Preferred Provider Organization Plans Research Articles

Measuring restrictiveness of Medicare Advantage networks: A claims-based approach.

To develop and validate a measure of provider network restrictiveness in the Medicare Advantage (MA) population. Prescription drug event data and beneficiary information for Part D enrollees from the Center for Medicare and Medicaid Services, along with prescriber identifiers; geographic variables from the Area Health Resources Files. A prediction model was used to predict the unique number of primary care providers that would have been seen by MA beneficiaries absent network restrictions. The model was trained and validated on Traditional Medicare (TM) beneficiaries. A pseudo-Poisson and a random forest model were evaluated. An observed-to-expected (O/E) ratio was calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based the TM prediction model. Multivariable linear models were used to assess the relationship between network restrictiveness and plan and market factors. Prescription drug event data were obtained for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017. Health Maintenance Organization plans were more restrictive (O/E = 55.5%; 95% CI 55.3%-55.7%) than Health Maintenance Organization-Point of Service plans (67.2%; 95% CI 66.7%-67.8%) or Preferred Provider Organization plans (74.7%; 95% CI 74.3%-75.1%), and rural areas had more restrictive networks (31.6%; 95% CI 29.0%-34.2%) than metropolitan areas (61.5%; 95% CI 61.3%-61.7%). Multivariable results confirmed these findings, and also indicated that increased provider supply was associated with less restrictive networks. We developed a means of estimating provider network restrictiveness in MA from claims data. Our results validate the approach, providing confidence for wider application (e.g., for other markets and specialties) and use for regulation.

Comparison of Out-of-Pocket Spending on Ultra-Expensive Drugs in Medicare Part D vs Commercial Insurance

Little is known about how out-of-pocket burden differs between Medicare and commercial insurance for ultra-expensive drugs. To investigate out-of-pocket spending for ultra-expensive drugs in the Medicare Part D program vs commercial insurance. This was a retrospective, population-based cohort study of individuals using ultra-expensive drugs included in a 20% nationally random sample of prescription drug claims from Medicare Part D and individuals aged 45 to 64 years using ultra-expensive drugs included in a large national convenience sample of outpatient pharmaceutical claims from commercial insurance plans. Claims data from 2013 through 2019 were used, and data were analyzed in February 2023. Claims-weighted mean out-of-pocket spending per beneficiary per drug by insurance type, plan, and age. In 2019, 37 324 and 24 159 individuals using ultra-expensive drugs were identified in the 20% Part D and commercial samples, respectively (mean [SD] age, 66.2 [11.7] years; 54.9% female). A statistically significant higher share of commercial enrollees vs Part D beneficiaries were female (61.0% vs 51.0%; P < .001), and a statistically significantly lower share were using 3 or more branded medications (28.7% vs 42.6%; P < .001). Mean out-of-pocket spending per beneficiary per drug in 2019 was $4478 in Part D (median [IQR], $4169 [$3369-$5947]) compared with $1821 for commercial (median [IQR], $1272 [$703-$1924]); these differences were statistically significant every year. Differences in out-of-pocket spending comparing commercial enrollees aged 60 to 64 years and Part D beneficiaries aged 65 to 69 years exhibited similar magnitudes and trends. By plan, mean out-of-pocket spending per beneficiary per drug in 2019 was $4301 (median [IQR], $4131 [$3000-$6048]) in Medicare Advantage prescription drug (MAPD) plans, $4575 (median [IQR], $4190 [$3305-$5799]) in stand-alone prescription drug plans (PDPs), $1208 (median [IQR], $752 [$317-$1240]) in health maintenance organization plans, $1569 (median [IQR], $838 [$481-$1472]) in preferred provider organization plans, and $4077 (median [IQR], $2882 [$1075-$4226]) in high-deductible health plans. There were no statistically significant differences between MAPD plans and stand-alone PDPs in any study year. Mean out-of-pocket spending was statistically significantly higher in MAPD plans compared with health maintenance organization plans and in stand-alone PDPs compared with preferred provider organization plans in each study year. This cohort study demonstrated that the $2000 out-of-pocket cap included in the Inflation Reduction Act may substantially moderate the potential increase in spending faced by individuals who use ultra-expensive drugs when moving from commercial insurance to Part D coverage.

"It's just not easy to understand": A mixed methods study of health insurance literacy and insurance plan decision-making in cancer survivors.

