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Abstract: We compare health care spending in public and private Medicare using newly available claims data from Medicare Advantage (MA) insurers. MA insurer revenues are 30 percent higher than their health care spending. Adjusting for enrollee mix, health care spending per enrollee in MA is 9 to 30 percent lower than in Traditional Medicare (TM), depending on the way we define "comparable" enrolle...

Abstract Background: Area-level deprivation is associated with multiple adverse birth outcomes. Few studies have examined the mediating pathways through which area-level deprivation affects these outcomes. The objective of this study was to investigate the association between area-level deprivation and preterm birth, and examine the mediating effects of maternal medical, behavioural, and psyc...

ABSTRACT We examined the growth in health spending on people with employer-sponsored private insurance in the period 2007–14. Our analysis relied on information from the Health Care Cost Institute data set, which includes insurance claims from Aetna, Humana, and UnitedHealthcare. In the study period private health spending per enrollee grew 16.9 percent, while growth in Medicare spending per fee-f...

​Abstract: In 2014, insurers paid an average of 13–14 percent less for in-network mental health services in their commercial and Medicare Advantage plans than fee-for-service Medicare paid for identical services—despite paying up to 12 percent more than Medicare when the same services were provided by other physician specialties. However, patients went out of network more frequently for mental hea...

Abstract: Evidence suggests that growth in providers' prices drives growth in health care spending on the privately insured. However, existing work has not systematically differentiated between the growth rate of hospital prices and that of physician prices. We analyzed growth in both types of prices for inpatient and hospital-based outpatient services using actual negotiated prices paid by insure...

 Abstract Background: More than half of all medical procedures performed in the United States occur in an outpatient setting, yet few studies have explored how competition among ambulatory surgery centers (ASCs) and hospitals affects prices for commercially insured outpatient services. Objectives: We examined the association between prices for commercially insured outpatient procedu...

ABSTRACT   BACKGROUND: The health care costs associated with treating autism spectrum disorder (ASD) in children can be substantial. State-level mandates that require insurers to cover ASD-specific services may lessen the financial burden families face by shifting health care spending to insurers. METHODS: We estimated the effects of ASD mandates on out-of-pocket spending, insurer spendi...

Executive Summary: High and rising health care prices play a major role in the persistent increases in health care spending. This study, undertaken by the American Academy of Actuaries Health Practice Council, explores the potential for reference pricing to counter high health care prices and contain health care spending growth. Reference pricing is a system in which an insurer selects a price it ...

Abstract: Intensity-modulated radiation therapy (IMRT) is an important driver of rising costs in oncology care, but the level of evidence supporting its routine use varies across disease sites, including breast, lung, and prostate. While Medicare Advantage (MA) plans have incentives to reduce health care spending, the effect of MA enrollment on utilization of high-cost medical services and quality...

 ABSTRACT: Policies and practices have proliferated to optimize prescribers' use of their states' prescription drug monitoring programs, which are statewide databases of controlled substances dispensed at retail pharmacies. Our study assessed the effectiveness of three such policies: comprehensive legislative mandates to use the program, laws that allow prescribers to delegate its use to offi...

Abstract: One of the key terms in contracts between hospitals and insurers is how the parties apportion the financial risk of treating unexpectedly costly patients. "Prospective" payment contracts give hospitals a lump-sum amount, depending on the medical condition of the patient, with limited adjustment for the level of services provided. We use data from the Medicare Prospective Payment System a...

​BACKGROUND: National guidelines make recommendations regarding the initial opioid prescriptions, but most of the supporting evidence is from the initial episode of care, not the first prescription. OBJECTIVE: To examine associations between features of the first opioid prescription and high-risk opioid use in the 18 months following the first prescription. DESIGN: Retrosp...

​Abstract:  We use insurance claims data covering 28% of individuals with employer-sponsored health insurance in the United States to study the variation in health spending on the privately insured, examine the structure of insurer-hospital contracts, and analyze the variation in hospital prices across the nation. Health spending per privately insured beneficiary differs by a factor of three ...

Abstract: Using the Health Care Cost Institute (HCCI) database, which contains claim information on approximately 47 million members annually over a seven-year time period, we examined which characteristics best predict and describe high-cost members. We found that cost history, age, gender and prescription drug coverage are all predictors of future high costs, with cost history being the most pre...

ABSTRACT: The prices that insurers pay physicians ultimately affect beneficiaries' health insurance premiums. Using 2014 claims data from three major insurers, we analyzed the prices insurers paid in their Medicare Advantage (MA) and commercial plans for 20 physician services, in and out of network, and compared those prices with estimated amounts that Medicare's fee-for-service (FFS) program...

ABSTRACT The prices that private insurers pay hospitals have received considerable attention in recent years, but most of that literature has focused on the commercially insured population. Although nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, little is known about the prices paid to hospitals by the private insurers that administer such plans. More in...

 ABSTRACT Objective: To compare differences in opioid prescription, health care utilization, and costs among patients with low back pain (LBP) who saw a physical therapist (PT) at the first point of care, at any time during the episode or not at all. Data Sources: Commercial health insurance claims data, 2009–2013. Study Design: Retrospective analyses using two‐stage residual inclusion instru...

ABSTRACT: We use insurance claims data covering 28 percent of individuals with employer-sponsored health insurance in the US to study the variation in health spending on the privately insured, examine the structure of insurer-hospital contracts, and analyze the variation in hospital prices across the nation. Health spending per privately insured beneficiary differs by a factor of three across...

ABSTRACT Background: Laparotomy followed by inpatient hospitalization has traditionally been the most common surgical care for hysterectomy. The financial implications of the increased use of laparoscopy and outpatient hysterectomy are unknown. Objectives: The objective of the study was to quantify the increasing use of laparoscopy and outpatient hysterectomy and to describe the financial implicat...

ABSTRACT Objectives: There is substantial variation in treatment intensity among children with autism spectrum disorder (ASD). This study asks whether policies that target health care utilization for ASD affect children differentially based on this variation. Specifically, we examine the impact of state-level insurance mandates that require commercial insurers to cover certain treatments for ASD f...

Abstract OBJECTIVE: To analyze utilization of, and payments for, pelvic organ prolapse procedures after the 2011 U.S. Food and Drug Administration (FDA) communication regarding transvaginal mesh. METHODS: This is a retrospective cohort study examining private claims from three insurance providers for inpatient and outpatient prolapse procedures from 2010 to 2013 in the Health Care Cost Institute. ...

ABSTRACT: A longstanding debate in health economics and health policy concerns how hospitals adjust prices with private insurers following reductions in public funding. A common argument is that hospitals engage in some degree of "cost-shifting," wherein hospitals increase prices with private insurers in response to a reduction in public payments; however, evidence of significant costshifting...

ABSTRACT:  Proponents of hospital-based observation care argue that it has the potential to reduce health care spending and lengths-of-stay, compared to short-stay inpatient hospitalizations. However, critics have raised concerns about the out-of-pocket spending associated with observation care. Recent reports of high out-of-pocket spending among Medicare beneficiaries have received cons...

ABSTRACT: Forty-six states and the District of Columbia have enacted insurance mandates that require commercial insurers to cover treatment for children with autism spectrum disorder (ASD). This study examined whether implementing autism mandates altered service use or spending among commercially insured children with ASD. We compared children age twenty-one or younger who were eligible for m...

ABSTRACT Research comparing quality of cancer care by insurance categories concluded that cancer patients without insurance or with Medicaid experienced inferior quality of care compared with those with private insurance. A new insurance category created from the Affordable Care Act (ACA) is insurance purchased from the Health Insurance Marketplace (also known as the exchange). The present st...