Patient Cost-sharing Research Articles

SAVING LIVES OR SAVING MONEY? UNDERSTANDING THE DUAL NATURE OF PHYSICIAN PREFERENCES

A longstanding literature has highlighted the tension between the altruism of physicians and their desire for profit. This paper develops new implications for how these competing forces drive pricing and utilization in healthcare markets. Altruism dictates that providers reduce utilization in response to higher prices, but profit-maximization does the opposite. Rational physicians will behave more altruistically when treating poorer patients or those that face higher medical cost burdens, and when foregone profits are lower. These insights help explain the observed heterogeneity in pricing dynamics across different healthcare markets. We empirically test the implications of our model by utilizing two exogenous shocks in Medicare price setting policies. Our results indicate that patient income, out-of-pocket costs, and profitability alone explain up to one-quarter of the variation in price elasticities. Finally, we demonstrate that uniform policy changes in reimbursement or patient cost-sharing may lead to unintended consequences.

Addressing discriminatory benefit design for people living with HIV: a California case study

ABSTRACTConcern is growing in the United States regarding the potential for health insurance benefit designs to discriminate against persons living with HIV as research demonstrates that such practices are occurring. A recent complaint filed against health insurers in seven states alleges that some health insurance companies have been using benefit designs that discourage enrollment of people living with HIV either by not covering essential HIV medications or by requiring cost-sharing for these prohibitively expensive medications. Legislators across the country have reacted by introducing legislation to address these growing problems. This paper describes Assembly Bill 339, legislation passed in California in 2015 and going into effect on 1 January 2017, which provides protection for people living with HIV by requiring coverage for single-tablet regimens to manage HIV while placing a cap on patient cost-sharing. Given California’s size and influence, and the uncertainty of the future of the Affordable Care Act, this legislation has the potential to influence the national policy debate.

Effect of cost sharing on adherence to evidence-based medications in patients with acute coronary syndrome

ObjectivesCost-sharing scheme for pharmaceuticals in Spain changed in July 2012. Our aim was to assess the impact of this change on adherence to essential medication in patients with acute coronary...

The Ethics of Patient Cost-Sharing for Total Joint Arthroplasty Implants.

The number of total joint arthroplasties being performed in the United States continues to grow1-3. Current estimates are that approximately 512,000 hip arthroplasties and 787,000 knee arthroplasties are performed yearly4. Many of these procedures are performed on Medicare recipients (approximately 400,000), and total joint arthroplasty represents the largest share of Medicare spending among inpatient surgical procedures5-7. The Centers for Medicare & Medicaid Services (CMS) has developed alternative payment models designed to decrease costs without negatively affecting outcomes. The Bundled Payment for Care Improvement program and the Comprehensive Care for Joint Replacement (CJR) program are recent attempts to control total joint arthroplasty cost8. It is unclear what effect these programs will have on outcomes, quality, or patient access. The cost of implants is highly variable and represents a substantial financial portion of a total joint arthroplasty episode of care9. Therefore, among other factors, cost containment strategies must focus on lowering implant costs. Moreover, many higher-cost prostheses have unproven clinical benefits. This has led to novel discussions among surgeons and hospitals about whether patients should contribute to the costs of their implants. There are examples of patients paying for medical devices; however, there is no mechanism in place for patients to contribute toward arthroplasty implants10. Previous research suggests that U.S. patients are willing to pay for implants, and their motivations for doing so may be varied11-14. Allowing patients to cost-share for implants generates myriad ethical dilemmas, and this article will review those dilemmas. This article will not discuss patient cost-sharing in other areas. Patient cost-sharing for implants has real potential to enhance patient autonomy, to increase transparency, to respect shared decision-making, and to strengthen the health-care system’s long-term financial viability. However, the …

Increased cost sharing and changes in noncompliance with specialty referrals in The Netherlands

