Commercial Prices for Primary Care Physician Office Visits.

Abstract

Background: Primary care is the frontline and cornerstone of the US healthcare system. Prices paid by commercial insurance plans, which cover the majority of the US population, influence primary care physicians' (PCPs) labor supply and patients' access to care. However, little is known regarding the level and variation of commercial prices for primary care and the associated factors.

Objective: To examine the level and variation in commercial prices for PCP office visits and assess physician-level, practice-level, and market-level factors that explain the price variation.

Design: Cross-sectional observational study.

Participants: A total of 174,561 PCPs offering office visit services for commercially insured patients from four national insurers-Blue Cross Blue Shield (BCBS), Cigna, Elevance Health, and United Healthcare, using insurer-disclosed Transparency in Coverage (TiC) pricing data as of March 2024.

Main measures: Outcomes are 876,079 commercial prices for level 3 PCP office visits for both new and established patients, measured at the physician-insurer-service level.

Key results: National mean commercial prices were $145.2 (95% CI $145.0-$145.4) and $101.6 (95% CI $101.5-$101.7) for level 3 new and established patient office visits, respectively. For new patient office visits, PCPs with corporate ownership obtained 17.9% (95% CI 17.7-18.2%) higher prices. PCPs practicing in organizations with more than 100 physicians negotiated 28% (95% CI 27.3-28.7%) higher prices than solo practices. Prevalence of corporate ownership and large practice affiliation was substantially higher among young PCPs aged 31-40. PCPs specializing in family medicine and practicing in counties with lower median household income negotiated lower prices. Results were consistent for established patient office visits.

Conclusions: PCPs' corporate ownership, size of practice, age, specialty, and local income level are important factors that explain the commercial pricing variation and are crucial for improving the US primary care system.