Understanding cancer survivors' health insurance decision-making is needed to improve insurance choice, potentially resulting in reduced financial hardship. This explanatory mixed methods study assessed health insurance decision-making in cancer survivors. Health Insurance Literacy Measure (HILM) captured HIL. Quantitative eye-tracking data collected from two simulated health insurance plan choice sets gauged dwell time (seconds), or interest, in benefits. Dwell time differences by HIL were estimated using adjusted linear models. Qualitative interviews explored survivors' insurance decision-making choices. Cancer survivors (N = 80; 38% breast cancer) had a median age of 43 at diagnosis (IQR 34-52). When comparing traditional and high-deductible health plans, survivors were most interested in drug costs (median dwell time 58 s, IQR 34-109). When comparing health maintenance organization and preferred provider organization plans, survivors were most interested in test/imaging costs (40s, IQR 14-67). Survivors with low versus high HIL had more interest in deductible (β = 19 s, 95% CI 2-38) and hospitalization costs (β = 14 s, 95% CI 1-27) in adjusted models. Survivors with low versus high HIL more often ranked out-of-pocket (OOP) maximums and coinsurance as the most important and confusing benefits, respectively. Interviews (n = 20) revealed survivors felt alone "to do their own research" about insurance choices. OOP maximums were cited as the deciding factor since it is "how much money is going to be taken out of my pocket." Coinsurance was considered "rather than a benefit, it's a hindrance." Interventions to aid in health insurance understanding and choice are needed to optimize plan choice and potentially reduce cancer-related financial hardship.

Abstract P366: Enrollment in Medicare Managed Care Plan is Associated With Higher Adherence to Anti-Hypertensive Drugs

Introduction: Adherence to anti-hypertensive drugs, which is sub-optimal despite public health and policy efforts, is essential in controlling high blood pressure. Medicare Advantage plans are gaining popularity, partly due to their managed care designs that held promise to improve chronic disease management. Hypothesis: We assessed the hypothesis that hypertensive patients with a managed care plan have higher adherence to antihypertensive drugs than those with a non-managed care plan. Methods: We analyzed medication adherence – measured using proportion of days covered (PDC) over 12 months for antihypertensive drugs – among 174,172 patients with a hypertension diagnosis from the medical and pharmacy claims and benefits data in the 2017-2019 IBM MarketScan Research Database. We fitted separate generalized linear regression models among monotherapy (use of one class of antihypertensive drugs) and polytherapy (combined use of at least two classes of antihypertensive drugs) users and computed postestimation margins with the best-fitted model to compare medication adherence by plan type: 1) Managed Care exclusive provider organization and health management organization (EPO/HMO) plan, 2) Managed Care point-of-service plan, 3) Managed Care preferred provider organization plan, 4) non-Managed Care comprehensive plan, 5) non-Managed Care consumer driven health plan / high deductible health plan. Other patient characteristics included in the analyses were age, age-squared, sex, comorbidities, census region, and their interaction terms. Results: The average PDC among Medicare patients on monotherapy was 0.53 and among those on polytherapy was 0.74. Patients with a managed-care EPO/HMO plan had the highest PDC (0.53, 95% confidence interval [CI]: 0.52, 0.54 among monotherapy users and 0.73, 95% CI: 0.72, 0.74 among polytherapy users, respectively) and those with a non-managed care comprehensive plan had the lowest PDC (0.42, 95% CI: 0.41, 0.43 among monotherapy users and 0.62, 95% CI: 0.61, 0.63 among polytherapy users, respectively). By census region, patients living in the North Central region with a managed care EPO/HMO plan had the highest average PDC (0.71, 95% CI: 0.70, 0.72 among monotherapy users and 0.85, 95% CI: 0.84, 0.86 among polytherapy users, respectively). Other factors such as age, sex, and number of chronic conditions were significantly associated with PDC. Conclusions: In conclusion, with an increase in the proportion of older adults enrolled in Medicare Advantage insurance, managed care models may play a more important role in influencing adherence to essential drugs such as anti-hypertensive drugs among Medicare beneficiaries. Future research should investigate factors that promote adherence to medications across different managed care plan designs.

