Preferred Provider Organizations Research Articles

Comparison of Low-Value Services Among Medicare Advantage and Traditional Medicare Beneficiaries

Low-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care. To compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care. This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022. Enrollment in MA vs TM. Low-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries. Among a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements. In this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.

Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults

The bidirectional association between health and financial stability is increasingly recognized. To describe the association between chronic disease burden and patients' adverse financial outcomes. This cross-sectional study analyzed insurance claims data from January 2019 to January 2021 linked to commercial credit data in January 2021 for adults 21 years and older enrolled in a commercial preferred provider organization in Michigan. Thirteen common chronic conditions (cancer, congestive heart failure, chronic kidney disease, dementia, depression and anxiety, diabetes, hypertension, ischemic heart disease, liver disease, chronic obstructive pulmonary disease and asthma, serious mental illness, stroke, and substance use disorders). Adjusted probability of having medical debt in collections, nonmedical debt in collections, any delinquent debt, a low credit score, or recent bankruptcy, adjusted for age group and sex. Secondary outcomes included the amount of medical, nonmedical, and total debt among individuals with nonzero debt. The study population included 2 854 481 adults (38.4% male, 43.3% female, 12.9% unknown sex, and 5.4% missing sex), 61.4% with no chronic conditions, 17.7% with 1 chronic condition, 14.8% with 2 to 3 chronic conditions, 5.4% with 4 to 6 chronic conditions, and 0.7% with 7 to 13 chronic conditions. Among the cohort, 9.6% had medical debt in collections, 8.3% had nonmedical debt in collections, 16.3% had delinquent debt, 19.3% had a low credit score, and 0.6% had recent bankruptcy. Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions. This cross-sectional study of commercially insured adults linked to patient credit report outcomes shows an association between increasing burden of chronic disease and adverse financial outcomes.

P89. Patient out of pocket cost burden with elective spine surgery

<h3>BACKGROUND CONTEXT</h3> Out-of-pocket (OOP) costs for medical and surgical care can result in substantial financial burden for patients and families. Relatively little is known regarding OOP costs for commercially insured patients receiving spinal fusion surgery. <h3>PURPOSE</h3> The aim of this study is to analyze the trends in OOP costs for common, elective spinal fusion surgeries performed in the hospital inpatient setting. <h3>STUDY DESIGN/SETTING</h3> Retrospective review. <h3>PATIENT SAMPLE</h3> This study utilized an employer-sponsored insurance claims database to analyze billing data of commercially insured patients who underwent elective spinal fusion between 2014 and 2019. Patients who received single-level anterior cervical discectomy and fusion (ACDF) and single-level posterior lumbar fusion (PLF) were identified. <h3>OUTCOME MEASURES</h3> OOP costs associated with the surgical episode and the ratio of OOP costs to total insurer contribution (payments from insurers to providers) were assessed. <h3>METHODS</h3> OOP costs associated with the surgical episode were calculated as the sum of deductible payments, co-payments and co-insurance. Monetary data were adjusted to 2019 dollars. General linear regression, Wilcoxon-Mann-Whitney and Krustal-Wallis tests were utilized for analysis, as appropriate. <h3>RESULTS</h3> In total, 10,225 ACDF and 28,841 PLF patients were analyzed. Most patients in our study sample had preferred provider organization (PPO) insurance plans (ACDF 70.3%, PLF 66.9%). The mean OOP costs for patients, by procedure were: ACDF $3,180 (SD=2,495) and PLF $3,166 (SD=2,529). Total OOP costs increased significantly from 2014 - 2019 for both procedures (p<0.0001). Among the insurance plans examined, patients with high-deductible health plans had the highest OOP costs. The ratio of patient contribution (OOP costs) to total insurer contribution (payments from insurers to providers) was 0.07 for ACDF and 0.04 for PLF. <h3>CONCLUSIONS</h3> Among commercially insured patients who underwent elective spinal fusion, OOP costs increased from 2014 to 2019. The OOP costs for elective spinal fusion represent a substantial and increasing financial burden for patients. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Treatment decision-making among Asian Americans with chronic rhinosinusitis.

Treatment decision-making among Asian Americans with chronic rhinosinusitis.

