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The No Surprises Act (NSA), implemented in 2022, has protected patients nationally from surprise medical bills in most settings. However, out-of-network care resulting in arbitration between insurers and providers under the NSA may result in very high costs for this care. The objective of this paper is to characterize payments for out-of-network care resulting from disputes that underwent arbitration under the NSA and compare the settlement amounts to in-network prices. Using 2023 dispute and claims data from Elevance Health (EH), we described insurer and provider bids, and compared the final settlement amounts to the qualifying payment amount (QPA) – which is used in arbitration and is intended to represent average in-network market rates – and to in-network prices for similar procedures. Lastly, we compared settlement amounts to Medicare rates. 7076 disputes between EH and providers with arbitration under the NSA were analyzed, eighty percent of which were won by providers. Median (mean) final arbitration amounts were 3.72 (4.99) times the QPA, 2.04 (3.23) times actual median local in-network commercial rates, and 4.5 (5.8) times Medicare rates for the same services. This analysis shows that settlement amounts were substantially higher than QPA and median in-network prices, indicating that out-of-network providers are receiving substantially higher payments than in-network providers when they go through arbitration under the NSA. This contrasts with the Congressional Budget Office’s prediction of savings through arbitration settlements close to average in-network prices.

Background Hypertensive disorders during pregnancy continue to increase in prevalence and are associated with several adverse outcomes and future cardiovascular risk for mothers. This study evaluated the association of hypertensive disorders compared to no hypertension during pregnancy with neonatal and maternal outcomes. We then evaluated risk factors associated with progression from a less to more severe hypertensive disorder during pregnancy. Methods We conducted a propensity-matched retrospective cohort study utilizing Medicaid claims data from a national insurer. The study population consisted of mothers with and without hypertensive disorders who delivered between 7/1/2016–12/31/2018 and their infants. Hypertensive disorders included gestational hypertension, chronic hypertension, preeclampsia, and superimposed preeclampsia. Propensity score matching was used to match mothers without to those with hypertensive disorders. Regression models were used to compare maternal and neonatal outcomes. Stepwise logistic regression was used to determine characteristics associated with the progression of gestational hypertension to preeclampsia or chronic hypertension to superimposed preeclampsia. Results We observed the highest risk of cesarean delivery (odds ratio [OR]:1.61 and 1.99) in mothers and preterm delivery (OR:2.22 and 5.37), respiratory distress syndrome (OR:2.39 and 4.19), and low birthweight (OR:3.64 and 9.61) in babies born to mothers with preeclampsia or superimposed preeclampsia compared to no hypertension, respectively ( p  < 0.05 for all outcomes). These outcomes were slightly higher among chronic or gestational hypertension compared to no hypertension, however, most were not statistically significant. Risk of neonatal intensive care unit utilization was higher among more severe hypertensive disorders (OR:2.41 for preeclampsia, OR:4.87 for superimposed preeclampsia). Obesity/overweight and having a history of preeclampsia during a prior pregnancy were most likely to predict progression from gestational/chronic hypertension to preeclampsia/superimposed preeclampsia. Conclusion Mothers and neonates born to mothers with preeclampsia or superimposed preeclampsia experienced more adverse outcomes compared to those without hypertension. Mothers and neonates born to mothers with gestational hypertension had outcomes similar to those without hypertension. Outcomes for those with chronic hypertension fell in between gestational hypertension and preeclampsia. Obesity/overweight and having a history of preeclampsia during a prior pregnancy were strong risk factors for hypertension progression.

