Department of Radiology, NYU Langone Medical Center, New York, New York.
Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.
J Am Coll Radiol. 2018 Apr;15(4):607-614.e1. doi: 10.1016/j.jacr.2017.12.010. Epub 2018 Feb 22.
The aim of this study was to characterize out-of-pocket patient costs for advanced imaging across the US private insurance marketplace.
Using the 2017 CMS Health Insurance Marketplace Benefits and Cost Sharing Public Use File, which details coverage policies for qualified health plans on federally facilitated marketplaces, measures of out-of-pocket costs for advanced imaging and other essential health benefits were analyzed for all 18,429 plans.
Independent of deductibles, 48.0% of plans required coinsurance (percentage fees) for advanced imaging, 9.7% required copayments (flat fees), and 8.0% required both; 34.3% required neither. For out-of-network services, 91.5% required coinsurance, 0.1% copayments, and 1.0% both; only 7.4% required neither. In the presence of deductibles, patient coinsurance burdens for advanced imaging in and out of network were 27.7% and 47.7%, respectively, and average in- and out-of-network copayments were $319 and $630, respectively. In the presence of deductibles, patients' average coinsurance ranged from 10.0% to 40.9% in network and from 29.1% to 75.0% out of network by state; these tended to be higher in lower income states (r = -0.332). For no-deductible policies, patients' average out-of-network coinsurance burden for advanced imaging was 99.9%. Among assessed benefits, advanced imaging had the highest in-network and second highest out-of-network copayments.
In the US private insurance marketplace, patients very commonly pay coinsurance when undergoing advanced imaging, both in and out of network. But out-of-network services usually involve drastically higher patient financial responsibilities (potentially 100% of examination cost). To more effectively engage patients in shared decision making and mitigate the hardships of surprise balance billing, radiologists should facilitate transparent communication of advanced imaging costs with patients.
本研究旨在描述美国私人保险市场中高级影像学的自费患者成本。
使用 2017 年 CMS 医疗保险市场福利和费用分担公共使用文件，该文件详细说明了联邦便利市场上合格健康计划的覆盖政策，分析了所有 18429 个计划中高级影像学和其他基本健康福利的自费措施。
无论免赔额如何，48.0%的计划对高级影像学需要共付保险（百分比费用），9.7%需要共同支付（固定费用），8.0%需要两者；34.3%不需要。对于网络外服务，91.5%需要共付保险，0.1%需要共同支付，1.0%需要两者；只有 7.4%不需要。在存在免赔额的情况下，网络内和网络外高级影像学的患者共付保险负担分别为 27.7%和 47.7%，平均网络内和网络外共同支付分别为 319 美元和 630 美元。在存在免赔额的情况下，患者在网络内的平均共付保险范围从 10.0%到 40.9%，网络外从 29.1%到 75.0%，各州的共付保险范围从 10.0%到 40.9%不等；在低收入州，这些数字往往更高（r=-0.332）。对于无免赔额政策，患者在网络外进行高级影像学检查的平均自费负担为 99.9%。在所评估的福利中，高级影像学的网络内和网络外共同支付最高。
在美国私人保险市场中，患者在进行高级影像学检查时通常需要支付共付保险，无论是在网络内还是网络外。但网络外服务通常涉及患者更高的经济责任（可能为检查费用的 100%）。为了更有效地让患者参与共同决策，并减轻意外平衡计费的困难，放射科医生应促进与患者进行高级影像学成本的透明沟通。
