sharing for USPSTF recommended services. However, if the US Court of Appeals for the Fifth Circuit fully upheld a US District Court ruling in Braidwood Management v. Becerra, 666 F. Supp. 3d 613 (N.D. Tex 2023), cost-sharing for USPSTF recommendations made after ACA passage would have been reinstated for over 150 million people. The case could still reinstate cost-sharing for colorectal cancer (CRC) screening for ages 45-49 years and for polyp removal during (diagnostic) colonoscopy across all ages. Using the MISCAN-Colon model, we simulated the potential impact on CRC outcomes, assuming early-onset CRC trends, and lower screening participation. An 8-percentage-points decline in screening participation could increase CRC incidence by 5.1%, and CRC mortality by 9.1%, with slightly lower costs due to increased cost-sharing. Larger decreases in screening participation can result in higher costs from increased incidence and delayed diagnoses.

Algorithm-based Management of Infantile Hemangiomas: Reducing Sequelae and Surgical Interventions

Background: In Japan, oral propranolol (PPL) and pulsed dye laser are available for infantile hemangioma (IH) treatment without patient cost-sharing. However, no standardized algorithm exists to guide treatment selection that balances efficacy, potential side effects, and aesthetic risks. This study presents a comprehensive approach utilizing a treatment algorithm and aesthetic risk scoring system. Methods: This retrospective study analyzed outcomes from 156 patients with IHs. Oral PPL was used in IH patients with functional issues, whereas the rest underwent an aesthetic risk assessment that categorized them into low-, moderate-, or high-risk groups to guide treatment choices. Final treatment decisions depended on parental preference. The outcomes of algorithm-compliant and noncompliant patients were compared statistically. Results: The risk score's interrater reliability was 0.973 (95% confidence interval 0.933–0.992), with a mean intrarater reliability of 0.968 ± 0.027 and a mean evaluation time of 14.1 ± 5.0 seconds per case. Among the 156 patients, 88% pursued the algorithm-recommended treatment, whereas 12% opted for different approaches. Algorithm-compliant patients experienced significantly fewer sequelae than did noncompliant patients (5% versus 33%, P < 0.001). Compared with noncompliant patients, algorithm-compliant patients tended to require shorter treatment durations (17.9 versus 25.4 mo, P = 0.08) and fewer laser sessions (5.8 versus 7.2, P = 0.30), with a younger age at resolution (21.3 versus 29.0 mo, P = 0.08). Conclusions: Aesthetic concerns can be crucial for patients with IHs. This study introduces a comprehensive IH management algorithm to reduce the sequelae requiring surgical interventions and improve patients’ quality of life.

The Association Between Type of Insurance Plan, Out-of-Pocket Cost, and Adherence to Antihypertensive Medications in Medicare Supplement Insurance Enrollees.

Medicare supplement insurance, or Medigap, covers 21% of Medicare beneficiaries. Despite offsetting some out-of-pocket (OOP) expenses, remaining OOP costs may pose a barrier to medication adherence. This study aims to evaluate how OOP costs and insurance plan types influence medication adherence among beneficiaries covered by Medicare supplement plans. We conducted a retrospective analysis of the Merative MarketScan Medicare Supplement Database (2017-2019) in Medigap enrollees (≥65 years) with hypertension. The proportion of days covered (PDC) was a continuous measure of medication adherence and was also dichotomized (PDC ≥0.8) to quantify adequate adherence. Beta-binomial and logistic regression models were used to estimate associations between these outcomes and insurance plan type and log-transformed OOP costs, adjusting for patient characteristics. Among 27,407 patients with hypertension, the average PDC was 0.68 ± 0.31; 47.5% achieved adequate adherence. A mean $1 higher in 30-day OOP costs were associated with a 0.06 (95% confidence intervals [CIs]: -0.09 to -0.03) lower probability of adequate adherence, or a 5% (95% CI: 4%-7%) decrease in PDC. Compared with comprehensive plan enrollees, the odds of adequate adherence were lower among those with point-of-service plans (odds ratio [OR]: 0.69, 95% CI: 0.62-0.77), but higher among those with preferred provider organization (PPO) plans (OR: 1.08, 95% CI: 1.01-1.15). Moreover, the association between OOP costs and PDC was significantly greater for PPO enrollees. While Medicare supplement insurance alleviates some OOP costs, different insurance plans and remaining OOP costs influence medication adherence. Reducing patient cost-sharing may improve medication adherence.

