Shield Plans Research Articles

Hospital Prices for Physician-Administered Drugs for Patients with Private Insurance

BackgroundHospitals can leverage their position between the ultimate buyers and sellers of drugs to retain a substantial share of insurer pharmaceutical expenditures.MethodsIn this study, we used 2020–2021 national Blue Cross Blue Shield claims data regarding patients in the United States who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Markups of the reimbursement prices were measured in terms of amounts paid by Blue Cross Blue Shield plans to hospitals and physician practices relative to the amounts paid by these providers to drug manufacturers. Acquisition-price reductions in hospital payments to drug manufacturers were measured in terms of discounts under the federal 340B Drug Pricing Program. We estimated the percentage of Blue Cross Blue Shield drug spending that was received by drug manufacturers and the percentage retained by provider organizations.ResultsThe study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times (95% confidence interval [CI], 6.02 to 7.16) as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (95% CI, 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%.ConclusionsThis study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.)

Spending patterns among commercially insured individuals suring the COVID-19 pandemic.

To describe trends in US health care spending in a large, national, and commercially insured population during the COVID-19 pandemic. Cross-sectional study of commercially insured members enrolled between May 1, 2018, and December 31, 2021. The study utilized a population-based sample of continuously enrolled members in a geographically diverse federation of Blue Cross Blue Shield plans across the United States. Our sample excluded Medicare and Medicare Advantage beneficiaries. The COVID-19 exposure period was defined as 2020-2021; 2018-2019 were pre-COVID-19 years. We defined 4 post-COVID-19 periods: March 1 to April 30, 2020; May 1 to December 31, 2020; January 1 to March 31, 2021; and April 1 to December 31, 2021. The primary outcome was inflation-adjusted overall per-member per-month (PMPM) medical spending adjusted for age, sex, Elixhauser comorbidities, area-level racial composition, income, and education. Our sample included 97,319,130 individuals. Mean PMPM medical spending decreased from $370.92 in January-February 2020 to $281.00 in March-April 2020. Between May and December 2020, mean PMPM medical spending recovered to-but did not exceed-prepandemic levels. Mean PMPM medical spending stayed below prepandemic levels between January and March 2021, rose above prepandemic baselines between April and June 2021, and decreased below baseline between July and December 2021. The COVID-19 pandemic induced a spending shock in 2020, and health care spending did not recover to near baseline until mid-2021, with some emerging evidence of pent-up demand. The observed spending below baseline through the end of 2021 will pose challenges to setting spending benchmarks for alternative payment and shared savings models.

PCV47 Evidence Requirements in Coverage Determinations for Reimbursement Related to Carotid Artery Stenting: A Systematic Review

This research aims to discern what evidence is sourced by payers and how often, and analyze the characteristics of evidence used in a coverage determination policy. Ascertainable standards can ensure that coverage decisions are fair, orderly, and consistent rather than arbitrary. Six coverage determinations for Carotid Artery Stenting(CAS) from Cigna, Aetna, CMS, and three Blue Cross Blue Shield plans were used to determine the quality of evidence used in coverage decisions. Evidence used was analyzed for age, study type, level of evidence, geographic information and population size from the body and abstracts of the policy references. The 245 unique articles that had PubMed identification numbers were used in the analysis. The support of CAS within the coverage determinations was mixed but all policies indicated coverage of CAS. By assigning 1 to CAS supporting articles, 0 to neutral articles, and -1 to articles with a negative conclusion to the effectiveness or safety of CAS compared to carotid enterectomy (CEA) it was calculated that the evidence supported CAS over CAE in 50% of the policies. Systematic Reviews, Society Guidelines, Prospective and non-randomized trials, literature reviews, cohort studies and case-controlled studies were more likely to support CAS over the standard of care (CEA). Randomized Controlled Trials, Meta-analysis, and Expert Opinion were more likely to come to a negative conclusion on CAS. There is a large variation of evidence selected by payers to support the coverage of CAS. This could indicate selection bias by the payers. The research did not demonstrate when awareness of a new technology led to evidence inclusion in coverage policies because age of evidence used varied so much among the payers. We can assume all payers have access to the same evidence but, the policies indicate that they only include a limited number of articles to support their coverage determinations.

