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Reframing the Unaffordability Debate: Patient Responsibility for Physician Care

The American Journal of Managed CareNovember 2017
Volume 23
Issue 11

Despite concerns about rising patient costs for expensive care, we find that many patients face only moderately rising costs for physician care.


Objectives: Public discussion suggests that rising out-of-pocket costs have dramatically reduced the value of insurance and led to patients doing without needed care. Our aim was to ascertain trends in patient responsibility for cost sharing.

Study Design: We used data from an organization that serves over 78,000 healthcare providers and has access to visit-level data, including the amounts paid by patients. These practices are broadly representative of physicians and patients nationally.

Methods: We analyzed trends in patient obligations among a cohort of about 21,000 providers in 1078 practices who had used athenahealth software since 2011, including primary care physicians, obstetricians and gynecologists, surgeons, and some other specialists. Our analysis focused on what commercially insured patients pay out of pocket when seeking ambulatory care.

Results: The average patient obligation for approximately 2.5 million primary care visits each year rose from $23.52 per visit in 2011 to $26.40 per visit in 2015, for an overall increase of $2.88, or about 3% annually. This rate of increase is moderate and below growth in overall healthcare spending during the same time period.

Conclusions: Average increases in patient obligations for outpatient visits in recent years have been fairly moderate, and multiple sources of survey data suggest that consumers’ concerns about overall affordability are decreasing. The high cost of healthcare continues to pose challenges, both at the individual level and for society as a whole. Nevertheless, it is important that potential strategies to improve affordability are informed by trends in patient obligations.

Am J Manag Care. 2017;23(11):690-692Takeaway Points

Despite concerns about rising cost sharing, on average patients face only moderately rising costs for physician care.

  • Average increases in patient obligations for outpatient visits in recent years have been moderate for most specialties, especially primary care.
  • Survey data suggest that consumers’ concerns about unaffordability for healthcare services are decreasing.

The affordability of healthcare for those with insurance has become an increasingly important public issue. The most recent data from the Medical Expenditure Panel Survey (MEPS) show that 84.5% of private sector employees with health insurance had a plan with a deductible in 2016, compared with 77% in 2010. The average size of an individual deductible increased over the same time period from approximately $1000 to $1700.1 A brief from the Kaiser Family Foundation showed a 66% increase in patient cost sharing between 2005 and 2015 for workers covered by employer health plans.2 Many have written about “underinsurance” and affordability problems, particularly for those who participate in the Affordable Care Act (ACA) marketplace.3,4

On the other hand, much of the news on affordability is encouraging. A great deal has been done in the past several years to expand financial access to healthcare, with nearly 20 million gaining coverage as a result of the provisions of the ACA. For most of those gaining coverage, their access to affordable healthcare has greatly improved. More broadly, data from national surveys suggest that, by many measures, consumer perceptions of affordability are increasing. For example, the National Health Interview Survey found that the percentage of respondents who failed to obtain needed care due to cost in the preceding 12 months declined from 6.9% to 4.3% between 2010 and January to March 2017.5 Similarly, the Health Reform Monitoring Survey, a quarterly online survey administered by the Urban Institute, found a decline in the percentage of respondents who reported having an unmet need for care due to affordability.6,7 The prevalence of affordability problems varies by survey, but there is consistency in the direction of the trend. The Commonwealth Fund’s biennial survey similarly showed a decline in the share of respondents who reported difficulties paying medical bills or who were carrying medical debt.8 A growing number of workers report being willing to trade health insurance benefits for higher wages, suggesting that healthcare costs are not the main monetary concern for many workers.9 Finally, a J.D. Power and Associates study of 2016 Marketplace enrollees found that customer satisfaction in 2016 had increased from 2015, which itself was higher than in 2014. Satisfaction with coverage and benefits (among other plan attributes such as customer service and information and communication) has increased the most.10

Despite these concerns about affordability, there have been relatively little recent data on actual patient obligations for specific types of healthcare services. The MEPS Insurance Component Chartbook 2016, published in September 2017 by the Agency for Healthcare Research and Quality, is one of the few sources of information on patient cost sharing for employer-sponsored insurance.1 Data presented here show trends in patient obligations for physician services in ambulatory settings. Patient obligation is defined as the amount of money a practice asks a patient to pay for the services provided to them after the primary source of insurance has paid its portion of the total cost. These data reflect obligations for patients choosing to come in for care and do not estimate obligations for patients who might have forgone care due to concerns about cost.

