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In 2024, the average annual premium for employer-sponsored family health coverage was $25,572, an increase of $1,604 (7 percent) from 2023. Over the course of the past five years, the average family premium has increased 24 percent, which is similar to growth seen in inflation (23 percent) and wages (28 percent). On average, covered workers contributed 16 percent ($1,368) of the cost of single coverage and 25 percent ($6,296) of the cost of family coverage. The average general annual deductible for single coverage for workers with a deductible was $1,787, similar to that in recent years but 47 percent higher than a decade ago. In 2024, 18 percent of large firms offering health benefits, including 28 percent of those with 5,000 or more employees, covered GLP-1 antagonists for weight loss. Large employers were more likely to perceive their overall provider networks as broader than their networks for mental health and substance use conditions.

Hypothesis: After the expansion of high deductibles, patients will delay cochlear implant (CI) surgery to the end of the year, and the risk of postoperative known risks will increase., Background: The Affordable Care Act was associated with increased enrollment in high-deductible health plans (HDHPs), which resulted in rising health insurance deductibles. Health insurance plans can cover a patient's cost of healthcare once the deductible is met. Patients have been shown to be economic rational decision makers and make decisions based on cost rather than health. They wait for their deductible to be met, typically at the end of the year, then proceed to have costly care. The goal of this study was to evaluate the impact of rising health insurance deductibles on the rate and postoperative outcomes of cochlear implantation and to assess changes by the Tax Cuts and Jobs Act., Methods: TriNetX was used to accumulate summary data on patients who obtained a CI between 2005 and 2022 at the beginning (quarter 1) and the end of the year (quarter 4) from the electronic medical records of 75 healthcare organizations. The trends in average rate of cochlear implantation and resultant postoperative known risks or complications were statistically evaluated., Results: After expansion of HDHPs, the rate of cochlear implantation between quarter 4 (19 cases per year) and quarter 1 (17 cases/year) was similar (p = 0.18). For all patient groups, the case volume significantly increased. Between quarter 4 and quarter 1, postoperative tinnitus was more common in the beginning of the year (risk ratio, 0.68; 95% confidence interval, 0.46-0.99)., Conclusions: The number of patients receiving CIs significantly increased despite the expansion of HDHPs. Tinnitus was a rare postoperative known risk in the beginning of the year. Patients are less likely concerned about cost of CI surgery because of the impact of hearing loss on quality of life., Competing Interests: There are no outside sources of funding and no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Background: In 2015, the Centers for Medicare & Medicaid Services and commercial insurance plans began covering lung cancer screening (LCS) without patient cost-sharing for all plans. We explore the impact of enrolling into a deductible plan on the utilization of LCS services despite having no out-of-pocket cost requirement., Methods: This retrospective study analyzed data from the Population-based Research to Optimize the Screening Process Lung Consortium. Our cohort included non-Medicare LCS-eligible individuals enrolled in managed care organizations between February 5, 2015, and February 28, 2019. We estimate a series of sequential logistic regression models examining utilization across the sequence of events required for baseline LCS. We report the marginal effects of enrollment into deductible plans compared with enrollment in no-deductible plans., Results: The total effect of deductible plan enrollment was a 1.8 percentage-point (PP) decrease in baseline LCS. Sequential logistic regression results that explore each transition separately indicate deductible plan enrollment was associated with a 4.3 PP decrease in receipt of clinician visit, a 1.7 PP decrease in receipt of LCS order, and a 7.0 PP decrease in receipt of baseline LCS. Reductions persisted across all observable races and ethnicities., Conclusions: These findings suggest individuals enrolled in deductible plans are more likely to forgo preventive LCS services despite requiring no out-of-pocket costs. This result may indicate that increased cost-sharing is associated with suboptimal choices to forgo recommended LCS. Alternatively, this effect may indicate individuals enrolling into deductible plans prefer less health care utilization. Patient outreach interventions at the health plan level may improve LCS., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Opioid-related overdose is a public health emergency in the United States. Meanwhile, high-deductible health plans (HDHPs) have become more prevalent in the United States over the last 2 decades, raising concern about their potential for discouraging high-need populations, like those with opioid use disorder (OUD), from engaging in care that may mitigate the probability of overdose. This study assesses the impact of an employer offering an HDHP on nonfatal opioid overdose among commercially insured individuals with OUD in the United States., Research Design: We used deidentified insurance claims data from 2007 to 2017 with 97,788 person-years. We used an intent-to-treat, difference-in-differences regression framework to estimate the change in the probability of a nonfatal opioid overdose among enrollees with OUD whose employers began offering an HDHP insurance option during the study period compared with the change among those whose employer never offered an HDHP. We also used an event-study model to account for dynamic time-varying treatment effects., Results: Across both comparison and treatment groups, 2% of the sample experienced a nonfatal opioid overdose during the study period. Our primary model and robustness checks revealed no impact of HDHP offer on the probability of a nonfatal overdose., Conclusions: Our study suggests that HDHP offer was not associated with an observed increase in the probability of nonfatal opioid overdose among commercially insured person-years with OUD. However, given the strong evidence that medications for OUD (MOUD) can reduce the risk of overdose, research should explore which facets of insurance design may impact MOUD use., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: High-deductible health plans (HDHPs) are becoming increasingly common, but their financial implications for enrollees with and without chronic conditions and the mitigating effects of health savings accounts (HSAs) are relatively unknown., Objective: Our aim was to compare financial hardship between non-HDHPs and HDHPs with and without HSAs, stratified by enrollees' number of chronic conditions., Design: We used data from 2015 to 2018 Medical Expenditure Panels Surveys (MEPS) to compare rates of financial hardship across individuals with HDHPs and non-HDHPs using linear and logistic regression models., Participants: A nationally representative sample of 30,981 adults aged 18-64 enrolled in HDHPs and non-HDHPs., Main Measures: We examined several measures of financial hardship, including total yearly out-of-pocket medical spending as well as rates of delaying medical care or prescriptions in the past year due to cost, forgoing medical care or prescriptions in the past year due to cost, paying medical bills over time, or having problems paying medical bills. We compared rates using the non-HDHP as the control., Key Results: On most measures, HDHPs are associated with greater financial hardship compared to non-HDHPs, including average annual out-of-pocket spending of $637 for non-HDHPs, $939 for HDHPs with HSAs, and $825 for HDHPs without HSAs (p < 0.01). However, for HDHP enrollees with multiple chronic conditions, having an HSA was associated with less financial hardship (p < 0.05)., Conclusions: Our findings suggest that HSAs may be most beneficial for those with chronic conditions, in part due to the tax benefits they offer as well as the fact that those with chronic conditions are more likely to take advantage of their HSAs than their younger, healthier counterparts. However, as HDHPs are more likely to be correlated with worse financial outcomes regardless of health status, recent trends of increasing participation may be a reason for concern., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Hypothesis: With rising deductibles, patients will delay ear surgeries toward the end of the year, and there will be an increase in postoperative complications., Background: The Affordable Care Act (ACA), passed on March 23, 2010, expanded high deductible health plans. The deductible can provide support for patients with high medical costs, but high deductibles deter patients from seeking necessary preventive health care and having elective procedures. Patients may defer care toward the end of the year until the deductible is met. The purpose of this study is to evaluate the relationship between expanding high deductible health plans and the repeal of the ACA's individual mandate on December 22, 2017, with the economic behavior trends of tympanoplasty and mastoidectomy in the fiscal year and surgical outcomes., Methods: TriNetX was used to obtain summary statistics of patients who had tympanoplasty and/or mastoidectomy from 58 health care organizations. TriNetX is a global federated database that contains de-identified patient data from the electronic medical records of participating health care institutions. This study evaluated the trends in ear surgeries from 2005 to 2021 in the fiscal quarters 1 and 4. Relative risk of developing postoperative complications was statistically interrogated., Results: The average rate of ear surgeries measured in cases/year was higher in Quarter 4 than in Quarter 1 after the expansion of higher deductible health plans (180; 124; p < 0.0001). After the repeal of the ACA's individual mandate, the rate of ear surgeries in Quarter 4 significantly decreased compared to post-ACA (-3.7; 287; p = 0.0002). No statistically significant differences were notable in postoperative complications., Conclusions: The expansion of high deductible health plans with a rise in deductibles is associated with an increase in ear surgeries toward the end of the year. The repeal of the ACA's individual mandate is associated with a decreased rate of ear surgeries compared to post-ACA implementation. Despite financial concern, there was no increase in postoperative complications toward the end of the year., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Background: High-deductible health plans (HDHPs) are used within the United States to curb unnecessary health care spending; however, the resulting increased out-of-pocket (OOP) costs may be associated with financial toxicity. The aim was to assess the impact of HDHPs on use and seasonality of mastectomy and breast reconstruction procedures. The hypothesis is that the high OOP costs of HDHPs will lead to decreased overall service use and greater fourth-quarter use after the deductible has been met., Methods: MarketScan was queried from 2014 to 2017 for episodes of mastectomy, breast reconstruction (immediate and delayed), breast revision, and reduction. Only patients continuously enrolled for the full calendar year after the index operation were included. HDHPs and low-deductible health plans (LDHPs) were compared based on OOP cost sharing. Outcomes included surgery use rates, seasonality of operations, and median/mean OOP costs., Results: Annual mastectomy and breast reconstruction use rates varied little between LDHPs and HDHPs. Mastectomies, delayed breast reconstruction, and elective breast procedures (P < 0.001) all showed significant increases in fourth-quarter use, whereas immediate breast reconstruction did not. Regardless of timing and reconstruction method, HDHPs had significantly greater median OOP costs compared to LDHPs (all P < 0.001)., Conclusions: Mastectomy and breast reconstruction rates did not differ between LDHPs and HDHPs, but seasonality for all breast procedures was measured with the exception of immediate breast reconstruction, suggesting that women are rational economic actors. Regardless of service timing and reconstruction modality, HDHP patients had greater OOP costs compared to LDHP patients, which serves as a good starting point for provider engagement in financial toxicity., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Objective: To assess the influence of being both poor and sick on the association of high-deductible health plans (HDHPs) with delayed/forgone care., Findings: In this cross-sectional study that included 14,203 respondents, representing 120 million Americans, individuals insured by HDHPs had 2.23 times the odds of delayed/foregone care compared with non-HDHP insureds. When examined across strata of income and health status, the association yielded similar odds of delayed/foregone care. Additionally, the interaction of being poor and sick on the association of HDHPs to delayed/foregone care was not statistically significant. Meaning. Being insured on a HDHP affected delayed/foregone care largely consistently, regardless of health, income, or combined health/income category.