Adventures in getting paid

Adventures in getting paid

Caron in‐network with Aetna

Caron Treatment Centers is an in‐network provider for Aetna, effective Oct. 1, the Pennsylvania‐based program announced last week. “The COVID‐19 pandemic is taking a toll on the mental health of Americans,” said Doug Tieman, CEO and President of Caron Treatment Centers. “Unfortunately, isolation and anxiety make addiction worse, and we are already seeing a spike in substance use and substance use disorders. It's imperative that families have access to affordable, high‐quality, life‐saving treatment programs and support services.” The expansion of in‐network insurance relationships is among several recent moves by Caron to make treatment more accessible. Caron is also an in‐network provider with Highmark and the Blue Card program, which covers persons entitled to benefits as a member of any other Blue Cross and/or Blue Shield plan licensed by the Blue Cross Blue Shield Association, Independence Blue Cross, AmeriHealth Administrators, Independence Administrators, UPMC, Blue Cross Blue Shield, Employer Groups of Penn Medicine and Tower Health. “Accessing quality substance use disorder treatment has always been difficult for many families,” continued Tieman. “With more than 20 percent of the treatment sector reducing or closing services and programs as a result of the pandemic, it's even more difficult. This in‐network agreement with Aetna allows their members to access Caron at a time when they are needed the most.”

Increases in Actual Health Care Costs and Claims After Firearm Injury.

The incidence of firearm injury and death in the United States is increasing. Although the health care-related effect of firearm injury is estimated to be high, existing data are largely cross-sectional, do not include data on preinjury and postinjury health care visits and related costs, and use hospital charges rather than actual monetary payments. To compare actual health care costs (that is, actual monetary payments) and utilizations within the 6 months before and after an incident (index) firearm injury. Before-after study. Blue Cross Blue Shield plans of Illinois, Texas, Oklahoma, New Mexico, and Montana. Plan members continuously enrolled for at least 12 months before and after an index firearm injury sustained between 1 January 2015 and 31 December 2017. Eligible costs, out-of-pocket costs, and firearm injury-related International Classification of Diseases, Ninth or 10th Revision, codes. Total initial (emergency department [ED]) health care costs for persons with index firearm injuries who were discharged from the ED were $8158786 ($5686 per member). Total initial (hospital admission) costs for persons with index firearm injuries who required hospitalization were $41255916 ($70644 per member). Compared with the 6 months before the index firearm injury, in the 6 months after, per-member costs increased by 347% (from $3984 to $17806 per member) for those discharged from the ED and 2138% (from $4118 to $92151 per member) for those who were hospitalized. The number of claims increased by 187% for patients discharged from the ED and 608% for those who were hospitalized. Firearm injury intent was not specified because of misclassification concerns. In the 6 months after a firearm injury, patient-level health care visits and costs increased by 3 to 20 times compared with the 6 months prior. The burden of firearm injury on the health care system is large and quantifiable. None.

The Impact of Medicaid Managed Care Plan Type on Continuous Medicaid Enrollment: A Natural Experiment

To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage. 2011-2016 Medicaid claims from a Northeastern state. Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis. We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011. Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid. Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features.

Cognitive Treatment: Is It Covered?

Cognitive Treatment: Is It Covered?

