Anna D Sinaiko

• Ph. D
• Harvard University

Importance Rising out-of-pocket costs of maternal health care for people with commercial insurance may affect use of health care and outcomes. There are stark racial and ethnic disparities in outcomes, but little is known about differences in spending. Objective To measure differences in out-of-pocket spending for maternity care by race and ethnic...

Importance Improving access to high-quality maternity care and reducing maternal morbidity and mortality are major policy priorities in the US. Previous research has primarily focused on access to general obstetric care rather than access to high-risk pregnancy care provided by maternal-fetal medicine subspecialists (MFMs). Objective To measure ac...

Background: Patients with HF average >$4000/year in out-of-pocket (OOP) costs for their care, including GDMT. High OOP costs lead to nonadherence and poor outcomes. The OOP costs of GDMT often fluctuate over the course of the year due to deductibles and other variable cost-sharing requirements. Poor understanding of these changes present a barrier...

Introduction: The use of virtual care for patients with hematologic malignancies significantly increased during the COVID-19 pandemic, and its use has continued as an effective means for care delivery. In Ontario, Canada's largest province, all physicians are remunerated through publicly funded payment programs. On December 1, 2022, a policy change...

Importance Vertical relationships (ownership, affiliations, joint contracting) between physicians and health systems are increasing in the US. Many proponents of vertical relationships argue that increased spending associated with consolidation is accompanied by improvements in quality of care. Objective To assess the association of vertical relat...

This Viewpoint describes issues with cost sharing for health care costs and suggests improvements to current cost sharing systems.

Background For consumers without access to employer-sponsored or public insurance, health plan choices in the non-group (individual) insurance market that do not meet consumer needs have the potential for negative downstream implications for health and financial well-being. Objective This qualitative interview study sought to understand consumers’...

Importance Tiered physician network (TPN) health plans sort physicians into tiers based on their cost and quality, and patients pay lower copays for visits with physicians in the lower-cost and better-quality tiers. When the plans are first introduced, they lead patients to seek care from higher-value physicians. Objectives To examine whether TPNs...

Medication cost conversations occur less frequently than patients prefer, and it is unclear whether patients have positive experiences with them when they do occur. To describe patients’ experiences discussing their medication costs with their health care team. Cross-sectional survey. Nationally representative survey fielded in the United States in...

This cross-sectional study examines whether clinicians changed their medication orders after seeing the patient’s out-of-pocket drug costs in the electronic health record.

Objective: To understand variation in enrollment in tiered network health plans (TNPs) and the local provider market characteristics associated with TNP penetration. Data sources and study setting: We used 2013-2017 Massachusetts three-digit ZIP code level employer-sponsored health insurance enrollment data, data on physician horizontal and vert...

Importance: Vertical relationships (eg, ownership or affiliations, including joint contracting) between physicians and health systems are increasing in the US. Objective: To analyze how vertical relationships between primary care physicians (PCPs) and large health systems are associated with changes in ambulatory and acute care utilization, refe...

Paper describes our development of a web-based tool to make Medicare patient prices for cancer drugs known to their care teams.

Objective: The study aims to analyze the relationship between care integration and care quality, and to examine if the relationship varies by patient risk. Data sources and study setting: The key independent variables used validated measures derived from a provider survey of functional (i.e., administrative and clinical systems) and social (i.e....

Importance: High-deductible health plans with health savings accounts (HDHP-HSAs) incentivize patients to use less health care, including necessary care. Preventive drug lists (PDLs) exempt high-value medications from the deductible, reducing out-of-pocket cost sharing; the associations of PDLs with health outcomes among patients with asthma is un...

Objective: To examine whether physicians in tiered physician networks where tier assignments are based on "intensity" of care, which is the quantity of resources used per-episode of care, change their intensity after learning detailed information about how their intensity compares to their peers. Data sources: Administrative data on intensity an...

Importance: Rising prescription drug costs and increasing prices for consumer goods may increase cost-related medication nonadherence. Cost-conscious prescribing can be supported by real-time benefit tools, but patient views on real-time benefit tool use and their potential benefits and harms are largely unexplored. Objective: To assess older ad...

