How Do the Hospital Prices Paid by Medicare Advantage Plans and Commercial Plans Compare With Medicare Fee-for-Service Prices?

Maeda, Jared Lane K.; Nelson, Lyle

doi:10.1177/0046958018779654

Cited by 17 publications

(23 citation statements)

References 6 publications

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“…These findings are surprising because prior research has found that private insurers typically pay more than Medicaid, 8,16 and Medicare rates. 3,6,[8][9][10] Although median prices paid by private insurers in Maine and Connecticut were similar to Medicaid rates for fluoride varnish in these states, these states' Medicaid agencies pay for fluoride varnish plus additional preventive oral health services (i.e., risk assessment and/or oral evaluation), just like 14 other Medicaid agencies. 37 The combined Medicaid payments for "fluoride varnish plus" were substantially higher than prices paid by private insurers for nearly fluoride varnish claims-more than double the median price paid by private insurers for fluoride varnish in these states.…”

Section: Discussionmentioning

confidence: 88%

“…[1][2][3][4][5][6] Studies find higher prices among private insurers than Medicare and Medicaid. 3,[6][7][8][9][10] These studies, however, are generally focused on adults, hospital prices, and comparisons between private insurers and Medicare, which rarely covers pediatric services. 11 Research has typically focused on comparisons to Medicare which is a national program with prices set administratively.…”

Section: Introductionmentioning

confidence: 99%

“…Variation in prices paid for health care services is well‐documented across geography and payer 1–6 . Studies find higher prices among private insurers than Medicare and Medicaid 3,6–10 . These studies, however, are generally focused on adults, hospital prices, and comparisons between private insurers and Medicare, which rarely covers pediatric services 11 .…”

Section: Introductionmentioning

confidence: 99%

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Variation in prices for an evidence‐based pediatric preventive service

Kranz

Gahlon

Dick

et al. 2022

Health Services Research

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Objective To examine variation in prices paid by private medical insurers for fluoride varnish applications in medical settings, a newly reimbursed service that few children receive. Data Sources Private‐insurance medical claims from Connecticut, Maine, New Hampshire, and Rhode Island (2016–2018). Study Design We examined prices paid for fluoride varnish by private insurers and compared these to prices paid by Medicaid. Data Collection/Extraction Methods Private claims for fluoride varnish during medical visits for children aged 1–5 years. State Medicaid rates for fluoride varnish were obtained from the American Academy of Pediatrics. Principal Findings Prices paid for fluoride varnish by private insurers varied within and across states, ranging from less than $5 to $50. Median prices closely followed Medicaid rates in three of the four states. In states covering a package of fluoride varnish plus additional preventive oral health services during medical visits, combined Medicaid rates were nearly double the median price paid by private insurers. Conclusions Fluoride varnish is a recommended service, but few children receive it. Price variation may contribute to the low uptake of this service. Ensuring sufficient Medicaid and private insurance rates could increase fluoride varnish applications in medical settings and improve oral health.

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Section: Discussionmentioning

confidence: 88%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Variation in prices for an evidence‐based pediatric preventive service

Kranz

Gahlon

Dick

et al. 2022

Health Services Research

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“…Medicare Fee-for-Service [FFS], Medicaid Advantage [MA], and Medicaid versus commercial) but were anchored to the FFS reimbursement rates captured through the 2019 Medicare Fee Schedules and adjusted to 2020 US dollars using the medical care component of the US Consumer Price Index. The reimbursement for commercial plans was inflated by 89% over FFS rates 32 , while other plan types were set equal to FFS rates. FFS reimbursement rates reflect the mean base Diagnosis-Related Group (DRG) and add-on payments to hospitals.…”

Section: Methodsmentioning

confidence: 99%

Cost analysis of the impact of caplacizumab in the treatment of acquired thrombotic thrombocytopenic purpura from a US hospital perspective

Pollissard

Leinwand

Fournier

et al. 2021

Journal of Medical Economics

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Aim: This study aimed to model the financial impact of caplacizumab with therapeutic plasma exchange (TPE) þ immunosuppression for patients experiencing an acute acquired thrombotic thrombocytopenic purpura (aTTP) episode versus TPE þ immunosuppression, from a US hospital's perspective. Methods and materials:We developed an economic model to estimate the impact of caplacizumab on a US hospital's budget. Cost offsets from caplacizumab utilization targeted inpatient general ward days, intensive care unit (ICU) days, and TPE utilization. Costs and event probabilities were estimated from primary data analyses of the phase 3 HERCULES trial and peer-reviewed literature or other public sources. Plan reimbursement was obtained from 2019 Medicare Fee Schedules and adjusted to represent reimbursement from different US payers. Cost of ICU and general ward utilization were estimated from Medicare Provider Analysis and Review data analyses capturing hospital discharges.

