Out-of-Network Physicians: How Prevalent Are Involuntary Use and Cost Transparency?
ABSTRACT OBJECTIVE: To determine the proportion of privately insured adults using an out-of-network physician, the prevalence of involuntary out-of-network use, and whether patients experienced problems with cost transparency using out-of-network physicians. DATA SOURCES: Nationally representative internet panel survey conducted in February 2011. STUDY DESIGN: Screener questions identified a sample of 7,812 individuals in private health insurance plans with provider networks who utilized health services within the prior 12 months. Participants reported details of their inpatient and outpatient contacts with out-of-network physicians. An inpatient out-of-network contact was defined as involuntary if: (1) it was due to a medical emergency; (2) the physician's out-of-network status was unknown at the time of the contact; or (3) an attempt was made to find an in-network physician in the hospital but none was available. Outpatient contacts were only defined as involuntary if the physician's out-of-network status was unknown at the time of the contact. PRINCIPAL FINDINGS: Eight percent of respondents used an out-of-network physician. Approximately 40 percent of individuals using out-of-network physicians experienced involuntary out-of-network care. Among out-of-network physician contacts, 58 percent of inpatient contacts and 15 percent of outpatient contacts were involuntary. The majority of inpatient involuntary contacts were due to medical emergencies (68 percent). In an additional 31 percent, the physician's out-of-network status was unknown at the time of the contact. Half (52 percent) of individuals using out-of-network services experienced at least one contact with an out-of-network physician where cost was not transparent at the time of care. CONCLUSIONS: The frequency of involuntary out-of-network care is not inconsequential. Policy interventions can increase receipt of cost information prior to using out-of-network physician services, but they may be less helpful when patients have constrained physician choice due to emergent problems or limited in-hospital physician networks.
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ABSTRACT: Background Approximately 40 percent of individuals using out-of-network physicians experience involuntary out-of-network care, leading to unexpected and sometimes burdensome financial charges. Despite its prevalence, research on patient experiences with involuntary out-of-network care is limited. Greater understanding of patient experiences may inform policy solutions to address this issue. Objective To characterize the experiences of patients who encountered involuntary out-of-network physician charges. Methods Qualitative study using 26 in-depth telephone interviews with a semi-structured interview guide. Participants were a purposeful sample of privately insured adults from across the United States who experienced involuntary out-of-network care. They were diverse with regard to income level, education, and health status. Recurrent themes were generated using the constant comparison method of data analysis by a multidisciplinary team. ResultsFour themes characterize the perspective of individuals who experienced involuntary out-of-network physician charges: (1) responsibilities and mechanisms for determining network participation are not transparent; (2) physician procedures for billing and disclosure of physician out-of-network status are inconsistent; (3) serious illness requiring emergency care or hospitalization precludes ability to choose a physician or confirm network participation; and (4) resources for mediation of involuntary charges once they occur are not available. Conclusions Our data reveal that patient education may not be sufficient to reduce the prevalence and financial burden of involuntary out-of-network care. Participants described experiencing involuntary out-of-network health care charges due to system-level failures. As policy makers seek solutions, our findings suggest several potential areas of further consideration such as standardization of processes to disclose that a physician is out-of-network, holding patients harmless not only for out-of-network emergency room care but also for non-elective hospitalization, and designation of a mediator for involuntary charges.Health Services Research 06/2013; 48(5). DOI:10.1111/1475-6773.12071 · 2.49 Impact Factor
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ABSTRACT: OBJECTIVE:: Previous research has shown relatively high use of out-of-network mental health providers, although direct comparisons with rates among general health providers are not available. We aimed to (1) estimate the proportion of privately insured adults using an out-of-network mental health provider in the past 12 months; (2) compare rates of out-of-network mental health provider use with out-of-network general medical use; (3) determine reasons for out-of-network mental health care use. METHODS:: A nationally representative sample of privately insured US adults was surveyed using the internet in February 2011. Screener questions identified if the participant had used either a general medical physician or a mental health professional within the past 12 months. Respondents using either type of out-of-network provider completed a 10-minute survey on details of their out-of-network care experiences. RESULTS:: Eighteen percent of individuals who used a mental health provider reported at least 1 contact with an out-of-network mental health provider, compared to 6.8% who used a general health provider (P<0.01). The most common reasons for choosing an out-of-network mental health provider were the physician was recommended (26.1%), continuity with a previously known provider (23.7%), and the perceived skill of the provider (19.3%). CONCLUSIONS:: Out-of-network provider use is more likely in mental health care than general health care. Most respondents chose an out-of-network mental health provider based on perceived provider quality or continuing care with a previously known provider rather than issues related to the availability of an in-network provider, convenient location, or appointment wait time.Medical care 06/2013; 51(8). DOI:10.1097/MLR.0b013e31829a4f73 · 2.94 Impact Factor
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ABSTRACT: This report presents information on the state of the U.S. health system in 2012 and early 2013, specifically the period prior to the implementation of the individual mandate and full rollout of the Affordable Care Act's online health exchanges. The authors include data on the uninsured and underinsured and their access to health care, on socioeconomic inequality in health care, the rising costs of the U.S. health system, and the role of corporate money in health care, with special reference to the pharmaceutical industry. They also provide updates on Medicare health maintenance organizations, Medicaid, and a prelude to the complete implementation of the Affordable Care Act. In addition, the authors include some results from public opinion polls on health systems and international system comparisons. The article concludes with an assessment of the rapid consolidation in the delivery of health care being driven by the Affordable Care Act.International Journal of Health Services 04/2014; 44(2):215-32. DOI:10.2190/HS.44.2.b · 0.99 Impact Factor