The Affordable Care Act aimed to increase use of preventive services by eliminating cost-sharing to consumers. However, patients may be unaware of this benefit or they may not seek preventive services if they anticipate that the cost of potential diagnostic or treatment services will be too high, both more likely among those in high deductible health plans. We used nationally representative private health insurance claims (100% sample of IBM ® MarketScan ® ) for the United States from 2006 to 2018, restricting the data to enrollment and claims for non-elderly adults who were enrolled for the full plan year. The cross-sectional sample (185 million person-years) is used to describe trends in preventive service use and costs from 2008 through 2016. The cohort sample (9 million people) focuses on the elimination of cost-sharing for certain high-value preventive services in late 2010, requiring continuous enrollment across 2010 and 2011. We examine whether HDHP enrollment is associated with use of eligible preventive services using semi-parametric difference-in-differences to account for endogenous plan selection. Our preferred model implies that HDHP enrollment was associated with a reduction of the post-ACA change in any use of eligible preventive services by 0.2 percentage points or 12.5%. Cancer screenings were unaffected but HDHP enrollment was associated with smaller increases in wellness visits, immunizations, and screening for chronic conditions and sexually transmitted infections. We also find that the policy was ineffective at reducing out-of-pocket costs for the eligible preventive services, likely due to implementation issues.