IntroductionThe compulsory deductible, a form of patient cost-sharing in the Netherlands, has more than doubled during the past years. There are indications that as a result, refraining from medical care has increased. We studied the relation between patient cost-sharing and refraining from medical care by evaluating noncompliance with referrals to medical specialists over several years. MethodsNoncompliance with specialty referrals was assessed in the Netherlands from 2008 until 2013, using routinely recorded referrals from general practitioners to medical specialists and claims from medical specialists to health insurers. Associations with patient characteristics were estimated using multilevel logistic regression analyses. ResultsNoncompliance rates were approximately stable from 2008 to 2010 and increased from 18% in 2010 to 27% in 2013. Noncompliance was highest in adults aged 25–39 years. The increase was highest in children and patients with chronic diseases. No significantly higher increase among patients from urban deprived areas was found. Discussion/conclusionNoncompliance increased during the rise of the compulsory deductible. Our results do not suggest a one-to-one relationship between increased patient cost-sharing and noncompliance with specialty referrals. In order to develop effective policy for reducing noncompliance, it is advisable to focus on the mechanisms for noncompliance in the groups with the highest noncompliance rates (young adults) and with the highest increase in noncompliance (children and patients with chronic diseases).

Estimated Budget Impact of Adopting the Affordable Care Act's Required Smoking Cessation Coverage on United States Healthcare Payers.

IntroductionDespite abundant information on the negative impacts of smoking, more than 40 million adult Americans continue to smoke. The Affordable Care Act (ACA) requires tobacco cessation as a preventive service with no patient cost share for all FDA-approved cessation medications. Health plans have a vital role in supporting smoking cessation by managing medication access, but uncertainty remains on the gaps between smoking cessation requirements and what is actually occurring in practice. This study presents current cessation patterns, real-world drug costs and plan benefit design data, and estimates the 1- to 5-year pharmacy budget impact of providing ACA-required coverage for smoking cessation products to understand the fiscal impact to a US healthcare plan.MethodsA closed cohort budget impact model was developed in Microsoft Excel® to estimate current and projected costs for US payers (commercial, Medicare, Medicaid) covering smoking cessation medicines, with assumptions for coverage and smoking cessation product utilization based on current, real-world national and state-level trends for hypothetical commercial, Medicare, and Medicaid plans with 1 million covered lives. A Markov methodology with five health states captures quit attempt and relapse patterns. Results include the number of smokers attempting to quit, number of successful quitters, annual costs, and cost per-member per-month (PMPM).ResultsThe projected PMPM cost of providing coverage for smoking cessation medications is $0.10 for commercial, $0.06 for Medicare, and $0.07 for Medicaid plans, reflecting a low incremental PMPM impact of covering two attempts ranging from $0.01 for Medicaid to $0.02 for commercial and Medicare payers.ConclusionThe projected PMPM impact of covering two quit attempts with access to all seven cessation medications at no patient cost share remains low. Results of this study reinforce that the impact of adopting the ACA requirements for smoking cessation coverage will have a limited near-term impact on health plan’s budgets.FundingPfizer Inc.Electronic supplementary materialThe online version of this article (doi:10.1007/s12325-016-0446-y) contains supplementary material, which is available to authorized users.

PCN247 - Is utilization of Adjuvant Endocrine Therapy Affected Mainly by Patient Drug Costs? An Analysis of Two Databases

Although adjuvant endocrine therapy (AET) is becoming an important cornerstone of treatment in Medicare breast cancer survivors, few studies have examined variations in the use of this treatment by potentially important sociodemographic influences like patient race and geography are independent of economic drivers such as patient costs associated with these medications. To test our hypotheses that utilization may be driven by sociodemographics independent of drug costs, we compared and contrasted AET therapy use in two survivor populations with breast cancer, those enrolled in Medicare Part D (with significant copayment and medication cost issues) with survivor populations enrolled in the Medicaid program (with little to no copayments for these medications). We compared 18,075 Medicare breast cancer survivors enrolled in Part D plans with 1,307 Medicaid survivors in three states (West Virginia, Maryland and Ohio) over a 5 year period. Similar to what we found in the SEER-Medicare data, white patients had significantly higher use rate of AET than African American patients (6.6% vs. 4.6%, p<0.0001), while other minorities had significantly higher use rate of AET than white patients (8.5% vs. 6.6%, p = 0.02). These were consistent with what we found in the SEER-Medicare data. We also identified significant differences in the use rate of AET among the three states, which have different geographies (use rate of AET in WV, MD, and OH were 10.8%, 7.0%, and 4.7%, respectively (p<0.0001). These findings were confirmed in multivariate models. Our analyses of data from two different insurance programs with differential patient economic cost burden for AET therapy finds evidence that there are distinct sociodemographic factors such as patient race and rural status that affect the use of AET therapy, and these effects are independent of patient cost-sharing for these medication therapies.

