Dataset Information

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

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 outpatient 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.

SUBMITTER: Sen AP

PROVIDER: S-EPMC9441285 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

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

Sen Aditi P AP Singh Yashaswini Y Anderson Gerard F GF

Health services research 20220215 5

<h4>Objective</h4>To compare prices paid by commercial insurers for ambulatory services in physician office and hospital outpatient settings.<h4>Data sources</h4>MarketScan Commercial Claims and Encounters database obtained from Truven Health Analytics.<h4>Study design</h4>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-drive ...[more]

PMID: 35041209

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Project description:ObjectivesCommunity-based health insurance (CBI) is a common mechanism to generate financial resources for health care in developing countries. We review for the first time provider payment methods used in CBI in developing countries and their impact on CBI performance.MethodsWe conducted a systematic review of the literature on provider payment methods used by CBI in developing countries published up to January 2010.ResultsInformation on provider payment was available for a total of 32 CBI schemes in 34 reviewed publications: 17 schemes in South Asia, 10 in sub-Saharan Africa, 4 in East Asia and 1 in Latin America. Various types of provider payment were applied by the CBI schemes: 17 used fee-for-service, 12 used salaries, 9 applied a coverage ceiling, 7 used capitation and 6 applied a co-insurance. The evidence suggests that provider payment impacts CBI performance through provider participation and support for CBI, population enrolment and patient satisfaction with CBI, quantity and quality of services provided and provider and patient retention. Lack of provider participation in designing and choosing a CBI payment method can lead to reduced provider support for the scheme.ConclusionCBI schemes in developing countries have used a wide range of provider payment methods. The existing evidence suggests that payment methods are a key determinant of CBI performance and sustainability, but the strength of this evidence is limited since it is largely based on observational studies rather than on trials or on quasi-experimental research. According to the evidence, provider payment can affect provider participation, satisfaction and retention in CBI; the quantity and quality of services provided to CBI patients; patient demand of CBI services; and population enrollment, risk pooling and financial sustainability of CBI. CBI schemes should carefully consider how their current payment methods influence their performance, how changes in the methods could improve performance, and how such effects could be assessed with scientific rigour to increase the strength of evidence on this topic.

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Dataset Information

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

Objective

Data sources

Study design

Data collection

Principal findings

Conclusions

Publications

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

Similar Datasets

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