Dusetzina Stacie B, Basch Ethan, Keating Nancy L
Stacie B. Dusetzina (
Ethan Basch is director of the Cancer Outcomes Research Program of the Lineberger Comprehensive Cancer Center and an associate professor in the School of Medicine and Gillings School of Global Public Health, both at the University of North Carolina at Chapel Hill.
Health Aff (Millwood). 2015 Apr;34(4):584-91. doi: 10.1377/hlthaff.2014.0801.
Reimbursement information for public and private payers has long been available. However, information about charges—the amounts that providers request before payments are negotiated—has been scarce, particularly for outpatient care. Using the new Medicare Provider Utilization and Payment Data Public Use File and other sources, we evaluated physician charges, reimbursements by Medicare and large private health plans, and expected patient cost sharing for outpatient oncology care. In 2012 the average Medicare reimbursement for chemotherapy was 39.6 percent of charges; for private insurance, the share was 55.7 percent. Uninsured patients faced potential prices for chemotherapy that were 2-43 times as much as the total Medicare-allowed amount and 2-5 times as much as the private insurance-allowed amount. Charges for outpatient chemotherapy and office visits were substantially higher than insurer-reimbursed amounts, which is consistent with previous evidence about hospital charges. The charges for outpatient services underscore the pressure that the current system places on the people who are least able to pay. Encouraging rational pricing for health care services will be an important step toward ensuring access to care for everyone.
长期以来，公共和私人支付方的报销信息都是可以获取的。然而，有关收费（即提供者在协商付款前要求的金额）的信息却很少，尤其是门诊护理方面。利用新的医疗保险提供者使用情况和支付数据公共使用文件及其他来源，我们评估了医生的收费、医疗保险和大型私人健康保险计划的报销情况，以及门诊肿瘤护理中患者预期的费用分担情况。2012年，医疗保险对化疗的平均报销额占收费的39.6%；对于私人保险，这一比例为55.7%。未参保患者面临的化疗潜在价格是医疗保险允许总额的2至43倍，是私人保险允许金额的2至5倍。门诊化疗和门诊就诊的收费大幅高于保险公司的报销金额，这与先前关于医院收费的证据一致。门诊服务收费凸显了当前体系给最无力支付费用的人群带来的压力。鼓励合理制定医疗服务价格将是确保人人都能获得医疗服务的重要一步。