Steering Clear of Providers

Person-first language is a hallmark of conscientious, professional writing. Most writers and editors of scientific content (especially in medicine and related fields) are familiar with terms that empower patients or do not trivialize or label them. Instead of “asthmatics” we write “patients with asthma”; instead of “the aged” we write “elderly patients” or “older people.” The recent update to inclusive language in the AMA Manual of Style also notes this approach for racial and ethnic terms: instead of “Blacks and Whites” we write “Black and White individuals” (after clarifying the categories used in the study and if people were able to self-identify their race and ethnicity).1 Yet this approach to using terms of respect is not limited to patients or study participants: terms applied to health care workers should also be chosen with the same care. For example, the terms “orthopod” (orthopedic surgeon) and “osteopath” (osteopathic physician) are considered jargon.2 One term in particular has engendered a vigorous response: “provider.” What’s Wrong With “Provider”? At first blush, one might think there’s nothing inherently bad about the word “provider.” According to Merriam-Webster, a provider is someone who provides; in other words, supplies something or makes it available.3 Seems accurate enough, no? We’ve all seen documents that discuss our “primary care provider (PCP)” and “preferred provider organization (PPO).” In the cases of insurance documentation, billing codes, and the like, “provider” is a standard term with a very specific, sometimes even legal, definition. In the Health Insurance Portability and Accountability Act (HIPAA), for […]

Patient Out-of-Pocket Cost Burden With Elective Orthopaedic Surgery.

Out-of-pocket (OOP) costs for medical and surgical care can result in substantial financial burden for patients and families. Relatively little is known regarding OOP costs for commercially insured patients receiving orthopaedic surgery. The aim of this study is to analyze the trends in OOP costs for common, elective orthopaedic surgeries performed in the hospital inpatient setting. This study used an employer-sponsored insurance claims database to analyze billing data of commercially insured patients who underwent elective orthopaedic surgery between 2014 and 2019. Patients who received single-level anterior cervical diskectomy and fusion (ACDF), single-level posterior lumbar fusion (PLF), total knee arthroplasty (TKA), and total hip arthroplasty (THA) were identified. OOP costs associated with the surgical episode were calculated as the sum of deductible payments, copayments, and coinsurance. Monetary data were adjusted to 2019 dollars. General linear regression, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests were used for analysis, as appropriate. In total, 10,225 ACDF, 28,841 PLF, 70,815 THA, and 108,940 TKA patients were analyzed. Most patients in our study sample had preferred provider organization insurance plans (ACDF 70.3%, PLF 66.9%, THA 66.2%, and TKA 67.0%). The mean OOP costs for patients, by procedure, were as follows: ACDF $3,180 (SD = 2,495), PLF $3,166 (SD = 2,529), THA $2,884 (SD = 2,100), and TKA $2,733 (SD = 1,994). Total OOP costs increased significantly from 2014 to 2019 for all procedures (P < 0.0001). Among the insurance plans examined, patients with high-deductible health plans had the highest episodic OOP costs. The ratio of patient contribution (OOP costs) to total insurer contribution (payments from insurers to providers) was 0.07 for ACDF, 0.04 for PLF, 0.07 for THA, and 0.07 for TKA. Among commercially insured patients who underwent elective spinal fusion and major lower extremity joint arthroplasty surgery, OOP costs increased from 2014 to 2019. The OOP costs for elective orthopaedic surgery represent a substantial and increasing financial burden for patients.

Human papilloma virus vaccination and cervical cancer screening coverage in managed care plans — United States, 2018

Human papilloma virus (HPV) vaccination for adolescents aged 11–12 years and cervical cancer screening for women aged 21–65 years are recommended to help prevent cervical cancer. The purpose of this study was to describe 2018 National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) data for the United States on HPV vaccination and cervical cancer screening from 275 commercial preferred provider organizations (PPOs), 219 commercial health maintenance organizations (HMOs), and 204 Medicaid HMOs. The Centers for Disease Control and Prevention and NCQA analyzed the data in 2021. The HEDIS® measure for HPV vaccination was the percentage of male and female adolescents aged 13 years who completed HPV immunization (2– or 3–dose series) on or before their 13th birthday. The measure for cervical cancer screening was the percentage of women screened either with cervical cytology within the last 3 years for women aged 21–64 years or with cervical cytology/HPV co-testing within the last 5 years for women aged 30–64 years. Nationally, the mean rate for HPV vaccination in 2018 was 37.8% in Medicaid HMOs, 30.3% in commercial HMOs, and 24.9% in commercial PPOs. The mean rate for cervical cancer screening was 75.9% in commercial HMOs, 72.6% in commercial PPOs, and 60.3% among Medicaid HMOs. Medicaid HMOs reported higher HPV vaccination rates but lower cervical cancer screening rates than commercial plans. These differences raise questions about explanatory factors and how to improve prevention performance by plan category.

