5 Findings From the December 2019 Issue of AJMC®

The December issue of The American Journal of Managed Care^® included studies on out-of-network cost sharing, unhealthy alcohol use, patient health literacy, and more. Here are 5 findings from research published in the issue.

1. Health plans bear nearly all costs of new HCV medications

As new direct-acting antivirals have become the standard of care for hepatitis C virus (HCV) in recent years, this retrospective study examined trends in a commercial health plan’s spending on medications for its members with HCV. The authors found that following the availability of new HCV drugs, the proportion of members receiving HCV medication doubled and average health plan spending on HCV medications rose from $2868 to $16,503 per member with HCV. Costs paid by patients remained relatively low, as the health plan contributed more than 99% of spending on HCV medications.

The authors did not observe financial savings for the health plan resulting from curing HCV infection with the new drugs, but they noted that this may be due to the short 2-year study period. “Given that the average membership duration is about 2 to 3 years in most commercial health plans, financial benefits following cure of HCV infection by new DAAs…might not be realized during the enrollment span of most members receiving treatment,” they wrote.

2. Knowing the difference between preventive and office visits may be important for satisfaction

About two-thirds of participants in an online survey could not correctly answer all questions about the difference between a no-cost preventive visit and an office visit for a specific health concern, which could contribute to surprise medical bills and dissatisfaction with insurance providers. The researchers also found that patients who reported greater ease of obtaining information from their health insurance providers were less likely to say that they had been erroneously charged for medical visits.

The results suggest opportunities to further educate patients on what type of care is covered, which could help increase their satisfaction with their insurer and encourage more regular utilization of preventive care. According to the authors, “If patients continue to be confused or even scared that they will be charged for a healthcare visit when they should not be, population health will likely be slow to improve.”

3. Patients with unhealthy alcohol use more likely to be prescribed benzodiazepines

Despite the dangers of concurrent use of benzodiazepines and alcohol, this cross-sectional analysis found that patients with unhealthy alcohol use had 15% higher odds of using benzodiazepines than patients with low-risk alcohol use, but they had 40% lower daily doses and 18% shorter durations of benzodiazepine prescriptions. Women had 64% higher odds of benzodiazepine use than men, and white patients were most likely to use benzodiazepines.

According to the study authors, the observed patterns may be because patients with unhealthy alcohol use are more likely to use multiple abusable substances, but they or their clinicians limit their dose and duration to avoid the impairment associated with simultaneous alcohol and benzodiazepine use. They concluded that “concomitant benzodiazepine and excessive alcohol use among primary care patients should receive increased vigilance, and health system—wide efforts to reduce this potentially lethal combination should be considered.”

4. Utilization, spending compared across varying levels of financial risk

This study used claims and encounter data to examine utilization and spending in a large delivery system’s Medicare Advantage (MA) plan and Pioneer accountable care organization (ACO) as well as a local traditional Medicare comparison group. Investigators found that MA enrollees had lower risk-adjusted utilization and spending than members of the other 2 groups. Hospitalization rates in the Pioneer ACO group declined more rapidly than in the Medicare comparison group, but the effect on total medical spending was not significant.

Analyses showed few differences between the commercial ACO and the Medicare comparison group, which may be due to a higher degree of churn among the ACO patients. Still, the authors wrote, “our results overall support CMS’ efforts to transition Medicare reimbursement away from traditional fee-for-service.”

5. Rising patient cost sharing for out of-network care, especially for nonemergent hospitalizations

Cost-sharing payments for out-of-network (OON) care are gaining attention, with Congress working on legislation to limit surprise medical bills. This data analysis found that although rates of OON care slowly decreased from 2012 to 2017, patients’ cost-sharing amounts for this type of care increased rapidly during this time, especially for nonemergent hospitalizations, which nearly doubled from $671 to $1286. Better health status was associated with lower out-of-pocket payments for nonemergent hospitalizations but not outpatient care.

The study authors raised concerns about the financial burden imposed on patients by OON cost sharing. They recommended several policy fixes, including notifying patients of provider network status at the point of care and ensuring network adequacy in commercial plans, and concluded that “health plans that leverage networks to lower costs must be balanced with the potential need for broader consumer protections.”