1793. Evaluation of Ambulatory Antibiotic Use in Children and Adult Patients of a Healthcare System in Bolivia Using the AWaRe Classification

Abstract Background The World Health Organization (WHO) has established the AWaRe (Access, Watch and Reserve) classification based on the impact of different antibiotics on antimicrobial resistance. For ambulatory patients, WHO recommends Access antibiotics to represent &amp;gt;60% of all prescriptions, and an Access to Watch (AW) index of ≥1.5. The use of Access and Watch antibiotics has not been evaluated in ambulatory patients in Latin America. The aim of this study was to describe antibiotic use among members of two health plans within a private health insurance in Bolivia. Methods We retrospectively evaluated antibiotic use among 8,405 members of a private healthcare system in Santa Cruz de la Sierra, Bolivia, between Jan-2017 and Dec-2018. Antibiotic use was calculated as defined daily doses (DDD) per 1,000 member-days, and compared between two plans, one a Health Maintenance Organization (HMO) (2,419 members) and the other a Preferred Provider Organization (PPO) (5,986 members). In the HMO plan, members have a general practitioner (GP) as the primary point of care, whereas in the PPO plan, members can access specialists directly without a referral from the GP. Differences between groups were calculated using Byar test with 95% confidence intervals (CI). Results Antibiotic use in DDD/1,000 member-days for the study period was 8.31 in ambulatory, 10.7 in the Emergency Department, and 0.72 in the hospital. Ambulatory antibiotic use in the HMO plan was lower than the PPO plan (6.95 vs. 8.89 DDD/1,000 member-days; diff. –1.94, 95%CI –2.15 to –1.72) (Table). Of all ambulatory antibiotics, 55% were Access and 45% were Watch (AW index: 1.24). By patient group, 52% of pediatric and 58% of adult prescriptions were Access; diff. –6%; p&amp;lt; 0.001 (AW index: 1.07 and 1.39, respectively). By health plan, 62% of HMO and 53% of PPO antibiotics were Access; diff. 9%; p&amp;lt; 0.001 (AW index: 1.13 and 1.67, respectively). Conclusion Ambulatory antibiotic use in this cohort was high. Overall use of Access antibiotics was lower than the recommended by WHO; however, we found less broad-spectrum antibiotic use in the HMO plan compared to the PPO plan. These findings highlight the urgent need for antibiotic stewardship in the ambulatory setting, and the important role of GPs in appropriate antibiotic prescribing. Disclosures Sara E. Cosgrove, MD, Basilea: Member of Infection Adjudication Committee.

“It’s just not easy to understand”: Health insurance literacy and insurance plan decision-making among cancer survivors.

16 Background: Little is known about how cancer survivors choose health insurance plans and whether low health insurance literacy (HIL) may lead to inadequate coverage or high out-of-pocket (OOP) costs. Methods: This prospective, explanatory mixed methods study assessed health insurance decision-making in a sample of adult cancer survivors &lt; 5 years from diagnosis. Quantitative eye-tracking data were collected from two simulated health insurance plan choice sets to gauge interest in plan benefits (measured by dwell time, or seconds of no eye movement; longer dwell time indicates more interest). Ranking of the most important and confusing plan benefit, HIL (HIL Measure; scored 20-84, higher scores indicate higher HIL), and sociodemographic data were also captured. Differences in benefit-specific dwell time by HIL were estimated using adjusted linear models. Qualitative, semi-structured interviews clarified a subset of survivors’ health insurance plan decision-making. Content analysis identified emergent patterns and themes. Results: With a median HIL score of 60 (IQR 50-70), survivors (N = 80) were 65% female, 59% non-Hispanic White, and a median age of 43 at diagnosis (IQR 34-52). Breast cancer diagnoses were most common (38%) and most survivors had received surgery (75%), radiation (55%), or systemic therapy (75%). In the choice set comparing a traditional and high-deductible health plan, survivors were most interested in prescription drug costs (median dwell time 58s, IQR 34-109), but no differences in interest were found comparing survivors with high and low HIL in adjusted models. In the choice set comparing a health maintenance organization and preferred provider organization plan, survivors were most interested in test and imaging costs (40s, IQR 14-67), with survivors with low vs. high HIL having more interest in deductible (β = 19s, 95% CI 2-38) and hospitalization costs (β = 14s, 95% CI 1-27) in adjusted models. Survivors with low vs. high HIL more often ranked low OOP maximums as the most important benefit (53% vs. 38%) and coinsurance as most confusing (68% vs. 53%). Interviews (n = 20) revealed survivors felt alone “ to do their own research” about insurance choices. OOP maximums were cited as the deciding factor since it’s “how much money is going to be taken out of my pocket.” Coinsurance was referred to “rather than a benefit, it's a hindrance.” Opinions about specialist gatekeeping were mixed; some survivors valued the accompanying lower OOP costs, while others worried about care delays. Survivors also reported issues with coverage and cost transparency post-insurance decision. Conclusions: Benefit considerations in health insurance decisions are varied and confusing for cancer survivors with both high and low HIL. Interventions to aid in health insurance understanding and choice are needed to optimize plan choice and prevent cancer-related financial hardship.