Patient Cost Sharing and Healthcare Utilization in Early Childhood: Evidence from a Regression Discontinuity Design

This paper exploits longitudinal insurance claims data and a cost-sharing subsidy that has exempted co-payment and coinsurance of healthcare services for children under the age of 3 in Taiwan. We use a regression discontinuity design to estimate its effect on children's healthcare utilization. Our results show that cost-sharing subsidy significantly increases the utilization of outpatient care, especially low-value care at high-cost hospitals. In contrast, the utilization of inpatient care is price insensitive. Finally, we find that a lower level of cost-sharing has little impact on children's health.

Early Impact of the Affordable Care Act on Uptake of Long-acting Reversible Contraceptive Methods.

The Affordable Care Act (ACA) required most private insurance plans to cover contraceptive services without patient cost-sharing as of January 2013 for most plans. Whether the ACA's mandate has impacted long-acting reversible contraceptives (LARC) use is unknown. The aim of this article is to assess trends in LARC cost-sharing and uptake before and one year after implementation of the ACA's contraceptive mandate. A retrospective cohort study using Truven Health MarketScan claims data from January 2010 to December 2013. Women aged 18-45 years with continuous insurance coverage with claims for oral contraceptive pills, patches, rings, injections, or LARC during 2010-2013 (N=3,794,793). Descriptive statistics were used to assess trends in LARC cost-sharing and uptake from 2010 through 2013. Interrupted time series models were used to assess the association of time, ACA, and time after the ACA on LARC cost-sharing and initiation rates, adjusting for patient and plan characteristics. The proportion of claims with $0 cost-sharing for intrauterine devices and implants, respectively, rose from 36.6% and 9.3% in 2010 to 87.6% and 80.5% in 2013. The ACA was associated with a significant increase in these proportions and in their rate of increase (level and slope change both P<0.001). LARC uptake increased over time with no significant change in level of LARC use after ACA implementation in January 2013 (P=0.44) and a slightly slower rate of growth post-ACA than previously reported (β coefficient for trend, -0.004; P<0.001). The ACA has significantly decreased LARC cost-sharing, but during its first year had not yet increased LARC initiation rates.

Claims-based Identification Methods and the Cost of Fall-related Injuries Among US Older Adults.

Compare expenditures of fall-related injuries (FRIs) using several methods to identify FRIs in administrative claims data. Using 2007-2009 Medicare claims and 2008 Health and Retirement Survey data, FRIs were identified using external-cause-of-injury (e-codes 880/881/882/884/885/888) only, e-codes plus a broad set of primary diagnosis codes, and a newer approach using e-codes and diagnostic and procedural codes. Linear regression models adjusted for sociodemographic, health, and geographic characteristics were used to estimate per-FRI, service component, patient cost share, expenditures by type of initial FRI treatment (inpatient, emergency department only, outpatient), and total annual FRI-related Medicare expenditures. The analysis included 5497 community-dwelling adults ≥65 (228 FRI, 5269 non-FRI individuals) with continuous Medicare coverage and alive during the 24-month study. The 3 FRI identification methods produced differing distributions of index FRI type and varying estimated expenditures: $12,171 [95% confidence interval (CI), $4662-$19,680], $5648 (95% CI, $3819-$7476), and $9388 (95% CI, $5969-$12,808). In all models, most spending occurred in hospital, outpatient, and skilled nursing facility (SNF) settings, but greater proportions of SNF and outpatient spending were observed with commonly used FRI identification methods. Patient cost-sharing was estimated at $691-$1900 across the 3 methods. Inpatient-treated index FRIs were more expensive than emergency department and outpatient-treated FRIs across all methods, but were substantially higher when identifying FRI using only e-codes. Estimated total FRI-related Medicare expenditures were highly variable across methods. FRIs are costly, with implications for Medicare and its beneficiaries. However, expenditure estimates vary considerably based on the method used to identify FRIs.

