Reference payments for colonoscopy may reduce cost without complication increase

1. Implementation of reference payments for colonoscopy was associated with a shift in patient choice towards lower-price colonoscopy facilities.

2. Despite changes in consumer preferences, there was no significant difference in procedural complications.

Evidence Rating Level: 2 (Good)

Study Rundown: With the introduction of the Affordable Care Act, many preventative health services, such as colonoscopy for cancer screening, must now be provided without co-payments or deductibles. This helps to ensure that everyone has increasingly equal access to these necessary services. However, this may result in reduced incentive for hospitals and facilities to restrain their prices. Many employers and insurers are now looking to methods of reference payment, where individuals are covered for an amount that is the average of the nearby facilities’ prices, and the patient is to pay the difference if they attend a higher costing facility. However, it is unclear the impact that reference payments have on access to care and consumer or insurer costs. This study aimed to ascertain the effect of reference payments on facility choice, insurer spending, consumer cost-sharing and procedural complications of colonoscopy.

The implementation of reference payments as a means for cost sharing in colonoscopy resulted in an acceleration of patient preference for lower-costing facilities. This resulted in a $7.0 million (28%) decrease in spending for the California Public Employees’ Retirement System (CalPERS) over two years. This decrease in cost and shift in choice to lower costing facilities was not accompanied by an increase in procedural complications. The strengths of this study include studying a timely issue and helping to elucidate how the American government can decrease healthcare costs. However, this study used patients covered by an employment-based health insurance company, and thus the results of procedural complications should be generalized with caution to the elderly population.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Coverage and preventive screening

In-Depth [retrospective cohort]: This retrospective cohort was conducted from 2009 to 2014. It used the California Public Employees’ Retirement System (CalPERS) database to determine the impact of the 2012 implementation of reference payments on consumer choice of facility, insurer spending, consumer cost sharing, and procedural complications. They collected data from 21 644 enrollees who underwent colonoscopy 3 years prior to reference payment implementation, and from 13 551 enrollees who underwent colonoscopy 2 years after reference payment implementation. They were compared to 258 616 Anthem Blue Cross enrollees who were not subject to a reference payment system. Difference-in-difference multivariable regression was used to determine if there was a change in outcomes after implementation of reference payments and this was compared across the CalPERS and Anthem Blue cross groups.

Implementation of the reference payment systems increased usage of low-priced facilities by 17.6% (95%CI 11.8%-23.4%; p < 0.001). This was accompanied by $200 decrease in mean price paid for colonoscopy for reference payment consumers after the implementation of this system. After adjustment for confounders, reference payment enactment was responsible for a 21.0% (95%CI -26.0% to -15.6%; p < 0.001) decrease in price of colonoscopy. There was also no significant difference between procedural complications before and after implementation (2.1% in 2009 to 2.0% in 2013, p = 0.47).

Image: CC/Wiki

©2015 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.