Site-based payment differentials for ambulatory services among individuals with commercial insurance.

To compare prices paid by commercial insurers for ambulatory services in physician office and hospital outpatient settings. MarketScan Commercial Claims and Encounters database obtained from Truven Health Analytics. We examined ambulatory service claims for a sample of privately insured individuals who were continuously enrolled in a health maintenance organization plan, preferred provider organization plan, high-deductible/consumer-driven health plan, or exclusive provider organization plan in 2018. We categorized services into five categories: Evaluation & Management, Medical Services & Procedures, Pathology/Lab, Radiology, and Surgical. We identified services commonly provided in both outpatient and office settings and computed the price differential between outpatient and office services overall and for each service category, controlling for observable patient characteristics and geography. We examined 89 services (defined by Current Procedural Terminology [CPT] code) that were provided in both office and outpatient settings in our sample (102.7 million claims, 8.3 million individuals). Adjusting for patient and geographic characteristics and across all services, total payment for an ambulatory service was, on average, 145% higher in a hospital outpatient department than the same service in a physician office. Out-of-pocket spending was 109% higher. Price differences between outpatient and office services were highest for pathology/laboratory services. Patients receiving services in outpatient departments had higher mean risk scores and received more services on the date of their visit (in addition to the index CPT being studied) than patients receiving the same index CPT in a physician's office. Payments in hospital outpatient departments were significantly higher than payments for the same services in physician offices among commercially insured patients. Policies such as site-neutral payment would lower costs and could reduce incentives for further consolidation in health care markets. Care must be given to adjusting for patient severity across settings.

Use of Hand Therapy After Distal Radius Fracture: A National Perspective

To assess whether certain distal radius fracture (DRF) patients, such as opioid users or complex regional pain syndrome (CRPS) patients, receive more hand therapy. Using the IBM MarketScan Research Databases from January 1, 2012, to December 31, 2016, we identified a cohort of DRF patients and created 4 subgroups of interest: frequent follow-up patients, persistent opioid users, prior opioid users, and patients with CRPS. We measured rates and demographic characteristics associated with therapy use in our populations of interest. In this cohort of 87,313 patients, 21% received hand therapy after primary DRF treatment. Patients with CRPS had a higher rate of therapy than non-CRPS patients (44% vs 21%, respectively). Frequent follow-up patients used more therapy than those with less follow-up (30% vs 17%, respectively). Persistent opioid users demonstrated slightly increased therapy use compared to the remaining population (25% vs 22%, respectively). Prior opioid users underwent less therapy than patients without prior opioid use (19% vs 22%, respectively). Female sex, residing in the Northeast, being on a preferred provider organization plan, and having more intense surgical treatments were associated with increased therapy use. This study showed variations in therapy use after DRF in subpopulations of interest. Patients with CRPS, persistent opioid use, and frequent follow-ups had higher rates of therapy. Patients with prior opioid use had lower rates of therapy. Therapy is more common in patients with DRF with CRPS, persistent opioid use, or more follow-up visits.

Patterns and Predictors of First-Line Taxane Use in Patients with Metastatic Triple-Negative Breast Cancer in US Clinical Practice

We investigated first-line (1L) treatment patterns and predictors of taxane use to better understand the evolving metastatic triple-negative breast cancer (mTNBC) treatment landscape. This retrospective analysis of the Truven Health MarketScan® (Somers, NY, USA) Database included women with mTNBC who received 1L therapy within six months of diagnosis (January 2005–June 2015). Multivariate logistic regression models identified predictors of taxane use, adjusting for prognostic factors. A total of 2271 women with newly diagnosed mTNBC received 1L treatment during the study period. Half received a 1L taxane (53%), more often in combination than as monotherapy (58% versus 42%), though this varied by specific taxane. Nab-Paclitaxel monotherapy increased substantially after 2010. More recent treatment year (odds ratio, 2.16 (95% CI 1.69–2.76]) and number of metastases (≥3 versus 1: 1.73 (1.25–2.40)) predicted taxane monotherapy versus combination. Having a health maintenance organization versus a preferred provider organization plan predicted less nab-paclitaxel versus paclitaxel (0.32 (0.13–0.80)) or docetaxel (0.30 (0.10–0.89)) use. More recent index year (2011–2015 vs. 2005–2010) was the only predictor favoring nab-paclitaxel versus paclitaxel (2.01 (1.26–3.21)) or docetaxel (3.63 (2.11–6.26)). Taxane-containing regimens remained the most common 1L mTNBC treatments. Paclitaxel and nab-paclitaxel use changed substantially over time, with nab-paclitaxel use associated with insurance coverage.

