Jeremy B Hatcher, George Lin, Cullen P Moran, Sara Al Hussein Al Awamlh, Lina Sulieman, Natalia G Morales, Sean T Berkowitz, Shriji Patel, Jennifer Lindsey
{"title":"费用分摊对平价医疗法案市场中眼科医疗使用的影响。","authors":"Jeremy B Hatcher, George Lin, Cullen P Moran, Sara Al Hussein Al Awamlh, Lina Sulieman, Natalia G Morales, Sean T Berkowitz, Shriji Patel, Jennifer Lindsey","doi":"10.1080/09286586.2023.2199849","DOIUrl":null,"url":null,"abstract":"<p><strong>Purpose: </strong>To determine the distribution and quantity of ophthalmic care consumed on Affordable Care Act (ACA) plans, the demographics of the population utilizing these services, and the relationship between ACA insurance coverage plan tier, cost sharing, and total cost of ophthalmic care consumed.</p><p><strong>Methods: </strong>This cross-sectional study analyzed ACA individual and small group market claims data from the Wakely Affordable Care Act (WACA) 2018 dataset, which contains detailed claims, enrollment, and premium data from Edge Servers for 3.9 million individual and small group market lives. We identified all enrollees with ophthalmology-specific billing, procedure, and national drug codes. We then analyzed the claims by plan type and calculated the total cost and out-of-pocket (OOP) cost.</p><p><strong>Results: </strong>Among 3.9 million enrollees in the WACA 2018 dataset, 538,169 (13.7%) had claims related to ophthalmology procedures, medications, and/or diagnoses. A total of $203 million was generated in ophthalmology-related claims, with $54 million in general services, $42 million in medications, $20 million in diagnostics and imaging, and $86 million in procedures. Average annual OOP costs were $116 per member, or 30.9% of the total cost, and were lowest for members with platinum plans (16% OOP) and income-driven cost sharing reduction (ICSR) subsidies (17% OOP). Despite stable ocular disease distribution across plan types, beneficiaries with silver ICSR subsidies consumed more total care than any other plan, higher than platinum plan enrollees and almost 1.5× the cost of bronze plan enrollees.</p><p><strong>Conclusions: </strong>Ophthalmic care for enrollees on ACA plans generated substantial costs in 2018. Plans with higher OOP cost sharing may result in lower utilization of ophthalmic care.</p>","PeriodicalId":19607,"journal":{"name":"Ophthalmic epidemiology","volume":" ","pages":"159-168"},"PeriodicalIF":1.7000,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Effects of Cost Sharing on Ophthalmic Care Utilization in the Affordable Care Act Marketplace.\",\"authors\":\"Jeremy B Hatcher, George Lin, Cullen P Moran, Sara Al Hussein Al Awamlh, Lina Sulieman, Natalia G Morales, Sean T Berkowitz, Shriji Patel, Jennifer Lindsey\",\"doi\":\"10.1080/09286586.2023.2199849\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Purpose: </strong>To determine the distribution and quantity of ophthalmic care consumed on Affordable Care Act (ACA) plans, the demographics of the population utilizing these services, and the relationship between ACA insurance coverage plan tier, cost sharing, and total cost of ophthalmic care consumed.</p><p><strong>Methods: </strong>This cross-sectional study analyzed ACA individual and small group market claims data from the Wakely Affordable Care Act (WACA) 2018 dataset, which contains detailed claims, enrollment, and premium data from Edge Servers for 3.9 million individual and small group market lives. We identified all enrollees with ophthalmology-specific billing, procedure, and national drug codes. We then analyzed the claims by plan type and calculated the total cost and out-of-pocket (OOP) cost.</p><p><strong>Results: </strong>Among 3.9 million enrollees in the WACA 2018 dataset, 538,169 (13.7%) had claims related to ophthalmology procedures, medications, and/or diagnoses. A total of $203 million was generated in ophthalmology-related claims, with $54 million in general services, $42 million in medications, $20 million in diagnostics and imaging, and $86 million in procedures. Average annual OOP costs were $116 per member, or 30.9% of the total cost, and were lowest for members with platinum plans (16% OOP) and income-driven cost sharing reduction (ICSR) subsidies (17% OOP). Despite stable ocular disease distribution across plan types, beneficiaries with silver ICSR subsidies consumed more total care than any other plan, higher than platinum plan enrollees and almost 1.5× the cost of bronze plan enrollees.