The Milbank Quarterly最新文献

{"title":"A Comparative Analysis of International Drug Price Negotiation Frameworks: An Interview Study of Key Stakeholders","authors":"ISELIN DAHLEN SYVERSEN, KEVIN SCHULMAN, AARON S. KESSELHEIM, WILLIAM B. FELDMAN","doi":"10.1111/1468-0009.12714","DOIUrl":"https://doi.org/10.1111/1468-0009.12714","url":null,"abstract":"<jats:label/><jats:boxed-text content-type=\"box\" position=\"anchor\"><jats:caption>Policy Points</jats:caption><jats:list list-type=\"bullet\"> <jats:list-item>Health care systems around the world rely on a range of methods to ensure the affordability of prescription drugs, including negotiating prices soon after drug approval and relying on formal clinical assessments that compare newly approved therapies with existing alternatives.</jats:list-item> <jats:list-item>The negotiation framework established under the Inflation Reduction Act is far more limited than other frameworks explored in this study. Adding elements from these frameworks could lead to more effective price negotiation in the United States.</jats:list-item> </jats:list></jats:boxed-text>ContextIn 2022, Congress passed the Inflation Reduction Act, which allowed Medicare, for the first time, to begin negotiating the prices for certain high‐cost brand‐name prescription drugs. Many other industrialized countries negotiate drug prices, and we sought to compare and contrast key features of the negotiation process across several health systems. We focused, in particular, on the criteria for selecting drugs for price negotiation, procedures for negotiation, factors that influence negotiated prices, and how prices are implemented.MethodsWe included four G7 countries in our analysis (Canada, France, Germany, and the United Kingdom [England]), two Benelux countries (Belgium and the Netherlands), and one Scandinavian country (Norway) with long‐established frameworks for drug price negotiation. We also analyzed the Veterans Affairs Health System in the United States. For each system, we gathered relevant legislation, government publications, and guidelines to understand negotiation frameworks, and we reached out to key drug price negotiators in each system to conduct semistructured interviews. All interviews were recorded, transcribed, and coded, and data were analyzed based on an internal assessment tool that we developed.FindingsAll eight systems negotiate the prices of brand‐name prescription drugs soon after approval and rely on formal clinical assessments that compare newly approved drugs with existing therapies. Systems in our study differed on characteristics such as whether the body performing clinical assessments is separate from the negotiating authority, how added health benefit is assessed, whether explicit willingness‐to‐pay thresholds are employed, and how specific approaches for priority disease areas are taken.ConclusionsHigh‐income countries around the world adopt different approaches to conducting price negotiations on brand‐name drugs but coalesce around a set of practices that will largely be absent from the current Medicare negotiation framework. US policymakers might consider adding some of these characteristics in the future to improve negotiation outcomes.","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248850","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In the September 2024 Issue of the Quarterly","authors":"ALAN B. COHEN","doi":"10.1111/1468-0009.12716","DOIUrl":"https://doi.org/10.1111/1468-0009.12716","url":null,"abstract":"","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":"55 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Orphan Drug Act at 40: Legislative Triumph and the Challenges of Success","authors":"PETER SALTONSTALL, HEIDI ROSS, PAUL T. KIM","doi":"10.1111/1468-0009.12680","DOIUrl":"https://doi.org/10.1111/1468-0009.12680","url":null,"abstract":"<div>\u0000<div>\u0000<h3>Policy Points</h3>\u0000<p>\u0000</p><ul>\u0000<li>The Orphan Drug Act (ODA) was the result of patient advocacy and by many measures has been strikingly successful. However, approximately 95% of the more than 7,000 known rare diseases still have no US Food and Drug Administration–approved treatment.</li>\u0000<li>The ODA's success led to sustained criticism of high drug prices, often for products that have orphan drug indications. Critics misconstrue the ODA's intent and propose reducing its incentives instead of pursuing policies focused on addressing broader prescription drug price challenges that exist in both the orphan and nonorphan drug market.</li>\u0000<li>Patients and their families will continue to defend the purpose and integrity of the ODA and to drive investments into rare disease research and clinical development.</li>\u0000</ul><p></p></div>\u0000</div>","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":"34 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138693355","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Life Satisfaction and Subsequent Physical, Behavioral, and Psychosocial Health in Older Adults.","authors":"Eric S Kim,&nbsp;Scott W Delaney,&nbsp;Louis Tay,&nbsp;Ying Chen,&nbsp;E D Diener,&nbsp;Tyler J Vanderweele","doi":"10.1111/1468-0009.12497","DOIUrl":"https://doi.org/10.1111/1468-0009.12497","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Policy Points Several intergovernmental organizations (Organisation for Economic Co-operation and Development, World Health Organization, United Nations) are urging countries to use well-being indicators (e.g., life satisfaction) in addition to traditional economic indicators when making important policy decisions. As the number of governments implementing this new approach grows, so does the need to continue evaluating the health and well-being outcomes we might observe from policies aimed at improving life satisfaction. The results of this study suggest that life satisfaction is a valuable target for policies aiming to enhance several indicators of psychosocial well-being, health behaviors, and physical health outcomes.