Affordable False Teeth: The Effects of Patient Cost Sharing on Denture Utilization and Subjective Chewing Ability

Abstract We evaluate the impact of patient cost sharing on the use of dentures and subjective chewing ability exploiting a sharp reduction in the coinsurance rate, the percentage of costs born by the user, from 30 % to 10 % at the age of 70 with a regression discontinuity design. Using data from the Japanese Study of Aging and Retirement (JSTAR), we find that the utilization rate of dentures increases from approximately 50 % to 63 % around the threshold, implying that the extensive margin elasticity of denture usage with respect to the coinsurance rate is about –0.41. In addition, we find this jump is almost entirely due to the change in the rate among women. On the other hand, we do not find a significant improvement in self-reported chewing ability, although chewing ability may not be the only social benefit from dentures. Our empirical findings are also confirmed by complementary analysis with randomization tests.

PCN81 - Utilization and Spending Trends for Pain Medications among Cancer Survivors in the United States: Results from Medical Expenditure Panel Survey

Cancer pain, either tumor-related or treatment-related, is common among cancer survivors. The objective of this study was to quantify annual trends in utilization, cost, and patient cost shares of pain medications, overall and by drug class, among cancer survivors in the United States. Data were obtained from the Medical Expenditure Panel Survey (MEPS) annually from 2008-2013. Cancer survivors, excluding survivors of nonmelanoma skin cancer, were identified using survey questions and clinical classification codes. Utilization, cost, and patient cost shares were obtained for the following classes of pain medications taken by survivors: non-opioids (NSAIDs, salicylates, non-narcotic analgesic combinations), opioids, narcotic analgesic combinations, and adjuvant analgesics (for neuropathic pain). Descriptive statistics were computed using appropriate statistical procedures for the MEPS with its unique sampling design. Out of 23.4 million cancer survivors in 2008, 40.8% took pain medication; in 2013, 43.9% of 24.8 million survivors did so. These percentages exceed those for patients without a history of cancer. The total number of prescriptions for pain medications prescribed to cancer survivors increased from 60.3 million in 2008 to 74.4 million in 2013. The number of prescriptions for non-opioids, opioids, and adjuvant analgesics increased from 14.3, 8.9 and 20.6 million, respectively, in 2008, to 19.0, 11.6 and 27.1million, respectively, in 2013. There were approximately 16.5 million prescriptions for narcotic analgesic combinations in both 2008 and 2013. The cost (not adjusted for inflation) of pain medication increased from $3.5 billion in 2008 to $5.6 billion in 2013. Overall, the patient cost share has decreased from 23.3% in 2008 to 17.0% in 2013. A high percentage of cancer survivors take pain medication for the disease or for treatment. A substantial share of the rise in the cost of pain medication for survivors is due to an increase in national spending on adjuvant analgesics.

Patient cost-sharing for ambulatory neuropsychiatric services in Abu Dhabi, UAE.

