HealthDay News — The out-of-pocket costs for out-of-network (OON) care grew rapidly for privately insured Americans from 2012 to 2017, according to a study published in the American Journal of Managed Care.

Wendy Yi Xu, PhD, from The Ohio State University in Columbus, and colleagues used data from the IBM MarketScan Commercial Claims and Encounter Database (2012 to 2017) to study patterns of cost sharing for OON care among those enrolled in employer-sponsored insurance plans as either policyholders or dependents (ages 18 to 64 years). Data included fully paid and adjudicated claims for inpatient and outpatient services and prescription drugs from 22,054,244 enrollees.

The researchers found that the prevalence of use of OON care dropped during the study period, while cost sharing for that care rose rapidly from 2012 through 2016 before slowing down in 2017. About 16% of individuals encountered OON care, with an average out-of-pocket cost of $621. The fastest cost-sharing increases for enrollees were for nonemergency hospitalizations. During the study period, the average out-of-pocket cost for this type of OON hospital care increased from $671 to $1,286. Consumer costs for OON emergency hospitalizations also rose, from $452 to $565. To address consumer protection from costs of OON care, the authors make policy recommendations, including telling patients if providers and facilities are out of network, regardless of the urgency of their care; calling for disclosure requirements that hold patients harmless if providers fail to inform the patient of network status; and reexamining state criteria for network adequacy in an effort to ensure that patients can get the care they need without going out of network.

“Health care costs are putting pressure on many American families, and we believe that they shouldn’t be held responsible for these bills if these higher-cost services are provided without their knowledge or consent,” Xu said in a statement. “Even when a hospital is in-network, care is often provided by out-of-network physicians.”


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