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Context: &lt;/strong&gt;Several intergovernmental organizations (Organisation for Economic Co-operation and Development, World Health Organization, United Nations) are urging countries to use well-being indicators (e.g., life satisfaction) in addition to traditional economic indicators when making important policy decisions. As the number of governments implementing this new approach grows, so does the need to continue evaluating the health and well-being outcomes we might observe from policies aimed at improving life satisfaction.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;We evaluated whether positive change in life satisfaction (between t&lt;sub&gt;0&lt;/sub&gt; ;2006/2008 and t&lt;sub&gt;1&lt;/sub&gt; ;2010/2012) was associated with better outcomes on 35 indicators of physical, behavioral, and psychosocial health and well-being (in t&lt;sub&gt;2&lt;/sub&gt; ;2014/2016). Data were from 12,998 participants in the University of Michigan's Health and Retirement Study-a prospective and nationally representative cohort of US adults over age 50.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;Participants with the highest (versus lowest) life satisfaction had better subsequent outcomes on some physical health indicators (lower risk of pain, physical functioning limitations, and mortality; lower number of chronic conditions; and higher self-rated health) and health behaviors (lower risk of sleep problems and more frequent physical activity), and nearly all psychosocial indicators (higher positive affect, optimism, purpose in life, mastery, health mastery, financial mastery, and likelihood of living with spouse/partner; and lower depression, depressive symptoms, hopelessness, negative affect, perceived constraints, and loneliness) over the 4-year follow-up period. However, life satisfaction was not subsequently associated with many specific health conditions (i.e., diabetes, hypertension, stroke, cancer, heart disease, lung disease, arthritis, overweight/obesity, or cognitive impairment), other health behaviors (i.e., binge drinking or smoking), or frequency of contact with children, family, or friends.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;These results suggest that life satisfaction is a valuable target for policies aiming to enhance several indicators of psychosocial well-being, ","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":" ","pages":"209-239"},"PeriodicalIF":6.6,"publicationDate":"2021-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1111/1468-0009.12497","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25321360","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In the March 2021 Issue of the Quarterly.","authors":"Alan B Cohen","doi":"10.1111/1468-0009.12512","DOIUrl":"https://doi.org/10.1111/1468-0009.12512","url":null,"abstract":"Since the launch of the Quarterly’s Building Back Better series of policy opinion posts in November 2020, the United States has experienced one of the most tumultuous and traumatic periods in its history. In fact, the entire year of 2020 will be remembered as a “perfect storm” of global pandemic, tragically avoidable death, reduced life expectancy, economic depression, racial injustice, and civil unrest. Fortunately, the violent insurrection at the US Capitol on January 6, 2021, failed, and the inauguration of President Biden occurred two weeks later without incident. Since taking office, the Biden administration has initiated a host of federal policy changes affecting not only health but other areas of policy that relate to health, most notably environmental protection and climate change. Some of these policy shifts reverse Trump-era policies harmful to health, while others aim to improve or strengthen existing programs. Not surprisingly, many have aligned closely with ideas and recommendations contained in the 13 pieces posted thus far in the Building Back Better series. Because the administration continues to face formidable challenges that require timely, practical, evidence-based policy advice, we will continue the series for the foreseeable future and invite readers to visit our website (https://www.milbank.org/quarterly/ building-back-better/). The four Perspectives in this issue of the Quarterly all embrace the spirit of “building back better.” In “Population Health Science: Fulfilling the Mission of Public Health,” Frederick Zimmerman argues that public health has been distracted from its historical mission of ensuring the conditions in which people can be healthy. He attributes this to a heavy reliance on randomized controlled trials, a dearth of formal theoretical models, and a reluctance to engage in politics. However, he believes that the field of population health is bringing needed scientific tools to the aid of public health in fulfilling its core mission. Persistent communication inequities have limited the access of racial and ethnic minorities to life-saving health information, making them more vulnerable to the harmful effects of misinformation. In “The Com-","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":" ","pages":"5-8"},"PeriodicalIF":6.6,"publicationDate":"2021-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1111/1468-0009.12512","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25504957","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?","authors":"Frank A Sloan","doi":"10.1111/1468-0009.12502","DOIUrl":"https://doi.org/10.1111/1468-0009.12502","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Context: &lt;/strong&gt;The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a \"must.