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1 Supplementary Online Content Robinson JC, Brown TT, Whaley C, Finlayson E. Association of reference payment for colonoscopy with consumer choices, insurer spending, and procedural complications. JAMA Intern Med. Published online September 8, doi: /jamainternmed efigure. Prices in Hospital Outpatient Departments (HOPD) and Freestanding Ambulatory Surgery Centers (ASC) Prior to Implementation of Reference-Based Benefits etable 1. Descriptive Statistics etable 2. Multivariable Regression Association Between Reference Payment and Consumer Choice, Facility Prices, and Procedural Complications etable 3. Multivariable Regression Association between Reference Payment and Consumer Choice, Facility Prices, and Procedural Complications Stratified by Screening vs. Diagnostic Colonoscopy This supplementary material has been provided by the authors to give readers additional information about their work.

2 efigure. Prices in Hospital Outpatient Departments (HOPD) and Freestanding Ambulatory Surgery Centers (ASC) Prior to Implementation of Reference-Based Benefits The efigure presents the distribution of prices (allowed charges) for colonoscopy across ASCs and HOPDs in California in 2011, the year prior to implementation of reference payment by CalPERS. $10,000 $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 Reference Price ASC Price HOPD Price

3 etable 1. Descriptive Statistics CalPERS Number of procedures 7,097 7,299 7,248 7,043 6,508 Percent Screening Colonoscopy 67% 46% 51% 53% 54% Percent Diagnostic Colonoscopy 33% 54% 49% 47% 46% Percent Intervention Colonoscopy 47% 51% 53% 55% 57% Procedures Performed at Ambulatory Surgical Center (ASC) 4,873 5,026 5,023 5,434 5,176 Procedures Performed at Hospital Outpatient Department (HOPD): Not exempt from RBB 2,224 2,273 2, Procedures Performed at Hospital Outpatient Department (HOPD): Exempt from RBB NA NA NA Average Procedure Price (allowed charge) $1,587 $1,699 $1,716 $1,666 $1,730 Average HOPD Procedure Price (allowed charge) $2,490 $2,747 $2,883 $2,993 $3,014 Average ASC Procedure Price (allowed charge) $1,175 $1,225 $1,199 $1,273 $1,400 Average Charlson Score Percent Male 44% 43% 44% 43% 42% Average Age Any complication within 30 days of procedure 2.1% 2.4% 2.2% 2.0% 2.0% Anthem Blue Cross Number of procedures 50,091 49,443 49,406 52,733 56,943 Percent Screening Colonoscopy 63% 40% 45% 48% 50% Percent Diagnostic Colonoscopy 37% 60% 55% 52% 50% Percent Intervention Colonoscopy 50% 53% 55% 56% 58% Procedures Performed at Ambulatory Surgical Center (ASC) 35,337 35,387 36,137 38,925 41,737 Procedures Performed at Hospital Outpatient Department (HOPD) 14,754 14,056 13,269 13,808 15,206 Average Procedure Price (allowed charge) $1,436 $1,492 $1,537 $1,699 $1,758 Average HOPD Procedure Price (allowed charge) $2,406 $2,648 $2,738 $2,863 $2,848 Average ASC Procedure Price (allowed charge) $1,030 $1,033 $1,096 $1,286 $1,361 Average Charlson Score Percent Male 46% 46% 46% 46% 47% Average Age Any complication within 30 days of procedure 2.3% 2.5% 2.6% 2.5% 2.3%