Background: The United States faces an ongoing drug crisis, worsened by the undertreatment of substance use disorders (SUDs). Family enrollment in high deductible health plans (HDHPs) and the resulting increased cost exposure could exacerbate the undertreatment of SUD. This study characterized the distribution of health care spending within families where a member has a SUD and estimated the association between HDHPs and family health care spending., Methods: Using commercial claims and enrollment data from OptumLabs (2007-2017), we identified a treatment group of enrollees whose employers began offering an HDHP and comparison group whose employers never offered an HDHP. We used a difference-in-differences analysis that compared health care spending in families at firms that did vs. did not offer an HDHP before and after the HDHP offer. All models were adjusted for employer and year fixed effects, as well as family demographics, size, and chronic conditions., Results: Our sample was comprised of 317,353 family-years. Family members with a SUD, on average, contributed an outsized proportion of total family health care expenditures (56.9% in a family of three). Offering a family HDHP was associated with a 6.1% reduction (95% confidence interval [CI]: 9.7-2.6%) in the probability of families having any SUD-related expenditures. The HDHP offer was associated with a $1546 reduction in family total expenditures and a $1185 reduction for the individual with SUD (95% CI: -2272 to -821 and -1845 to -525, respectively)., Conclusions: The increased prevalence of family enrollment in HDHPs may further the existing issue of undertreatment of SUDs., Competing Interests: Conflict of interest No conflict declared., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Commercial insurance covers a follow-up colonoscopy after a positive colorectal cancer-screening test with no patient cost-sharing. Instituting a similar policy for Medicare beneficiaries may increase screening adherence and improve outcomes. The cost-effectiveness of stool-based colorectal cancer screening was compared across adherence scenarios that assumed Medicare coinsurance status quo (20% for follow-up colonoscopy) or waived coinsurance. The CRC-AIM model simulated previously unscreened eligible Medicare beneficiaries undergoing stool-based colorectal cancer screening at age 65 for 10 years. Medicare costs, colorectal cancer cases, colorectal cancer-related deaths, life-years gained (LYG), and quality-adjusted life-years (QALY) were estimated versus no screening. Scenario 1 (S1) assumed 20% coinsurance for follow-up colonoscopy. Scenario 2 (S2) assumed waived coinsurance without adherence changes. Scenarios 3-7 (S3-S7) assumed that waiving coinsurance increased real-world stool-based screening and/or follow-up colonoscopy adherence by 5% or 10%. Sensitivity analyses assumed 1%-4% increased adherence. Cost-effectiveness threshold was ≤$100,000/QALY. Waiving coinsurance without adherence changes (S2) did not affect outcomes versus S1. S3-S7 versus S1 over 10 years estimated up to 3.6 fewer colorectal cancer cases/1,000 individuals, up to 2.1 fewer colorectal cancer deaths, up to 20.7 more LYG, and had comparable total costs per-patient (≤$6,478 vs. $6,449, respectively) as reduced colorectal cancer medical costs offset increased screening and colonoscopy costs. In sensitivity analyses, any increase in adherence after waiving coinsurance was cost-effective and increased LYG. In simulated Medicare beneficiaries, waiving coinsurance for follow-up colonoscopy after a positive stool-based test improved outcomes and was cost-effective when assumed to modestly increase colorectal cancer screening and/or follow-up colonoscopy adherence., Prevention Relevance: Follow-up colonoscopy after a positive stool-based test is necessary to complete the colorectal cancer-screening process. This analysis demonstrated that in a simulated Medicare population, waiving coinsurance for a follow-up colonoscopy improved estimated outcomes and was cost-effective when it was assumed that waiving the coinsurance modestly increased screening adherence. See related Spotlight, p. 641., (©2022 The Authors; Published by the American Association for Cancer Research.)

In this paper, I study tiered cost sharing, an innovative incentive structure designed to steer patients toward low-cost providers using large out-of-pocket price differentials. Using administrative data from New Hampshire, where two large insurers utilize tiered pricing programs, I estimate the effects of tiering on choices and spending for common gastrointestinal endoscopic procedures. I first conduct a difference-in-differences analysis using the rollout of one insurer's tiered option. I then develop and estimate a demand model to explicitly compare the tiered design with other common plans. Both the reduced form and structural models imply that the tiered plans are associated with 4.5%-6.3% less in mean per-episode spending than high-deductible and coinsurance-based plans, and do not affect the likelihood of seeking care. I find evidence that the savings is in part due to a salience or "simple pricing" effect whereby patients respond to tiered out-of-pocket prices but not to traditional deductibles or coinsurance rates., (Published by Elsevier B.V.)

Objective: The Affordable Care Act mandates that primary preventive services have no out-of-pocket costs but does not exempt secondary prevention from out-of-pocket costs. Most commercially insured patients with diabetes have high-deductible health plans (HDHPs) that subject key microvascular disease-related services to high out-of-pocket costs. Brief treatment delays can significantly worsen microvascular disease outcomes., Research Design and Methods: This cohort study used a large national commercial (and Medicare Advantage) health insurance claims data set to examine matched groups before and after an insurance design change. The study group included 50,790 patients with diabetes who were continuously enrolled in low-deductible (≤$500) health plans during a baseline year, followed by up to 4 years in high-deductible (≥$1,000) plans after an employer-mandated switch. HDHPs had low out-of-pocket costs for nephropathy screening but not retinopathy screening. A matched control group included 335,178 patients with diabetes who were contemporaneously enrolled in low-deductible plans. Measures included time to first detected microvascular disease screening, severe microvascular disease diagnosis, vision loss diagnosis/treatment, and renal function loss diagnosis/treatment., Results: HDHP enrollment was associated with relative delays in retinopathy screening (0.7 months [95% CI 0.4, 1.0]), severe retinopathy diagnosis (2.9 months [0.5, 5.3]), and vision loss diagnosis/treatment (3.8 months [1.2, 6.3]). Nephropathy-associated measures did not change to a statistically significant degree among HDHP members relative to control subjects at follow-up., Conclusions: People with diabetes in HDHPs experienced delayed retinopathy diagnosis and vision loss diagnosis/treatment of up to 3.8 months compared with low-deductible plan enrollees. Findings raise concerns about visual health among HDHP members and call attention to discrepancies in Affordable Care Act cost sharing exemptions., (© 2022 by the American Diabetes Association.)