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.

Do health insurers use target marketing as a tool for risk selection? Evidence from the Netherlands

In health care systems based on managed competition, enrolees can choose between insurers who are positioned as prudent buyers of care on their behalf. To avoid risk selection, insurers are compensated through a system of risk equalisation. The Dutch system of risk equalisation is generally considered to be one of the most sophisticated in the world. Empirical evidence, however, shows there are still consumer segments that are profitable for insurers. To examine whether insurers use target marketing for attracting these segments, we assessed promotional material used by Dutch insurers during the switching season of 2019. Our findings provide preliminary evidence that large insurers with different brands primarily use their sub brands as strategic vehicles to improve their competitive positions by targeting these brands at financially favourable groups and price sensitive buyers. By contrast, the more visible main brands are targeted at a much broader spectrum of consumer groups to display the insurer's social character. Only a minority of insurers’ marketing expressions are targeted at actual users of care. Despite continuous improvements in the risk equalisation system, on average this group is still unprofitable for insurers. From a health policy perspective, further improvements are key to motivate health insurers to target their efforts at improving care for the chronically ill and to eliminate incentives for risk selection.

Advancing Health Equity for Medicaid Beneficiaries by Adding Colorectal Cancer Screening to the Centers for Medicare and Medicaid Services Adult Core Set

Advancing Health Equity for Medicaid Beneficiaries by Adding Colorectal Cancer Screening to the Centers for Medicare and Medicaid Services Adult Core Set

The Financial Burden of Nonoperatively Treated Pediatric Distal Radius Fractures: Medical Debt in Privately Versus Publicly Insured Patients.

Patients with public health insurance have greater difficulty obtaining orthopaedic care than their privately insured counterparts because of lower reimbursements. However, the relationship between insurance status and financial burden for patients and treating institutions is unknown. We compared patient medical debt and uncompensated hospital costs by insurance type for pediatric patients who received nonoperative treatment for distal radius fractures (DRFs). We reviewed medical records of 100 pediatric patients (above 18 y) treated nonoperatively at our US academic hospital for DRFs from 2016 to 2020. Patients were grouped according to insurance type at the time of treatment: preferred-provider organization (PPO), n=30; health maintenance organization (HMO), n=29; Medicaid, n=28; and uninsured, n=13. These groups were matched by number of encounters, total original charge, and total number of charges. The primary outcomes were patient medical debt and uncompensated costs to the hospital, comprising unpaid balance, uncollectible debt, and self-adjustments offered by the hospital. χ2 tests and analysis of variance were used to compare financial outcomes among subgroups (alpha=0.05). Patient medical debt (ie, uncollectible debt) was generated by 20% of PPO, 7.7% of uninsured, and 6.9% of HMO patients (P=0.06). Medicaid patients generated no patient medical debt, whereas PPO patients generated a mean (±SD) of $15±$39 and HMO patients generated $26±$130, which was not significantly different than that of uninsured patients ($25±$89) (P<0.0001). Uncompensated costs were generated by 54% of uninsured, 20% of PPO, 6.9% of HMO, and 0% of Medicaid patients (P<0.0001). Uncompensated costs were the same as uncollectible debt for privately insured and Medicaid patients, whereas uninsured patients generated an additional $550±$600 from self-adjustments (P<0.0001). Unlike the Medicaid group, the privately insured and uninsured groups incurred patient medical debt and uncompensated costs after nonoperative DRF treatment. Thus, orthopaedic providers should be cost conscious with privately insured patients, while publicly insured patients may provide more consistent-albeit lower-reimbursement for the hospital. Level III.

Payors Train PCPs to Treat Mental Health in House

Payors Train PCPs to Treat Mental Health in House

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.