Do hospitalizations push households into poverty in India: evidence from national data.

High percentage of OOP (Out-of-Pocket) costs can lead to poverty and exacerbate existing poverty, with 21.9% of India's 1.324 billion people living below the poverty line. Factors such as increased patient cost-sharing, high-deductible health plans, and expensive medications contribute to high OOP costs. Understanding the poverty-inducing impact of healthcare payments is essential for formulating effective measures to alleviate it. The study used data from the 75th round of the National Sample Survey Organization (Household Social Consumption in India: Health) from July 2017-June 2018, focusing on demographic-socio-economic characteristics, morbidity status, healthcare utilization, and expenditure. The analysis included 66,237 hospitalized individuals in the last 365 days. Logistic regression model was used to examine the impact of OOP expenditures on impoverishment. Logistic regression analysis shows that there is 0.2868 lower odds of experiencing poverty due to OOP expenditures in households where there is the presence of at least one child aged 5 years and less present in the household compared to households who do not have any children. There is 0.601 higher odds of experiencing poverty due to OOP expenditures in urban areas compared to households in rural areas. With an increasing duration of stay in the hospital, there is a higher odds of experiencing poverty due to OOP health expenditures. There is 1.9013 higher odds of experiencing poverty due to OOP expenditures if at least one member in the household used private healthcare facility compared to households who never used private healthcare facilities. In order to transfer demand from private to public hospitals and reduce OOPHE, policymakers should restructure the current inefficient public hospitals. More crucially, there needs to be significant investment in rural areas, where more than 70% of the poorest people reside and who are more vulnerable to OOP expenditures because they lack coping skills.

Patient Cost-Sharing and Redistribution in Health Insurance

Patient Cost-Sharing and Redistribution in Health Insurance

Beyond the AJR: Patient Cost-Sharing Adversely Affects Adherence to Downstream Imaging After Mammography Screening.

Beyond the AJR: Patient Cost-Sharing Adversely Affects Adherence to Downstream Imaging After Mammography ScreeningLiane E. Philpotts, MD1Audio Available | Share

The Effects of Patient Cost-Sharing on Adolescents' Healthcare Utilization and Financial Risk Protection: Evidence from South Korea

The Effects of Patient Cost-Sharing on Adolescents' Healthcare Utilization and Financial Risk Protection: Evidence from South Korea

Long-term economic outcomes of ureteral injury in the United States

Objectives Ureteral injuries (UIs) during surgical procedures can have serious consequences for patients. Although UIs can result in substantial clinical burden, few studies report the impact of these injuries on payer reimbursement and patient cost-sharing. This retrospective study evaluated 30-day, 90-day, and 1-year healthcare resource utilization for patients with UIs and estimated patient and payer costs. Methods Patients aged ≥ 12 years who underwent abdominopelvic surgery from January 2016 to December 2018 were identified in a United States claims database. Patients were followed for 1 year to estimate all-cause healthcare visits and costs for patients and payers. Surgeries resulting in UIs within 30 days from the surgery date were matched to surgeries without UIs to estimate UI-attributable visits and costs. Results Five hundred and twenty-two patients with UIs were included. Almost a third (29.9%) of patients with UIs had outpatient surgery. Patients with UIs had slightly more healthcare visits and a 15.3% higher 30-day hospital readmission rate than patients without UIs. Patient costs due to UIs were not statistically significant, but annual payer costs attributable to UIs were $38,859 (95% CI = 28,142–49,576), largely driven by inpatient costs. Conclusions UIs add substantial cost for payers and result in more healthcare visits for patients. These findings highlight the importance of including inpatient and outpatient settings for UI prevention. Although UIs are rare, the associated patient and payer burdens are high; thus, protocols or techniques are needed to recognize and avert UIs as current guideline recommendations are lacking.

