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

Author

Sen, Aditi P., Singh, Yashaswini, and Anderson, Gerard F.

Subjects
Medical care, Cost of -- Evaluation, Insurance policies -- Evaluation, Clinics -- Usage -- Evaluation, Medical care -- Quality management, Business, Health care industry
Abstract

Objective: To compare prices paid by commercial insurers for ambulatory services in physician office and hospital outpatient settings. Data Sources: MarketScan Commercial Claims and Encounters database obtained from Truven Health Analytics. Study Design: 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 out-patient and office services overall and for each service category, controlling for observable patient characteristics and geography. Data Collection: 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). Principal Findings: 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. Conclusions: 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. KEYWORDS access/demand/utilization of services, ambulatory/outpatient care, anti-trust/health care markets/competition, health care costs, health economics, health policy/politics/law/regulation, hospitals What is known on this topic * Documented payment differentials in Medicare have shown that payments are generally higher for services provided in hospital outpatient departments relative to the same services provided in physician offices. * Private insurers pay, on average, double what Medicare pays for the same services, and therefore site-based payment differentials are likely to be larger in private insurance than in Medicare, however, there is little evidence on this topic. * Payment differentials in Medicare have led to policies to institute 'site-neutral payments,' which could be applied to commercial insurance as well. What this study adds * In 2018, among individuals with employer-sponsored insurance, total payments across five categories of ambulatory care were, on average, 145% higher for services provided in hospital outpatient departments relative to the same services provided in physician offices. * In six states, outpatient prices were over 200% higher than office prices for the same services. * The average patient out-of-pocket payment was 109% higher for outpatient versus office services. The average outpatient patient also received more services during their visit than a patient receiving office-based care, potentially further raising costs., 1 | INTRODUCTION Prices are the major driver of health care spending in the United States, prompting state and federal policy makers to develop approaches to control health care prices. [...]

Published
2022
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21. Global Production of Active Pharmaceutical Ingredients for US Generic Drugs Experiencing Shortages.

Author

Socal, Mariana P., Crane, Matthew A., and Anderson, Gerard F.

Subjects
GENERIC drugs, SCARCITY, DRUG factories, DRUG utilization
Abstract

This study evaluates the characteristics of generic active pharmaceutical ingredients (APIs) used to manufacture drugs with shortages in the US and facilities producing APIs worldwide. [ABSTRACT FROM AUTHOR]

Published
2024
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37. Tackling NCD in LMIC: Achievements and Lessons Learned From the NHLBI–UnitedHealth Global Health Centers of Excellence Program

