During 2020, most private and Medicare Advantage insurers waived cost sharing for COVID-19 hospitalizations, thus protecting patients from financial liability.1 However, most insurers abandoned these cost-sharing waivers by August 2021.2 In an analysis of COVID-19 hospitalizations from March through September 2020, few privately insured or Medicare Advantage patients had cost sharing for hospital facility services, such as room-and-board charges, likely because waivers were widespread.3 We assessed whether the incidence of cost sharing for facility services increased in early 2021, when waivers began to expire.4 Among hospitalizations with patient cost sharing for facility services, we determined the factors associated with the magnitude of out-of-pocket spending for hospitalization care, thus identifying patients at elevated risk for large bills going forward.
The IQVIA PharMetrics Plus for Academics database (IQVIA Inc) reports medical claims from 1.0 million patients covered by Medicare Advantage plans and 7.7 million patients covered by fully insured private plans across the US. Because the data were deidentified, the University of Michigan institutional review board exempted the analyses from review. This cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
We included hospitalizations with a primary diagnosis of COVID-19 that began and ended between March 1, 2020, and March 30, 2021. We excluded hospitalizations if plans were the secondary insurer or if any hospitalization-associated claim had missing data for out-of-pocket spending or billing provider type. We calculated the monthly proportion of hospitalizations with cost sharing for facility services, a potential indicator that cost-sharing waivers were absent.3 Among these hospitalizations, we calculated the mean total out-of-pocket spending for all hospitalization-related services (see the eAppendix in the Supplement for details).
To identify factors associated with total out-of-pocket spending, we fitted generalized linear models with a log link and gamma variance function. Covariates were age group, sex, census region, admission month, plan type, intensive care use, and length of stay. To express coefficients as changes in out-of-pocket spending, we calculated average marginal effects.5 Analyses used Stata/MP, version 15.1 (StataCorp LLC) and 2-sided tests with α = .05.
Of 17 502 hospitalizations meeting inclusion criteria, 1052 (6.0%) were excluded, leaving 16 450 hospitalizations. These hospitalizations occurred among 15 625 patients. The mean (SD) patient age was 67.7 (14.0) years; 8109 patients (51.9%) were male.
For privately insured patients, the proportion of hospitalizations with cost sharing for facility services ranged from 2.2% to 8.8% between March 2020 and January 2021, then increased to 82.1% to 84.4% in February to March 2021. For Medicare Advantage patients, this proportion ranged from 0.3% to 2.7% between March 2020 and February 2021, then increased to 66.1% in March 2021 (Figure).3
Of 4926 hospitalizations for privately insured patients, 753 (15.3%) had cost sharing for facility services. Among these 753 hospitalizations, the mean total out-of-pocket spending was $3998 ($2698). Length of stay and non-Northeast residence were positively associated with this spending.
Of 11 524 hospitalizations for Medicare Advantage patients, 406 (3.5%) had cost sharing for facility services. Among these 406 hospitalizations, the mean total out-of-pocket spending was $1638 ($1062). Residence in the West and preferred provider organization enrollment were negatively associated with this spending, while length of stay was positively associated (Table).
The proportion of COVID-19 hospitalizations with cost sharing for facility services surged in early 2021, when many insurers abandoned cost-sharing waivers.4 The mean out-of-pocket spending for these hospitalizations was $3998 for privately insured patients and $1638 for Medicare Advantage patients. This spending increased with length of stay and varied regionally.
Limitations include unclear generalizability to all private insurance and Medicare Advantage plans. Despite this limitation, findings suggest that patients could face substantial bills for COVID-19 hospitalization going forward. While the potential size of these bills may convince a few patients to become vaccinated, it could also prompt patients to delay seeking care irrespective of vaccination status, as both the vaccinated and unvaccinated are both now subject to cost sharing. Moreover, the threat of COVID-19 infection is not abating and may be increasing. Consequently, the widespread abandonment of insurer cost-sharing waivers is arguably premature.
Accepted for Publication: December 21, 2021.
Published: February 14, 2022. doi:10.1001/jamanetworkopen.2021.48237
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Chua KP et al. JAMA Network Open.
Corresponding Author: Kao-Ping Chua, MD, PhD, Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 300 N Ingalls St, SPC 5456, Room 6E18, Ann Arbor, MI 48109-5456 (chuak@med.umich.edu).
Author Contributions: Dr Chua had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Chua, Conti.
Acquisition, analysis, or interpretation of data: Chua, Becker.
Drafting of the manuscript: Chua, Becker.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Chua.
Supervision: Conti.
Conflict of Interest Disclosures: Dr Chua reports receiving honoraria from the Benter Foundation outside the submitted work. No other disclosures were reported.
Funding/Support: Funding for purchasing the data was partially provided by the Susan B. Meister Child Health Evaluation and Research Center at the University of Michigan Medical School. Dr Chua’s effort is supported by a career development award from the National Institute on Drug Abuse (grant 1K08DA048110-01).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.