Objectives Congress and Medicare have required real-time benefit tools (RTBT) to provide patient-specific medication price information during prescribing to decrease the cost of medications. We sought physicians' perspectives on how these tools might most effectively improve their selection of low-cost medication. Methods We conducted 15 semi-struc...

e18823 Background: Cancer care delivery has been described as a “system in crisis” in part due to lack of affordable care. In 2019, out-of-pocket (OOP) costs alone were estimated to be over $16 billion in the US. Transparency and early conversations about expected OOP costs may prevent financial toxicity and improve patient-centered care. Methods:...

Vertical integration in health care has recently garnered scrutiny by antitrust authorities and state regulators. We examined trends, geographic variation, and price effects of vertical integration and joint contracting between physicians and hospitals, using physician affiliations and all-payer claims data from Massachusetts from the period 2013-1...

Racial inequities in clinical performance diminish overall health care system performance; however, quality assessments have rarely incorporated reliable measures of racial inequities. We studied care for more than one million Medicare fee-for-service beneficiaries with cancer to assess the feasibility of calculating reliable practice-level measure...

This cohort study assesses cost-related experiences in non-group plans purchased on or off Marketplace and variation by Marketplace enrollment, decision support use, and other characteristics.

Background Out-of-pocket health care costs can cause financial burden and deferred care for many Americans. Little is known about out-of-pocket (OOP) spending for asthma-related care among the commercially insured. Objectives To analyze OOP spending for asthma-related care overall, across types of care, and by income. Methods Using enrollment, cl...

Political orientation can be a powerful motivator of certain health care decisions. This study examines how political orientation was associated with decisions to use the Affordable Care Act Marketplaces to enroll in nongroup health insurance plans and whether it was also associated with adverse financial consequences. We used administrative record...

Importance When introduced a decade ago, patient-facing price transparency tools had low use rates and were largely not associated with changes in spending. Little is known about how such tools are used by pregnant individuals in anticipation of childbirth, a shoppable service with increasing out-of-pocket spending. Objective To measure changes ov...

Objective To document the change in contraceptive visits in the United States during the COVID-19 pandemic. Study design Using a nationwide sample of claims we analyzed the immediate and sustained changes in contraceptive visits during the pandemic by calculating the percentage change in number of visits between May 2019 and April 2020 and between...

More is known about the structural features of health system integration than the social features—elements of normative integration (alignment of norms) and interpersonal integration (collaboration among professionals and with patients). We surveyed practice managers and 1,360 staff and physicians at 59 practice sites within 17 health systems (828...

6533 Background: Equity is now recognized as an essential aspect of health care quality. Racial inequities in clinical performance diminish overall system performance. We assessed the feasibility and reliability of practice-level measures of racial disparities in chemotherapy-associated emergency department (ED) visits and hospitalizations. Methods...

Importance High-deductible health plans (HDHPs) are increasingly common and associated with decreased medication use in some adult populations. How children are affected is less certain. Objective To examine the association between HDHP enrollment and asthma controller medication use and exacerbations. Design, Setting, and Participants For this l...

Disenrollment from health plans purchased on Affordable Care Act (ACA) Marketplaces is frequent; little is known whether disenrollment from off-Marketplace plans is as common or about the experiences and consequences of disenrollment. Using longitudinal administrative data on 2017-2018 nongroup plan enrollment linked with survey data, we analyze pl...

Background Guidelines on mammographic surveillance following breast cancer treatment have been disseminated internationally and incorporated into Choosing Wisely recommendations to reduce low-value care. However, adherence within different countries prior to their publication is unknown. Methods Low-value mammography, defined as “short-interval” (...

This cross-sectional study analyzes data on aggregate utilization and aggregate spending by patients and by pharmacy benefit managers to pharmacies for every brand-name drug prescription dispensed to all fully insured patients and some self-insured patients with commercial insurance in Massachusetts from 2015 to 2017.