Background and objectivesNeuropsychiatric disorders are of high concern and burden of disease in the United Arab Emirates (UAE). The aim of this study is to describe patient cost-sharing patterns, insurance coverage of ambulatory neuropsychiatric disorders, and utilization of neuropsychiatric services in Abu Dhabi.MethodsThe study utilized the data published by Health Authority-Abu Dhabi (HAAD) and the American Center for Psychiatry and Neurology (ACPN) records in Abu Dhabi. The data were collected from the ACPN to describe patterns of insurance coverage and patient cost-sharing. The data included information on patient visits to the ACPN from January 1, 2010 till May 16, 2013. The data also included insurance coverage, total cost of treatment for each patient and the amount of coinsurances and deductibles paid by each patient. Additionally, the study utilized data published by HAAD on health services utilization, and health insurance plans in 2014. The percentage of total costs paid by patients and insurance were calculated by insurance groups and health service. Insurance plans with different patient cost-sharing arrangements for mental health treatment benefits were divided into three groups. ANOVA and MANOVA analyses were performed to test for differences among three categories of neuropsychiatric services (neurology, psychiatry and psychotherapy) in terms of the total costs and patient cost-sharing. The data were analysed using STATA version 12.ResultsAbout 36 % of the total costs on ambulatory neuropsychiatric services was paid directly by patients; 1 % of total costs was covered by patients as co-insurances and deductibles, and 63 % of total costs was covered by insurance providers. The average cost per visit was about 485 AED ($132), including 304 AED ($83) paid by insurance and 181 AED ($49) paid by patient. About 44 % of total costs was related to psychiatry services, 28 % of total costs was related to neurology services, and 28 % of total costs was related to psychotherapy services. Using ANOVA analyses, statistical differences were found among three categories of neuropsychiatric services in terms of the total costs and patient cost-sharing. These findings provide hint on some degree of association between patient cost-sharing and neuropsychiatry services utilization.ConclusionsThe determination of parities in the coverage and finance between neuropsychiatric and physical health services will help policymakers make informed decisions on regulations of health insurance plans. Given the level of unmet need for neuropsychiatric services in Abu Dhabi, there is a need to fully include neuropsychiatric services in all basic and enhanced insurance plans. The study provided a description of patient cost-sharing and coverage of neuropsychiatric services in order for policymakers to recognize the disparities of the coverage and the degree of economic burden on households.

Commentary: Patient Cost Sharing and Medical Expenditures for the Elderly.

Commentary: Patient Cost Sharing and Medical Expenditures for the Elderly.

Reductions in Diagnostic Imaging With High Deductible Health Plans.

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

Patient cost-sharing and insurance arrangements are associated with hospital readmissions after abdominal surgery: Implications for access and quality health care

Readmission rates after operative procedures are used increasingly as a measure of hospital care quality. Patient access to care may influence readmission rates. The objective of this study was to determine the relationship between patient cost-sharing, insurance arrangements, and the risk of postoperative readmissions. Using the MarketScan Research Database (n = 121,002), we examined privately insured, nonelderly patients who underwent abdominal surgery in 2010. The main outcome measures were risk-adjusted unplanned readmissions within 7 days and 30 days of discharge. Odds of readmissions were compared with multivariable logistic regression models. In adjusted models, $1,284 increase in patient out-of-pocket payments during index admission (a difference of one standard deviation) was associated with 19% decrease in the odds of 7-day readmission (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.78-0.85) and 17% decrease in the odds of 30-day readmission (OR 0.83, 95% CI 0.81-0.86). Patients in the noncapitated point-of-service plans (OR 1.19, 95% CI 1.07-1.33), preferred provider organization plans (OR 1.11, 95% CI 1.03-1.19), and high-deductible plans (OR 1.12, 95% CI 1.00-1.26) were more likely to be readmitted within 30 days compared with patients in the capitated health maintenance organization and point-of-service plans. Among privately insured, nonelderly patients, increased patient cost-sharing was associated with lower odds of 7-day and 30-day readmission after abdominal surgery. Insurance arrangements also were significantly associated with postoperative readmissions. Patient cost sharing and insurance arrangements need consideration in the provision of equitable access for quality care.

