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Reference Pricing, Consumer Cost-Sharing, and Insurer Spending for Advanced Imaging Tests

Robinson, James C., PhD; Whaley, Christopher, PhD; Brown, Timothy T., PhD

doi: 10.1097/MLR.0000000000000605
Original Articles
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Background: Fees charged for similar imaging tests often vary dramatically within the same market, leading to wide variation in insurer spending and consumer cost-sharing. Reference pricing is an insurance design that offers good coverage to patients up to a defined contribution limit but requires the patients who select high-priced facilities to pay the remainder out of pocket.

Objectives: To measure the association between implementation of reference pricing and patient choice of facility, test prices, out-of-pocket spending, and insurer spending for advanced imaging (CT and MRI) procedures.

Research Design: Difference-in-differences multivariable analysis of insurance claims data. Study included 4751 employees of a national grocery chain (treatment group) and 23,428 enrollees in the nation’s largest private insurance plan (comparison group) that used CT or MRI tests between 2010 and 2013.

Measures: Patient choice of facility, price paid per test, patient out-of-pocket cost-sharing, and employer spending.

Results: Compared with trends in prices paid by insurance enrollees not subject to reference pricing, and after adjusting for characteristics of tests and patients, implementation of reference pricing was associated with a 12.5% (95% CI, −25.0%, 2.1%) reduction in average price paid per test by the end of the second full year of the program for CT scans and a 10.5% (95% CI, −16.9%, 3.6%) for MRIs. Out-of-pocket cost-sharing by patients declined by $71,508 (13.8%). The savings accruing to employees amounted to 45.5% of total savings from reference pricing, with the remainder accruing to the employer.

Conclusions: Implementation of reference pricing led to reductions in payments by both employer and employees.

School of Public Health, University of California, Berkeley, Berkeley, CA

Supported by the Robert Wood Johnson Foundation, Grant No. 71780.

The authors declare no conflict of interest.

Reprints: James C. Robinson, PhD, School of Public Health, University of California, Berkeley, 247 University Hall, Berkeley, CA 94720-7360. E-mail: james.robinson@berkeley.edu.

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