In 2012 South Carolina's Medicaid program was the first state Medicaid program to separate payment for the immediate postpartum placement of long-acting reversible contraception (intrauterine devices and contraceptive implants) from its global maternity payment. Examining data on all Medicaid-insured South Carolina women giving birth from 2010 to 2...

In 2018, spending on prescription drugs in the United States reached $335 billion, with 78.7% of this spending on brand-name drugs,1,2 and slowing the growth of drug spending in the United States has become a major policy concern. Among nonelderly adults and seniors taking prescription drugs, 24% and 23%, respectively, had difficulty affording thei...

Objective Examine care integration—efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them—to understand whether and at which organizational level health systems impact care quality and staff experience. Data Sources Surveys administered to one practice manager (56/59) a...

(Abstracted from J Perinatol 2020;40:1091–1099) Preterm birth and low birthweight incur large medical, social, and economic costs on affected families and the US health care system. A 2007 study from the Institute of Medicine estimated that the total cost associated with preterm delivery in the United States was at least $26.2 billion annually or $...

Importance: Systematically capturing cancer stage is essential for any serious effort by health systems to monitor outcomes and quality of care in oncology. However, oncologists do not routinely record cancer stage in machine-readable structured fields in electronic health records (EHRs). Objective: To evaluate whether a peer comparison email in...

Asthma is the most common pediatric chronic condition, with substantial morbidity, health care utilization, and costs. Enrollment has increased in high‐deductible health plans (HDHPs) that require families to assume greater responsibility for out‐of‐pocket (OOP) costs for asthma and other family health care needs, creating potential barriers to use...

Research Objective Patient cost‐sharing has been increasing over the past two decades, in particular due to high‐deductible health plans (HDHP). Asthma is a very common, serious, chronic disease in the United States. We analyzed a large, national sample of asthma patients to provide new evidence on OOP spending overall, across types of asthma care,...

The growth in healthcare spending is an important topic in the United States, and preterm and low-birthweight infants have some of the highest healthcare expenditures of any patient population. We performed a retrospective cohort study of spending in this population using a large, national claims database of commercially insured individuals. A tota...

Objective: To examine the association of a national insurer's reference-based pricing (RBP), program for outpatient advanced imaging-a benefit design to encourage patients to choose lower-price facilities. Data source/study setting: Administrative and medical claims data for three self-insured employers that introduced RBP and a comparison group...

Background Prostate cancer is the most common male cancer, with a wide range of treatment options. Payment reform to reduce unnecessary spending variation is an important strategy for reducing waste, but its magnitude and drivers within prostate cancer are unknown. Methods In total, 38,971 men aged ≥66 years with localized prostate cancer who were...

A primary driver of high spending in the US health care system, relative to other countries, is the higher prices paid for health care in the United States. Part of what sustains these high prices is that health care prices are largely opaque.¹,2 The goal of price transparency is to empower patients with new information so they can consider prices,...

The extent of price variation across a local market has important implications for value-based purchasing. Using a new data set containing health care prices for nearly every insurer-provider-service triad across a large local market, we comprehensively examined variation in fee-for-service paid commercial prices in Massachusetts for 291 predominan...

Objectives: Healthcare payers are increasingly using price transparency and benefit design to encourage patients to choose lower-priced providers. We quantify potential savings from shifting patients to lower-priced providers. If there is limited price variation or if higher-priced providers command little market share, savings could be minimal....

Short interpregnancy intervals (defined variously as 6, 12, 18, or 24 months between pregnancies) are associated with adverse newborn outcomes.¹ Immediate postpartum long-acting reversible contraception (IPP-LARC)—ie, receipt of an intrauterine device or contraceptive implant before hospital discharge following a birth—is recommended to reduce shor...

In an effort to increase use of preventive health care, The Patient Protection and Affordable Care Act (ACA) eliminated cost-sharing for preventive cancer screening services for the privately insured. The impact on patient spending and use of these screenings is still poorly understood. We used an interrupted time series analysis with the Massachus...

The health insurance Marketplaces established by the Affordable Care Act include features designed to simplify the process of choosing a health plan in the individual, or nongroup, insurance market. While most individual health insurance enrollees purchase plans through the federal and state-based Marketplaces, millions also purchase plans directly...