PCN100 Economic Burden in Patients with Metastatic Cervical Cancer: A Truven MarketScan Database Study

This study aimed to describe the real-world economic burden of metastatic cervical cancer and identify factors associated with healthcare costs in the US. This retrospective analysis included adult women diagnosed with metastatic cervical cancer between January 1, 2010, and December 31, 2018, using Truven MarketScan Commercial and Medicare Supplemental claims databases. Patients were followed from metastatic diagnosis date until death or end of enrollment or data availability. Healthcare utilization and costs were calculated per patient per year (PPPY) for all patients including those patients receiving platinum-based chemotherapy (PBC). Utilization included outpatient, inpatient, hospice, and prescription claims. Costs comprised medical and pharmacy costs, adjusted to 2018 US dollars. Multivariable regression analysis was performed to identify factors (age, region, insurance, employment status, comorbidities, PBC) associated with costs. Of 2,413 eligible patients with metastatic cervical cancer, mean age was 52 years, 40% were employed full time, 40% lived in the southern US, and 56% had preferred provider organization plans; 1,231 patients (51%) had ≥1 comorbidity, and 684 patients (28%) received PBC. The mean PPPY numbers of outpatient, inpatient, hospice, and prescription claims were 83, 12, 4, and 195, respectively. The mean PPPY healthcare cost was $148,575 for all patients, while patients receiving PBC had a mean PPPY cost of $179,827. Regression analysis identified increased healthcare costs from several independent factors, including patients who were aged 18-30 years, lived in the northeastern US, and received PBC (p<0.0001). Patients with comprehensive coverage generally had lower healthcare costs (p<0.0001). Compared with the literature reporting PPPY cost of $35,161 for patients without cancer, this analysis demonstrated that patients with metastatic cervical cancer represent a substantial economic burden, which was higher among those receiving PBC. Further studies are needed to evaluate the economic burden between patients receiving different lines of treatments.

Frequency and Costs of Out-of-Network Bills for Outpatient Laboratory Services Among Privately Insured Patients

Patients may be unaware of which laboratory is processing their clinical tests, limiting their ability to choose an in-network laboratory. Out-of-network laboratory services could increase patients' out-of-pocket costs and their reluctance to obtain necessary tests. To evaluate the frequency and cost of out-of-network bills for outpatient laboratory services compared with other services. This retrospective cohort study of claims data from the Truven MarketScan Commercial Claims database evaluated claims from 3 946 210 individuals (30.5% of the total) in the MarketScan database who were continually enrolled in health maintenance organization plans, preferred provider organization plans, exclusive provider organization plans, or consumer-driven health plans/high-deductible health plans with at least 1 outpatient clinical laboratory service in 2018. Outpatient laboratory services occurred in independent laboratories, physician offices, and outpatient centers. Laboratory bills from January 1, 2010, to December 31, 2018, were studied. Receipt and cost of outpatient laboratory service. The primary outcome was the proportion of outpatient laboratory services billed as out of network. The secondary outcome was the total potential out-of-pocket cost associated with the out-of-network bill, the sum of observed cost sharing, and the potential balance bill. Of the 12 958 130 in the total sample, 30.5% (3 946 210) had a laboratory test, of whom 5.9% received an out-of-network laboratory test. In comparison, 7.1% of the total sample had an emergency department visit, of whom 4.9% had a service billed as out of network, and 1.6% had an inpatient anesthesiology service, of whom 3.4% had an out-of-network service. Observed out-of-pocket spending was $24.59 higher for an out-of-network laboratory service than an in-network laboratory service. In addition, patients with an out-of-network laboratory service may receive an additional balance bill from the laboratory service; the estimated mean balance bill was $80.63. For the most common laboratory services, the total potential out-of-pocket cost associated with an out-of-network bill ranged from $15.68 for venipuncture to $88.09 for lipid panel but was as high as $303.18 for a drug screening test. In this cohort study, out-of-network laboratory services were 5 times more common than out-of-network emergency department visits and 34 times more common than out-of-network anesthesiology services. It is important for patients that consumer protections against out-of-network bills apply to laboratory services.

