Waivers Mitigated COVID-19 Bills for Hospital Facility Services

Heidi Splete

October 18, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Out-of-pocket spending for facility services was less than 5% for hospitalized COVID-19 patients in the United States, according to data from a cross-sectional study of more than 7 million patients.

To mitigate the financial burden of hospitalization for COVID-19, many insurance companies waived cost-sharing during the height of the pandemic in all or part of 2020, write Kao-Ping Chua, MD, of the University of Michigan, Ann Arbor, and colleagues.

However, some patients may have been billed for categories of care not covered by waivers, the researchers say. Categories of bills include facility services, "such as accommodation and inpatient pharmacy services," and services from clinicians and ancillary service providers, referred to as "professional and ancillary services," they note.

"Protecting patients from the costs of COVID-19 hospitalizations specifically may be especially important given the number of hospitalizations that may occur and given that the threat of cost sharing could deter patients with serious COVID-19 symptoms from seeking care," but the amounts for which COVID-19 patients were billed in 2020 in different service categories have not been evaluated, the researchers emphasize.

In the study, published in JAMA Network Open, the researchers reviewed data from March 2020 to September 2020 from the IQVIA PharMetrics Plus for Academics Database, a national claims database including 7.7 million patients with private insurance and 1.0 million patients with Medicare Advantage. The main outcome measure was the total out-of-pocket spending, defined as the sum of spending for facility services billed by hospitals and professional and ancillary services billed by clinicians and other providers.

The final analysis included 4075 hospitalizations; 1377 of these were privately insured patients and 2968 were for Medicare Advantage patients. The mean age of the patients was 66.8 years, and 51.3% were male.

Overall, 981 (71.2%) of privately insured patients and 1324 (49.1%) of Medicare Advantage patients reported some out-of-pocket spending on facility services, professional and ancillary services, or both for COVID-19 hospitalizations during the study period. The mean total amounts of out-of-pocket spending were $788 for privately insured patients and $277 for Medicare Advantage patients.

The mean length of hospital stay for privately insured patients was 7.3 days, and 640 (46.5%) of the hospitalizations included intensive care unit use. For Medicare Advantage patients, the mean length of stay was 9.2 days, and 44.9% included intensive care use.

However, out-of-pocket spending for facility services only was reported in 63 hospitalizations of privately insured patients (4.3%) and 36 hospitalizations of Medicare Advantage patients (1.3%). In these cases, the mean amount of out-of-pocket spending was $3,840 for privately insured patients and $1,536 for Medicare Advantage patients.

Total out-of-pocket spending topped $4,000 in 2.5% of hospitalizations for privately insured patients compared with 0.2% of Medicare Advantage patients.

The researchers also examined the out-of-pocket spending for each of three main types of professional and ancillary services: ambulance, clinician, and miscellaneous.

A total of 137 (9.9%) privately insured patients and 985 (36.5%) of Medicare Advantage patients had out-of-pocket ambulance costs; 918 (66.7%) and 595 (22.1%), respectively, had clinician-related costs.

In a further subtype analysis of clinician services, 516 (37.5%) of privately insured patients had out-of-pocket spending for inpatient evaluation and management services, compared with 394 (14.6%) of Medicare Advantage patients. The mean out-of-pocket cost for the 516 hospitalizations with inpatient evaluation and management services was $622 for privately insured patients and $162 for Medicare Advantage patients.

The study findings were limited by several factors, mainly the inability to confirm that COVID-19 hospitalizations were covered by plans with cost-sharing waivers, the researchers note. Other limitations included the inability to account for spending by patients who did not pay what they were billed or who were not billed because they died in the hospital, and the potential inexact estimates of out-of-pocket facilities spending because of the comparatively small numbers, the researchers write.

However, the results were strengthened by the use of a large national database that included a large percentage of older adults, who are at increased risk for COVID-19 hospitalization, they note. The results suggest not only that insurer cost-sharing waivers may not capture all hospitalization-related care for COVID-19 patients, but also that the financial burden for these patients could be significant without waivers, the researchers emphasize.

To help protect patients from the extensive costs of COVID-19 hospitalizations, "federal policymakers might consider legislation mandating insurers to waive cost sharing for COVID-19 hospitalizations throughout the public health emergency," with a mandate that would include all hospitalization-related care, similar to current federal mandates for the coverage of all direct and related COVID-19 testing and vaccine costs, the researchers write.

"Future research should include monitoring of patient financial burden resulting from COVID-19 hospitalizations as coverage policies change," they conclude.

Funds for the purchase of IQVIA data were provided in part by the Susan B. Meister Child Health Evaluation and Research Center at the University of Michigan Medical School. Chua disclosed support from the National Institute on Drug Abuse, National Institutes of Health.

JAMA Netw Open. 2021;4(10):e2129894. Full text

Heidi Splete is a freelance medical journalist with 20 years of experience.

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