Key State Blue Cross and Blue Shield Plan: A Strategy for Winning in the Market through Customer-Focused Service

Key State Blue Cross and Blue Shield Plan (a disguised case of an actual BCBS Plan) is the merged product of three state plans. Initially burdened with a reputation of poor customer service, Key State's executives decided to invest heavily in service improvement, eventually achieving superior levels. Key State's high-quality customer service emerged as a true competitive advantage for its customers, who were primarily businesses and health benefits consultants who influenced corporate purchasers of health insurance. The Key State brand came to be synonymous with personal service, security, choice, and dependability. But the health care insurance market was changing under Key State's feet. Spiraling costs meant that high-quality service became less of a competitive advantage as employers were lured by low-cost, low-service providers. Many employers cut or dropped health care benefits entirely, swelling the ranks of the under- and uninsured, who in turn were extremely price-sensitive when shopping for health insurance on their own. Finally, the health care insurance market was being revolutionized by financial institutions willing to hold health benefit accounts and pay providers directly, thereby eliminating the need for Key State as a mediator. Key State executives were aware of these changes but were challenged by the mindset, culture, and organizational design custom-fit to their business accounts. The case asks the reader to consider whether Key State has the right number of target markets, whether it should have one brand or several for its different target markets, what it should do for the uninsured, and how it should improve its brand experience in light of the industry's changing landscape. All of these decisions will have significant implications for the organizational design of Key State.To better understand the challenges involved in a successful health insurance company to cope with a rapidly changing and unpredictable environment; to formulate a new strategy and a new organizational design to accomplish this adaptation.

In Second Year Of Marketplaces, New Entrants, ACA 'Co-Ops,' And Medicaid Plans Restrain Average Premium Growth Rates.

Premiums for health insurance plans offered through the federally facilitated and state-based Marketplaces remained steady or increased only modestly from 2014 to 2015. We used data from the Marketplaces, state insurance departments, and insurer websites to examine patterns of premium pricing and the factors behind these patterns. Our data came from 2,964 unique plans offered in 2014 and 4,153 unique plans offered in 2015 in forty-nine states and the District of Columbia. Using descriptive and multivariate analysis, we found that the addition of a carrier in a rating area lowered average premiums for the two lowest-cost silver plans and the lowest-cost bronze plan by 2.2 percent. When all plans in a rating area were included, an additional carrier was associated with an average decline in premiums of 1.4 percent. Plans in the Consumer Operated and Oriented Plan Program and Medicaid managed care plans had lower premiums and average premium increases than national commercial and Blue Cross and Blue Shield plans. On average, premiums fell by an appreciably larger amount for catastrophic and bronze plans than for gold plans, and premiums for platinum plans increased. This trend of low premium increases overall is unlikely to continue, however, as insurers are faced with mounting medical claims.

APA Presses for Enforcement of Mental Health Parity Law

APA Presses for Enforcement of Mental Health Parity Law

Laboratory Testing for and Diagnosis of Nutritional Deficiencies in Pregnancy Before and After Bariatric Surgery

Bariatric surgery can reduce the risk of obesity-related complications of pregnancy, but may cause essential nutrient deficiencies. To assess adherence to laboratory testing guidelines, we examined frequency of testing for and diagnosis of deficiency during preconception and pregnancy using claims data in women with a delivery and bariatric surgery. Retrospective analysis of claims from seven Blue Cross/Blue Shield plans between 2002 and 2008. We included women with a delivery and bariatric surgery within the study period. We used common procedural terminology (CPT) and ICD-9 codes to define laboratory testing and deficiencies for iron, folate, vitamin B12, vitamin D, and thiamine. Using Student's t-test and chi-square testing, we compared frequency of laboratory tests and diagnoses during 12 months preconception and 280 days of pregnancy between women with pregnancy before versus after surgery. We used multivariate logistic regression to evaluate for predictors of laboratory testing. We identified 456 women with pregnancy after bariatric surgery and 338 before surgery. The frequency of testing for any deficiency was low (9%-51%), but higher in those with pregnancy after surgery (p<0.003). The most common deficiency was vitamin B12 (12%-13%) with pregnancy after surgery (p<0.006). Anemia and number of health provider visits were independent predictors of laboratory testing. Women with pregnancy after bariatric surgery were tested for and diagnosed with micronutrient deficiencies more frequently than those with pregnancy before surgery. However, most laboratory testing occurred in less than half the women and was triggered by anemia. Increased testing may help identify nutrient deficiencies and prevent consequences for maternal and child health.