Author

Rubinstein, Adolfo, He, Jiang, Alam, Dewan S., Peters, David H., Wu, Yangfeng, Yan, Lijing L., Merson, Michael, Ramirez, Manuel, Caballero, Benjamin, Xavier, Denis, Yusuf, Salim, Prabhakaran, Dorairaj, Narayan, K.M. Venkat, Kimaiyo, Sylvester, Velazquez, Eric, Denman, Catalina A., Cornejo, Elsa, de Zapien, Jill, Rosales, Cecilia, Miranda, J. Jaime, Gilman, Robert H., Levitt, Naomi, Gaziano, Thomas A., Ghannem, Hassen, Laatikainen, Tiina, Rabadan-Diehl, Cristina, Engelgau, Michael M., Belis, Deshiree, Sampson, Uchechukwu, Smith, Richard, Dianis, Nancy L., Wolbach, Tracy L., Matta, Gabriela, Gutierrez, Laura, Elorriaga, Natalia, Poggio, Rosana, Irazola, Vilma, Bazzano, Lydia, Bhuiya, Abbas, Wazed, Abdul, Khan, Alfazal, Siddiquee, Ali T., Islam, Anwar, Khan, Jahangir A.M., Uddin, Jasim, Hasan, Khaled, Khanam, Masuma A., Yunus, Mohammad, Chowdhury, Muhammad A.H., Monalisa, Nazratun N., Alam, Nurul, Streatfield, Peter K., Ahmed, Shyfuddin, Parvin, Sonia, Ali, Taslim, Niessen, Louis W., Hossain, Mohammad D., Koehlmoos, Tracey L.P., Standing, Hilary, Lucas, Henry, Bleich, Sara N., Anderson, Gerard F., Trujillo, Antonio J., Mirelman, Andrew J., Hao, Jesse, Zhang, Jing, Tian, Maoyi, Huang, Polly, Luo, Rong, Fang, Weigang, Li, Xian, Feng, Xiangxian, Li, Zhifang, Deal, Kelly, Peterson, Eric, DeLong, Elizabeth, Zhou, Bo, Shi, Jingpu, Neal, Bruce, Jan, Stephen, Li, Nicole, McMahon, Stephen, Zhang, Jianxin, Sun, Jixin, Elliot, Paul, Zhao, Yi, Zhang, Yuhong, Yao, Chen, Sun, Ningling Huang, Han, Qide, Shen, Ruqun, Niu, Wenyi, Wang, Yanfang, Ke, Yang, Huang, Yining, Leeder, Stephen, Lopez, Alan, Zhang, Ruijuan, Yu, Yan, Roman, Ana V., Mendoza, Carlos, Roche, Dina, Mejicano, Gabriela, Cordova, Maria A., Kroker, Maria F., Fort, Meredith, Letona, Paola, Kanter, Rebecca, Garcia, Regina, Murillo, Sandra, Chacon, Violeta, Montero, Rafael, Lopez, Erika J., Peña, Liz, Castro, Maricruz, Dengo, Ana L., Ulate, Emilce, Alvarado, Nadia, Sibrian, Josefina, Alegria, Astarte, Gutierrez, Ana M., Fontes, Flavia, Sigamani, Alben, Kamath, Deepak, Xavier, Freeda, Deepthi, K.B., Anupama, M., Mathu, Nandini, George, Nisha, Rahul, Pranjali, Pais, Prem, Girish, Preeti, Thomas, Seena, Usha, T., Thomas, Tinku, Joshi, Rajnish, Chidambaram, N., Gupta, Rajeev, Chow, Clara, Pogue, Janice, O'Donnell, Martin, Devereaux, P.J., Misquith, Dominic, Agrawal, Twinkle, Fathima, Farah N., Reddy, Kolli Srinath, Shivashankar, Roopa, Ajay, Vamadevan S., Khan, Hassan M., Kadir, M. Masood, Masood, Muhammad Q., Fatmi, Zafar, Krishnan, Anand, Singh, Kavita, Tandon, Nikhil, Khadgawat, Rajesh, Menon, V. Usha, Sethi, Bipin Kumar, Unnikrishnan, A.G., Hutcheson, Mark L., Ali, Mohammed K., Cunningham, Solveig A., Patel, Shivani A., Gujral, Unjali, Desai, Ankush, Mohan, Deepa, Pradeepa, R. Guha, Mohan, V., Viswanathan, Vijay, Sahay, Rakesh, Shah, Seema, Bantwal, Ganapathi, Varthakavi, Premlata K., Nair, Manisha, Akwanalo, Constantine, Lagat, David, Barasa, Felix, Koech, Myra, Sugut, Wilson, Korir, Belinda, Mosol, Priscah, Ali, Shamim, Sherman, Charles B., Carter, Jane, Bloomfield, Gerald, Binanay, Cynthia, Vedanthan, Rajesh, Bernabé-Ortiz, A., León-Velarde, F., Smith, George D., Málaga, Germán, García, Héctor H., Casas, Juan P., Sacksteder, Katherine, Smeeth, Liam, Huicho, Luis, Rivera, María, Gamboa, Raúl, Ebrahim, Shah, Montori, Víctor M., Wise, Robert A., Checkley, William, Diette, Gregory B., Nojilana, Beatrice, Majikela-Dlangamandla, Buyelwa, Sylvester, Carmelita, Malan, Johanna, Murphy, Katherine, Steyn, Krisela, van Niekerk, Lindi, Mash, Robert, Puoane, Thandi, Kim, Grace, Pandya, Ankur, Abrahams-Gessel, Shafika, Rhode, Hilary, Pather, Michael, Andrade, Alvaro R., Garcia, Beatriz, Velasco, Carlos, Medina, David, Bravo, Delia, Munguia, Diana, Bateman, Eric, Castro, Francisco, Schneider, Helen, Ibarra, Ilse, Zulu, Jabulisiwe, Felix, Joel, Tribe, Karla, Bobrow, Kirsten, Fairall, Lara, Folb, Naomi, Murillo, Norma, Pacheco, Norma, Rodriguez, Paloma, Navarro, Paola, Flores, Reyna, Van Zyl Smit, Richard, Meddoza, Rosario, Surka, Sameer, Van Haght, Serena, Hernandez, Yanira, Tsolekile, Lungiswa, Jeridi, Gouider, Harrabi, Imed, Maatoug, Jihen, Boughammoura, Lamia, Chaieb, Larbi, Mrizek, Nejib, Gaha, Rafika, Limam, Khalifa, Amimi, Souad, Gaha, Karima, Gamra, Habib, Al'Absi, Mustafa, Vartiainen, Erkki, Moore, Cornelius, Spillan, Debi, Cooper, Kristiane, Mitchell, Megan, Kirby, Ruth, Gao, Yunling, Aluko, Emmanuel, Sampson, Uchechukwu K., Miranda, Jaime, and Bloomfield, Gerald S.

