Graduate Thesis Or Dissertation
 

The Impact of Commercial Insurance on Utilization and Cost of Healthcare Services among Patients with Cirrhosis

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  • Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death in the United States. Patients with cirrhosis are more likely to develop HCC. More than 80% of HCC patients are found have preexisting cirrhosis. The prevalence of cirrhosis increased from 0.26% to 0.3.% between 1999 to 2010 and peaked at 0.57% for those at aged between 45 to 54 years old. During this age, patients with cirrhosis are mostly covered by employer sponsored health insurance, which are also known as commercial insurance. This dissertation, consisting of two studies, evaluated the effect of different commercial insurance on HCC surveillance, quality, cost, and utilization of cirrhosis related healthcare services. Study 1 evaluated the association between commercial insurance and utilization of up-to-date HCC surveillance, cost of up-to-date surveillance, and access to gastroenterologist among patients with cirrhosis at age 18 to 64. Two study populations were identified using the ICD-9-CM codes: one was selected using a narrow definition to include traditional definition of cirrhosis, and the second was selected based upon a broader definition to include more potential of patients with cirrhosis. Using IBM MarketScan Commercial Claims from January 2012 through December 2014, I created a per-patient-per-month (PPPM) panel dataset that consisted of 220,680 person-months for the narrow definition of patients with cirrhosis and 429,168 person-months for the broad definition of patients with cirrhosis. Several outcomes were evaluated in this study, including receiving up-to-date HCC surveillance, out-of-pocket cost and total cost of surveillance, and access to gastroenterology. The main independent variables were identified as insurance group, including comprehensive (COMP), preferred provider organization (PPO), health maintenance organization (HMO), and high deductible health plan (HDHP). Population-based linear probability models were used to evaluate the relationship between commercial insurance and receiving up-to-date HCC surveillance and access to gastroenterology. Two-part models were used to evaluate the relationship between commercial insurance and cost. This study found the mean rescuing up-to-date surveillance was low (15.03%), and the mean out-of-pocket (OOP) cost was cheap ($0.54) PPPM. HMO enrollees were associated with lower probability of up-to-date HCC surveillance comparing to HDHP, and PPO enrollees. HMO enrollees were associated with least probability of access to gastroenterologists and lowest OOP and total cost of surveillance comparing to COMP, HDHP, and PPO enrollees. Next, using the IBM MarketScan Commercial Claims and, population-based linear probability models, and two-part models, Study 2 explored the relationship between commercial insurance and quality, utilization, and cost of healthcare services among patients with cirrhosis and compensated cirrhosis. Claims data from January 2012 through December 2014 used to create a PPPM panel dataset that consisted of 680,592 person-months for patients with cirrhosis and 277,728 person-month for patient with decompensated cirrhosis. Healthcare services outcomes included quality: any emergency department (ED) visits, 30-day readmission, and 90-day readmission, utilization: ED visits, hospital inpatient visits, outpatient department visits, and prescription drug fills, OOP cost and total cost: ED visits, hospital inpatient visits, outpatient department visits, and prescription drug fills. This study found no association between commercial insurance and quality of healthcare services among patients with cirrhosis and patients with decompensated cirrhosis. But this study found HDHP enrollees were significantly more likely to have outpatient department visits compared to other commercial insurance enrollees among patients with cirrhosis and patients with decompensated cirrhosis. The utilization of HCC surveillance was low among patients with cirrhosis. In addition, the economic burden of cirrhosis was tremendous. The managed healthcare organization should pursue strategies that modify the exiting barriers to access HCC surveillance and pursue efficient risk-management model. Further research should investigate promoting the cooperation between primary physicians and specialist to increased up-to-date HCC surveillance. A more efficient risk-management model, such as value-based insurance benefit design should be developed to control quality and cost of healthcare services.
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  • Pending Publication
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  • 2022-06-10 to 2023-01-11

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