Effects of Cost Sharing on Ophthalmic Care Utilization in the Affordable Care Act Marketplace

ABSTRACT

Purpose

To determine the distribution and quantity of ophthalmic care consumed on Affordable Care Act (ACA) plans, the demographics of the population utilizing these services, and the relationship between ACA insurance coverage plan tier, cost sharing, and total cost of ophthalmic care consumed.

Methods

This cross-sectional study analyzed ACA individual and small group market claims data from the Wakely Affordable Care Act (WACA) 2018 dataset, which contains detailed claims, enrollment, and premium data from Edge Servers for 3.9 million individual and small group market lives. We identified all enrollees with ophthalmology-specific billing, procedure, and national drug codes. We then analyzed the claims by plan type and calculated the total cost and out-of-pocket (OOP) cost.

Results

Among 3.9 million enrollees in the WACA 2018 dataset, 538,169 (13.7%) had claims related to ophthalmology procedures, medications, and/or diagnoses. A total of $203 million was generated in ophthalmology-related claims, with $54 million in general services, $42 million in medications, $20 million in diagnostics and imaging, and $86 million in procedures. Average annual OOP costs were $116 per member, or 30.9% of the total cost, and were lowest for members with platinum plans (16% OOP) and income-driven cost sharing reduction (ICSR) subsidies (17% OOP). Despite stable ocular disease distribution across plan types, beneficiaries with silver ICSR subsidies consumed more total care than any other plan, higher than platinum plan enrollees and almost 1.5× the cost of bronze plan enrollees.

Conclusions

Ophthalmic care for enrollees on ACA plans generated substantial costs in 2018. Plans with higher OOP cost sharing may result in lower utilization of ophthalmic care.

KEYWORDS:

• affordable care act
• cost sharing
• barriers to care
• health equity
• metal tier

Acknowledgments

All data from the Wakely Affordable Care Act (WACA) database (and all derived datasets described in this study) were curated, organized, and provided for research purposes by Wakely Consulting Group (Tampa, Fl). Special acknowledgements are due to Wakely analysts Darren Johnson and Jenna Stefan, in addition to Wakely senior consultant Ksenia Whittal and president Julia Lambert. Although Wakely provided the WACA dataset and related exhibits and assisted in answering data-related questions, the analysis and conclusions presented in this manuscript are the sole responsibility of the listed authors.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The data in this manuscript are the result of a research partnership Wakely Consulting Group. Please contact Wakely Consulting Group for data access https://www.wakely.com/services/product/wakely-aca-database-waca.

Geolocation information

Nashville, TN, USA

Additional information

Funding

Supported internally by the Vanderbilt Eye Institute Lefkovitz Resident Research Award. Supported in part by a Research to Prevent Blindness unrestricted grant to the Vanderbilt Eye Institute.