AHRQ Study: Cost Transparency Affects Patient Choice for Cataract Surgery

Patients in California chose ambulatory surgery centers over more expensive hospital outpatient departments for cataract removal surgery when they knew the costs of care, according to an AHRQ-funded study. The researchers looked at the impact of “reference-based benefits,” a new employer-based health insurance design that encourages patients to select lower-priced freestanding ambulatory surgery centers rather than hospital outpatient facilities. Analyzing this type of benefit design for cataract removal surgery from 2009 to 2013 among groups of California patients, researchers found that total employer and employee payments per procedure fell by 19.7 percent compared with those without reference-based benefits. Researchers compared data on 2,347 surgical patients ages 18 to 64 covered by the California Public Employees Retirement Systems (CalPERS) and data from 14,867 patients enrolled in non-CalPERS Anthem Blue Cross plans, which do not use reference-based benefits. With reference-based pricing, employers set a pricing cap on the maximum amount they will cover for certain medical services that have wide cost variations. The article andabstract, “Reference-Based Benefit Design Changes Consumers' Choices and Employers' Payment for Ambulatory Surgery,” appeared in the March issue of the journal Health Affairs.

2015 Mar 1;34(3):415-22. doi: 10.1377/hlthaff.2014.1198.

Reference-based benefit design changes consumers' choices and employers' payments for ambulatory surgery.

Robinson JC1, Brown T2, Whaley C3.

Author information

Abstract

Some employers are using reference-based benefit (RBB) designs, also known as "reference-based pricing," to encourage patients to select lower-price ambulatory surgery centers instead of expensive hospital outpatient departments. This article analyzes the impact of such benefit designs for cataract removal surgery from the period 2009-13, using data on 2,347 surgical patients covered by the California Public Employees Retirement System (CalPERS), in comparison to 14,867 patients enrolled in non-CalPERS Anthem Blue Cross plans, which are not covered by RBB. After adjusting for changes in patient case-mix and other factors, the shift to RBB was associated with an increase in ambulatory surgery center use by 8.6 percentage points compared to trends among Anthem enrollees. Total employer and employee payments per procedure, after adjusting for changes in case-mix severity and market factors, declined by 19.7 percent compared with Anthem enrollees not subject to RBB. Consumer cost-sharing requirements increased for CalPERS patients who continued to use hospital outpatient departments but who were not exempted from RBB because of geographic or clinical factors. Reference-based benefits for cataract surgery saved CalPERS $1.3 million in the two years after implementation.

Project HOPE—The People-to-People Health Foundation, Inc.