Review 1: "Out-of-Pocket Spending for Health Care Within 90 Days of COVID-19 Hospitalization"

Emmeline Chuang

doi:doi:10.1162/2e3983f5.e9a0df0b

Out-of-Pocket Spending Within 90 Days of Discharge from COVID-19 Hospitalization

by Kao-Ping Chua, Rena M. Conti, and Nora V. Becker

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dx.doi.org

Description

ABSTRACTINTRODUCTIONMillions of U.S. patients have been hospitalized for COVID-19. After discharge, these patients often have extensive health care needs, but out-of-pocket burden for this care is poorly described. We assessed out-of-pocket spending within 90 days of discharge from COVID-19 hospitalization among privately insured and Medicare Advantage patients.METHODSIn May 2021, we conducted a cross-sectional analysis of the IQVIA PharMetrics® Plus for Academics Database, a national de-identified claims database. Among privately insured and Medicare Advantage patients hospitalized for COVID-19 between March-June 2020, we calculated mean out-of-pocket spending for care within 90 days of discharge. For context, we repeated analyses for patients hospitalized for pneumonia.RESULTSAmong 1,465 COVID-19 patients included, 516 (35.2%) and 949 (64.8%) were covered by private insurance and Medicare Advantage plans. Among these patients, mean (SD) post-discharge out-of-pocket spending was $534 (1,045) and $680 (1,360); spending exceeded $2,000 for 7.0% and 10.3%. Compared with pneumonia patients, mean post-discharge out-of-pocket spending among COVID-19 patients was higher among the privately insured ($534 vs $445) and lower among Medicare Advantage patients ($680 vs $918).CONCLUSIONSFor the privately insured, post-discharge out-of-pocket spending was higher among patients hospitalized for COVID-19 than among patients hospitalized for pneumonia. The opposite was true for Medicare Advantage patients, potentially because insurer cost-sharing waivers for COVID-19 treatment covered the costs of some post-discharge care, such as COVID-19 readmissions. Nonetheless, given the high volume of U.S. COVID-19 hospitalizations to date, our findings suggest a large number of Americans have experienced substantial financial burden for post-discharge care.

RR:C19 Evidence Scale rating by reviewer:

Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.

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Review:

This study seeks to assess out-of-pocket spending within 90 days of discharge from COVID-19 hospitalization among privately insured and Medicare Advantage patients. Data are drawn from the IQVIA PharMetrics Plus for Academics Database, a national de-identified database that includes medical and pharmacy claims data on 7.7 million patients covered by fully-insured private plans and 1.0 million patients covered by Medicare Advantage plans in 2020. The study sample included all patients with a first hospitalization and primary diagnosis of COVID-19 that began and ended between May to June 2020 (n=1,465). The author(s) calculated mean out-ofpocket spending (sum of deductibles, co-insurance, and co-payments) for these patients during the first 90 days after discharge across all claims and across 14 service categories. To provide comparative context, the analysis was repeated for patients with a first hospitalization for bacterial pneumonia during this time frame (n=1,374). One part generalized linear models with log link and Poisson variance function were conducted to compare post-discharge spending for COVID-19 and pneumonia patients, by payer, controlling for age group, sex, Census region, and month of admission. The author(s) found that mean post-discharge spending was $534 for privately insured patients diagnosed with COVID-19, and $680 for those with Medicare Advantage, compared to $445 for privately insured patients with pneumonia and $918 for those with Medicare Advantage. Importantly, the author(s) noted that for ~10% of patients with a first hospitalization and primary diagnosis of COVID-19, out-of-pocket spending exceeded $2,000.

The study is cross-sectional and descriptive, and the study sample frame omits patients without continuous insurance coverage, those whose plan was a secondary insurer, those with any missing spending data on any claim, and those with prolonged hospitalization that may have required more intensive post-discharge care. The rationale for comparing out-of-pocket spending between patients diagnosed with COVID-19 with those diagnosed with pneumonia is not clearly explained. The author(s) were unable to determine whether insurers may have had any cost-sharing waivers for COVID-19 testing or treatment in place; patient sociodemographic information was also limited (e.g., no information regarding income, education, race/ethnicity, etc.), so equity and diversity considerations were not addressed. The author(s) acknowledge limitations of their study. They also note that their analyses likely underestimate out-of-pocket burden among all patients hospitalized for COVID-19 and suggest the need to more closely monitor financial health of patients diagnosed with COVID-19 moving forward.