\" For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":" ","pages":"273-327"},"PeriodicalIF":6.6,"publicationDate":"2021-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1111/1468-0009.12502","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25504958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Population Health Science: Fulfilling the Mission of Public Health.","authors":"Frederick J Zimmerman","doi":"10.1111/1468-0009.12493","DOIUrl":"https://doi.org/10.1111/1468-0009.12493","url":null,"abstract":"<p><p>Policy Points The historical mission of public health is to ensure the conditions in which people can be healthy, and yet the field of public health has been distracted from this mission by an excessive reliance on randomized-control trials, a lack of formal theoretical models, and a fear of politics. The field of population health science has emerged to rigorously address all of these constraints. It deserves ongoing and formal institutional support.</p>","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":" ","pages":"9-23"},"PeriodicalIF":6.6,"publicationDate":"2021-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1111/1468-0009.12493","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38711635","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Engaging Consumers in Medicaid Program Design: Strategies from the States.","authors":"Jane M Zhu,&nbsp;Ruth Rowland,&nbsp;Rose Gunn,&nbsp;Sarah Gollust,&nbsp;David T Grande","doi":"10.1111/1468-0009.12492","DOIUrl":"https://doi.org/10.1111/1468-0009.12492","url":null,"abstract":"<p><p>Policy Points As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are engaging consumers in the design and implementation of programs and policies. Through 50 semistructured interviews with Medicaid leaders in 14 states, we found significant variation in consumer engagement approaches, with many common facilitators, including leadership commitment, flexible strategies for recruiting and supporting consumer participation, and robust community partnerships. We provide early evidence on how state Medicaid agencies are integrating consumers' experiences and perspectives into their program design and governance.</p><p><strong>Context: </strong>Consumer engagement early in the process of health care policymaking may improve the effectiveness of program planning and implementation, promote patient-centric care, enhance beneficiary protections, and offer opportunities to improve service delivery. As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are currently engaging consumers in the design and implementation of programs and policies, and how this is being done.</p><p><strong>Methods: </strong>We conducted semistructured interviews with 50 Medicaid program leaders across 14 states, employing a stratified purposive sampling method to select state Medicaid programs based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interview data were audio-recorded, professionally transcribed, and underwent iterative coding with content and thematic analyses.</p><p><strong>Findings: </strong>First, we found variation in consumer engagement approaches, ranging from limited and largely symbolic interactions to longer-term deliberative bodies, with some states tailoring their federally mandated standing committees to engage consumers. Second, most states were motivated by pragmatic considerations, such as identifying and overcoming implementation challenges for agency programs. Third, states reported several common facilitators of successful consumer engagement efforts, including leadership commitment, flexible strategies for recruiting and supporting consumers' participation, and robust community partnerships. All states faced barriers to authentic and sustained engagement.</p><p><strong>Conclusions: </strong>Sharing best practices across states could help strengthen programs' engagement efforts, identify opportunities for program improvement reflecting community needs, and increase participation among a population that has traditionally lacked a political voice.</p>","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":" ","pages":"99-125"},"PeriodicalIF":6.6,"publicationDate":"2021-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1111/1468-0009.12492","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38711636","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In the September 2020 Issue of the Quarterly.","authors":"","doi":"10.1111/1468-0009.12478","DOIUrl":"https://doi.org/10.1111/1468-0009.12478","url":null,"abstract":"TheCOVID-19 pandemic remains in full swing across the globe, with the death toll mounting steadily while the search continues for effective vaccines and therapeutics to combat it. Few have been untouched by the epidemic’s rampage—whether having survived its deadly grip, suffered the loss of a loved one, lost one’s source of income, or simply had one’s life turned upside down by the restrictions put in place to stem its spread. COVID-19 pervasively rules the daily news cycle, dominates our thoughts and conversations, and dictates new norms of behavior that challenge and perhaps, at times, rankle our sensibilities. How