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 34percent increase. This was driven by increasing deductibles, which rose by 163percent. Across twenty clinical conditions whose hospitalizations commonly occurred in both ICU and non-ICU settings, ICU admission was associated with $155 higher cost sharing (13.0percent 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.

Individuals Eligible for Lung Cancer Screening Less Likely to Receive Screening When Enrolled in Health Plans With Deductibles.

In 2015, the Centers for Medicare & Medicaid Services and commercial insurance plans began covering lung cancer screening (LCS) without patient cost-sharing for all plans. We explore the impact of enrolling into a deductible plan on the utilization of LCS services despite having no out-of-pocket cost requirement. This retrospective study analyzed data from the Population-based Research to Optimize the Screening Process Lung Consortium. Our cohort included non-Medicare LCS-eligible individuals enrolled in managed care organizations between February 5, 2015, and February 28, 2019. We estimate a series of sequential logistic regression models examining utilization across the sequence of events required for baseline LCS. We report the marginal effects of enrollment into deductible plans compared with enrollment in no-deductible plans. The total effect of deductible plan enrollment was a 1.8 percentage-point (PP) decrease in baseline LCS. Sequential logistic regression results that explore each transition separately indicate deductible plan enrollment was associated with a 4.3 PP decrease in receipt of clinician visit, a 1.7 PP decrease in receipt of LCS order, and a 7.0 PP decrease in receipt of baseline LCS. Reductions persisted across all observable races and ethnicities. These findings suggest individuals enrolled in deductible plans are more likely to forgo preventive LCS services despite requiring no out-of-pocket costs. This result may indicate that increased cost-sharing is associated with suboptimal choices to forgo recommended LCS. Alternatively, this effect may indicate individuals enrolling into deductible plans prefer less health care utilization. Patient outreach interventions at the health plan level may improve LCS.

Comparison of Lung Cancer Screening Eligibility and Use between Commercial, Medicare, and Medicare Advantage Enrollees

ObjectiveLung cancer screening does not require patient cost-sharing for insured people in the U.S. Little is known about whether other factors associated with patient selection into different insurance plans affect screening rates. We examined screening rates for enrollees in commercial, Medicare Fee-for-Service (FFS), and Medicare Advantage plans. MethodSCounty-level smoking rates from the 2017 County Health Rankings were used to estimate the number of enrollees eligible for lung cancer screening in two large retrospective claims databases covering: a 5% national sample of Medicare FFS enrollees; and 100% sample of enrollees associated with large commercial and Medicare Advantage carriers. Screening rates were estimated using observed claims, stratified by payer, before aggregation into national estimates by payer and demographics. Chi-square tests were used to examine differences in screening rates between payers. ResultsThere were 1,077,142 enrollees estimated to be eligible for screening. The overall estimated screening rate for enrollees by payer was 1.75% for commercial plans, 3.37% for Medicare FFS, and 4.56% for Medicare Advantage plans. Screening rates were estimated to be lowest among females (1.55%-4.02%), those aged 75-77 years (0.63%-2.87%), those residing in rural areas (1.88%-3.56%), and those in the West (1.16%-3.65%). Among Medicare FFS enrollees, screening rates by race/ethnicity were non-Hispanic White (3.71%), non-Hispanic Black (2.17%) and Other (1.68%). ConclusionsConsiderable variation exists in lung cancer screening between different payers and across patient characteristics. Efforts targeting historically vulnerable populations could present opportunities to increase screening.