</p><p><strong>Conclusions: </strong>Ophthalmic care for enrollees on ACA plans generated substantial costs in 2018. Plans with higher OOP cost sharing may result in lower utilization of ophthalmic care.</p>\",\"PeriodicalId\":19607,\"journal\":{\"name\":\"Ophthalmic epidemiology\",\"volume\":\" \",\"pages\":\"159-168\"},\"PeriodicalIF\":1.7000,\"publicationDate\":\"2024-04-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Ophthalmic epidemiology\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1080/09286586.2023.2199849\",\"RegionNum\":4,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"2023/4/12 0:00:00\",\"PubModel\":\"Epub\",\"JCR\":\"Q3\",\"JCRName\":\"OPHTHALMOLOGY\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Ophthalmic epidemiology","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1080/09286586.2023.2199849","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2023/4/12 0:00:00","PubModel":"Epub","JCR":"Q3","JCRName":"OPHTHALMOLOGY","Score":null,"Total":0}
Effects of Cost Sharing on Ophthalmic Care Utilization in the Affordable Care Act Marketplace.
Purpose: To determine the distribution and quantity of ophthalmic care consumed on Affordable Care Act (ACA) plans, the demographics of the population utilizing these services, and the relationship between ACA insurance coverage plan tier, cost sharing, and total cost of ophthalmic care consumed.
Methods: This cross-sectional study analyzed ACA individual and small group market claims data from the Wakely Affordable Care Act (WACA) 2018 dataset, which contains detailed claims, enrollment, and premium data from Edge Servers for 3.9 million individual and small group market lives. We identified all enrollees with ophthalmology-specific billing, procedure, and national drug codes. We then analyzed the claims by plan type and calculated the total cost and out-of-pocket (OOP) cost.
Results: Among 3.9 million enrollees in the WACA 2018 dataset, 538,169 (13.7%) had claims related to ophthalmology procedures, medications, and/or diagnoses. A total of $203 million was generated in ophthalmology-related claims, with $54 million in general services, $42 million in medications, $20 million in diagnostics and imaging, and $86 million in procedures. Average annual OOP costs were $116 per member, or 30.9% of the total cost, and were lowest for members with platinum plans (16% OOP) and income-driven cost sharing reduction (ICSR) subsidies (17% OOP). Despite stable ocular disease distribution across plan types, beneficiaries with silver ICSR subsidies consumed more total care than any other plan, higher than platinum plan enrollees and almost 1.5× the cost of bronze plan enrollees.
Conclusions: Ophthalmic care for enrollees on ACA plans generated substantial costs in 2018. Plans with higher OOP cost sharing may result in lower utilization of ophthalmic care.
期刊介绍：
Ophthalmic Epidemiology is dedicated to the publication of original research into eye and vision health in the fields of epidemiology, public health and the prevention of blindness. Ophthalmic Epidemiology publishes editorials, original research reports, systematic reviews and meta-analysis articles, brief communications and letters to the editor on all subjects related to ophthalmic epidemiology. A broad range of topics is suitable, such as: evaluating the risk of ocular diseases, general and specific study designs, screening program implementation and evaluation, eye health care access, delivery and outcomes, therapeutic efficacy or effectiveness, disease prognosis and quality of life, cost-benefit analysis, biostatistical theory and risk factor analysis. We are looking to expand our engagement with reports of international interest, including those regarding problems affecting developing countries, although reports from all over the world potentially are suitable. Clinical case reports, small case series (not enough for a cohort analysis) articles and animal research reports are not appropriate for this journal.
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