Out-Of-Network Spending Mostly Declined In Privately Insured Populations With A Few Notable Exceptions From 2008 To...

Area of Science:

• Health Economics
• Health Services Research
• Public Health Policy

Background:

• Surprise medical billing and out-of-network care are growing concerns, especially in emergency and inpatient settings.
• Limited national data exists on overall out-of-network care patterns beyond these acute care scenarios.

Purpose of the Study:

• To analyze trends in out-of-network healthcare spending and utilization.
• To compare out-of-network versus in-network prices.
• To identify specific clinical areas with increasing out-of-network costs.

Main Methods:

• Analysis of two large national datasets (Truven MarketScan and HCCI) covering millions of individuals with employer-sponsored insurance from 2008-2016.
• Examination of the share of total healthcare spending and utilization occurring out-of-network.
• Subgroup analyses across different medical service categories.

Main Results:

• The overall share of out-of-network spending declined from 7.0% to 6.1% between 2008-2010 and 2014-2016.
• Out-of-network spending share remained stable or decreased in most care segments, except for hospitalist, pathologist, and laboratory services.
• Out-of-network prices were consistently higher than in-network prices.

Conclusions:

• While overall out-of-network spending decreased, specific services saw stable or increased out-of-network utilization.
• Higher out-of-network prices underscore the need for consumer protection measures.
• Policy efforts should target surprise billing and balance billing, particularly in situations with limited patient provider choice.