Patient Cost-Sharing and Utilization of Breast Cancer Diagnostic Imaging by Patients Undergoing Subsequent Testing After a Screening Mammogram

Out-of-pocket costs (OOPCs) have been largely eliminated for screening mammography. However, patients still face OOPCs when undergoing subsequent diagnostic tests after the initial screening, which represents a potential barrier to those who require follow-up testing after initial testing. To examine the association between the degree of patient cost-sharing and the use of diagnostic breast cancer imaging after undergoing a screening mammogram. This retrospective cohort study used medical claims from Optum's deidentified Clinformatics Data Mart Database, a commercial claims database derived from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The large commercially insured cohort included female patients aged 40 years or older with no prior history of breast cancer undergoing a screening mammogram examination. Data were collected from January 1, 2015, to December 31, 2017, and analysis was conducted from January 2021 to September 2022. A k-means clustering machine learning algorithm was used to classify patient insurance plans by dominant cost-sharing mechanism. Plan types were then ranked by OOPCs. A multivariable 2-part hurdle regression model was used to examine the association between patient OOPCs and the number and type of diagnostic breast services undergone by patients observed to undergo subsequent testing. In our sample, 230 845 women (220 023 [95.3%] aged 40 to 64 years; 16 810 [7.3%] Black, 16 398 [7.1%] Hispanic, and 164 702 [71.3%] White) underwent a screening mammogram in 2016. These patients were covered by 22 828 distinct insurance plans associated with 6 025 741 enrollees and 44 911 473 distinct medical claims. Plans dominated by coinsurance were found to have the lowest mean (SD) OOPCs ($945 [$1456]), followed by balanced plans ($1017 [$1386]), plans dominated by copays ($1020 [$1408]), and plans dominated by deductibles ($1186 [$1522]). Women underwent significantly fewer subsequent breast imaging procedures in dominantly copay (24 [95% CI, 11-37] procedures per 1000 women) and dominantly deductible (16 [95% CI, 5-28] procedures per 1000 women) plans compared with coinsurance plans. Patients from all plan types underwent fewer breast magnetic resonance imaging (MRI) scans than patients in the lowest OOPC plan (balanced, 5 [95% CI, 2-12] MRIs per 1000 women; copay, 6 [95% CI, 3-6] MRI per 100 women; deductible, 6 [95% CI, 3-9] MRIs per 1000 women. Despite policies designed to remove financial barriers to access for breast cancer screening, significant financial barriers remain for women at risk of breast cancer.

Research on the influence of patient cost-sharing on medical expenses and health outcomes: Taking patients with heart failure as an example.

The objective of this study is to assess the impact of the changes in patient cost-sharing on the medical expenses and health outcomes of patients with heart failure in China. The claim data of patients diagnosed with heart failure enrolled in the Urban Employees' Basic Medical Insurance (UEBMI) in the Zhejiang province, China, was used, covering the period from 1 January 2013 to 31 December 2017. The impact of the policy change was estimated through the use of the difference-in-differences method and the event study method. A total of 6,766 patients and their electronic health insurance claim data were included in the baseline year of 2013. Following the change in the UEBMI reimbursement policies (policy change), a notable decrease was observed in the patient cost-sharing ratios, particularly in the copayment ratio within the policy. However, it did not result in a reduction of the out-of-pocket ratio, which remains a primary concern among patients. An increase was observed in annual outpatient medical expenses, while annual inpatient medical expenses decreased, leading to higher annual medical expenses in the treatment group in comparison to the control group. The effect of the UEBMI reimbursement policy change on health outcomes showed a reduction in the rehospitalization rate within 90 days; however, no significant impact was seen on the rehospitalization rate within 30 days. The impact of the policy change on medical expenses and health outcomes was found to be modest. To effectively address the financial burden on patients, it is crucial for policymakers to adopt a comprehensive approach that considers all aspects of medical insurance policies, including reimbursement policies.

Patient Factors Associated With Use of Adult Primary Care and Virtual Visits During the COVID-19 Pandemic.