Published
2016
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47. Cover

Author

DiStefano, Michael J., primary, Alexander, G. Caleb, additional, Polsky, Daniel, additional, and Anderson, Gerard F., additional

Published
2022
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49. Public opinion regarding U.S. Food and Drug Administration approval of aducanumab: A nationally representative survey

Author

DiStefano, Michael J., Alexander, G. Caleb, Polsky, Daniel, and Anderson, Gerard F.

Subjects
Article
Abstract

BACKGROUND: Despite controversy among experts regarding aducanumab’s approval by the U.S. Food and Drug Administration, little is known about public opinion on this matter. METHODS: We conducted a representative survey of U.S. adults ages 35 and older to 1) determine opinions regarding aducanumab’s approval, 2) identify any evidence of reputational injury to the Food and Drug Administration, and 3) explore opinions regarding policy responses available to policymakers, such as those relating to a national coverage determination by the Centers for Medicare and Medicaid Services. The survey was administered online and in English and Spanish using a probability-based sample derived from the National Opinion Research Center’s AmeriSpeak® panel. Selection probabilities in the panel and survey design account for differences in population distribution and expected response rates by demographic. The survey was analyzed using survey weights to adjust for selection probabilities and non-response. RESULTS: A total of 1,205 respondents completed the survey. While approximately three-quarters of respondents were initially unfamiliar with aducanumab, respondents were less supportive of the drug’s approval once given information about the drug’s potential clinical and economic impact. Sixty-three percent of respondents support restricting aducanumab access to patients most likely to benefit. Seventy-one percent indicated a willingness to enroll a family member with mild Alzheimer’s disease in a “waitlist”-style trial to further study aducanumab; sixty percent indicated willingness to enroll a family member in a randomized placebo-controlled trial. Eighty-one percent agree aducanumab should be withdrawn from the market if confirmatory trials fail. The median respondent was willing to pay $1–5 in higher Part B premiums to cover aducanumab. CONCLUSION: These findings demonstrate support for a range of proposed policies in response to aducanumab’s approval. The opinions of an informed public ought to be considered when developing policies in response to aducanumab’s approval.

Published
2022

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