There is considerable interest in how

Transcription

1 doi: /hlthaff HEALTH AFFAIRS 34, NO. 7 (2015): Project HOPE The People-to-People Health Foundation, Inc. By Katherine Hempstead, Iyue Sung, Joshua Gray, and Stewart Richardson DATAWATCH Tracking Trends In Provider Reimbursements And Patient Obligations Primary payments those made by insurance carriers to office-based physicians rose moderately between 2013 and Payments declined for orthopedics and surgery while increasing for primary care and obstetrics-gynecology. Patients payment obligations rose for all specialties, and deductibles were the largest category of increased patient spending. Katherine Hempstead (khempstead@rwjf.org) is a director at the Robert Wood Johnson Foundation, in Princeton, New Jersey, and a visiting research assistant professor in the Rutgers Center for State Health Policy, in New Brunswick, New Jersey. Iyue Sung is director of athenahealth, in Watertown, Massachusetts. Joshua Gray is vice president of athenahealth. Stewart Richardson is a senior analyst at athenahealth. There is considerable interest in how health reform and associated market forces are affecting patients and providers. Given significant changes in payer-provider contracting, the emergence of narrow networks, coverage expansion, and other changes in plan design, there are a number of potential effects. 1 The proportion of health care costs paid directly by patients has increased, and the impact of this trend on provider payment is uncertain. This report presents some timely data on trends in payments to providers and patients payment obligations. The data come from ACA- View, 2 a joint project of the Robert Wood Johnson Foundation and athenahealth, a health care software and services company. One of our main findings, the percentage change in primary payments that is, payments made by insurance carriers to health care providers for several major physician specialties, is shown in Exhibit 1. ACAView attempts to capture how health reform affects the day-to-day practice of community-based medicine. The project has collected data on more than seventeen million visits to nearly 15,000 providers in 2013 and Because the data reside in athenahealth s cloud-based data set, the information can be analyzed to provide a detailed assessment of clinical practice patterns and providers economic situations, with very little time lag. Exhibit 1 Percentage Change In Primary Payments By Established And New Patients Per Physician Visit, By Specialty, January September 2013 Versus January September 2014 Study Data And Methods The visits included in this study come from a cohort of physician practices that have been athenahealth clients since Providers specialties included primary care, surgery, orthopedics, and obstetrics-gynecology. This analysis compared reimbursements to providers and patients payment obligations for visits from new or established patients in 2013 or Patient obligations represent the total amount a patient owes for a visit, including any copayment, coinsurance, and deductible. New patient visits were defined as visits from patients who had not visited the practice in the twenty-four months prior to the visit date. The comparison of new and established patients was intended to explore how provider reimbursements and patient obligations might differ for patients with new commercial coverage from the health insurance Marketplaces or elsewhere. Although new patients are more likely than established patients to have recently obtained or 1220 Health Affairs July :7

2 changed coverage, this is not necessarily the case. Since the data in ACAView are from athenahealth s physician clients, the question of representativeness is important. To address this, we compared the ACAView data to those from the probability-based National Ambulatory Medical Care Survey (NAMCS). 3 We found that payer mix, patients demographic characteristics, and geographical location of physicians practices were similar in the two data sets (for details, see the online Appendix). 4 However, compared to the ACAView data, the NAMCS data have a notably higher share of solo practices (32 percent versus 13 percent) and a far lower percentage of practices with more than eleven physicians (14 percent versus 32 percent). This suggests that larger practices may be more likely than small practices to purchase cloud-based medical software. Study Results Provider Payments The analysis compared average provider reimbursement and patients payment obligations between January September 2013, and January September There were two overarching shifts in provider reimbursement. First, some rebalancing took place across specialties. Payments for primary care provider visits increased the most, for both new and established patients. Average payments for obstetrics-gynecology (OB-GYN) visits increased nearly 3 percent for established patients. Yet nominal payments declined for surgery and orthopedics visits, for new and established patients alike (Exhibit 1). Second, growth in payment was modest. The mean primary payment increased by 2.0 percent for established patients and 1.4 percent for new patients (Exhibit 2). Since new patients, on average, have more complex visits than established patients do, average nominal reimbursement per visit was in most cases higher for new patients. However, when standardized by relative value unit (RVU), reimbursement was in most cases somewhat lower for new patients than for established ones. Patients Payment Obligations Reflecting the growth in high-deductible plans, the data also show that patients are responsible for an increasing portion of the cost of their care over time. Across all specialties, between 2013 and 2014 the mean patient obligation increased by 3.5 percent for established patients and 2.7 percent for new patients (Exhibit 3). Consistent with changes in plan design that subject more types of health care services to the deductible, the increase in patient obligations was driven almost entirely by growth in deductibles. They increased by 9.5 percent for established patients and 7.9 percent for new patients. Copays fell in most instances, and coinsurance increased slightly or declined. Compared with established patients, new patients had higher total obligations, and a higher share came from the deductible. However, the difference between new and established patient obligations per RVU was much less than the nominal Exhibit 2 Primary Payment Per Physician Visit For Established And New Patients, By Specialty, January September 2013 Versus January September 2014 Nominal Overall $ $ $ $ Primary care OB-GYN Orthopedics Surgery Other specialties Per relative value unit Overall Primary care OB-GYN Orthopedics Surgery Other specialties NOTE OB-GYN is obstetrics-gynecology. July :7 Health Affairs 1221