Two decades ago Congress enabled Americans to open tax-favored health savings accounts (HSAs) in conjunction with qualifying high-deductible health plans (HDHPs). This HSA tax break is regressive: Higher-income Americans are more likely to have HSAs and fund them at higher levels. Proponents, however, have argued that this regressivity is offset by reductions in wasteful health care spending because consumers with HDHPs are more cost-conscious in their use of care. Using published sources and our own analysis of National Health Interview Survey data, we argue that HSAs no longer appreciably achieve this cost-consciousness aim because cost sharing has increased so much in non-HSA-qualified plans. Indeed, people who have HDHPs with HSAs are becoming less likely than others with private insurance to report financial barriers to care. In sum, promised gains in efficiency from HSAs have not borne out, so it is difficult to justify maintaining this regressive tax break.

Background: For people with diabetes, adherence to prescribed medications is essential. However, the rising prevalence of high-deductible health plans (HDHPs), and prices of diabetes medications such as insulin, could deter adherence., Objective: To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US., Design: Repeated cross-sectional survey., Setting: National Health Interview Survey, 2011-2018., Participants: A total of 7469 privately insured adults ages 18-64 with diabetes who were prescribed medications and enrolled in a HDHP or a traditional commercial health plan (TCP)., Main Measures: Self-reported measures of CRN were compared between enrollees in HDHPs and TCPs overall and among the subset using insulin. Analyses were adjusted for demographic and clinical characteristics using multivariable linear regression models., Key Results: HDHP enrollees were more likely than TCP enrollees to not fill a prescription (13.4% vs 9.9%; adjusted percentage point difference (AD) 3.4 [95% CI 1.5 to 5.4]); skip medication doses (11.4% vs 8.5%; AD 2.8 [CI 1.0 to 4.7]); take less medication (11.1% vs 8.8%; AD 2.3 [CI 0.5 to 4.0]); delay filling a prescription to save money (14.4% vs 10.8%; AD 3.0 [CI 1.1 to 4.9]); and to have any form of CRN (20.4% vs 15.5%; AD 4.4 [CI 2.2 to 6.7]). Among those taking insulin, HDHP enrollees were more likely to have any CRN (25.1% vs 18.9%; AD 5.9 [CI 1.1 to 10.8])., Conclusion: HDHPs are associated with greater CRN among people with diabetes, particularly those prescribed insulin. For people with diabetes, enrollment in non-HDHPs might reduce CRN to prescribed medications., (© 2021. Society of General Internal Medicine.)

Objective: High-deductible health plans (HDHPs) are increasingly common in the U.S. health insurance market and are intended to reduce the use of low-value services, but evidence suggests that HDHP enrollees also reduce the use of high-value services. This study examined the effects of HDHPs on enrollees with mental health conditions, a population with high levels of unmet treatment need, often because of financial barriers. Enrollees with a co-occurring substance use disorder have greater treatment needs and unique barriers to care, perhaps changing their response to an HDHP., Methods: Commercial health insurance claims data in a difference-in-differences design was used to evaluate the effect of an employer's offer of an HDHP on 6,627,128 enrollee-years among enrollees with mental health conditions, stratified by having a co-occurring substance use disorder or not., Results: Among enrollees without a co-occurring substance use disorder, an HDHP offer was associated with a 4.8% (95% confidence interval [CI]=2.4%-7.2%) reduction in overall spending on mental health care, despite an 11.3% (95% CI=1.0%-21.6%) increase in spending on mental health-related emergency department visits. Among enrollees with a co-occurring substance use disorder, no significant changes attributable to an HDHP offer were found in most categories of spending on combined mental health and substance use disorder care, apart from a 4.5% (95% CI=1.9%-7.2%) reduction in spending on psychotropic medications., Conclusions: HDHPs may reduce use of necessary care among enrollees with mental health conditions, which could exacerbate undertreatment in this population and result in adverse health outcomes.

Background: While researchers use patient expenditures in claims data to estimate insurance benefit features, little evidence exists to indicate whether the resulting measures are accurate., Objective: To develop and test an algorithm for deriving copayment and coinsurance values from behavioral health claims data., Subjects: Employer-sponsored insurance plans from 2011 to 2013 for a national managed behavioral health organization (MBHO)., Measures: Twelve benefit features, distinguishing between carve-in and carve-out, in-network and out-of-network, inpatient and outpatient, and copayment and coinsurance, were created. Measures drew from claims (claims-derived measures), and benefit feature data from a claims processing engine database (true measures)., Study Design: We calculate sensitivity and specificity of the claims-derived measures' ability to accurately determine if a benefit feature was required and for plan-years requiring the benefit feature, the accuracy of the claims-derived measures. Accuracy rates using the minimum, 25th, 50th, 75th, and maximum claims value for a plan-year were compared., Principal Findings: Sensitivity (82% or higher for all but 3 benefit features) and specificity (95% or higher for all but 2 benefit features) were relatively high. Accuracy rates were highest using the 75th or maximum claims value, depending on the benefit feature, and ranged from 69% to 99% for all benefit features except for out-of-network inpatient coinsurance., Conclusions: For most plan-years, claims-derived measures correctly identify required specialty mental health copayments and coinsurance, although the claims-derived measures' accuracy varies across benefit design features. This information should be considered when creating claims-derived benefit features to use for policy analysis., Competing Interests: F.A. is an employee of Optum—United Health Group and as such she receives compensation in the form of salary and stock. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD., Objective: To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending., Design: Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group)., Participants: Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment., Main Measures: Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits., Key Results: HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services., Conclusions: HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population., (© 2021. Society of General Internal Medicine.)

Increasing health care consumerism has been proposed as a solution for rising U.S. health care costs. Although price transparency initiatives aim to inform patients about outof-pocket costs (OOPCs), challenges remain regarding price transparency tools, including limited accuracy of estimates, accounting for multiple payers for the same service, the need for quality measures, optimal OOPC delivery, and psychosocial consequences of OOPC information. As radiology practices consider implementing price transparency initiatives, improvements should address enhancing patients' experience with OOPC communication.

