Weiss Robert
Independent Lymphedema Patient Advocate, 10671 Baton Rouge Avenue, Porter Ranch, CA, 91326, USA.
Health Econ Rev. 2022 Jul 23;12(1):40. doi: 10.1186/s13561-022-00388-6.
Treatment of chronic illness accounts for over 90% of Medicare spending. Chronic lymphedema places 3-10 million Americans at risk for recurrent cellulitis. Without convincing predictions of the costs and benefits of lymphedema treatment, insurers are reluctant to fully cover treatment of this common condition. Earlier papers discussed the costs and benefits of the first 5, 7, and 10 years of a lymphedema treatment mandate in Virginia. This paper updates these costs and benefits to 16 years of experience, and includes the impacts of the Patient Protection and Affordable Care Act of 2010 and the transition to ICD-10-CM diagnostic codes in 2015. It provides added confidence that costs of a lymphedema treatment mandate are reasonable, and can result in health insurance contract savings for reduced medical visits and hospitalizations for lymphedema patients.
Virginia requires annual reporting of the segregated costs of each of its 30 medical mandates. Data on Virginia's lymphedema treatment mandate for the years 2004 to 2019 have been collected from the series of annual reports. These data include actual lymphedema treatment claims data, utilization data, and claims-based estimates of the premium impact.
The average actual lymphedema claim cost was $2.03 per individual contract and $3.54 per group contract for the years reported, representing 0.05 and 0.08% of average total claims. The estimated premium impact was 0.16-0.32% of total average premium for all mandated coverage contracts. While lymphedema claim costs increased 3-6% per year over the study period, generally following the rise of health care costs, claim costs as a percent of average contract claims fell at a rate of 1.26-1.52% per year over that period. Medical office visits for lymphedema-related services fell from 0.10 to 0.02 visits per year per contract from the beginning to the end of the study period, and hospitalizations for lymphedema or lymphedema-related cellulitis fell to almost zero.
The Virginia data confirmed previous conclusions that the costs of treatment of lymphedema are a small part of a typical health insurance contract, and that treatment of lymphedema by managing swelling results in lower overall medical costs and fewer hospitalizations. This is a potent model for reduction in healthcare costs while improving the quality of care for cancer survivors and others suffering with this chronic progressive condition.
慢性病治疗费用占医疗保险支出的90%以上。慢性淋巴水肿使300万至1000万美国人面临复发性蜂窝织炎的风险。由于缺乏令人信服的淋巴水肿治疗成本效益预测，保险公司不愿全额承保这种常见疾病的治疗。早期论文讨论了弗吉尼亚州淋巴水肿治疗规定实施的前5年、7年和10年的成本效益。本文将这些成本效益更新至16年的经验，并纳入了2010年《患者保护与平价医疗法案》的影响以及2015年向ICD-10-CM诊断代码的转换。这进一步证明了淋巴水肿治疗规定的成本是合理的，并且可以通过减少淋巴水肿患者的医疗就诊和住院次数为健康保险合同节省费用。
弗吉尼亚州要求每年报告其30项医疗规定中每项规定的单独成本。从一系列年度报告中收集了2004年至2019年弗吉尼亚州淋巴水肿治疗规定的数据。这些数据包括实际淋巴水肿治疗索赔数据、使用数据以及基于索赔的保费影响估计。
在所报告的年份中，平均每份个人合同的实际淋巴水肿索赔成本为2.03美元，每份团体合同为3.54美元，分别占平均总索赔的0.05%和0.08%。估计的保费影响为所有规定承保合同平均总保费的0.16%至0.32%。在研究期间，淋巴水肿索赔成本每年增长3%至6%，总体上跟随医疗保健成本的上升，但在此期间，索赔成本占平均合同索赔的百分比以每年1.26%至1.52%的速度下降。从研究期开始到结束，与淋巴水肿相关服务的医疗办公室就诊次数从每份合同每年0.10次降至0.02次，因淋巴水肿或与淋巴水肿相关的蜂窝织炎住院次数几乎降至零。
弗吉尼亚州的数据证实了先前的结论，即淋巴水肿治疗成本在典型的健康保险合同中占比很小，并且通过管理肿胀来治疗淋巴水肿可降低总体医疗成本并减少住院次数。这是一个在降低医疗保健成本的同时提高癌症幸存者和其他患有这种慢性进行性疾病患者护理质量的有效模式。