Disparities in nonmelanoma skin cancer in Hispanic/Latino patients based on Mohs micrographic surgery defect size: A multicenter retrospective study

There is limited literature regarding potential disparities in nonmelanoma skin cancer for patients with skin of color. Use the sizes of Mohs micrographic surgery defects to examine disparities in nonmelanoma skin cancer among Hispanic/Latino patients with a secondary aim to examine the effect of insurance type. We conducted a multicenter retrospective study using data from 3 major institutions in Los Angeles County. A total of 3486 Mohs micrographic surgeries of basal cell, squamous cell, and basosquamous cell carcinomas were analyzed. Mohs micrographic surgery defect sizes were 17% larger among Hispanic/Latino patients compared with non-Hispanic White patients. More notably, when comparing defect sizes of squamous cell carcinomas to those of basal cell carcinomas, defects were 80% larger among Hispanic/Latino patients compared to non-Hispanic White patients who had 25% larger defect sizes. Compared to patients with Medicare, patients with health maintenance organization and Medicaid/health maintenance organization had 22% and 52% larger defect sizes, respectively, whereas patients with preferred provider organization, had 10% smaller defect sizes. The data included were from a single county population. Disparities regarding nonmelanoma skin cancer exist between patients with skin of color and White patients. Patients and the medical community need to be cognizant that skin cancer can develop in patients regardless of their race and ethnicity.

Impact of Insurance Provider on Postoperative Hospital Length of Stay After Spine Surgery

Differences in insurer and payer status have been shown to increase patient hospital length of stay (LOS) by delaying the approval of transfer to a rehabilitation facility. The aim of the current study is to determine the impact of the type of insurance provider on postoperative hospital LOS after spine surgery. In our single-institution retrospective study, all patients undergoing elective spine surgery between August 2018 and August 2019 as part of an enhanced recovery after surgery (ERAS) protocol were enrolled in a prospectively collected registry. Insurance payer type was analyzed to determine its effect on total patient LOS after surgery. A total of 106 patients were included in the study. Insurance payers studied were Medicare, private insurers (preferred provider organization and health maintenance organization), and the Veterans Affairs payer TriWest. Patients in all groups had comparable demographic characteristics and procedural variables. There was a statistically significant difference in days stayed beyond medical clearance among the 3 insurance provider groups (P < 0.001); TriWest patients stayed an average of 3.2 days beyond clearance, compared with private insurance (1.2 days) and Medicare (0.3 days). Individual subanalysis of the ERAS complex pathway population mirrored these findings. Hospitalization beyond medical clearance after spine surgery follows a predictable pattern regardless of ERAS pathway complexity, with Medicare having a shorter delay in approving patient progression than private insurance, which has less of a delay than Triwest.

Evaluation of financial outcomes under a value-based payment program for community pharmacies.

BACKGROUND: Value-based payment models have been shown to limit health care spending and waste while improving quality of care. Evidence from value-based pharmacy programs (VBPPs) is needed to guide the use of these mechanisms in health care. OBJECTIVE: To evaluate financial outcomes of a VBPP implemented in 73 community pharmacies for about 40,000 commercial beneficiaries of Wellmark, Inc. METHODS: Beneficiaries were attributed to pharmacies based on the number of prescriptions dispensed. The VBPP paid community pharmacies a per capita payment based on their performance on a set of metrics to deliver care the pharmacists believed was necessary to optimize the beneficiaries' medication therapy and associated outcomes. Financial outcome variables were analyzed for the calendar year of 2018, including total cost of care, hospital admissions, and emergency department (ED) visits. Hospital admissions and ED visits were identified through claims data. Generalized linear models were used to test the effect of the VBPP on each of the outcome variables by comparing outcomes for beneficiaries attributed to the pharmacies participating in the VBPP (73 pharmacies) to Wellmark's beneficiaries attributed to nonparticipating pharmacies (847 pharmacies). Independent variables used in the models to control for possible confounding included beneficiary demographics and complexity scores, region code, accountable care organization (ACO) attribution, beneficiary product type (health maintenance organization (HMO), preferred provider organization (PPO), and several disease indicator variables. RESULTS: Analyses showed in 2018 that the per beneficiary per month total costs of care for the beneficiaries going to the VBPP pharmacies (N = 15,463) was $30.48 (4.5%; 95% CI = -6.2% to -2.7%) lower than that of the non-VBPP group (N = 140,717). The hospital admission rate for the VBPP group was 5.1% lower but was not statistically significant (95% CI = -12.9% to 3.3%). Similarly, the ED visit rate for the VBPP group was 2.1% lower than the non-VBPP group but did not reach statistical significance (95% CI = -8.6% to 3.3%). CONCLUSIONS: With the growing need for solutions to improve quality of care while reducing health care costs and waste, a value-based payment program using performance-determined capitated payments to community pharmacies offering enhanced clinical services significantly reduced total costs of care in a commercial population with one or more chronic conditions. Future work with this promising model is encouraged. DISCLOSURES: No external funding was obtained to support this study. Devolder and Heggen are employed by Wellmark, Inc. Doucette is supported by the Deborah K. Veale Professorship in Healthcare Policy at the University of Iowa. The authors have no other potential conflicts of interest to disclose.