We use data from ACAView, a joint project between athenaResearch and the Robert Wood Johnson Foundation.11 athenaResearch is the research division of athenahealth, a cloud-based technology company that serves over 78,000 healthcare providers and has access to visit-level data, including physician specialty, procedures rendered, patient diagnoses, insurance payments, and the amounts owed and actually paid by patients. These data provide a highly detailed view of trends in patient obligations for physician services.

Trends in patient obligations between 2011 and 2015 were analyzed among a cohort of about 21,000 providers in 1078 practices who had used the company’s software since before 2011. The cohort includes primary care providers, obstetricians and gynecologists (OB-GYNs), surgeons, and other specialists. In the ACAView data, about 29% of visits are by patients who have Medicare coverage, 14% who have Medicaid, and 3% who are uninsured. The remainder, 54%, are privately insured through either employers or the individual market. The payer mix at these practices is weighted toward Medicare and somewhat undermeasures the uninsured compared with the National Ambulatory Medicare Care Survey (NAMCS), which is administered by the CDC and provides a statistical profile of ambulatory medical care in the United States.12 However, in the following analyses, we limit our attention to out-of-pocket payments made by commercially insured patients when seeking ambulatory care. A majority of the physicians in the ACAView cohort are community-based practitioners, rather than affiliates of academic medical centers, with a larger proportion of visits from the South and a smaller proportion from the West compared with the NAMCS.12

Figure 1 shows the trends in out-of-pocket patient obligations for visits to a variety of specialist types between 2011 and 2015. Average patient obligations for approximately 2.5 million primary care visits each year rose from $23.52 to $26.40 per visit over this period, about 3% annually. Although greater than the rate of overall inflation, this rate of increase is moderate by most definitions and below the growth in overall national health expenditures, which have increased an average of 4.3% each year from 2011 to 2015, with more growth in 2014 and 2015 of 5.3% and 5.8%, respectively.13 For OB-GYN visits, average patient obligations increased from $31.72 to $34.28 over the period, less than 1% annually. Patient obligations for visits to surgeons increased somewhat more, from $50.90 to $59.53, an annual increase of slightly more than 4%, or 16.9% from 2011 to 2015.

Patient obligations can be broken into 4 components of payment: co-pay, deductible, coinsurance, and any other payments not classified under the first 3. The increase in the average patient obligation was primarily a result of growth in the deductible, which made up 47% of the patient obligations in 2015 versus 41% in 2011. A survey by Kaiser Family Foundation and the Health Research and Educational Trust found that deductibles for individual coverage increased 63% on average from 2011 to 2016 for people with health insurance through their employers.14

Although the average patient obligation for primary care visits increased moderately, the underlying distribution of payments at different cost levels shifted substantially. Figure 2 shows that the share of primary care visits that were low cost (ie, less than $20 but more than $0) decreased from 39% of all visits in 2011 to 29% in 2015. No-cost visits increased from 25% to 30% of all visits, whereas visits costing more than $20 increased from 36% to 41% of all visits. These trends reflect both the ACA requirement of no cost sharing for preventive visits and a moderate increase in the number of visits for which patients were responsible for higher costs. Despite the shift towards higher priced visits, only 14% of primary care visits cost patients more than $40, whereas 30% of visits cost the patient nothing.

The data presented in this study are limited to a single type of healthcare service and exclude other important sources of patient cost sharing, such as prescription drugs, outpatient surgery, emergency care, and hospitalization. However, these data suggest that average increases in patient obligations for outpatient visits in recent years have been fairly moderate, and data from multiple surveys suggest that consumers’ concerns about overall affordability are decreasing. The high cost of healthcare continues to pose challenges, both at the individual level and for society as a whole. Nevertheless, it is important that potential strategies to improve affordability are informed by trends in patient obligations.Author Affiliations: Robert Wood Johnson Foundation (KH), Princeton, NJ; athenahealth (JG, AZ), Watertown, MA.

Source of Funding: Funding for this work was provided to athenahealth by the Robert Wood Johnson Foundation under grant 71611.