Erlotinib patterns of use and out-of-pocket (OOP) expenses.

126 Background: Erlotinib is an oral oncology drug FDA-approved for advanced pancreatic and non-small cell lung cancers. Data on its patterns of use, pharmacy dispensing, and patient’s OOP are scarce. Methods: Using integrated medical and pharmaceutical data from 4 Blue Cross Blue Shield plans, we retrospectively identified individuals who received erlotinib between 01/2011 and 06/2011. Their claims were further queried for neoplasm ICD9 codes. A new user was defined as having no erlotinib claims filed in the prior 180 days. All new users were followed for 180 days or until their death/disenrollment (censor date). Excess erlotinib tablets were calculated for individuals with a censor date. The cost of unused tablets was estimated considering the standard 30-day, as well as a hypothetical 15-day drug supply. A gap of 45 days without erlotinib, during the follow-up, was defined as non-persistent to erlotinib therapy. The OOP costs were recorded from their first erlotinib claim. Results: Among 3,357,936 members insured, 125 (40 per million) received erlotinib in the period; 102 members (81.6%) had a lung cancer diagnosis, 18 (14.4%) pancreatic cancer, and 5 (4%) had cancers where erlotinib use is not evidence-based; 31 (24.8%) had a total cumulative supply of less than 30 days suggesting one fill and then discontinuation; 60 patients (48%) were new users in the period, 47 with lung cancer and 12 with pancreatic cancer. Among new users, 27 (45%) died or disenrolled; 18 (30%) of these patients had 211 unused tablets, which amounted to $35,237 or $587 per new user. With a hypothetical 15-day drug supply, there would be 45 unused tablets, totaling $7,515 or $125 per new user. Among the 60 new users, individual OOP on their first claim was &lt; $100 for 38 (63.3%) individuals and &gt; $100 for 22 (36.7%). OOP greater than $100 was associated with a 45-day gap in erlotinib therapy over the 6-month period, p=0.047 (21.0% versus 45.5%). Conclusions: A fourth of patients received erlotinib for less than a month, indicating these patients were either at the end of their lives or had intolerable toxicities. In this cohort, higher OOP costs negatively impacted persistence to therapy. For new users, a care management program with a 15-day drug supply could potentially be a cost-saving approach.

Evaluating systems of care.

100 Background: Blue Cross and Blue Shield Association (BCBSA) is an association of 38 independent, locally operated Blue Cross and/or Blue Shield Plans (each, a BCBS Company). BCBSA and the 38 Blue Companies developed the Blue Distinction (BD) Program, a hospital based quality recognition program with clinical focus on six areas of specialty care, including complex and rare cancers. In 2010, BCBSA and 7 BCBS companies engaged in a pilot study with 25 systems of cancer care, to examine the feasibility of measuring key components of quality that were developed with input from a national multidisciplinary expert panel. Breast and/or colon cancer programs were examined on a range of settings, to understand similarities and differences between systems of cancer care in various regions across the country. Methods: A series of structured discussions and a three-part survey were used to gather information about systems of cancer care. The surveys explored various structures and processes of care that support multidisciplinary, coordinated, evidence-based and patient-centered care across the continuum of care. Results: A diverse group of established multidisciplinary systems of cancer care [n =17 responses (68%)] participated, representing tertiary, community, urban, and rural settings from various regions. Approximately one-third of the responding systems provided written treatment plans or written treatment summaries to patients, and less than one-half had formal processes for comprehensive survivorship care. A majority provided patient navigators, care coordination, or case management services, and a similar majority communicated with the primary care provider at identified points in course of patient’s treatment (e.g., initial assessment, change in treatment, completion of treatment). Conclusions: The pilot study identified gaps in oncology care, similar to those found by the Institute of Medicine (National Cancer Policy Board, Institute of Medicine, and National Research Council. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press, 1999) and others. Opportunities exist for oncology stakeholders to promote quality improvement efforts to narrow these gaps and to improve the quality of cancer care.