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.

Out-of-Pocket Costs for Patients Undergoing Thyroid Surgery.

The aim of this study was to determine out-of-pocket costs (OOPC) in patients undergoing thyroidectomy for benign and malignant conditions in a commercially insured US population. Little is known about OOPC for thyroid surgery in the United States. Retrospective cohort study using claims of patients undergoing thyroidectomy from the IBM Watson Marketscan database from 2008 to 2017. OOPCs accrued from 90 days before surgery to 360 days after thyroid surgery were quantified. Costs were divided into expenditures for inpatient care, outpatient care and outpatient drug costs and over three time periods: from 90 days preoperatively to 30 days post operatively, from 30 days post operatively to 90 days postoperatively, and from 90 days to 1 year after surgery. A total of 45,971 commercially insured patients aged 18 to 95 years who underwent thyroidectomy were identified after excluding patients who changed coverage and patients on capitated plans. The median OOPC per patient in the study period of 90 days before surgery to 360 days after surgery was $2434 [interquartile range (IQR) $1273-$4226], the median insurance reimbursement was $15,520 (IQR $7653-$29,149). Patients undergoing thyroidectomy for malignant conditions had a median OOPC of $3019 (IQR $1596-$5021) compared to $2271 (IQR $1201-3954) for benign conditions ( P < 0.0001).Patients with preferred provider organization coverage had a median OOPC of $2624 (IQR $1458-$4358) compared to HMO patients with a median OOPC of $1529 (IQR $739 to 3058), and high deductible health plans with a median OOPC of $4265 (IQR $2788-$6210) ( P < 0.0001). Despite commercial insurance coverage, patients face substantial OOPCs in the surgical management of thyroid disease in the United States.

Trends in coverage and reimbursement for reproductive genetic counseling in New Jersey by multiple payers from 2010 to 2018

Lack of consistent insurance coverage for genetic counseling services billed under Current Procedural Terminology (CPT) code 96040 creates a barrier for access to this service. This retrospective study examined coverage and reimbursement for reproductive genetic counseling encounters billed under CPT code 96040 as a professional fee over an eight-year period at Rutgers Robert Wood Johnson Medical School, a regional perinatal center in New Jersey, a state requiring licensure. Descriptive statistics were tabulated to assess the disparity between Medicare/Medicaid, Managed Care Medicaid, and commercial insurance payers, including how often encounters were covered and if reimbursed, at what percentage of the amount billed. A comparison of individual plan types (Health Maintenance Organization, Point of Service, and Preferred Provider Organization) was carried out. Overall trends in reimbursement were assessed across payers. The study found 61% of 60-min encounters billed to Medicare/Medicaid, Managed Care Medicaid, and commercial insurance payers received coverage. Of all covered 60-min encounters billed to Managed Care Medicaid and commercial insurance payers, an average of 36% of the amount billed was reimbursed. Medicare/Medicaid encounters were never reimbursed. Commercial insurance covered 65% of encounters billed but this varied between payers. Across all payers, an overall downward trend of reimbursement was demonstrated over the eight-year period. Lack of consistent service coverage creates a barrier and patients cannot universally access genetic counseling services. Steps to improve coverage need to include passing of legislation, notably the next bill to replace the former H.R. 3235, 'Access to Genetic Counselor Services Act of 2019' and provisions within third-party payers that allow for credentialing of genetic counseling providers.

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.