Background: Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear., Methods: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low-deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. We performed a cumulative interrupted time-series analysis, comparing changes in annual outcomes between the HDHP and control groups before and after the index date using aggregate-level segmented regression. Members from higher-poverty neighborhoods were a subgroup of interest., Results: After matching, we included 557 501 members in the HDHP group and 5 861 990 in the control group, with mean ages of 42.0 years, 48% to 49% female, and 67% to 68% non-Hispanic White individuals. Employer-mandated HDHP switches were associated with a relative decrease of 4.3% (95% CI, -5.9 to -2.7; absolute change, -4.5 [95% CI, -6.3 to -2.8] per 10 000 person-years) in nonspecific chest pain ED visits and 11.3% (95% CI, -14.0 to -8.6) decrease (absolute change, -1.7 per 10 000 person-years [95% CI, -2.1 to -1.2]) in visits leading to hospitalization. There was no significant decrease in subsequent noninvasive testing or revascularization procedures. An increase in 30-day acute myocardial infarction admissions was not statistically significant (15.9% [95% CI, -1.0 to 32.7]; absolute change, 0.3 per 10 000 person-years [95% CI, -0.01 to 0.5]) but was significant among members from higher-poverty neighborhoods., Conclusions: Employer-mandated HDHP switches were associated with decreased nonspecific chest pain ED visits and hospitalization from these ED visits, but no significant change in post-ED cardiac testing. However, HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.

Importance: High-deductible health plans (HDHPs) are increasingly common and associated with decreased medication use in some adult populations. How children are affected is less certain., Objective: To examine the association between HDHP enrollment and asthma controller medication use and exacerbations., Design, Setting, and Participants: For this longitudinal cohort study with a difference-in-differences design, data were obtained from a large, national, commercial (and Medicare Advantage) administrative claims database between January 1, 2002, and December 31, 2014. Children aged 4 to 17 years and adults aged 18 to 64 years with persistent asthma who switched from traditional plans to HDHPs or remained in traditional plans (control group) by employer choice during a 24-month period were identified. A coarsened exact matching technique was used to balance the groups on characteristics including employer and enrollee propensity to have HDHPs. In most HDHPs, asthma medications were exempt from the deductible and subject to copayments. Statistical analyses were conducted from August 13, 2019, to January 19, 2021., Exposure: Employer-mandated HDHP transition., Main Outcomes and Measures: Thirty-day fill rates and adherence (based on proportion of days covered [PDC]) were measured for asthma controller medications (inhaled corticosteroid [ICS], leukotriene inhibitors, and ICS long-acting β-agonists [ICS-LABAs]). Asthma exacerbations were measured by rates of oral corticosteroid bursts and asthma-related emergency department visits among controller medication users., Results: The HDHP group included 7275 children (mean [SD] age, 10.8 [3.3] years; 4402 boys [60.5%]; and 5172 non-Hispanic White children [71.1%]) and 17 614 adults (mean [SD] age, 41.1 [13.4] years; 10 464 women [59.4%]; and 12 548 non-Hispanic White adults [71.2%]). The matched control group included 45 549 children and 114 141 adults. Compared with controls, children switching to HDHPs experienced significant absolute decreases in annual 30-day fills only for ICS-LABA medications (absolute change, -0.04; 95% CI, -0.07 to -0.01). Adults switching to HDHPs did not have significant reductions in 30-day fills for any controllers. There were no statistically significant differences in PDC, oral steroid bursts, or asthma-related emergency department visits for children or adults. For the 9.9% of HDHP enrollees with health savings account-eligible HDHPs that subjected medications to the deductible, there was a significant absolute decrease in PDC for ICS-LABA compared with controls (-4.8%; 95% CI, -7.7% to -1.9%)., Conclusions and Relevance: This cohort study found that in a population where medications were exempt from the deductible for most enrollees, HDHP enrollment was associated with minimal or no reductions in controller medication use for children and adults and no change in asthma exacerbations. These findings suggest a potential benefit from exempting asthma medications from the deductible in HDHPs.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Moniz reported receiving grants from the Agency for Healthcare Research and Quality and receiving personal fees from Society of Family Planning outside the submitted work; Dr Fendrick reported receiving consulting income from AbbVie, Amgen, Centivo, Community Oncology Association, Covered California, EmblemHealth, Exact Sciences, Freedman Health, GRAIL, Harvard University, Health & Wellness Innovations, Health at Scale Technologies, MedZed, Penguin Pay, Risalto, Sempre Health, State of Minnesota, Department of Defense, Virginia Center for Health Innovation, Wellth, and Zansors. He has received research support from the Agency for Healthcare Research and Quality, Arnold Ventures, Gary and Mary West Health Policy Center, National Pharmaceutical Council, Patient-Centered Outcomes Research Institute, Robert Wood Johnson Foundation, State of Michigan, and Centers for Medicare and Medicaid Services. He reports having equity in V-BID Health; the other authors have indicated they have no potential conflicts of interest to disclose.

Importance: List prices set by manufacturers for brand-name prescription drugs in the US have been increasing faster than inflation, although confidential manufacturer rebates offset some of these increases. Most commercially insured patients pay at least some out-of-pocket costs for prescription drugs, and higher patient spending is associated with lower adherence and worse health outcomes., Objective: To examine whether price changes for brand-name drugs are correlated with changes in patient out-of-pocket spending and whether this association varies by insurance benefit design., Design, Setting, and Participants: A cohort study of 79 brand-name drugs with available pricing data from January 2015 to December 2017 was conducted, with data obtained from a national commercial insurance claims database., Exposures: Change in the list prices set by manufacturers and estimated net prices after rebates among non-Medicaid payers., Main Outcomes and Measures: Change in median out-of-pocket spending among all patients and stratified by insurance pharmacy benefit design, including high-deductible insurance plans and plans with any amount of deductibles or coinsurance., Results: Among 79 drugs, median increases were 16.7% (interquartile range [IQR], 13.6%-21.1%) for list prices, 5.4% (IQR, -3.9% to 11.7%) for net prices, and 3.5% (IQR, 1.4%-9.1%) for out-of-pocket spending from 2015 to 2017. Changes in list prices were correlated with changes in net prices (r = 0.34; P = .002). Overall, changes in out-of-pocket spending were not correlated with changes in list prices (r = 0.14; P = .22) or net prices (r = 0.04; P = .71). Among 53.7% of patients who paid any drug deductible or coinsurance, median out-of-pocket spending increased by 15.0%, and changes were moderately correlated with changes in list prices (r = 0.38; P = .001) but not net prices (r = 0.06; P = .62)., Conclusions and Relevance: Some commercially insured patients who pay only prescription drug copayments appear to be insulated from increases in drug prices. However, more than half of patients pay deductibles or coinsurance and may experience substantial increases in out-of-pocket spending when drug prices increase. Among these patients, there was no evidence that manufacturer rebates to insurers are associated with patients' out-of-pocket spending. Policies to rein in unregulated annual increases in list prices for brand-name drugs may have important consequences for patient out-of-pocket spending.

