Medical loss ratio's role in the large group insurer market.

Objectives: To assess trends in the medical loss ratio (MLR) and understand how health insurance premiums in the large group market are driven by medical claims spending and insurer margins.

Study Design: Study of approximately 500 insurers covering more than 40 million lives annually in the large group market that submitted an MLR submission form (2014-2022).

Methods: We assessed trends in the MLR, premiums, medical claims spending, administrative costs, quality improvement spending, and margins among all insurers in the large group market.

Out-Of-Network Utilization and Plan Selection Among Medicare Advantage Cost Plan Enrollees.

Objective: To understand how Medicare Advantage (MA) networks impact utilization patterns and plan choices, using the 2019 discontinuation of MA 1876 Cost plans as a natural experiment.

Study Setting And Design: We study 1876 Cost plans, MA plans for which out-of-network care is covered through traditional Medicare (TM) and many of which CMS discontinued in 2019. We characterize the proportion of Cost plan enrollees who utilized out-of-network care in 2018 from different types of medical specialties.

Expected Out-Of-Pocket Costs: Comparing Medicare Advantage With Fee-For-Service Medicare.

We compared the generosity of Medicare plans in terms of out-of-pocket costs attributable to cost sharing and premiums, including both basic and supplemental services. From 2014 through 2019, projected out-of-pocket costs for a typical enrollee were 18-24 percent lower in Medicare Advantage than traditional fee-for-service Medicare.

Beyond average spending: distributional and seasonal commercial insurance trends, 2012-2021.

Objectives: The annual mean spending measures typically used to study longitudinal trends mask distributional and seasonal variation that is relevant to patients' perceptions of health care affordability and, in turn, provider collections. This study describes shifts in the distribution and seasonality of plan and patient out-of-pocket spending from 2012 through 2021.

Study Design: Analysis of multipayer commercial claims data.

Disparate Patient Advocacy When Facing Unaffordable and Problematic Medical Bills.

Importance: People in the US face high out-of-pocket medical expenses, yielding financial strain and debt.

Objective: To understand how households respond to medical bills they disagree with or cannot afford.

Design, Setting, And Participants: A retrospective cohort study was carried out using a survey fielded between August 14 and October 14, 2023.

Growing divergence between Medicare Advantage plan bids and payments to plans.

As the Medicare Advantage (MA) program grows in enrollment and costs, there has been increasing concern that federal payments to MA plans exceed necessary levels. Estimates suggest that, in 2023, MA plans were paid up to 6% more per enrollee than would have been spent had that beneficiary instead enrolled in traditional Medicare (TM). We evaluated the factors driving this overpayment, characterizing trends in MA benchmarks, bids, and total payments from pre-Affordable Care Act (pre-ACA) levels through 2023.

Deductible double jeopardy: patients may pay more out of pocket when pregnancy crosses 2 years.

Objectives: This study explores the concern that annual high-deductible commercial insurance plan design may yield higher out-of-pocket costs when an episode of maternity care spans 2 years, exposing patients to their cost-sharing limits twice during their episode of care.

Study Design: Cross-sectional study of Health Care Cost Institute commercial claims.

Methods: The study sample comprises 1,379,300 deliveries among high-deductible health plan enrollees in years 2012 through 2021.

Financial assistance and payment plans for underinsured patients shopping for "shoppable" hospital services.

Recent price transparency laws are designed to better inform patients as they compare hospital options and "shop" for health care services. In addition to prices, underinsured patients seeking care need information on financial assistance, discounts, payment plans, and upfront payment requirements to compare the affordability of care across hospitals. Little is known about the availability of this information and the experience of prospective patients seeking it.

Trends in the level and composition of supplemental benefits in Medicare Advantage.

Medicare Advantage (MA) plans that bid below benchmarks (or bidding targets) receive a portion of that difference as rebates, which they then must return to beneficiaries through supplemental benefits or reduced premiums or cost-sharing. Using Centers for Medicare & Medicaid Services data, we evaluate the growth in rebates and concomitant changes in supplemental benefit composition among health maintenance organizations (HMOs) and local preferred provider organizations (PPOs) from 2011 through 2022. Average rebates grew considerably, particularly after 2015 and among PPOs.

Fostering Flexibility: How Medicare Advantage Potentially Accelerated Telehealth Benefits.

In 2018, the US Congress enacted a policy permitting Medicare Advantage (MA) plans to cover telehealth services in a beneficiary's home and through audio-only means as part of the basic benefit package of services, where prior to the policy change such benefits were only allowed to be covered as a supplemental benefit. MA plans were afforded 2 years of lead time for strategizing, negotiating, and capital investment prior to the start date (January 1, 2020) of the new coverage option. Our data analysis found basic benefit telehealth was offered by plans comprising 71% of enrollment in 2020 and increased to 95% in 2021.