long it will last is anyone’s guess. Recently, we issued a call for papers about health beyond COVID in three broad areas: improving population health; improving public health infrastructure; and improving health care. Thus far, we have been pleased to receive several thoughtful commentaries and original research articles in all three areas that will directly inform policymakers and policymaking in health and social sectors. The call for papers (https://www.milbank.org/quarterly/call-for-papers/) remains open through December 31, 2020. This issue of the Quarterly opens with two insightful Perspectives related to population health. In “Population Health in the Time of COVID-19: Confirmations and Revelations,” Ana Diez Roux reflects upon the clinical, epidemiologic, and social factors that drive the many visible manifestations of the pandemic in the population. She observes that the pandemic has revealed how we as a society have acted (or have failed to act) to protect our health, and she discusses the challenges and implications for the future, including how the pandemic may yield unanticipated opportunities for population health. She offers several suggestions for how we can change the way we live and how we may create systems and environments that promote health and health equity. In “Well-Being in the Nation: A Living Library of Measures to Drive Multisector Population Health Improvement and Address Social Determinants,” Somava Saha and colleagues describe how the 100 Million Healthier Lives framework facilitated a multisector collaboration to","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":" ","pages":"623-628"},"PeriodicalIF":6.6,"publicationDate":"2020-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1111/1468-0009.12478","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38364726","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Out-of-Network Air Ambulance Bills: Prevalence, Magnitude, and Policy Solutions.","authors":"Erin C Fuse Brown,&nbsp;Erin Trish,&nbsp;Bich Ly,&nbsp;Mark Hall,&nbsp;Loren Adler","doi":"10.1111/1468-0009.12464","DOIUrl":"https://doi.org/10.1111/1468-0009.12464","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Policy Points Out-of-network air ambulance bills are a type of surprise medical bill and are driven by many of the same market failures behind other surprise medical bills, including patients' inability to choose in-network providers in an emergency or to avoid potential balance billing by out-of-network providers. The financial risk to consumers is high because more than three-quarters of air ambulances are out-of-network and their prices are high and rising. Consumers facing out-of-network air ambulance bills have few legal protections owing to the Airline Deregulation Act's federal preemption of state laws. Any federal policies for surprise medical bills should also address surprise air ambulance bills and should incorporate substantive consumer protections-not just billing transparency-and correct the market distortions for air ambulances.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Context: &lt;/strong&gt;Out-of-network air ambulance bills are a growing problem for consumers. Because most air ambulance transports are out-of-network and prices are rising, patients are at risk of receiving large unexpected bills. This article estimates the prevalence and magnitude of privately insured persons' out-of-network air ambulance bills, describes the legal barriers to curtailing surprise air ambulance bills, and proposes policies to protect consumers from out-of-network air ambulance bills.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;We used the Health Care Cost Institute's 2014-2017 data from three large national insurers to evaluate the share of air ambulance claims that are out-of-network and the prevalence and magnitude of potential surprise balance bills, focusing on rotary-wing transports. We estimated the magnitude of potential balance bills for out-of-network air ambulance services by calculating the difference between the provider's billed charges and the insurer's out-of-network allowed amount, including the patient's cost-sharing. For in-network air ambulance transports, we calculated the average charges and allowed amounts, both in absolute magnitude and as a multiple of the rate that Medicare pays for the same service.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;We found that less than one-quarter of air ambulance transports of commercially insured patients were in-network. Two-in-five transports resulted in a potential balance bill, averaging $19,851. In the latter years of our data, in-network rates for transports by independent (non-hospital-based) carriers averaged $20,822, or 369% of the Medicare rate for the same service.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Because the states' efforts to curtail air ambulance balance billing have been preempted by the Airline Deregulation Act, a federal solution is needed. Owing to the failure of market forces to discipline either prices or supply, out-of-network air ambulance rates should be benchmarked to a multiple of Medicare rates or, alternatively, air ambulance services could be delivered and financed through an approach that combines competiti","PeriodicalId":501846,"journal":{"name":"The Milbank Quarterly","volume":" ","pages":"747-774"},"PeriodicalIF":6.6,"publicationDate":"2020-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1111/1468-0009.12464","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38033466","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}