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The American Journal of Managed Care December 2019
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Cost-Sharing Payments for Out-of-Network Care in Commercially Insured Adults
Wendy Yi Xu, PhD; Bryan E. Dowd, PhD; Macarius M. Donneyong, PhD; Yiting Li, PhD; and Sheldon M. Retchin, MD, MSPH
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Hussain S. Lalani, MD; Patti L. Ephraim, MPH; Arielle Apfel, MPH; Hsin-Chieh Yeh, PhD; Nowella Durkin; Lindsay Andon, MSPH; Linda Dunbar, PhD; Lawrence J. Appel, MD; and Felicia Hill-Briggs, PhD; for the Johns Hopkins Community Health Partnership
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Cost-Sharing Payments for Out-of-Network Care in Commercially Insured Adults

Wendy Yi Xu, PhD; Bryan E. Dowd, PhD; Macarius M. Donneyong, PhD; Yiting Li, PhD; and Sheldon M. Retchin, MD, MSPH
This study of claims among adults covered by employer-sponsored plans revealed substantial variations in out-of-network cost-sharing payments. The growth of cost sharing for nonemergent hospitalizations is concerning.

The characteristics of the general and continuously enrolled samples are shown in Table 1. Both samples consisted of slightly more women than men, and the average age reflected a slightly older population among those continuously enrolled. Most enrollees lived in metropolitan areas, consistent with Census Bureau data.21 For both samples, the average HCC score was 1.59. The average annual total healthcare expenditures were almost identical. The most common health plan types were PPOs, accounting for 55% of individuals in the general adult sample, followed by HDHPs (23%) and HMOs (11%). The enrollment by plan types in our data was similar to the distribution of plans offered by employers from the Kaiser Family Foundation and the Health Research and Educational Trust Employer Health Benefits Survey data during the study interval.22-27 On average, 16% of individuals encountered OON care, with an average cost-sharing amount of $621 toward OON care in the general sample. The average spending for in-network care was $895. Nearly 94% of total OON cost sharing contributed toward medical care instead of fills from OON pharmacies.

Estimates from regression analyses are shown in Table 2. Compared with in 2012, the probability of receiving OON care decreased modestly during 2015 to 2017: by 1.56, 2.82, and 3.14 percentage points each year, respectively. Sicker individuals were more likely to have OON payments. Estimated cost sharing among those who used OON care accelerated annually from 2012 to 2016, plateauing in 2017. On average, those who received OON care paid $679 and $648 in cost sharing in 2016 and 2017, respectively. Further, a 1-point-higher HCC score was associated with $97.72 more spending for OON care. Plan types also affected cost-sharing payments. For example, enrollees in PPO and HDHP plans had $483.62 and $491.23 higher cost-sharing payments, respectively, relative to those in HMO plans.

Also shown in Table 2, analyses of cost-sharing spending for in-network care exhibited similar trends by insurance plan design types and risk scores, as observed with OON care. Controlling for the other covariates, the cost-sharing amount for in-network care decreased during 2013 to 2014 and increased in 2016 to 2017—a period when deductible payments rose significantly nationwide. Although the incremental changes in estimated cost sharing during 2012 to 2016 were larger for OON care than for in-network care, this trend was reversed during 2016 to 2017.

The cost sharing for OON care also exhibited substantial geographic variations (Figure 1). The average regression-adjusted cost-sharing spending for OON care in Connecticut and Oklahoma consistently ranked highest in both 2012 and 2017, reaching $1049 and $976, respectively, by 2017. Overall, states experienced an average 13.68% increase in cost-sharing payments for OON care during the study period. Enrollees with OON care in many states experienced average spending growth substantial enough to reach the next quartile level between 2012 and 2017.

The patterns of OON care differed by care settings and urgency levels. The adjusted rates of OON care by ED status and care settings are displayed in Figure 2. (The full regression results are available upon request.) As shown, a substantially higher portion of individuals encountered OON care in outpatient settings unrelated to ED use than in other settings. Moreover, the prevalence of OON care decreased since 2014 in all settings. For example, the average probability of experiencing nonemergent outpatient OON care decreased from 16.2% in 2012 to 12.5% in 2017.

Figure 3 displays the adjusted OOP spending trends for OON medical services according to ED status and care setting. As shown, the OON cost sharing for nonemergent care was higher than for care associated with ED visits. In contrast to the decreased OON rates over time, the cost sharing for OON-related medical services increased for both ED and non-ED care, and the nonemergent hospitalizations saw the fastest growth—the adjusted spending grew from 2012 to 2017, from $671 to $1286, accelerating since 2014. OOP payments for OON care with emergent hospitalizations increased from $452 to $565. Growth rates of OOP spending for OON care in outpatient settings were modest compared with those of hospitalizations. Furthermore, in contrast to OON care in outpatient settings, better health status was associated with substantially lower amount of OOP payments for nonemergent hospitalizations.

Results for the continuously enrolled sample are largely consistent with the general adult sample (eAppendix C), suggesting that our findings were not driven by time-invariant characteristics of the enrollees. Finally, the robustness test (results available upon request) that allowed insurance benefits to change over time within the same plan type also confirmed our main findings, indicating that changes of the benefit levels within health plans did not impact the trends that we observed.

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