Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, 635 Downey Way, VPD 414F, Los Angeles, CA 90089-3333. Email:
Am J Manag Care. 2024 Sep;30(9):415-420. doi: 10.37765/ajmc.2024.89600.
The annual mean spending measures typically used to study longitudinal trends mask distributional and seasonal variation that is relevant to patients' perceptions of health care affordability and, in turn, provider collections. This study describes shifts in the distribution and seasonality of plan and patient out-of-pocket spending from 2012 through 2021.
Analysis of multipayer commercial claims data.
Medical spending per enrollee was calculated by summing inpatient, outpatient, and professional services, which comprised plan payments and out-of-pocket payments (deductible, coinsurance, co-payment). To account for the long right tail of the spending distribution, enrollees were stratified by their decile of annual medical spending, and annual mean spending estimates were calculated overall and by decile. Mean spending estimates were also calculated by quarter-year.
Inflation-adjusted medical spending grew most quickly among the highest decile of spenders, without proportional growth in their out-of-pocket expenses. Out-of-pocket spending increased for the majority of enrollees in our sample prior to the COVID-19 pandemic, in real dollars and as a share of total medical spending. Out-of-pocket spending was increasingly concentrated in the early months of the calendar year, driven by deductible spending, and was lower in 2020 and 2021, plausibly due to policies limiting cost sharing for COVID-19-related services.
Insurance is working well to protect the highest spenders at the cost of reduced insurance generosity among spenders elsewhere in the distribution. The increasing cross-subsidization among enrollees through cost-sharing design-vs premiums-is a trend to watch among rising public concerns about underinsurance and medical debt.
用于研究纵向趋势的年度平均支出衡量标准通常掩盖了与患者对医疗保健负担能力的看法相关的分布和季节性变化，而这反过来又会影响提供者的收款。本研究描述了 2012 年至 2021 年期间计划和患者自付支出的分布和季节性变化。
多付款人商业索赔数据分析。
每位参保者的医疗支出是通过汇总住院、门诊和专业服务费用计算得出的，这些费用包括计划支付和自付支付（免赔额、共付额、自付额）。为了考虑支出分布的长尾，参保者按其年度医疗支出的十分位数进行分层，总体和按十分位数计算年度平均支出估计值。还按季度计算平均支出估计值。
在最高支出十分位的人群中，经通胀调整后的医疗支出增长最快，但其自付支出并未按比例增长。在 COVID-19 大流行之前，我们样本中的大多数参保者的自付支出实际美元和占总医疗支出的份额都有所增加。自付支出在日历年的前几个月呈上升趋势，这主要是由于免赔额支出，2020 年和 2021 年的自付支出较低，这可能是由于限制 COVID-19 相关服务自付费用的政策所致。
保险在保护高支出者方面运作良好，但以降低分布中其他支出者的保险慷慨程度为代价。通过成本分担设计与保费相比，参保者之间的交叉补贴不断增加，这是一个值得关注的趋势，因为公众对保险不足和医疗债务的担忧日益增加。