Medicare Advantage (MA) enrollment has grown significantly over the last 2 decades while Medicare program spending per capita has moderated over that same period. An open question is how the growth in MA enrollment has impacted Medicare program spending. The objective of this study is to estimate the association between MA penetration (ie, the percentage of Medicare beneficiaries enrolled in MA) and total Medicare spending per capita. We estimated linear regression models that examine the relationship between county-level MA penetration and total Medicare spending per capita. The study used county-level Medicare spending and enrollment data—including MA, Medicare Fee-for-Service, and Part D—from the Centers for Medicare & Medicaid Services from 2012 to 2021. The study included counties from all 50 states and Washington, D.C. 3045 counties were included in the analysis, which represents 97% of U.S. counties. We found that counties with higher MA penetration showed lower standardized Medicare spending per capita. Specifically, 10 percentage point higher annual MA penetration was associated with$194 lower ( P < .001) total Medicare spending per capita, representing 1.5% lower spending. After adjusting risk scores to reflect the Medicare Payment Advisory Commission’s estimates of higher coding intensity in MA, 10 percentage point higher annual MA penetration was associated with $ 146 lower ( P < .001) total Medicare spending per capita, representing 1.1% lower spending. If these associations are causal in nature, then higher MA enrollment over the last 2 decades may have moderated total Medicare program spending over the same period.

Objective Bariatric procedures have become safer in recent years, warranting new data on long‐term costs. This study examined the impact of bariatric procedures on a person's long‐term healthcare costs up to 10 years and if it differed by socio‐economic status (SES). Methods This retrospective observational study compared the downstream health care cost of patients with obesity who had undergone bariatric surgery (BS) between 2009 and 2018 to a 1:1 matched group of members with obesity but no surgery. Results 167,764 individuals from administrative claims data with an obesity diagnosis were included; 83,882 in the BS group and 83,882 in the non‐surgical group. In follow‐up years 2–10, the BS group was associated with lower total medical healthcare cost compared to the non‐surgical group (cost ratios ranged 0.85–0.93, p values < 0.05). When stratifying the BS group by SES quartiles, there were no significant cost differences by SES (cost ratios ranged from 0.96 to 1.05, most p values > 0.05). Conclusions BS was associated with lower long‐term follow‐up medical cost and cost savings appeared similar among the SES quartiles in the BS group. The study results may help policy makers and employers in designing benefits and extending coverage for bariatric surgical procedures. In our study, with 10‐year follow‐up data, we find that bariatric surgery (BS) is associated with lower follow‐up cost from Year 2 to Year 9 compared with a matched cohort. We believe that the lower cost in the surgery group is mainly due to newer, safer bariatric surgeries and lower medication spending. This study can provide guidance to policy makers, researchers, and clinicians to make informed decisions regarding long‐term cost benefits associated with BS. It can also help payors and employers understand the benefits of covering BS.

Introduction/Objectives: In 2018, a Medicaid managed care plan launched a new community health worker (CHW) initiative in several counties within a state, designed to improve the health and quality of life of members who could benefit from additional services. The CHW program involved telephonic and face-to-face visits from CHWs who provided support, empowerment, and education to members, while identifying and addressing health and social issues. The primary objective of this study was to evaluate the impact of a generalized (not disease-specific), health plan-led CHW program on overall healthcare use and spending. Methods: This retrospective cohort study used data from adult members who received the CHW intervention (N = 538 participants) compared to those who were identified for participation but were unable to be reached (N = 435 nonparticipants). Outcomes measures included healthcare utilization, including scheduled and emergency inpatient admissions, emergency department (ED) visits, and outpatient visits; and healthcare spending. The follow-up period for all outcome measures was 6 months. Using generalized linear models, 6-month change scores were regressed on baseline characteristics to adjust for between-group differences (eg, age, sex, comorbidities) and an indicator for group. Results: Program participants experienced a greater increase in outpatient evaluation and management visits (0.09 per member per month [PMPM]) than the comparison group during the first 6 months of the program. This greater increase was observed across in-person (0.07 PMPM), telehealth (0.03 PMPM), and primary care (0.06 PMPM) visits. There was no observed difference in inpatient admissions, ED utilization or allowed medical spending and pharmacy spending. Conclusions: A health plan-led CHW program successfully increased multiple forms of outpatient utilization in a historically disadvantaged population of patients. Health plans may be particularly well positioned to finance, sustain, and scale programs that address social drivers of health.