Out-of-Pocket Spending for Influenza Hospitalizations in Medicare Advantage

IntroductionAlthough many Medicare Advantage plans have waived cost sharing for COVID-19 hospitalizations, these waivers are voluntary and may be temporary. To estimate the magnitude of potential patient cost sharing if waivers are not implemented or are allowed to expire, this study assesses the level and predictors of out-of-pocket spending for influenza hospitalizations in 2018 among elderly Medicare Advantage patients.MethodsUsing the Optum De-Identified Clinformatics DataMart, investigators identified Medicare Advantage patients aged ≥65 years hospitalized for influenza in 2018. For each hospitalization, out-of-pocket spending was calculated by summing deductibles, coinsurance, and copays. The mean out-of-pocket spending and the proportion of hospitalizations with out-of-pocket spending exceeding $2,500 were calculated. A 1-part generalized linear model with a log link and Poisson variance function was fitted to model out-of-pocket spending as a function of patient demographic characteristics, plan type, and hospitalization characteristics. Coefficients were converted to absolute changes in out-of-pocket spending by calculating average marginal effects.ResultsAmong 14,278 influenza hospitalizations, the mean out-of-pocket spending was $987 (SD=$799). Out-of-pocket spending exceeded $2,500 for 3.0% of hospitalizations. The factors associated with higher out-of-pocket spending included intensive care use, greater length of stay, and enrollment in a preferred provider organization plan (average marginal effect=$634, 95% CI=$631, $636) compared with enrollment in an HMO plan.ConclusionsIn this analysis of elderly Medicare Advantage patients, the mean out-of-pocket spending for influenza hospitalizations was almost $1,000. Federal policymakers should consider passing legislation mandating insurers to eliminate cost sharing for COVID-19 hospitalizations. Insurers with existing cost-sharing waivers should consider extending them indefinitely, and those without such waivers should consider implementing them immediately.

Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value.

Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored. Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices. Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact. Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.

The Value Employees Place on Health Insurance Plans: A Discrete-Choice Experiment

The federally-facilitated Health Insurance Marketplace-also known as the Health Insurance Exchange-was designed as a tool to help people purchase insurance plans, yet many Americans remain uninsured, partially due to rising premiums. One possible strategy to stabilize its premiums is to encourage healthier people to purchase their plans through the Marketplace instead of through their employers. This study examined the values that single adults with employer-based coverage place on health insurance plan attributes using a discrete-choice experiment (DCE). As part of an online survey, each respondent completed 28 paired comparisons trading off four attributes: source of coverage, plan type, monthly out-of-pocket premium, and quality of coverage. Based on our results (N = 2207), single employees slightly preferred their employer over the Marketplace as a source of coverage (0.726 odds ratio; p value < 0.01). Single employees would be willing to switch to the Marketplace for a US$25 reduction in monthly premiums. Preferred Provider Organization (PPO) plans were overwhelmingly preferred over all other plan types, especially compared to Fee-for-Service (FFS) plans (4.230 odds ratio; p value < 0.01). The predicted probability that a health insurance plan from the Marketplace would be chosen ranged from 42 to 43.7%. This study demonstrated that a US$25 subsidy or providing slightly more generous coverage (Bronze-Silver) would motivate employees to purchase PPO plans through the Marketplace, potentially improving its risk pooling, reducing employers' administrative burden, and enhancing labor mobility.

Impact of insurance plan design on bariatric surgery utilization

BackgroundBariatric surgery is underused in the United States. ObjectivesThis study examined whether utilization of bariatric surgery is associated with payor and insurance plan type, after removing potential sociodemographic confounders. SettingThe study used Pennsylvania Health Care Cost Containment Council’s data in 5 counties of Pennsylvania from 2014 to 2016. MethodsBariatric surgery patients and eligible patients who did not undergo surgery were identified and 1:1 matched by age, sex, race, and zip code (n = 5114). A logistic regression was performed to investigate the association of payor type and insurance plan within payor type with odds of undergoing bariatric surgery. ResultsThe odds of undergoing bariatric surgery were not statistically different based on payor type. Medicare preferred provider organization plan was associated with greater odds of undergoing surgery (odds ratio [OR] = 2.49, 95% confidence interval [CI] 1.23–5.04, P = .01) compared with Medicare health maintenance organization (HMO). Medicaid fee for service plan was associated with smaller odds of undergoing surgery (OR = .04, 95% CI .005–.27, P = .001) compared with Medicaid HMO. Individuals with Blue Cross preferred provider organization (OR = 2.43, 95% CI 1.83–3.24, P < .001), Blue Cross fee for service (OR = 1.79, 95% CI 1.32–2.43, P < .001), and Blue Cross HMO (OR = 1.85, 95% CI 1.39–2.46, P < .001) had greater odds of undergoing surgery compared with those with other commercial HMO plans. ConclusionsSpecific aspects of insurance plan design, rather than more general payor type, is more strongly associated with the utilization of bariatric surgery. Further investigations could identify which components of insurance plan design have the greatest influence on the utilization of bariatric surgery.