The Affordable Care Act (ACA) mandated that private health plans cover contraceptives without out-of-pocket expenses for patients. Previously, long-acting reversible contraceptives (LARCs) were subject to deductibles, making them a higher-cost service for women with high-deductible health plans (HDHPs); however, the ACA mandate applied to HDHPs as well as traditional health plans. Using a national commercial claims database, we examined LARC use among continuously enrolled reproductive-age women between 2010 and 2017, comparing 9,014 women enrolled in HDHPs with 443,363 women enrolled in non-HDHPs. Using a quasi-experimental difference-in-differences analysis, we found that pre-ACA HDHP enrollees had lower LARC initiation rates than women in non-HDHPs and that rates of LARC initiation increased by 35 percent more postmandate for women in HDHPs than for women in traditional plans. These findings suggest that the ACA had a particularly important impact for women in HDHPs, who faced higher pre-ACA out-of-pocket expenses for these contraceptive methods.

Objectives: To examine changes in carve-out financial requirements (copayments, coinsurance, use of deductibles, and out-of-pocket maxima) following the Mental Health Parity and Addiction Equity Act (MHPAEA)., Data Source/study Setting: Specialty mental health benefit design information for employer-sponsored carve-out plans from a national managed behavioral health organization's claims processing engine (2008-2013)., Study Design: This pre-post study reports linear and logistic regression as the main analysis., Data Collection/extraction Methods: NA., Principal Findings: Copayments for in-network emergency room (-$44.9, 95% CI: -78.3, -11.5; preparity mean: $56.2), outpatient services (eg, individual psychotherapy: -$7.4, 95% CI: -10.5, -4.2; preparity mean: $17.8), and out-of-network coinsurance for emergency room (-11 percentage points, 95% CI: -16.7, -5.4; preparity mean: 38.8 percent) and outpatient (eg, individual psychotherapy: -5.8 percentage points, 95% CI: -10.0, -1.6; preparity mean 41.0 percent) decreased. Probability of family OOP maxima use (29 percentage points, 95% CI: 19.3, 38.6; preparity mean: 36 percent) increased. In-network outpatient coinsurance increased (eg, individual psychotherapy: 4.5 percentage points, 95% CI: 1.1, 7.9; preparity mean: 2.7 percent), as did probability of use of family deductibles (15 percentage points, 95% CI: 6.1, 23.3; preparity mean: 38 percent)., Conclusions: MHPAEA was associated with increased generosity in most financial requirements observed here. However, increased use of deductibles may have reduced generosity for some patients., (© Health Research and Educational Trust.)

With the rise in the share of privately insured patients covered by high-deductible health plans (HDHPs), understanding sociodemographic trends in the uptake of health savings accounts (HSAs) is increasingly important, as HSAs may help offset the higher up-front costs of care in HDHPs. We used nationally representative data from the National Health Interview Survey from the period 2007-18 to examine trends in HDHP enrollment and HSA participation among privately insured adults by income level and race/ethnicity. Our findings show a substantial increase in HDHP enrollment across all racial/ethnic and income groups from 2007 to 2018. However, Black, Hispanic, and low-income HDHP enrollees were significantly less likely than their White and higher-income counterparts to participate in HSAs, and these gaps increased over time. This means that the HDHP enrollees most likely to benefit from the potential financial protection of HSAs were the least likely to have them. If these trends persist, racial/ethnic and income-based disparities in cost-related barriers to care may widen.

High-deductible health plans (HDHPs) have become increasingly prevalent among employer-sponsored health plans and plans offered through the Health Insurance Marketplace in the United States. This study examined the impact of deductible levels on health care experiences in terms of care access, affordability, routine checkup, out-of-pocket cost, and satisfaction using data from the Health Reform Monitoring Survey. The study also tested whether the experiences of Marketplace enrollees differed from off-Marketplace individuals, controlling for deductible levels. Results from multivariable and propensity score weighted regression models showed that many of the outcomes were adversely affected by deductible levels and Marketplace enrollment. These results highlight the importance of efforts to help individuals choose the plan that fits both their medical needs and their budgets. The study also calls for more attention to improving provider acceptance of HDHPs and Marketplace plans as these plans become increasingly common over time.

Importance: Most people with commercial health insurance in the US have high-deductible plans, but the association of such plans with major health outcomes is unknown., Objective: To describe the association between enrollment in high-deductible health plans and the risk of major adverse cardiovascular outcomes., Design, Setting, and Participants: This cohort study examined matched groups before and after an insurance design change. Data were from a large national commercial (and Medicare Advantage) health insurance claims data set that included members enrolled between January 1, 2003, and December 31, 2014. The study group included 156 962 individuals with risk factors for cardiovascular disease who were continuously enrolled in low-deductible (≤$500) health plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans with typical value-based features after an employer-mandated switch. The matched control group included 1 467 758 individuals with the same risk factors who were contemporaneously enrolled in low-deductible plans. Data were analyzed from December 2017 to March 2020., Exposures: Employer-mandated transition to a high-deductible health plan., Main Outcomes and Measures: Time to first major adverse cardiovascular event defined as myocardial infarction or stroke., Results: The study group included 156 962 individuals and the control group included 1 467 758 individuals; the mean age of members was 53 years (SD: high-deductible group, 6.7 years; control group, 6.9 years), 47% were female, and approximately 48% lived in low-income neighborhoods. First major adverse cardiovascular events among high-deductible health plan members did not differ relative to controls at follow-up vs baseline (adjusted hazard ratio, 1.00; 95% CI, 0.89-1.13). Findings were similar among subgroups with diabetes (adjusted hazard ratio, 0.93; 95% CI, 0.75-1.16) and with other cardiovascular risk factors (adjusted hazard ratio, 0.93; 95% CI, 0.81-1.07)., Conclusions and Relevance: Mandated enrollment in high-deductible health plans with typical value-based features was not associated with increased risk of major adverse cardiovascular events.