Part D beneficiaries' incentives and responses under preferred pharmacy networks.

Objectives: The share of Medicare stand-alone prescription drug plans with a preferred pharmacy network has grown from less than 9% in 2011 to 98% in 2021. This article assesses the financial incentives that such networks created for unsubsidized and subsidized beneficiaries and their pharmacy switching.

Study Design: We analyzed prescription drug claims data for a nationally representative 20% sample of Medicare beneficiaries from 2010 through 2016.

Substantial Growth In Medicare Advantage And Implications For Reform.

Medicare Advantage (MA) enrollment increased by 22.2 million beneficiaries (337.0 percent) from 2006 through 2022, whereas traditional Medicare enrollment declined by 1.

Ground Ambulance Billing And Prices Differ By Ownership Structure.

The No Surprises Act prohibits most surprise billing but notably does not apply to ground ambulance services. In this study we created a novel data set that identifies the ownership structure of ground ambulance organizations to compare pricing and billing between private- and public-sector ambulances, with a specific focus on organizations owned by private equity or publicly traded companies. Overall, we found that 28 percent of commercially insured emergency ground ambulance transports during the period 2014-17 resulted in a potential surprise bill.

Comparison of Estimated No Surprises Act Qualifying Payment Amounts and Payments to In-Network and Out-of-Network Emergency Medicine Professionals.

Importance: The No Surprises Act (NSA), which took effect on January 1, 2022, applies a qualifying payment amount (QPA) as an out-of-network payment reference point. An understanding of how QPA measures compare with the in-network and out-of-network payments physicians received before the NSA implementation may be useful to policy makers and stakeholders.

Objective: To estimate the QPA for geographic and funding markets and compare QPA estimates with in-network and out-of-network payments for 2019 emergency medicine claims.

Insurers negotiate lower hospital prices for HIX than for commercial groups.

Objectives: This study investigates a sample of the pricing data released by hospitals under the price transparency law effective January 2021 to better understand the prices paid by health insurance exchange (HIX) plans relative to commercial group and Medicare Advantage plans.

Study Design: Cross-sectional analysis of hospital pricing data.

Methods: We compared allowed amounts for 25 common inpatient services and 56 common outpatient services across 22 hospital-insurer dyads, selected by the availability of plan-specific pricing data from the top 100 hospitals by bed counts and the top 100 hospitals by gross revenue based on 2017 CMS data.

Medicare Advantage Plans Pay Large Markups To Consolidated Dialysis Organizations.

The 21st Century Cures Act of 2016 lifted regulations prohibiting Medicare Advantage (MA) enrollment after patients initiate dialysis, starting in 2021, and early reports indicate increased MA enrollment among such patients. Large shifts into Medicare Advantage could disrupt the market because the consolidated dialysis industry can negotiate payment from MA plans that is higher than that for fee-for-service Medicare. For three large insurers representing 48 percent of the 2016-17 MA market, we found that MA plans paid 27 percent more than fee-for-service Medicare.

Reforming the Medicare Part D Benefit Design: Financial Implications for Beneficiaries, Private Plans, Drug Manufacturers, and the Federal Government.

Context: Reforming the Medicare Part D program-which provides prescription drug coverage to 49 million beneficiaries-has emerged as a key policy priority.

Methods: The authors evaluate prescription drug claims from a 100% sample of Medicare Part D beneficiaries to evaluate the current spending distribution across different payers for different types of beneficiaries across different benefit phases. They then model how these estimates would change under a proposal to redesign the Medicare Part D standard benefit.

Dispute Resolution Outcomes for Surprise Bills in Texas.

This study examines Texas independent dispute resolution payment outcomes for clinicians and compares them with arbitration benchmarks.

Pharmacy switching in response to preferred pharmacy networks in Medicare Part D.

Objective: To evaluate the effects of preferred pharmacy networks-a tool that Medicare Part D plans have recently adopted to steer patients to lower cost pharmacies-on the use of preferred pharmacies and factors underlying beneficiaries' decisions on whether to switch to preferred pharmacies.

Data Sources: Medicare claims data were collected for a nationally representative 20% sample of beneficiaries during 2010-2016 and merged with annual Part D pharmacy network files.

Study Design: We examined preferred networks' impact on pharmacy choice by estimating a difference-in-differences model comparing preferred pharmacies' claim share before and after implementation among unsubsidized and subsidized beneficiaries.

Comparison of Spending on Common Generic Drugs by Medicare vs Costco Members.

This cross-sectional study uses 2017 and 2018 Medicare Part D clams to compare the amount Medicare pays for common generic prescriptions in Part D with prices available to patients without insurance at Costco.