Erlotinib and patterns of pharmacogenomic (PGx) testing.

182 Background: Erlotinib is an oral oncology drug that costs approximately $5,000 per month. Both the NCCN Guidelines (since March 2011) and ASCO (since April 2011) recommend PGx testing for tumor epidermal growth factor receptor (EGFR) mutation in patients with advanced non-small cell lung cancer prior to erlotinib use in the first line setting. Insight into early utilization patterns of PGx testing is crucial as new reimbursement methods, care models and evidence-based clinical pathways are developed. Methods: Using integrated medical and pharmaceutical data from four Blue Cross Blue Shield plans, we retrospectively identified members who received erlotinib between 01/2011 and 06/2011 and identified the date of the first erlotinib claim (index date). A new erlotinib user was defined as having no erlotinib claims filed in the prior 180 days. Among members who received erlotinib, medical claims were queried for the presence of ICD-9 codes for malignant neoplasm of trachea, bronchus and lung and for any current procedure terminology (CPT) code indicating PGx testing and other chemotherapy in the prior 24-month period and 1-month post the index date. Total paid amounts from all PGx test codes were obtained. The closest PGx testing date to the index date was used to calculate days between PGx testing and index date. Further analyses examining lines of therapy, monthly patterns of erlotinib usage and PGx testing pre- and post-guidelines recommendations, as well as a description of differences in utilized PGx CPT codes per individual patient, were performed. Results: Among 3,357,936 members insured, 125 (40 per million) received erlotinib, and 102 (81.6%) of those patients had a lung cancer diagnosis. Sixty (48%) were new erlotinib users, and 47 had a diagnosis of lung cancer. Of these, 36 (76.5%) had a PGx CPT code claim. The time between the PGx test and erlotinib start ranged from 4 days to 22 months. A total of $30,391 was spent on all PGx testing with an average of $844 per member tested. Conclusions: In a privately insured cohort of members who newly initiated erlotinib for lung cancer, 23.5% had no prior PGx testing. There is an opportunity for consensus guidelines, care management programs and a single PGx CPT code to possibly reduce variation regarding PGx testing patterns.

Federal Employees Health Program Experiences Lack Of Competition In Some Areas, Raising Cost Concerns For Exchange Plans

The Affordable Care Act calls for creation of health insurance exchanges designed to provide private health insurance plan choices. The Federal Employees Health Benefits Program is a national model that to some extent resembles the planned exchanges. Both offer plans at the state level but are also overseen by the federal government. We examined the availability of plans and enrollment levels in the Federal Employees Health Benefits Program throughout the United States in 2010. We found that although plans were widely available, enrollment was concentrated in plans owned by just a few organizations, typically Blue Cross/Blue Shield plans. Enrollment was more concentrated in rural areas, which may reflect historical patterns of enrollment or lack of provider networks. Average biweekly premiums for an individual were lowest ($58.48) in counties where competition was extremely high, rising to $65.13 where competition was extremely low. To make certain that coverage sold through exchanges is affordable, policy makers may need to pay attention to areas where there is little plan competition and take steps through risk-adjustment policies or other measures to narrow differences in premiums and out-of-pocket expenses for consumers.

Unique American Health Insurance Policies Cause Price Inflation

Many studies conclude that the main reason Americans pay more for health care is that its providers charge higher prices. There is little agreement on why prices are higher. I argue that higher prices are caused by a type of insurance contract unique to America. “Service benefit” contracts originated by Blue Cross/Blue Shield plans paid no monetary “indemnity” to the people insured. Rather payments went directly to providers. Initially participating providers accepted the plan benefit as payment in full, and, so long as this remained true, these contracts provided no special incentive for providers to raise their prices. This changed around 1950, when independent insurance companies began to market a new type of policy called “major medical”. These policies were imitated by the Blues and, in so doing, they introduced “coinsurance” and “deductibles” provisions into the service benefit plans. In these new service benefit hybrids, providers were free to charge patients more than the plan benefit to be paid directly by the patient. An unintended consequence of this development was the release of an inflationary spiral. A model, based on the theory of two-sided matching, provides quantitative predictions of the increase in provider prices caused by insurance. The model can quantitatively account for the inflationary spiral observed from 1949 to 1959. If service benefit insurance is the major cause of the rise in provider prices, then a reform proposed here could reverse the spiral.