Provider Acceptance And Beneficiary Access Under TRICARE's PPO Health Plan.

TRICARE provides health benefits to more than nine million beneficiaries (active duty and retired military members and their families). Complaints about access to civilian providers in TRICARE's preferred provider organization (PPO) plan led Congress to mandate surveys of beneficiaries and providers to identify the extent of the problem and the reasons for it. The beneficiary survey asked about beneficiaries' perceived access to care, and the provider survey asked about providers' acceptance of TRICARE patients. TRICARE's civilian PPO plans are required to maintain provider networks wherever TRICARE's health maintenance organization option (known as Prime) is offered. For the years 2012-15, we describe beneficiary access and utilization and provider participation in TRICARE's PPO plans in Prime and non-Prime markets. We also compare individual market rankings for access and acceptance. In both market types, most providers reported participating in TRICARE's PPO network, and most PPO users reported using network providers. In areas where Prime is not offered, PPO users reported slightly better access, and providers were more likely to accept new PPO patients. Areas with low access and acceptance, or where multiple access measures indicate problems, may be fruitful for in-depth investigation.

Health Care Utilization and Costs Among Patients with Chronic Myeloid Leukemia Using Tyrosine Kinase Inhibitors

INTRODUCTIONTyrosine kinase inhibitors (TKIs) remain mainstay in the management of patients with CML. Several TKIs have been approved over the last two decades. Even though efficacy and safety remain as the primary drivers in treatment selection, in recent years importance has been placed on treatment affordability and economic burden associated with the long-term cancer treatments such as TKIs. However, current literature lacks real-world data on healthcare utilization (HCU) and costs among patients with CML using TKIs, which this study aims to address. METHODSRetrospective cohort study was conducted using MarketScan Commercial, and Supplemental Medicare databases (2012-2016). Data includes medical and pharmacy utilization and costs for over 90 million individuals enrolled in employer-sponsored health-plans in the US. Data includes information on but not limited to medical diagnosis, procedures, drugs dispensed, date of service, health plan enrollment. Study involves adult patients (≥18 years) with ≥2 medical claims with a diagnosis of CML (ICD-9-CM: 205.10 - 205.12; ICD-10: C92.10-C92.12) and with a prescription claim for TKI. The date of first-TKI claim defined the index date. Patients were required to have continuous health plan enrollment ≥6 months before (defined as baseline period) and ≥6 months after index date. Selected patients were further classified into 5 sub-groups based on the index TKI observed (prescribed) post CML diagnosis (imatinib, dasatinib, nilotinib, bosutinib, ponatinib). Among the selected patients, all-cause HCU and costs were assessed from index date until end of database or end of enrollment, whichever occurred earlier. HCU and associated costs were assessed overall and by care settings including inpatient, emergency room, physician office, outpatient hospital, outpatient pharmacy, nursing facility and ancillary care. In addition, baseline (6 month) utilization and costs were assessed. Monthly and annual resource utilization and costs were reported for the overall CML cohort (across all TKI users) and by index TKI sub-groups. All costs were reported from a payer perspective (i.e., costs reimbursed by health plan) and adjusted to 2017 US dollars using the US consumer price index (medical component). All analyses were descriptive in nature. RESULTSThe study cohort included 2,213 CML patients. Distribution for the index TKI treatment was as follows: 41% imatinib, 36% dasatinib, 21% and 1% each for bosutinib and ponatinib. Mean age (standard deviation [SD]) of the cohort was 55 (15) years which was similar for individual TKI sub-groups. Majority of patients were males (55%) and 56% were enrolled in a preferred provider organization plan. The mean follow-up duration post-TKI initiation was 607 (442) days. The average baseline monthly all-cause costs were $4,365 with inpatient and pharmacy costs accounting for over 3/4th of the total costs (Figure 1). Post-TKI initiation the average monthly costs were twice ($9,288) compared with the baseline costs ($4,365) and the increase was primarily attributable to higher outpatient pharmacy costs ($6,619, accounted for 71% of total costs) (Figure 2). Monthly costs across other care settings (inpatient, outpatient, emergency room) were similar for the baseline and post-TKI initiation. On average patients had 1.4 office visits, 2.5 prescriptions and 0.7 hospital outpatient visits per month at baseline, which increased by 23%, 38% and 49%, respectively post TKI-initiation. During the 1st year post TKI-initiation, 17% patients in the overall CML cohort had at least 1 inpatient admission and this was consistent across individual TKI-sub-groups (except ponatinib, 50%). CONCLUSIONSFindings on TKI utilization and costs in employer-sponsored health-plan database indicate that average costs and utilization were similar across the TKI sub-groups with pharmacy costs accounting for 71% of the total post TKI initiation costs. Overall, this study helps address the literature gap by providing recent real-world treatment care-setting specific utilization and costs among TKI uses and these data can be of value to several healthcare stakeholders including physicians, managed care plans and researchers in supporting clinical and formulary decisions and also serve as inputs for economic models. Finally, the sample sizes for ponatinib and bosutinb were small and results for these TKIs should be interpreted with caution. [Display omitted] DisclosuresHuang:ZS Associates: Employment; Novo Nordisk Inc: Equity Ownership; AstraZeneca: Research Funding. Karve:AbbVie: Employment, Equity Ownership. Porwal:ZS Associates: Employment. Thakkar:ZS Associates: Employment. Marshall:AbbVie: Employment, Equity Ownership. Rosenberg:AbbVie: Employment, Equity Ownership.

