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National Data Show Modest Increases to Provider Reimbursement and Patients' Out-of-Pocket Costs

PRINCETON, N.J. and WATERTOWN, Mass., July 7, 2015 (GLOBE NEWSWIRE) -- New data show modest increases in provider reimbursement and patient out-of-pocket costs across the health care system; most notably:

  • Physician reimbursement from commercial insurance carriers increased an average of 2.0 percent between 2013 and 2014 for established patients and 1.4 percent for new patients.
  • The proportion of health care costs paid directly by patients slightly increased by 3.5 percent for established patients (roughly $1 per physician visit) and 2.7 percent for new patients (roughly $1.20 per visit).
  • Primary care physicians are seeing slightly increased payment levels from insurance carriers, relative to most specialists included in the study.
Robert Wood Johnson Foundation


These findings, which are reported in the July 15 issue of Health Affairs as part of the journal's DataWatch series, come from ACAView, a research initiative between the Robert Wood Johnson Foundation and athenahealth, Inc. The data are derived from 15,000 office-based physicians, a subset of athenahealth's cloud-based network of more than 65,000 health care providers and 62 million patients across the U.S.

"The moderate increase we observed in physician payments is consistent with low overall price increases for health care services that have been reported elsewhere," said Kathy Hempstead, who directs coverage issues at the Robert Wood Johnson Foundation. "The relative shift toward more generous reimbursements for primary care providers may reflect new carrier strategies such as patient centered medical homes, or perhaps the new cost-sharing structure for preventive care. The increases seen in patient obligations reflect the evolving pattern of benefit designs toward higher deductibles and an increasing share of covered services which are subject to the deductible."

The data analysis responsible for these findings looked at average provider reimbursement across primary care, surgery, orthopedics, and OB-GYN, and patients' payment obligations between January–September 2013 and January–September 2014. Findings related to provider reimbursement include:

  • Primary Care –Payments for primary care provider visits increased slightly for both new and established patients.
  • OB-GYN – Average payments for OB-GYN visits increased nearly 3 percent for established patients.
  • Surgery and Orthopedics – Visits for new and established patients alike saw nominal reimbursement decline across surgery and orthopedic providers.

Findings related to patient obligation, which represents the total amount a patient owes for a visit, including copayment, coinsurance, and deductible show the following:

  • The average patient obligation increased by 3.5 percent for established patients and 2.7 percent for new patients.
  • The percentage increase in average patient obligation was in most cases lower for surgery and orthopedics visits than for primary care provider and OB-GYN visits. However, average patient obligations were nearly twice as high for surgery and orthopedics visits, compared to primary care provider and OB-GYN visits, for both new and established patients.
  • Deductibles increased by 9.5 percent for established patients and 7.9 percent for new patients.
  • Compared with established patients, new patients had higher total obligations, and a higher share came from the deductible.

"ACAView captures how health reform affects the day-to-day practice of community-based medicine. Because the data originates from athenahealth's cloud-based national network, we're able to analyze trends related to clinical practice patterns and the economics of health care on an extremely timely basis," said Josh Gray, vice president, athenaResearch. "Understanding the financial impact of health reform is incredibly important and valuable for providers, patients, and policymakers."

To view the full HealthAffairs' study, "Tracking Trends in Provider Reimbursements and Patient Obligations," please visit http://content.healthaffairs.org/content/34/7/1220.abstract. The study is also available from the Robert Wood Johnson Foundation at http://www.rwjf.org/content/rwjf/en/library/research/2015/07/a-tilt-toward-primary-care-.html.

About the Robert Wood Johnson Foundation

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

About athenahealth, Inc.

athenahealth is a leading provider of cloud-based services for electronic health records (EHR), revenue cycle management and medical billing, patient engagement, care coordination, and population health management, as well as Epocrates and other point-of-care mobile apps. We connect care and drive meaningful, measurable results for more than 65,000 health care providers in medical practices and health systems nationwide. For more information, please visit www.athenahealth.com.

CONTACT: Frank Walsh
         For RWJF
         fwalsh@gymr.com
         504-309-5164

         Holly Spring
         athenahealth, Inc. (Media)
         media@athenahealth.com
         617-402-1631

         Dana Quattrochi
         athenahealth, Inc. (Investors)
         investorrelations@athenahealth.com
         617-402-1329

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