The delivery of adult primary care (APC) shifted from predominately in-person to modes of virtual care during the COVID-19 pandemic. It is unclear how these shifts impacted the likelihood of APC use during the pandemic, or how patient characteristics may be associated with the use of virtual care. A retrospective cohort study using person-month level datasets from 3 geographically disparate integrated health care systems was conducted for the observation period of January 1, 2020, through June 30, 2021. We estimated a 2-stage model, first adjusting for patient-level sociodemographic, clinical, and cost-sharing factors, using generalized estimating equations with a logit distribution, along with a second-stage multinomial generalized estimating equations model that included an inverse propensity score treatment weight to adjust for the likelihood of APC use. Factors associated with APC use and virtual care use were separately assessed for the 3 sites. Included in the first-stage models were datasets with total person-months of 7,055,549, 11,014,430, and 4,176,934, respectively. Older age, female sex, greater comorbidity, and Black race and Hispanic ethnicity were associated with higher likelihood of any APC use in any month; measures of greater patient cost-sharing were associated with a lower likelihood. Conditional on APC use, older age, and adults identifying as Black, Asian, or Hispanic were less likely to use virtual care. As the transition in health care continues to evolve, our findings suggest that to ensure vulnerable patient groups receive high quality health care, outreach interventions to reduce barriers to virtual care use may be warranted.

"It was kind of a nightmare, it really was:" financial toxicity among rural women cancer survivors.

The purpose of this study was to examine how rural women cancer survivors experience and manage financial toxicity. A qualitative descriptive design was used to explore experiences of financial toxicity among rural women who received cancer treatment. We conducted qualitative interviews with 36 socioeconomically diverse rural women cancer survivors. Participants were categorized into three groups: (1) survivors who struggled to afford basic living expenses but did not take on medical debt; (2) survivors who took on medical debt but were able to meet their basic needs; and (3) survivors who reported no financial toxicity. The groups differed by financial and job security and insurance type. We describe each group and, for the first two groups, the strategies they used to manage financial toxicity. Financial toxicity related to cancer treatment is experienced differently by rural women cancer survivors depending on financial and job security and insurance type. Financial assistance and navigation programs should be tailored to support rural patients experiencing different forms of financial toxicity. Rural cancer survivors with financial security and private insurance may benefit from policies aimed at limiting patient cost-sharing and financial navigation to help patients understand and maximize their insurance benefits. Rural cancer survivors who are financially and/or job insecure and have public insurance may benefit from financial navigation services tailored to rural patients that can assist with living expenses and social needs.

Economic Burden of Hematopoietic Cell Transplantation (HCT) Among Commercially Insured Patients with Hematological Malignancies in the United States (US)