Expansion of virtual health care-real-time video consultation with a physician via the Internet-will continue as use of mobile devices and patient demand for immediate, convenient access to care grow. The objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions. A cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy. A total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%, P=.99) and RHC visits (28.59%, P=.51). During the episode, lab rates for virtual visits (12.56%) were lower than in-person locations (RHC: 36.79%, P<.001; UCC: 39.01%, P<.001; ED: 53.15%, P<.001; PCP: 37.40%, P<.001), and imaging rates for virtual visits (6.62%) were typically lower than in-person locations (RHC: 5.97%, P=.11; UCC: 8.77%, P<.001; ED: 43.06%, P<.001; PCP: 11.26%, P<.001). RHC, UCC, ED, and PCP were estimated to be $36, $153, $1735, and $162 more expensive than virtual visit episodes, respectively, including medical and pharmacy costs. Virtual care appears to be a low-cost alternative to care administered in other settings with lower testing rates. The similar follow-up rate suggests adequate clinical resolution and that patients are not using virtual visits as a first step before seeking in-person care.

Background We aimed to identify the impact of COVID infection in children in the US prior to vaccine availability on clinical and healthcare utilization outcomes within 6 months of infection. Methods Using claims data from a large national insurer, we identified 223,842 children with a COVID diagnosis in May 2020–March 2021 and matched them to 223,842 children with a COVID test and no diagnosis. We compared the two cohorts’ outcomes during the 6 months after infection/test. Results Uncommon acute adverse events occurring in <0.5% of cases, including MIS-C (relative risk (RR) = 45.2), myocarditis (RR = 10.3), acute heart failure (RR = 2.14), sepsis (RR = 2.02), and viral pneumonia (RR = 2.43) were more frequent in the COVID cohort (all p  < 0.001). Development of arrhythmias (RR = 1.24, p  < 0.001) and atherosclerotic cardiovascular disease (RR = 1.41, p  = 0.007) were more common in the COVID group, while behavioral health disorders were less common (RR = 0.94, p  < 0.001). Lab testing and imaging were slightly higher in the COVID group (RR ranging 1.05–1.11 depending on the service and timeframe), though medical costs did not increase. Conclusion Severe disease and diagnoses of new conditions are rare in children following COVID infection. We observed an increase in cardiac complications, though they may not last long term. Impact Few studies have analyzed the association between COVID infection and medium-term outcomes in children. Our study of >447,000 geographically and socioeconomically diverse children in the US found that uncommon acute adverse events, including myocarditis, MIS-C, and acute heart failure, were more frequent in children with COVID than matched controls, and development of arrhythmias and cardiovascular disease were 1.2 and 1.4 times more common, respectively. Six-month healthcare utilization was similar between cohorts. We provide data on the risks of COVID in children, particularly with respect to cardiac complications, that decision makers may find useful when weighing the benefits and harms of preventive measures.

Surprise billing laws that allow dispute arbitration relying on provider charges may incentivize out-of-network providers to increase their charges to increase upcoming or future out-of-network payments. Although the federal No Surprises Act forbids arbitrators from considering charges during payment disputes over surprise bills covered by the act, states with existing laws can continue to use the specified state laws, which may allow the consideration of charges. This analysis examined provider charges in two such states, using claims data to compare trends in billed charges for out-of-network care during surprise bill scenarios involving nonemergency inpatient hospitalizations. The analysis considered New York, where state law uses arbitration tied to charges; California, where state law uses a payment standard rather than charges; and a comparison group of states without a law regarding surprise billing. We estimated that provider out-of-network charges for the nonemergency out-of-network bills we studied increased by$1,157 (24 percent) in New York after the passage of New York's surprise billing law and decreased by $ 752 (25 percent) in California compared to states without surprise billing laws. Assistant surgeons and surgical assistants had a large increase in charges in New York from before to after the law's passage, which may have driven the overall increase in charges.