Author Disclosures: Dr Hempstead works at Robert Wood Johnson Foundation, which funded ACAView. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (KH, JG, AZ); acquisition of data (JG); analysis and interpretation of data (KH, JG, AZ); drafting of the manuscript (KH, JG, AZ); critical revision of the manuscript for important intellectual content (KH, JG, AZ); statistical analysis (AZ); provision of patients or study materials (JG); obtaining funding (JG, KH); administrative, technical, or logistic support (KH, JH, AZ); and supervision (JG, KH).

Address Correspondence to: Josh Gray, MBA, athenahealth, 311 Arsenal St, Watertown, MA 02472. E-mail: jogray@athenahealth.com. REFERENCES

1. MEPS Insurance Component chartbook 2016. Agency for Healthcare Research and Quality website. meps.ahrq.gov/data_files/publications/cb21/cb21.pdf. Published September 2017. Accessed October 11, 2017.

2. Claxton G, Levitt L, Long M. Payments for cost sharing increasing rapidly over time. Kaiser Family Foundation website. kff.org/health-costs/issue-brief/payments-for-cost-sharing-increasing-rapidly-over-time/. Published October 5, 2017. Accessed October 9, 2017.

3. Commonwealth Fund Health Care Affordability Index finds costs unaffordable for a quarter of working-age adults with private health insurance [press release]. New York, NY: The Commonwealth Fund; November 20, 2015. commonwealthfund.org/publications/press-releases/2015/nov/commonwealth-fund-health-care-affordability-index. Accessed March 5, 2016.

4. Blumberg LJ, Holahan J, Buettgens M. How much do marketplace and other nongroup enrollees spend on health care relative to their incomes? Urban Institute website. urban.org/sites/default/files/alfresco/publication-pdfs/2000559-How-Much-Do-Marketplace-and-Other-Nongroup-Enrollees-Spend-on-Health-Care-Relative-to-Their-Incomes.pdf. Published December 2015. Accessed March 5, 2016.

5. Early release of selected estimates based on data from the January-March 2017 National Health Interview Survey. National Center for Health Statistics website. cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201709.pdf. Published September 2017. Accessed October 9, 2016.

6. Karpman M, Kenney GM. QuickTake: health care access and affordability for parents and children: changes between 2013 and 2017. Urban Institute Health Reform Monitoring Survey website. hrms.urban.org/quicktakes/health-care-access-affordability-children-parents-march-2017.html. Published September 7, 2017. Accessed October 11, 2017.

7. Holahan J, Karpman M, Zuckerman S. Health care access and affordability among low- and moderate-income insured and uninsured adults under the Affordable Care Act. Urban Institute Health Reform Monitoring Survey website. hrms.urban.org/briefs/health-care-access-affordability-low-moderate-income-insured-uninsured-adults-under-ACA.html. Published April 21, 2016. Accessed April 21, 2016.

8. Collins SR, Rasmussen PW, Doty MM, Beutel S. The rise in health care coverage and affordability since health reform took effect. The Commonwealth Fund website. commonwealthfund.org/publications/issue-briefs/2015/jan/biennial-health-insurance-survey. Published January 15, 2015. Accessed April 12, 2016.

9. Fronstin P, Helman R. Views on employment-based health benefits: findings from the 2015 Health and Voluntary Workplace Benefits Survey. Employee Benefit Research Institute website. ebri.org/pdf/notespdf/EBRI_Notes_03_Mar16.WBS.pdf. Published March 2016. Accessed April 12, 2016.

10. Health plan member satisfaction climbs to highest levels since ACA implementation [press release]. New York, NY: J.D. Power; March 17, 2016. jdpower.com/press-releases/2016-member-health-plan-study. Accessed April 12, 2016.

11. Gray J, Zink A, Dreyfus T. Effects of the Affordable Care Act through 2015. athenahealth website. athenahealth.com/~/media/athenaweb/files/pdf/acaview_tracking_the_impact_of_health_care_reform. Published March 1, 2016. Accessed March 5, 2016.

12. National Ambulatory Medical Care Survey: 2012 state and national summary tables. National Center for Health Statistics website. cdc.gov/nchs/data/ahcd/namcs_summary/2012_namcs_web_tables.pdf. Published August 2015. Accessed March 5, 2016.

13. National health expenditure data: historical. CMS website. cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Updated December 6, 2016. Accessed October 10, 2017.

14. 2016 Employer Health Benefits Survey. Kaiser Family Foundation website. kff.org/health-costs/report/2016-employer-health-benefits-survey. Published September 14, 2016. Accessed September 14, 2016.

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