Importance: Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills ("surprise bills") from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians., Objective: To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities., Design, Setting, and Participants: Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116 749]; laparoscopic cholecystectomy [82 372]; hysterectomy [67 452]; total knee replacement [42 313]; breast lumpectomy [18 018]; colectomy [14 074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017., Exposure: Patient, clinician, and insurance factors potentially related to out-of-network bills., Main Outcomes and Measures: The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service., Results: Among 347 356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P < .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P < .001). Among 83 021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill., Conclusions and Relevance: In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.

Objective: Study occurrence and consequences of deductibles and medical debt among privately insured under the Affordable Care Act., Methods: Analysis of 2012-2016 National Health Interview Survey data on privately insured adults younger than age 65 on the effect of deductibles on medical debt, deferred medical care, and office visits, by demographic characteristics, and treatable chronic diseases., Results: Rates of medical debt and deferred care decreased. Medical debt is greater for those with any type of high deductible (HD) insurance, and among those more vulnerable (lower income, minority, treatable chronic diseases). Medical debt with HD's increased deferred needed medical care 6 fold and is highest for those with more treatable chronic diseases., Conclusion: While medical debt and deferred care decreased for all privately insured, those HD-insured and vulnerable report higher medical debt rates markedly increasing deferred needed medical care. Highdeductible insurance risks adverse health and social consequences for those vulnerable.

Importance: High-deductible health plans (HDHPs) are a common cost-savings option for employers but may lead to underuse of necessary treatments because beneficiaries bear the full cost of health care, including medications, until a deductible is met., Objectives: To evaluate the association between switching from a non-HDHP to an HDHP and discontinuation of antihyperglycemic medication and to assess whether the association differs in patients using branded vs generic antihyperglycemic medications., Design, Setting, and Participants: This retrospective matched cohort study used administrative claims from MarketScan databases to identify commercially insured adult patients with type 2 diabetes who used at least 1 antihyperglycemic medication in 2013. Patients in the HDHP cohort (n = 1490) were matched by propensity scores to a non-HDPH control cohort (n = 1490). Data were collected and analyzed from January 1, 2013, through December 31, 2014., Exposures: Switching from a non-HDHP in 2013 to a full replacement HDHP in 2014 (no non-HDHP option offered) vs staying on a non-HDHP., Main Outcomes and Measures: Difference-in-differences models estimated discontinuation of branded and generic antihyperglycemic medications., Results: Among the 2980 patients included in the analysis (1932 men [64.8%]; mean [SD] age, HDHP cohort: 52.6 [6.9] years; non-HDHP cohort: 52.7 [7.3] years), no difference between the HDHP and non-HDHP cohorts was found in unadjusted follow-up discontinuation rates for all antihyperglycemic medications (255 [22.7%] vs 255 [23.3%]; P = .72); however, among patients using branded medication, a significantly greater proportion of patients in the HDHP group did not refill branded medications (81 of 396 [20.5%] vs 61 of 437 [14.0%]; P = .009). Difference-in-differences models were not statistically significant., Conclusions and Relevance: These findings suggest switching to an HDHP is associated with discontinuation specifically of branded medications. Unintended health consequences may result and should be considered by employers making health care benefit decisions.

Importance: Individuals in the United States with mental illnesses and substance use disorders can face major access barriers from limited provider (eg, clinicians and facilities) networks in health insurance plans., Objective: To evaluate the cost-sharing payments for out-of-network (OON) care for private insurance plan enrollees with mental health conditions, alcohol use disorders, or drug use disorders compared with those with congestive heart failure (CHF) or diabetes., Design, Setting, and Participants: This cross-sectional study used data from a large commercial claims database from 2012 to 2017. The study included adults with mental health conditions, with alcohol use disorders, with drug use disorders, with CHF, and with diabetes who were aged 18 to 64 years and enrolled in employer-sponsored insurance plans., Main Outcomes and Measures: Main outcomes included OON care during hospitalization, OON care during outpatient care, cost-sharing payments with OON care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing., Results: The study sample included 3 209 929 enrollees with mental health conditions (mean [SD] age, 45.9 [12.6] years; 64.8% women), 294 550 with alcohol use disorders (mean [SD] age, 42.8 [13.4] years; 60.9% men), 321 535 with drug use disorders (mean [SD] age, 41.1 [13.9] years; 59.1% men), 178 701 with CHF (mean [SD] age, 53.8 [8.9] years; 62.6% men), and 1 383 398 with diabetes (mean [SD] age, 52.5 [9.0] years; 58.9% men). Enrollees with behavioral conditions were more likely to encounter OON clinicians in inpatient and outpatient settings. For instance, those with drug use disorders were 12.9 percentage points (95% CI, 12.5-13.2 percentage points; P < .001) more likely to have inpatient OON care than those with CHF and 15.3 percentage points (95% CI, 15.1-15.6 percentage points; P < .001) more likely to receive outpatient OON care. Behavioral conditions also had higher cost sharing for OON care. For example, individuals with mental health conditions had cost-sharing payments for OON care $341 (95% CI, $331-$351) higher than those with diabetes (P < .001), individuals with drug use disorders had cost-sharing payments for OON care $1242 (95% CI, $1209-$1276) higher than those with diabetes (P < .001), and individuals with alcohol use disorders had cost-sharing payments for OON care $1138 (95% CI, $1101-$1174) higher than those with diabetes (P < .001). The OON care rates and cost-sharing payments were much higher when enrollees sought care from behavioral clinicians and facilities., Conclusions and Relevance: In this cross-sectional study of enrollees in commercial insurance plans, cost sharing for OON care among those with behavioral health conditions was significantly higher than those with chronic physical conditions. These disparities may be indicative of limited in-network availability for behavioral health care.