3 Exhibit 3 Mean Patient Obligation Per Physician Visit For Established And New Patients, By Specialty, January September 2013 Versus January September 2014 Overall Copay $10.69 $11.13 $10.30 $ Coinsurance Deductible Total Primary care Copay Coinsurance Deductible Total Obstetrics/gynecology Copay Coinsurance Deductible Total Orthopedics Copay Coinsurance Deductible Total Surgery Copay Coinsurance Deductible Total Other specialties Copay Coinsurance Deductible Total difference (see the Appendix). 4 The percentage increase in average patient obligation was in most cases lower for surgery and orthopedics visits than for primary care provider and OB-GYN visits (Exhibit 3). However, mean patient obligations were nearly twice as high for surgery and orthopedics visits, compared to primary care provider and OB-GYN visits, for both new and established patients. Obligations And Allowables Patient obligations increased more than primary payments (Exhibit 4). In most cases, for primary care provider and OB-GYN visits, the increase in patient obligations was similar to that in primary payments. For surgery and orthopedics visits, the increase in patient obligations somewhat offset the decline in primary payments (Exhibit 4). However, the total allowables that is, the sum of primary payments and patient obligations for surgery and orthopedics visits declined for both established and new patients between 2013 and 2014 (Exhibit 5). For these two specialties, the patient share was approximately one-quarter of the total allowable amount, while for OB- GYN and primary care provider visits the patient share was approximately 22 percent (Exhibit 4). For all specialties and patient groups with the exception of primary care providers and new patients patient obligations increased more than primary payments did. Overall, total allowables increased by 2.3 percent for established and 1.7 percent for new patients (Exhibit 5). Discussion The trends in provider payment shown here are consistent with the slow growth in health care service prices reported elsewhere. 5 They also reflect a trend toward greater patient financial re Health Affairs July :7

4 Exhibit 4 Total Payment Per Physician Visit For Established And New Patients, By Specialty, January September 2013 Versus January September 2014 Overall Primary payment $ $ $ $ Patient obligation Total payment Patient share 20% 21% 20% 22% Primary care Primary payment $ $ $ $ Patient obligation Total payment Patient share 22% 21% 22% 21% Obstetrics/gynecology Primary payment $ $ $ $ Patient obligation Total payment Patient share 13% 15% 14% 15% Orthopedics Primary payment $ $ $ $ Patient obligation Total payment Patient share 23% 25% 24% 26% Surgery Primary payment $ $ $ $ Patient obligation Total payment Patient share 21% 22% 22% 23% Other specialties Primary payment $ $ $ $ Patient obligation Total payment Patient share 22% 22% 23% 23% sponsibility. 6 Compared to established patients, new patients appear to have had plan designs with greater cost sharing and lower provider payments. Overall, payments increased less for new patients than for established ones. Yet the upward trend in patient obligations for established patients, which overall grew at a higher rate than those for new patients, reflects the continued evolution of benefit design that is affecting the entire commercial insurance market. The differences in reimbursement trends by specialty reported here may reflect some broader changes in insurer strategy. Primary care providers have seen greater increases in insurance payments than their colleagues in surgery and orthopedics have. This relative increase may be due to two factors. First, the Affordable Care Act requires that patients not be required to pay out of pocket for selected preventive care services, which may fall disproportionately into primary care. Second, the relative increase in primary Exhibit 5 Percentage Change In Total Allowables Per Physician Visit By Established And New Patients, By Specialty, January September 2013 Versus January September 2014 NOTE Allowables are primary payments plus patients payment obligations (terms are explained in the text). July :7 Health Affairs 1223

5 care payments may reflect an insurer strategy to encourage the use of primary and preventive care while reducing the use of specialty care. Orthopedics lies at the other end of the spectrum. Primary payments for orthopedics visits fell substantially in This may also reflect a growing reliance on health plans with narrow networks, which may exclude certain high-cost specialists. With insurance payments for orthopedics visits declining on average, patients are now responsible for a greater portion of total payments than in the past. These trends were not explored in this analysis, but they may vary in important ways by characteristics of insurers and provider marketplaces. Conclusion Coverage expansion in the United States has benefited millions of people. However, the high out-of-pocket expenses that many people are facing may cause some to forgo nonurgent care. The overall implications for providers are unclear. Increased bad debt is one potential outcome. Providers who are able to do so may resist participating in networks with declining primary payments and a growing share due from patients. At the same time, these payment pressures may spur innovative behavior among providers to deliver care more efficiently, perhaps by using different payment models. It will be important to monitor changes in patient obligation and provider reimbursement as the effects of coverage expansion, risk contracting, and narrow networks continue to unfold. The degree to which these changes may affect access to care for low-income insured patients and debt levels for providers in particular deserves close scrutiny. Funding was provided by the Robert Wood Johnson Foundation. NOTES 1 Dunn A, Shapiro AH. Physician payments under health care reform. J Health Econ. 2015;39: athenaresearch. Observations on the Affordable Care Act: 2014 [Internet]. Watertown (MA): athenahealth; 2015 Feb 25 [cited 2015 May 1]. Available from: reports/issue_briefs/2015/ rwjf Centers for Disease Control and Prevention. Ambulatory health care data [Internet]. Atlanta (GA): CDC; [page last updated 2015 Apr 9; cited 2015 Apr 24]. Available from: To access the Appendix, click on the Appendix link in the box to the right of the article online. 5 Hartman M, Martin AB, Lassman D, Catlin A, National Health Expenditure Accounts Team. National health spending in 2013: growth slows, remains in step with the overall economy. Health Aff (Millwood). 2015; 34(1): Catlin MK, Poisal JA, Cowan CA. Out-of-pocket health expenditures, by insurance status, Health Aff (Millwood). 2015;34(1): Health Affairs July :7