4 etable 2. Multivariable Regression Association Between Reference Payment and Consumer Choice, Facility Prices, and Procedural Complications etable 2 presents the multivariable regression results for consumer choice of facility (column 1), procedure price paid in percentage terms (column 2), procedure price paid in dollar terms (column 3), and the probability of any complication within 30 days of procedure (column 4). Dependent variable (1) (2) (3) (4) Probability of Selecting ASC Procedure Price Paid Percent difference Procedure Price Paid Dollar difference Probability of Procedural Complication CalPERS X *** %*** *** (0.0295) (3.423) (63.35) ( ) CalPERS X *** %*** *** (0.0146) (2.976) (55.57) ( ) CalPERS X % (0.0103) (2.479) (38.64) ( ) CalPERS X % (0.0281) (2.073) (32.82) ( ) CalPERS ** 8.636%*** 132.7*** (0.0149) (2.781) (44.80) ( ) *** 14.76%*** 220.6*** (0.0373) (2.502) (39.35) ( ) *** 10.74%*** 163.5*** -4.67e-05 (0.0145) (2.072) (33.12) ( ) *** %*** *** (0.0174) (1.498) (23.64) ( ) *** %*** *** ** (0.0259) (1.882) (31.24) ( ) Exempt from RBB initiative *** 95.12%*** 1,071*** (0.0490) (9.619) (146.2) ( ) Interventional procedure %*** 206.4*** *** (0.0106) (3.478) (59.54) ( ) Screening procedure *** %** ** *** ( ) (2.078) (32.72) ( ) Screening procedure with intervention % *** ( ) (2.282) (37.45) ( ) Male % *** ( ) (0.882) (13.94) ( ) Charlson score *** 21.97%*** 318.3*** *** ( ) (2.142) (39.67) ( ) Age ** %*** ** *** ( ) (2.459) (51.89) ( ) Age *** %*** *** *** (0.0105) (4.296) (88.12) ( ) Age ** %*** *** *** (0.0126) (5.736) (112.3) ( )

5 Age %*** *** *** (0.0127) (5.215) (103.7) ( ) Observations 293, , , ,810 Robust standard errors clustered at provider-level in parentheses. *** p<0.01, ** p<0.05. Controls for Hospital Referral Region included but not reported.

6 etable 3. Multivariable Regression Association between Reference Payment and Consumer Choice, Facility Prices, and Procedural Complications Stratified by Screening vs. Diagnostic Colonoscopy etable 3 presents multivariable regression results that stratify by screening and diagnostic colonoscopy. Columns 1 and 2 present the probability of receiving care at an ASC for screening and colonoscopies, respectively. Columns 3 and 4 present the respective average procedure prices in percentage terms. Columns 5 and 6 present the probability of any complication within 30 days of colonoscopy. For all three outcomes, we find no substantial difference between screening and diagnostic colonoscopies. (1) (2) (3) (4) (5) (6) Outcome variable Probability of Selecting ASC Procedure Price Paid Probability of Surgical Complication Screening vs. diagnostic colonoscopy screening diagnostic screening diagnostic screening diagnostic CalPERS X *** 0.189*** %*** %*** (0.0322) (0.0279) (3.791) (4.355) ( ) ( ) CalPERS X *** 0.131*** %*** %*** (0.0240) (0.0196) (3.590) (3.279) ( ) ( ) CalPERS X % 2.869% (0.0123) (0.0107) (2.778) (3.002) ( ) ( ) CalPERS X % % (0.0124) (0.0128) (2.457) (3.337) ( ) ( ) CalPERS %** 10.67%*** (0.0155) (0.0142) (2.902) (3.196) ( ) ( ) %*** 19.50%*** -4.92e (0.0182) (0.0151) (2.436) (2.873) ( ) ( ) ** %*** 15.02%*** ( ) ( ) (1.742) (2.551) ( ) ( ) %** %*** ** ( ) ( ) (1.661) (1.598) ( ) ( ) ** %*** % *** ** (0.0126) (0.0105) (2.099) (2.148) ( ) ( ) exempt from RBB initiative *** *** 94.16%*** 94.38%*** (0.0729) (0.0596) (10.37) (9.641) ( ) ( ) interventional procedure %*** 13.74%*** *** *** (0.0111) (0.0118) (2.186) (3.419) ( ) ( ) male ** % % *** ( ) ( ) (1.003) (0.984) ( ) ( ) Charlson *** *** 29.28%*** 19.73%*** *** *** (0.0136) ( ) (2.981) (2.091) ( ) ( ) Age % %*** *** *** (0.0198) (0.0110) (6.284) (2.180) (0.0107) ( ) Age ** ** %** %*** *** *** (0.0255) (0.0164) (6.886) (4.146) (0.0111) ( ) Age ** ** %*** %*** *** *** (0.0286) (0.0195) (8.743) (5.487) (0.0113) ( ) Age ** %** %*** *** *** (0.0280) (0.0182) (8.427) (4.666) (0.0113) ( )

7 Observations 146, , , , , ,375 Robust standard errors clustered at provider-level in parentheses. *** p<0.01, ** p<0.05. Controls for Hospital Referral Region included but not reported.