Objectives: There is robust evidence that implementation of reference-based pricing (RBP) benefit design decreases spending. This paper investigates employer adoption of RBP as a strategy to improve the value of patients' healthcare choices, as well as facilitators and barriers to the adoption of RBP by employers. Study design: We conducted a qu...

Objective To estimate and describe factors driving variation in spending for breast cancer patients within geographic region. Data Source Surveillance, Epidemiology, and End Results (SEER)‐Medicare database from 2009‐2013. Study Design The proportion of variation in monthly medical spending within geographic region attributed to patient and physi...

Background: Providers need timely, clinically meaningful, and actionable information to improve quality of care. Payers may play an important role in providing such information in ambulatory care settings. We sought to learn about providers' use and perceptions of quality reports from insurers. Methods: We employed a mixed-methods study design....

The inaccessibility of price information in the US health care system prevents patients from anticipating and incorporating their health care costs into care-seeking decisions and from choosing the best-value clinician (physician or facility). There is wide price variation across clinicians in the same geographic areas,¹ which means that patients,...

Despite widespread interest in price transparency, it has not fulfilled its promise of encouraging price shopping. Among the barriers, possibly the most important are that high deductibles are a poor form of incentive for encouraging price shopping and that patients are reluctant to disrupt their provider relationships. Increasing evidence suggests...

Behavioural economic research has established that defaults, one form of nudge, powerfully influence choices. In most policy contexts, all individuals receive the same nudge. We present a model that analyses the optimal universal nudge for a situation in which individuals differ in their preferences and hence should make different choices and may i...

While family purchase of health insurance may benefit insurance markets by pooling individual risk into family groups, the correlation across illness types in families could exacerbate adverse selection. We analyze the impact of family pooling on risk for health insurers to inform policy about family-level insurance plans. Using data on 8,927,918 e...

Insurers, employers, and states increasingly encourage price transparency so that patients can compare health care prices across providers. However, the evidence on whether price transparency tools encourage patients to receive lower-cost care and reduce overall spending remains limited and mixed. We examined the experience of a large insured popul...

The growing awareness of the wide variation in health care prices, increased availability of price data, and increased patient cost sharing are expected to drive patients to shop for lower-cost medical services. We conducted a nationally representative survey of 2,996 nonelderly US adults who had received medical care in the previous twelve months...

Selecting a health plan in a health insurance exchange is a critical decision, yet consumers are known to face challenges with health plan choice. We surveyed new enrollees in two state-based exchanges in 2015 to investigate how a nonelderly, primarily low-income population chose their health plans and the implications of shopping behavior for earl...

Objectives: Driven by the growth of high deductibles and price transparency initiatives, patients are being encouraged to search for prices before seeking care, yet few do so. To understand why this is the case, we interviewed individuals who were offered access to a widely used price transparency website through their employer. Study design: Qu...

Employers and health plans are increasingly using tiered provider networks in their benefit designs to steer patients to higher quality and more efficient providers in an effort to increase value in the health care system.We evaluated the impact of a tiered-network health plan on total health care spending and on inpatient, outpatient, and outpatie...

In the United States, wide variation in prices for the same medical services continue to persist both across the country and within geographic areas, with no reliable correlation between clinician prices and quality. Helping patients and physicians identify and select high-quality medical services at the lowest price when services are needed is fre...

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a metaanalysis of methodologically standardized findings from evaluations of eleven major P...

Background and objectives: Ordering rates for imaging studies and procedures may change if clinicians are shown the prices of those tests while they are ordering. We studied the effect of 2 forms of paid price information, single median price and paired internal/external median prices, on how often pediatric-focused and adult-oriented clinicians (...

Background Prior studies have demonstrated how price transparency lowers the test-ordering rates of trainees in hospitals, and physician-targeted price transparency efforts have been viewed as a promising cost-controlling strategy. Objective To examine the effect of displaying paid-price information on test-ordering rates for common imaging studies...