To examine the association between the use of the grocery card supplemental benefit offered by Medicare Advantage (MA) plans and health care utilization. Observational study utilizing 2021-2022 MA claims data. This observational cohort study examined eligible adults who were continuously enrolled between January 1, 2021, and December 31, 2022, in MA dual-eligible special needs plans that offered a grocery card benefit from January 1, 2022, through December 31, 2022. We performed difference-in-differences analyses comparing health care utilization among dual-eligible members who opted to use grocery card supplemental benefits vs those who did not, before and after the benefit's introduction. Grocery card use was associated with an increase in the likelihood of annual wellness, primary care provider (PCP), and specialist visits (6.6%, 4.9%, and 6.6%, respectively) and increased number of office and specialist visits (2.3% and 2.8%, respectively). Frequent use (more than half of the available grocery card dollars) was analyzed separately and was associated with slightly greater increases in the likelihood and number of visits (all P <.05). This observational study of dual-eligible beneficiaries found a modest relative increase in office visits, including annual wellness, PCP, and specialist visits, among beneficiaries who opted to use the grocery card supplemental benefits after they were offered compared with beneficiaries who did not. These findings suggest that policy changes that allow for nonmedical supplemental benefits have had favorable results, especially for dual-eligible beneficiaries.

Importance Payers use oncology clinical pathways programs to increase evidence-based drug prescribing and control drug spending. However, compliance with these programs has been low, which may decrease their efficacy, and factors associated with pathway compliance are unknown. Objective To determine extent of pathway compliance and identify factors associated with pathway compliance using characteristics of patients, practices, and the companies that develop cancer treatment pathways. Design, Setting, and Participants This cohort study comprised patients with claims and administrative data from a national insurer and a pathways health care professional between July 1, 2018, and October 31, 2021. Adult patients with metastatic breast, lung, colorectal, pancreatic, melanoma, kidney, bladder, gastric, and uterine cancer being treated in the first line were included. Six months of continuous insurance coverage prior to the date of treatment initiation was required for determination of baseline characteristics. Stepwise logistic regression was used to identify factors associated with pathway compliance. Main Outcomes and Measures Use of a pathway program–endorsed treatment regimen in the first-line setting for metastatic cancer. Results Among 17 293 patients (mean [SD] age, 60.7 [11.2] years; 9183 [53.1%] women; mean [SD] Black patients per census block, 0.10 [0.20]), 11 071 patients (64.0%) were on-pathway, and 6222 (36.0%) were off-pathway. Factors associated with increased pathway compliance were higher health care utilization during the 6-month baseline period (measured in inpatient visits and emergency department visits) (5220 on-pathway inpatient visits [47.2%] vs 2797 off-pathway [45.0%]; emergency department visits, 3304 [27.1%] vs 1503 [24.2%]; adjusted odds ratio [aOR] for inpatient visits, 1.32; 95% CI, 1.22-1.43;P < .001), volume of patients with this insurance provider per physician (mean [SD] visits: on-pathway, 128.0 [258.3] vs off-pathway, 121.8 [161.4]; aOR, 1.12; 95% CI, 1.04-1.20;P = .002), and practice participation in the Oncology Care Model (on-pathway participation, 2601 [23.5%] vs 1305 [21.0%]; aOR, 1.13; 95% CI, 1.04-1.23;P = .004). Higher total medical cost during the 6-month baseline period were associated with decreased pathway compliance (mean [SD] costs: on-pathway,$55 990 [$ 69 706] vs$65 955 [$ 74 678]; aOR, 0.86; 95% CI, 0.83-0.88;P < .001). There was heterogeneity in odds of pathway compliance between different malignancies. Pathway compliance rates trended down from the reference year of 2018. Conclusions and Relevance In this cohort study, despite generous financial incentives, compliance with payer-led pathways remained at historically reported low rates. Factors such as increasing exposure to the program due to the number of patients impacted and participation in other value-based payment programs, such as the Oncology Care Model, were positively associated with compliance; factors such as the type of cancer and patient complexity may have played a role, but the directionality of potential effects was unclear.