The American journal of managed care · 2025
Pricing and insurance networks in outpatient surgery markets.
СтатьяНаблюдательное исследованиеНазвание и аннотация: Перевод пока не подготовлен
Обработка статьи · этапы, ошибки и управление
Загрузка состояния…
Ошибки и ограничения
История · было → стало
Состояние обновляется каждые 5 секунд, пока блок открыт. Процент показывается только там, где известен объём работы. Пауза останавливает продолжение этапа; текущий запрос к источнику может завершиться.
Zhao Xiaoxi, Whaley Christopher M, Munnich Elizabeth L, Lee Jessica Y, Kranz Ashley M
Аннотация
OBJECTIVE: To examine how site of care and insurance network contribute to price differences for common adult outpatient surgeries paid by commercial insurers.
STUDY DESIGN: Observational study using a 50-state sample of commercial medical claims data.
METHODS: We compared insurer-paid amounts, patient out-of-pocket payments, and balance billing amounts for 4 common adult outpatient surgeries (arthroscopy, cataract, colonoscopy, and upper gastrointestinal procedures) by site of care (ambulatory surgery center [ASC] vs hospital outpatient department [HOPD]) and insurance network status (in network vs out of network).
RESULTS: Compared with a surgery occurring at an in-network ASC, insurers paid $306 (32%) more to an out-of-network ASC, $1042 (110%) more to an in-network HOPD, and $1041 (110%) more to an out-of-network HOPD. Patients paid $186 more out of pocket at an in-network HOPD than at an in-network ASC, which both had cost-sharing rates lower than out-of-network facilities.
CONCLUSIONS: Patients saved money by choosing in-network facilities regardless of the site of care, whereas insurers saved by increasing the usage of ASCs for common adult outpatient surgeries paid by commercial insurers. Insurance models that better align patient and insurer incentives could increase utilization of ASCs and lower overall spending on outpatient surgeries.
STUDY DESIGN: Observational study using a 50-state sample of commercial medical claims data.
METHODS: We compared insurer-paid amounts, patient out-of-pocket payments, and balance billing amounts for 4 common adult outpatient surgeries (arthroscopy, cataract, colonoscopy, and upper gastrointestinal procedures) by site of care (ambulatory surgery center [ASC] vs hospital outpatient department [HOPD]) and insurance network status (in network vs out of network).
RESULTS: Compared with a surgery occurring at an in-network ASC, insurers paid $306 (32%) more to an out-of-network ASC, $1042 (110%) more to an in-network HOPD, and $1041 (110%) more to an out-of-network HOPD. Patients paid $186 more out of pocket at an in-network HOPD than at an in-network ASC, which both had cost-sharing rates lower than out-of-network facilities.
CONCLUSIONS: Patients saved money by choosing in-network facilities regardless of the site of care, whereas insurers saved by increasing the usage of ASCs for common adult outpatient surgeries paid by commercial insurers. Insurance models that better align patient and insurer incentives could increase utilization of ASCs and lower overall spending on outpatient surgeries.