INTRODUCTION: HCT is a potentially curative treatment option for high-risk hematologic malignancies. Approximately 20,000 HCTs are performed in the US annually. A wide range of costs for both autologous HCT (auto-HCT) and allogeneic HCT (allo-HCT) are reported. For commercially insured patients with hematologic malignancies, the economic burden of an auto-HCT was estimated at $390,159 and allo-HCT at $745,341 in 2011-2014 over a 6-month pre- and 12-month post-HCT period (Bonafede 2017), indirect and caregiver costs may further increase burden (Applebaum 2017; Denzen 2017). We characterize all-cause healthcare resource utilization (HRU) and costs among commercially insured patients with hematologic malignancies who received an auto- or allo-HCT in a more contemporary era. METHODS: Adults with hematologic malignancies and ≥1 inpatient admission for an auto- or allo-HCT (Jan 2015-Mar 2020) were identified from the MarketScan Commercial and Medicare Supplemental Databases. Patients were indexed on the date of first HCT inpatient admission. Included patients had 12 months of continuous enrollment before and after the index date and ≥2 medical claims with a diagnosis code for an eligible hematologic malignancy (acute myeloid leukemia, myelodysplastic syndrome, myelofibrosis, myeloproliferative disease, acute lymphoblastic leukemia, chronic myeloid leukemia, multiple myeloma, Hodgkin disease, or lymphoma) with ≥1 claim occurring on or before the index date. Patients with an HCT prior to the index date were excluded. Controls were selected from patients meeting study criteria with the exception of an HCT claim requirement. The index date for patients in the control group was randomly assigned based on the time between diagnosis and HCT for the HCT cohorts. Controls and HCT recipients were matched 3:1 based on age, sex, insurance type, Deyo-Charlson Comorbidity Index categories, and hematologic malignancy. Total all-cause HRU and inpatient, outpatient (ie, ED [emergency department], physician office, other visits), and pharmacy costs were compared between the HCT cohorts and controls over the 6-month pre- and 12-month post-index periods. Healthcare costs (2021 US$) were based on paid amounts of adjudicated claims, including insurer/health plan payments and patient cost-sharing (copayment, deductible, and coinsurance). RESULTS: A total of 1653 auto-HCT recipients were matched to 4959 controls and 411 allo-HCT recipients matched to 1233 controls. After matching, HCT cohorts and controls were similar in age, sex, insurance type (Table 1), Deyo-Charlson Comorbidity Index categories, and hematologic malignancy. Pre-index comorbidities differed among the HCT and control cohorts, with psychiatric disturbances, infections, and heart valve disease significantly more common in both the auto- and allo-HCT recipients vs matched controls (P<0.001 for all). Multiple myeloma was the most common eligible indication for auto-HCT whereas acute myeloid leukemia/myelodysplastic syndrome/myelofibrosis/myeloproliferative disease were the most common indications for allo-HCT. Over the 18-month observation period, total all-cause costs were significantly higher for auto-HCT recipients vs matched controls ($540,194 vs $182,846; P<0.001; Figure 1), with auto-HCT recipients having significantly higher costs than controls for all categories evaluated except ED visits during the post-index period ($817 vs $879; P<0.4). Auto-HCT costs were driven by inpatient and outpatient costs. For allo-HCT recipients vs matched controls, total all-cause costs were significantly higher ($929,799 vs $190,776; P<0.001) during the 18-month observation period, with allo-HCT recipients having significantly higher costs than controls for all categories evaluated except ED visits during the pre- and post-index periods ($568 vs $533; P=0.11, $824 vs $862; P>0.9). Inpatient costs were the primary cost driver for allo-HCT recipients. CONCLUSIONS: The use of HCT, a potentially curative treatment for some patients with hematologic malignancies, is associated with considerable HRU and economic burden. This analysis did not include indirect costs, caregiver burden, or donor costs, and therefore likely underestimates the true burden of HCT for patients with hematologic malignancies. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Clinical and Economic Outcomes in Patients with Transfusion-Dependent β-Thalassemia and Patients with Sickle Cell Disease with Recurrent Vaso-Occlusive Crises Receiving Hematopoietic Stem Cell Transplants in the United States