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“…HCRU and costs are usually different for those enrolled in commercial health insurance compared with those enrolled in MAPD plans (majority are aged 65 years and older). [22][23][24] Additionally, because the study population was predominantly enrolled in MAPD plans (~90%), the HCRU and costs were reported only for those enrolled in MAPD plans during the measurement year and follow-up year.…”

Section: Patient Selectionmentioning

confidence: 99%

Health Care Effect of Disease-Modifying Antirheumatic Drug Use on Patients with Rheumatoid Arthritis

Boytsov

Bhattacharya

Saverno

et al. 2019

JMCP

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BACKGROUND: Disease-modifying antirheumatic drugs (DMARDs) are recommended as the standard of care for patients with rheumatoid arthritis (RA) due to their ability to reduce pain and disability; however, DMARD use is low in some subgroups of the RA population.OBJECTIVE: To identify characteristics associated with DMARD use in the overall cohort of patients with RA and newly diagnosed RA patients.METHODS: This retrospective observational study used claims from a large national health plan. Use of DMARDs was measured according to the Healthcare Effectiveness Data and Information Set (HEDIS) as the proportion of patients with RA receiving DMARDs. Following HEDIS measure technical specifications, we identified patients aged 18-89 years with continuous enrollment during 2014 (measurement year) with ≥ 2 claims for RA outpatient visits and/or discharges on different dates between January and November 2014. Additionally, we identified a subset of patients newly diagnosed with RA in 2014 based on absence of any claims for RA or DMARDs in 2013. Descriptive analyses and bivariate associations were used to compare demographic and clinical characteristics of patients with RA with or without DMARD use in 2014. Health care resource utilization (HCRU) and costs were compared in 2014 for patients enrolled in Medicare Advantage Prescription Drug (MAPD) plans during both 2014 and 2015. Regression models were used to evaluate patient and provider characteristics associated with DMARD use in 2014 and the effect on HCRU and costs. RESULTS: Among the 33,880 patients identified with RA in 2014, most patients received a DMARD (75.2%); 29.4% of patients newly diagnosed with RA had been treated with DMARDs in 2014. Patients with DMARD use, on average, were younger (aged 67 years ± 10.7 vs. 69 years ± 10.7) and healthier (Deyo-Charlson Comorbidity Index [DCCI] 2.4 ± 1.9 vs. 2.6 ± 2.1) and included a greater proportion of women (75.9% vs. 71.0%) than those with no DMARD use (P < 0.0001). Use of DMARDs (P < 0.0001) was associated with 14.5% fewer hospitalizations and 18.0% fewer emergency department visits. Although total costs increased by 15.0% with use of DMARDs, when the cost of DMARDs was excluded, the total cost decreased by 13.7% (P < 0.0001). Female gender (32.2%), higher claims-based index for RA severity score (47.0%), higher RxRisk-V score (26.7%), visit to a rheumatologist (34.3%), and use of glucocorticoids (17.7%) increased the odds of DMARD use (P < 0.0001). Use of certain classes of medication, such as nonsteroidal anti-inflammatory drugs (12.3%), opioids (19.5%), antidepressants (20.0%), muscle relaxants (12.5%), and anticonvulsants (15.5%), were associated with lower use of DMARDs (P < 0.0001). CONCLUSIONS:We found significant differences in demographic and clinical characteristics between patients with and without DMARD use, which can potentially inform treatment decisions regarding DMARD use as deemed necessary by the provider. Future research should investigate the reasons for lack of treatment.

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How Do the Hospital Prices Paid by Medicare Advantage Plans and Commercial Plans Compare With Medicare Fee-for-Service Prices?

Cited by 17 publications

References 6 publications

Variation in prices for an evidence‐based pediatric preventive service

Variation in prices for an evidence‐based pediatric preventive service

Cost analysis of the impact of caplacizumab in the treatment of acquired thrombotic thrombocytopenic purpura from a US hospital perspective

Health Care Effect of Disease-Modifying Antirheumatic Drug Use on Patients with Rheumatoid Arthritis

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