Contemporary Trends in Out-of-Pocket Spending for Hospitalizations Among Adults in the United States
Authors: Emily Adrion, Andrew Ryan, Brahmajee Nallamothu
Theme: Costs and Benefits of Specific Medical Treatments
Health insurance policies have changed dramatically in recent years, with patients paying a growing share of their health care expenditures out-of-pocket. Beyond plan benefit surveys of deductibles and premiums, and patient-reported data subject to recall bias, few estimates of cost sharing exist, and little is known about the actual out-of-pocket expenses incurred by insured patients when they seek medical care. Understanding the out-of-pocket costs associated with inpatient hospitalizations is particularly important because, while cost sharing has the potential to reduce overuse and inappropriate use of health care, it can also impede access to appropriate care and affect treatment choices, and high levels of cost sharing can impact quality of life.
The data for this study were drawn from a large commercial health insurance claims database compiled by the Health Care Cost Institute (HCCI). Over 100 million inpatient claims and their associated member data were used to perform a retrospective analysis assessing the levels and trends in total cost sharing associated with inpatient hospitalizations among non-elderly commercially insured adults from 2009-2013, and to examine how inpatient cost sharing is distributed by mechanism (i.e., deductibles, copayments, coinsurance) as well as by age, gender, type of insurance, and geographic region. To ensure that differences in mean costs over time were not due to differences in case mix from one year to the next, we standardized the 2009-2012 claims to the 2013 pattern of inpatient hospitalizations. Generalized linear model (GLM) regression analysis was used to model total cost sharing for inpatient hospitalizations in 2013 as a function of demographic factors, plan type and geography.
Results showed that, from 2009 to 2013, mean total cost sharing per inpatient hospitalization increased by 33%, from $771 to $1,025, after adjusting for inflation and case-mix differences across years. GLM analysis found that enrollment in individual market plans was associated with 81 percent higher total cost sharing per inpatient hospitalization (0.812, 95% CI 0.799-0.824, p<.001) as compared to total cost sharing for patients enrolled in group insurance plans, holding all else constant. Enrollment in consumer-directed health plans (CDHPs) was associated with 34 percent higher total cost sharing per inpatient hospitalization (0.339, 95% CI 0.334-0.345, p<.001) as compared to patients enrolled in non-CDHP plans. Patients enrolled in HMO plans had adjusted total cost sharing that was 21.8% higher than for all other plan types (0.218, 95% CI 0.208-0.227, p<.001).
Our results suggest that out-of-pocket expenditures can be significant for inpatient admissions, even among insured individuals. Variation in spending highlights important features of insurance policies that are associated with a higher burden of out-of-pocket spending.