Background: Transfusion-dependent β-thalassemia (TDT) and sickle cell disease (SCD) are inherited blood disorders caused by mutations in the β-globin gene, resulting in abnormal, reduced, or absent expression of hemoglobin. TDT is characterized by ineffective red blood cell production that leads to chronic anemia, need for regular red blood cell transfusions (RBCTs), and organ complications. SCD is characterized by sickle-shaped red blood cells that cause vaso-occlusive crises (VOCs), hemolysis, and end-organ damage. Hematopoietic stem cell transplant (HSCT) is currently the only curative option for patients with TDT and patients with SCD. There is limited research on the frequency and outcomes of HSCT in these two patient populations. This study describes the economic and clinical outcomes for a combined population of patients with TDT and patients with SCD with recurrent VOCs who received HSCTs in the United States. Methods: This retrospective cohort study used administrative claims from the MerativeTM Commercial, Medicare, and Multi-State Medicaid Databases to identify patients with ≥1 inpatient or ≥2 outpatient claims for β-thalassemia or SCD between March 1, 2010, and March 1, 2019. Eligible patients with TDT were required to have ≥8 discrete RBCTs in any 12-month period on or after the date of the earliest qualifying β-thalassemia claim. At least 3 days between service dates of RBCT claims were required to be considered discrete RBCTs. Patients with TDT were required to have 1 year of continuous enrollment after their first transfusion to be included. Eligible patients with SCD with recurrent VOCs were required to have ≥2 diagnosed VOCs per year in any 2 consecutive years after and including the first qualifying SCD claim. A VOC was defined as inpatient or outpatient claim of acute chest syndrome, priapism, SCD crisis, or splenic sequestration; at least 3 days between VOC claims were required to be considered discrete VOCs. Eligible patients with SCD with recurrent VOCs were required to have 24 months of continuous enrollment before the second VOC in the second consecutive year and 12 months of continuous enrollment after. Patients with TDT and patients with SCD who met the above criteria and received an HSCT were included in the analysis set. Patients receiving HSCT were identified utilizing relevant procedure codes. The index date was the date of transplant. Patients were followed from the index date to the earliest of end of enrollment, death, or end of study period (March 1, 2020). Demographics were assessed at the index date, and clinical complications, healthcare resource utilization, and costs were descriptively summarized in the post-index period. Costs were based on paid amounts of adjudicated claims and patient cost-sharing and included costs in the 10 days before the index date to account for pre-transplant healthcare services associated with the transplant. Results: Two hundred thirty-four and 3500 patients met the criteria for TDT and SCD with recurrent VOCs, respectively, for a total of 3734 patients. Of that total, 62 patients (1.66%) underwent a transplant and were therefore included in the analysis cohort. Mean patient age at the index date was 12.6 years, and 46.8% were female. A proportion of transplant patients experienced graft versus host disease (GvHD) (37/62; 59.7%), unspecified HSCT complications (33/62; 53.2%), or bone marrow transplant rejection or failure (6/62; 9.7%) post-transplant. Average length of stay for the index HSCT admission was 42 days; in the first year post-transplant, patients averaged 58.3 days in the hospital. Total costs in the first 100 days and 1 year post-transplant were $442,752 and $623,301, respectively. Inpatient costs accounted for 93.7% and 88.7% of costs at 100 days and 1 year, respectively. Conclusions: This retrospective cohort study suggests that only a small proportion of patients with TDT and patients with SCD with recurrent VOCs receive HSCTs. Many patients who undergo transplants experience clinical complications, including graft failure and GvHD, and substantial economic burden. Given the limited utilization and potential safety risks of HSCT, additional curative treatment approaches are needed for patients with TDT and patients with SCD with recurrent VOCs.

Exploring the effectiveness of demand-side retail pharmaceutical expenditure reforms

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.

Reforming Patient Cost Sharing for Cancer Medications in Medicare Part D

Reforming Patient Cost Sharing for Cancer Medications in Medicare Part D

Prevalence, Burden, and Sources of Out-of-Network Billing in Elective Hand Surgery: A National Claims Database Analysis

Surprise out-of-network (OON) bills can represent a considerable cost burden on patients. However, OON billing remains underexplored in elective, outpatient surgery procedures, which have greater latitude for patient choice. We aimed to answer the following questions: (1) What is the prevalence and magnitude of OON charges in hand surgery? (2) What are the sources of OON charges? and (3) What factors are associated with OON charges? We analyzed patient-level data from the Clinformatics Data Mart database. We identified patients undergoing carpal tunnel release, trigger finger release, wrist ganglion removal, de Quervain release, limited palmar fasciectomy, or thumb carpometacarpal arthroplasty at in-network facilities with an in-network primary surgeon. The primary outcome was the proportion of surgical episodes with at least 1 OON charge. Secondary outcomes included the magnitude of potential balance bills (portion of OON bill exclusive of the standardized payment and expected patient cost-sharing), sources of OON charges, and factors associated with OON charges. Of 112,211 elective hand surgery episodes, 8% (9,158) had at least 1 OON charge. OON charges ranged from $1,154 (95% confidence interval, $1,018-$1,289) for wrist ganglion removal to $3,162 (95% confidence interval, $2,902-$3,423) for thumb carpometacarpal arthroplasty. In episodes with OON charges, the major sources of OON charges were anesthesiologists (75% of episodes), durable medical equipment (10% of episodes), and pathologists (9% of episodes). Site of service, geographic region, and health exchange-purchased plans were highly associated with OON charges. Out-of-network billing can represent a substantial cost burden to patients and should be considered in perioperative decision-making in elective hand surgery. Understanding the potential costs related to OON services during a surgical episode, and its drivers, allows surgeons to consider detailed cost discussions during perioperative decision making.