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.

587: Hospital contribution to variation in rates of vaginal birth after cesarean: A Michigan Value Collaborative study

Promoting vaginal birth after cesarean (VBAC) among appropriate candidates will reduce the cesarean delivery rate and improve maternal outcomes, but VBAC rates vary widely across maternity settings. Although patient and provider characteristics have been shown to influence VBAC rate, the contribution of hospitals to this variation is less clear. We sought to investigate the relationship between hospital characteristics and rate of VBAC. This is a retrospective cohort study using claims data from the Michigan Value Collaborative, a partnership between 88 hospitals and Blue Cross and Blue Shield/Blue Care Network (BCBSM). BCBSM data includes diagnostic and procedure codes among Preferred Provider Organization plans in a 90-day episode of maternity care. Women delivered between 2009 and 2015 and had a prior cesarean. The primary outcome was VBAC. ICD9 codes were used to identify obesity, diabetes, and hypertension. Hospital characteristics included urbanicity, obstetrics & gynecology residency program, number of obstetric beds, and obstetric care level. Multilevel models were used to estimate hospital-level contribution to observed variation in hospital VBAC rates after adjustment for patient and known hospital characteristics. Of 14,360 women with a prior cesarean delivery, 647 had a successful VBAC (4.5%). Of the 88 hospitals with obstetric services, 38 (43.2%) had no VBACs during the study period. Among hospitals where at least one VBAC occurred, the VBAC rate varied from 0.5% to 48.1%. There was significant geographic variation in availability of VBAC (figure). Obstetric care level, number of beds, residency program, and urban setting were all associated with VBAC in univariate analysis. In unadjusted models, individual delivery hospital explained 10.8% of the variation in VBAC rate. After adjusting for patient and hospital characteristics, the hospital-attributable variance in VBAC rate was 6.8%. Both patient and hospitals characteristics contribute to variation in VBAC rates across hospitals in Michigan. Where a patient delivers may significantly impact her chance of successful VBAC. Identifying and disseminating institutional practices associated with access to TOLAC and successful VBAC is an important next step.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Performance Measurement and Target-Setting in California's Safety Net Health Systems.

Health policies encourage implementing quality measurement with performance targets. The 2010-2015 California Medicaid waiver mandated quality measurement and reporting. In 2013, California safety net hospitals participating in the waiver set a voluntary performance target (the 90th percentile for Medicare preferred provider organization plans) for mammography screening and cholesterol control in diabetes. They did not reach the target, and the difference-in-differences analysis suggested that there was no difference for mammography ( P = .39) and low-density lipoprotein control ( P = .11) performance compared to measures for which no statewide quality improvement initiative existed. California's Medicaid waiver was associated with improved performance on a number of metrics, but this performance was not attributable to target setting on specific health conditions. Performance may have improved because of secular trends or systems improvements related to waiver funding. Relying on condition-specific targets to measure performance may underestimate improvements and disadvantage certain health systems. Achieving ambitious targets likely requires sustained fiscal, management, and workforce investments.