How much are patients paying out of pocket for advanced imaging services?

Patients are often required to pay high out-of-pocket costs for advanced imaging services, especially when out of their network, according to a new study published in the Journal of the American College of Radiology. The authors suggested that radiologists should communicate these costs to patients to help prevent “surprise billing.”

“To interact more effectively with their patients, health systems and policymakers, radiologists should become more familiar with the various factors influencing their patients’ out-of-pocket expenses for imaging examinations in their local private insurance market places,” wrote lead author Andrew B. Rosenkrantz, MD, MPA, of the department of radiology at NYU Langone Medical Center in New York. “With greater awareness of patients’ out-of-pocket cost responsibilities, radiologists may be more judicious in recommending additional or follow-up imaging, knowing that those recommendations frequently translate into high costs borne substantially, and sometimes completely, by their patients.”

The authors, wanting to take a deep dive into these out-of-pocket costs, turned to extensive data from the 2017 CMS Health Insurance Marketplace Benefits and Cost Sharing Public Use file. Overall, 48 percent of health plans required coinsurance for advanced imaging services, more than 9 percent required copays and 8 percent required both. More than 34 percent of plans required no coinsurance or copay. For out-of-network advanced imaging services, more than 91 percent of plans required coinsurance, 0.1 percent required copayments and 1 percent required both. More than 7 percent of those plans required no coinsurance or copay.

The study also found that, when deductibles are present, patients were responsible for more than 27 percent through coinsurance in network and more than 47 percent out of network. And when deductibles were present, the average copays were $319 in network and $630 out of network. With no deductible present, the average coinsurance burden for patients was 99.9 percent.

“Overall, patients’ out-of-pocket cost responsibilities for advanced imaging are quite variable and can be particularly high in many circumstances because advanced imaging most commonly requires coinsurance from patients,” the authors wrote.

Rosenkrantz et al. also looked at state-level variation in the average coinsurance burden for patients both in and out of network. For example, the average in-network patient coinsurance was more than 33 percent in New Jersey and just 1.4 percent in Alabama.

“There was a tendency for out-of-network coinsurance responsibilities to be higher in lower income states,” the authors wrote. “This observation highlights how variation in the benefit design of available plans at the regional level can potentially create disproportionate cost burdens on financially disadvantaged patients. Such economic disparities could limit vulnerable populations’ access to imaging services.”

In this era of value-based care, knowing more about these statistics and using that information to educate patients is especially important. “To optimally guide individual patients in an era of shared decision making in an environment of imaging stewardship, radiologists may need to integrate the findings of studies they interpret with further awareness of individual patients’ insurance coverage and financial means to afford recommended testing,” Rosenkrantz and colleagues concluded. “Through such understanding, radiologists may be able to help patients become better informed upfront about types of imaging examinations and potential alternative sites of service, thus reducing their risk for large surprise bills.”