Study concept and design: Sinaiko, Rosenthal. Acquisition, analysis, or interpretation of data: Sinaiko, Joynt. Drafting of the manuscript: Sinaiko. Critical revision of the manuscript for important intellectual content: Joynt, Rosenthal. Statistical analysis: Sinaiko, Rosenthal. Obtained funding: Sinaiko.

Objectives: Prior studies found that tiered provider networks channel patients to preferred providers in certain contexts. This paper evaluates whether the effects of tiered physician networks vary for different types of patients. Study design: Cross-sectional analysis of fiscal year 2009 to 2010 administrative enrollment and claims data on none...

Calls for transparency in health care prices are increasing, in an effort to encourage and enable patients to make value-based decisions. Yet there is very little evidence of whether and how patients use health care price transparency tools. We evaluated the experiences, in the period 2011-12, of an insured population of nonelderly adults with Aetn...

Health Insurance Marketplaces established by the Affordable Care Act implement reinsurance and risk corridors. Reinsurance limits insurer costs associated with specific individuals, while risk corridors protect against aggregate losses. Both tighten the insurer's distribution of expected costs. This paper compares the economic costs and consequence...

Research in behavioral economics suggests that certain circumstances, such as large numbers of complex options or revisiting prior choices, can lead to decision errors. This paper explores the enrollment decisions of Medicare beneficiaries in the Medicare Advantage (MA) program. During the time period we study (2007-2010), private fee-for-service (...

The Medicare Advantage (MA) program continues to grow and thrive, despite plan payment cuts imposed through the Affordable Care Act. What explains this surprising outcome (one that is strikingly different than the experience of MA plans in the late 1990s, when payment cuts led to dramatic shrinkage in enrollment and curtailment of plans)? This anal...

Background: Patient-centered medical homes (PCMH) may improve the quality of primary care while reducing costs and utilization. Early evidence on the effectiveness of PCMH has been mixed. Objectives: We analyze the impact of a PCMH intervention in Rochester NY on costs, utilization, and quality of care. Research Design: A propensity score-matched d...

This Viewpoint recommends actions for states to improve the content, availability, and salience of publicly available health care price information. To make smart choices about their health care, individuals need accurate and timely information about quality and price. States have broad responsibilities for the regulation of health insurance and t...

To help people shop for lower cost providers, several states have created their own price transparency Web sites or passed legislation mandating health plans provide such information. New Hampshire's HealthCost Web site is on the forefront of such initiatives. Despite the growing interest in price transparency, little is known about such efforts, i...

To assess whether patient choice of physician or health plan was affected by physician tier-rankings. Administrative claims and enrollment data on 171,581 nonelderly beneficiaries enrolled in Massachusetts Group Insurance Commission health plans that include a tiered physician network and who had an office visit with a tiered physician. We estimate...

The estimates of elasticity of demand for medical services provided by the RAND Health Insurance Experiment (HIE) of the 1970s have largely served as the gold standard for our understanding of how cost-sharing affects patient decisions to consume medical care. Owing to evolution in benefit design and a desire to test the generalizability of the HIE...

In two important health policy contexts - private plans in Medicare and the new state-run "Exchanges" created as part of the Affordable Care Act (ACA) - plan payments come from two sources: risk-adjusted payments from a Regulator and premiums charged to individual enrollees. This paper derives principles for integrating risk-adjusted payments and p...

Risk adjustment and reinsurance protect plans against risk of losses and contend with adverse selection in the new health insurance Exchanges. This article assesses the power of reinsurance in the context of other plan payment features, including prospective and concurrent risk adjustment. Using data from the Medicare Expenditure Panel Survey (MEPS...

Evidence from behavioral economics reveals that decision-making in health care settings can be affected by circumstances and choice architecture. This paper conducts an analysis of choice of private Medicare plans (Medicare Advantage plans) in Miami-Dade County. We provide a detailed description of the choice of MA plans available in Miami over muc...

Health insurance exchanges created under the Affordable Care Act will offer coverage to people who lack employer-sponsored insurance or have incomes too high to qualify for Medicaid. However, plans offered through an exchange may include high levels of cost sharing. We surveyed families participating in unsubsidized plans offered in the Massachuset...