Background: Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment., Aims of the Study: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level., Methods: A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted., Results: For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta&#95;visits=--0.00008, p-value=0.030; beta&#95;total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services., Discussion: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.

Patients with high-deductible health plans will increasingly be motivated to contact their hospitals or various websites to try to obtain information about the costs of expensive services like advanced imaging. Unfortunately, they will not find price transparency but rather confusion and opaqueness. Hospital personnel and commercial websites often unwittingly provide erroneous pricing information. The reasons for this are explained. Detailed examples of the erroneous information are provided. State-mandated websites may be somewhat of an improvement, but their methodology seems to vary from state to state, and they too can be confusing. All this obviously creates problems for patients, who are left not knowing what their true costs will be. The situation also creates problems for radiologists and their hospitals. Because of misunderstandings that can occur during the information-gathering phase, the pricing information shown for many hospital facilities may be greatly inflated, placing them at a competitive disadvantage. Certain strategic solutions to the problems are available, and these are discussed., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The annual Henry J. Kaiser Family Foundation Employer Health Benefits Survey found that in 2018 the average annual premium for single coverage rose 3 percent to $6,896 and the average annual premium for family coverage rose 5 percent to $19,616. Covered workers contributed 18 percent of the cost for single coverage and 29 percent of the cost for family coverage, on average, with considerable variation across firms. Eighty-five percent of covered workers face a general annual deductible before they use most services, including the 29 percent of covered workers who are enrolled in a high-deductible health plan with a savings option. The share of firms covering services provided via telemedicine has increased steadily over the past several years. Nearly a quarter of large employers expect the elimination of the individual mandate to result in lower take-up in plan offerings.

Background: High deductible health plans (HDHP) are associated with high levels of patient cost-sharing and are becoming increasingly used in the United Status as a means of reducing healthcare utilization and spending. Our objective is to determine whether HDHP enrollment is associated with a change in adherence to evidence-based medications to treat cardiovascular risk factors and whether such changes vary based on race/ethnicity or socioeconomic status., Methods and Results: We conducted a retrospective cohort study using an interrupted time series with concurrent control group design among beneficiaries of Aetna-a national commercial insurer. We included 14 866 patients who filled prescriptions for medications to treat hypertension, high cholesterol, or diabetes mellitus between 2009 and 2014 and who switched from a traditional plan into an HDHP and 14 866 controls who did not switch to an HDHP matched based on calendar time, medication class, race/ethnicity, socioeconomic status, and propensity score. We were specifically interested in evaluating 4 prespecified subgroups based on race/ethnicity (white versus nonwhite) and socioeconomic status (higher versus lower). The main outcome was medication adherence as measured by proportion of days covered. The overall cohort had an average age of 53 years, and 44% were women. Baseline adherence was the lowest in the nonwhite patient group. Switching to an HDHP was associated with a decrease in the level of adherence of 5 percentage points across all 4 subgroups (change in level, -5.0%; 95% CI, -5.9% to -4.0%; P<0.0001)., Conclusions: HDHP enrollment was associated with a reduction in adherence to medications to treat cardiovascular risk factors. The magnitude of this effect did not vary based on race/ethnicity or socioeconomic status. Because racial/ethnic minorities have lower rates of medication adherence, future studies should evaluate whether HDHP-associated changes in adherence have greater clinical consequences for these patients.

Rates of insurance coverage in high deductible health plans (HDHP) and deductible size have been increasing. Over-time, financial barriers can lead to a substantial reduction in opportunities for health promotion and care coordination. We investigated the impact of different types of HDHPs on primary and specialty services utilization and receipt of preventive services among adult (18-64 years) privately insured respondents using pooled 2011-2014 Medical Expenditure Panel Survey (MEPS). The sample (n = 25,965) was divided into four insurance types (1) no deductible (ND) (2) low deductible (LD), (3) high deductible with health savings account (HD-HSA), and (4) high deductible without health savings account (HD-NoHSA). Multivariable regression models were estimated, adjusting for demographic characteristics and health status. Number of visits to primary care physicians and specialists were lowest for persons in the HD-NoHSA group (IRR 0.88 95% CI [0.81-0.96]). HD-NoHSA beneficiaries had lower rates of receiving hypertension screening (IRR 0.97 95% CI [0.94-0.99]) and flu vaccination (IRR 0.92 95% CI [0.86-1.00]) when compared to ND enrollees. Female respondents in the HD-NoHSA group were 7% less likely to receive mammograms (IRR 0.93 95% CI [0.89-0.98]) compared to the ND group. There was no significant association between insurance type and the other preventive service measures. Higher deductibles significantly decrease opportunities for early detection and management of chronic diseases, immunizations and care coordination. Fiscal barriers to essential medical care should be eliminated at least for those most vulnerable.

Objectives: To assess the effect of households' outlays for medical expenditures on income inequality and changes since the implementation of the Affordable Care Act (ACA)., Methods: We analyzed data from the US Current Population Surveys for calendar years 2010 through 2014. We calculated the Gini index of income inequality before and after subtracting households' medical outlays (including insurance premiums and out-of-pocket costs) from income, the financial burden of medical outlays for each income decile, and the number of individuals pushed below poverty by medical outlays., Results: In 2014, the Gini index was 47.84, which rose to 49.21 after medical outlays were subtracted, indicating that medical outlays effectively redistributed about 1.37% of total income from poorer to richer individuals, a slightly smaller redistribution compared with the years before the ACA. Medical outlays reduced the median income of the poorest decile by 47.6% versus 2.7% for the wealthiest decile and pushed 7.013 million individuals into poverty., Conclusions: The way we finance medical care exacerbates income inequality and impoverishes millions of Americans. This regressive financing pattern improved minimally in the wake of the ACA.

Republicans seem intent on pursuing a disastrous Obamacare replacement plan that couples catastrophic coverage with subsidized health savings accounts.

Once change to the OPPS rule eliminates the L1 modifier for unrelated laboratory tests, which will now be packaged with other services.