Risk of complications after bariatric surgery among individuals with and without type 2 diabetes mellitus

BackgroundType 2 diabetes mellitus is highly prevalent in obese individuals. Bariatric surgery, promoted for reducing the medical problems of morbid obesity, has been increasingly recognized for its particular efficacy in treating diabetes. However, before bariatric surgery can be recommended for the treatment of diabetes, its safety in the diabetic population must be known. We assessed the odds of complications after bariatric surgery in patients with and without diabetes. MethodsThis was a retrospective cohort study. Using an administrative database from 7 Blue Cross/Blue Shield plans, we identified 22,288 subjects who had undergone bariatric surgery from 2002 to 2008. From this cohort, we selected 6754 pairs of surgical patients (1 with and 1 without diabetes) matched by age, gender, health plan, and year of surgery. With conditional logistic regression analysis, we determined the relative odds of postoperative complications for ≤12 months after surgery in the 2 groups. ResultsThe mean age of the surgical patients was 46 years, and 79% were women. Postoperative complications were rare and comparable in those with and without diabetes. The most common complications were nausea, vomiting, and abdominal pain (8.8%), the need for a gastric revision procedure (5.0%), and upper endoscopy (2.3%). Select cardiac, infectious, and renal complications occurred more frequently in the diabetic group. The incidence of cardiac complications was greater in the 2–3-month and 4–6-month postoperative periods (odds ratio [OR] 1.7, P < .001), the incidence of infectious complications was greater in the 0–1-month (OR 1.3, P < .02) and 4–6-month (OR 1.8, P < .001) periods, and the incidence of renal complications was greater in the 2–3-month postoperative period (OR 4.6, P = .01). ConclusionsOur findings support the safety of bariatric surgery in obese individuals with diabetes, although management strategies to avert postoperative cardiac, infectious, and renal complications in this population might be warranted.

Pay for Obesity? Pay-for-Performance Metrics Neglect Increased Complication Rates and Cost for Obese Patients

BackgroundRates of surgical complications are increasingly being used for pay-for-performance reimbursement structures. We hypothesize that morbid obesity has a significant effect on complication rates and costs following commonly performed general surgical procedures. MethodsWe studied 30,502 patients who underwent cholecystectomy for cholecystitis and 6,390 patients who underwent appendectomy for acute appendicitis using administrative claims data from seven Blue Cross and Blue Shield Plans over a 7-year period (2002–2008). We compared 30-day complications as well as total 30-day direct medical costs for obese and non-obese patients. Multivariate regressions were performed to determine the relationship of morbid obesity to complications and cost. ResultsObese patients were more likely to have a complication within 30 days after surgery than non-obese patients (19.2% vs. 15.7% for cholecystectomy, p < 0.0001; 20.2% vs. 15.2%, p < 0.0001, for appendectomy). The mean total 30-day postoperative cost for obese patients were $1,109 higher following a cholecystectomy (p < 0.0001) and $666 higher following an appendectomy (p = 0.09). ConclusionMorbid obesity is associated with a higher rate of complications for two commonly performed general surgical procedures and is associated with higher costs for cholecystectomy. Pay-for-performance metrics should account for the increased risk of complications and higher cost in this population.

Health Reform and the Scope of Benefits for Mental Health and Substance Use Disorder Services

Health Reform and the Scope of Benefits for Mental Health and Substance Use Disorder Services