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Original Investigation
September 2016

Out-of-Pocket Spending for Hospitalizations Among Nonelderly Adults

Author Affiliations
  • 1Center for Healthcare Outcomes and Policy, University of Michigan Medical School, Ann Arbor
  • 2Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
  • 3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 4Michigan Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor
  • 5Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
  • 6Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor
  • 7Center for Clinical Management and Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan
JAMA Intern Med. 2016;176(9):1325-1332. doi:10.1001/jamainternmed.2016.3663

Importance  Patients’ out-of-pocket spending for major health care expenses, such as inpatient care, may result in substantial financial distress. Limited contemporary data exist on out-of-pocket spending among nonelderly adults.

Objectives  To evaluate out-of-pocket spending associated with hospitalizations and to assess how this spending varied over time and by patient characteristics, region, and type of insurance.

Design, Setting, and Participants  A retrospective analysis of medical claims for 7.3 million hospitalizations using 2009-2013 data from Aetna, UnitedHealthcare, and Humana insurance companies representing approximately 50 million members was performed. Out-of-pocket spending was evaluated by age, sex, type of insurance, region, and principal diagnosis or procedure for hospitalized adults aged 18 to 64 years who were enrolled in employer-sponsored and individual-market health insurance plans from January 1, 2009, to December 31, 2013. The study was conducted between July 1, 2015, and March 1, 2016.

Main Outcomes and Measures  Primary outcomes were total out-of-pocket spending and spending attributed to deductibles, copayments, and coinsurance for all hospitalizations. Other outcomes included out-of-pocket spending associated with 7 commonly occurring inpatient diagnoses and procedures: acute myocardial infarction, live birth, pneumonia, appendicitis, coronary artery bypass graft, total knee arthroplasty, and spinal fusion.

Results  From 2009 to 2013, total cost sharing per inpatient hospitalization increased by 37%, from $738 in 2009 (95% CI, $736-$740) to $1013 in 2013 (95% CI, $1011-$1016), after adjusting for inflation and case-mix differences. This rise was driven primarily by increases in the amount applied to deductibles, which grew by 86% from $145 in 2009 (95% CI, $144-$146) to $270 in 2013 (95% CI, $269-$271), and by increases in coinsurance, which grew by 33% over the study period from $518 in 2009 (95% CI, $516-$520) to $688 in 2013 (95% CI, $686-$690). In 2013, total cost sharing was highest for enrollees in individual market plans ($1875 per hospitalization; 95% CI, $1867-$1883) and consumer-directed health plans ($1219; 95% CI, $1216-$1223). Cost sharing varied substantially across regions, diagnoses, and procedures.

Conclusions and Relevance  Mean out-of-pocket spending among commercially insured adults exceeded $1000 per inpatient hospitalization in 2013. Wide variability in out-of-pocket spending merits greater attention from policymakers.