PMS91 - Association of Medication Persistency with Route of Administration and Patient Cost-Sharing: Analysis of Commonly Used Biologics

PMS91 - Association of Medication Persistency with Route of Administration and Patient Cost-Sharing: Analysis of Commonly Used Biologics

Incentive Programs for Reducing Readmissions When Patient Care is Co-Produced

To reduce preventable readmissions, many healthcare systems are transitioning from Fee-for-Service (FFS) to other reimbursement schemes such as Pay-for-Performance (P4P) or Bundled Payment (BP) so that the funder of a healthcare system can transfer to the hospital some of the financial risks associated with patient re-hospitalizations. To examine the effectiveness of different schemes (FFS, P4P, and BP), we develop a health co-production model in which the patient's readmissions can be jointly controlled by the efforts exerted by both the hospital and the patient. Our analysis of the equilibrium outcomes reveals that FFS cannot entice the hospital and the patient to exert readmission-reduction efforts. Relative to BP, we find that P4P is more robust in the sense that it can induce readmission-reduction efforts under milder conditions. However, BP can induce greater efforts compared to P4P. More importantly, we characterize the conditions under which BP (or P4P) is the dominant scheme from the funder's perspective. Finally, we find that patient cost-sharing can generate two benefits: (a) it provides incentive for patients to exert efforts; and (b) if not excessive, it can reduce the readmission rate.

Use and Spending for Biologic Disease-Modifying Antirheumatic Drugs for Rheumatoid Arthritis Among US Medicare Beneficiaries.

Biologic therapies have assumed an important role in treating rheumatoid arthritis (RA). We sought to investigate use, spending, and patient cost-sharing for Medicare beneficiaries using biologic drugs for RA, comparing patients exposed to minimal cost-sharing because of a Part D low-income subsidy (LIS) to those facing substantial out-of-pocket costs (OOP). We performed a retrospective, nationwide study using 2009 Medicare claims for a 5% random sample of beneficiaries with RA who had at least 1 RA drug dispensed. We analyzed biologic drug utilization and costs across the Part B (medical benefit) and Part D (pharmacy benefit) programs by LIS status using multinomial regression. We also projected OOP costs as the Affordable Care Act (ACA) mandates closure of the Part D coverage gap by 2020. Among 6,932 beneficiaries, 1,812 (26.1%) received a biologic drug. LIS beneficiaries were significantly more likely to obtain Part D home-administered biologics (relative risk ratio [RRR] 2.98, 95% confidence interval [95% CI] 2.50-3.56), while non-LIS beneficiaries were less likely to receive Part D biologic agents (RRR 0.58, 95% CI 0.48-0.69). OOP costs in Part D were lower, as expected, for LIS beneficiaries ($72 versus $3,751 per year for non-LIS). Non-LIS beneficiaries had lower costs for Part B facility-administered biologic agents (range $0-$2,584) than for Part D home-administered biologic agents. ACA reforms will narrow OOP differences between Part D and B for non-LIS beneficiaries. In contrast to LIS beneficiaries who receive mostly Part D home-administered biologic DMARDs, nonsubsidized beneficiaries have significant cost-based incentives to obtain facility-administered biologic DMARDs through Part B. The ACA will result in only slightly lower costs for Part D biologic drugs for these beneficiaries.

Can European Countries Improve Sustainability of Health Care Financing through Patient Cost-Sharing?

Rising health care cost and resource constraints confront policy makers with the challenge to ensure the financial sustainability of health care systems, without jeopardizing the main health system objectives. To respond to this challenge, many European countries have introduced patient payments for publicly financed health care services (patient cost-sharing) (1–4). The potential of patient cost-sharing to contribute to the sustainability of the health care system relies on two elements. First, cost-sharing generates additional sources of funding. Hence, through cost-sharing, some of the health care cost might be shifted from public budgets to patients. Second, cost-sharing has the potential to improve efficiency in publicly financed health care, as it is expected that patients, when faced with the price of health care services, reduce the utilization of unnecessary and low-value health care (5, 6). It is also expected that this could slow the growth of health care costs. However, opponents of cost-sharing question the potential of cost-sharing to improve efficiency and instead point to its potentially negative effects on equity in health care. This is documented by evidence, among them the best known is the RAND health insurance experiment (7, 8). Whether the potential of cost-sharing can be realized without threatening equity and consumers financial protection depends on various context-specific factors as well as on the design of the cost-sharing systems applied by European countries.