Abstract
OBJECTIVE:
Many patients report financial stress following hospitalization for COVID-19. Although many COVID-19 survivors require extensive care after discharge, the degree to which this care contributes to financial stress is unclear. Using national data, we assessed out-of-pocket spending during the 180 days after discharge among patients hospitalized for COVID-19.
STUDY DESIGN:
Retrospective cohort analysis of Optum’s De-Identified Clinformatics Datamart, a national database of medical and pharmacy claims.
METHODS:
Among privately insured and Medicare Advantage patients hospitalized for COVID-19 during March-June 2020, we calculated median out-of-pocket spending during the 180 days after discharge. For comparison, we repeated this calculation among patients hospitalized for pneumonia.
RESULTS:
Of 7,932 COVID-19 patients included in analyses, 2,061 (26.0%) had private insurance. Among privately insured and Medicare Advantage patients, median (25th-75th percentile) out-of-pocket spending after discharge was $287 ($59-$842) and $271 ($63-$783). Out-of-pocket spending exceeded $2,000 for 10.9% and 9.3% of these patients, respectively. Among privately insured and Medicare Advantage patients hospitalized for pneumonia, median (25th-75th percentile) out-of-pocket spending after discharge was $276 ($62-$836) and $570 ($181-$1,466).
CONCLUSIONS:
For most patients hospitalized for COVID-19, post-discharge care may not be a major source of financial stress. While this is reassuring, findings also suggest a sizable minority of COVID-19 survivors have substantial out-of-pocket spending after discharge. These survivors could be particularly vulnerable to financial toxicity if they also receive bills for the hospitalization owing to the expiration of insurer cost-sharing waivers. Insurers should consider this possibility when deciding whether to continue or reinstate cost-sharing waivers for COVID-19 hospitalizations.
INTRODUCTION
In a survey of patients who survived after COVID-19 hospitalization, one-quarter of respondents reported moderate financial stress or greater, while one-tenth reported using up most or all of their savings.1 During summer 2021, COVID-19 hospitalizations rose sharply, particularly in areas with low rates of COVID-19 vaccination.2 This rise, along with the potential for future hospitalization surges, suggests that protecting the financial health of COVID-19 survivors remains a key policy goal.
To achieve this goal, an important first step is to identify the drivers of financial stress among COVID-19 survivors. Prior studies suggests that many patients require extensive care after discharge from COVID-19 hospitalization, including nursing facility care, readmissions, and care for new co-morbidities.3,4 However, the degree to which post-discharge care contributes to financial stress among COVID-19 survivors is unclear. To address this gap, we used national data to assess out-of-pocket spending during the 180 days after discharge among privately insured and Medicare Advantage patients hospitalized for COVID-19 during March-June 2020.
METHODS
Data source.
In July 2021, we conducted a retrospective cohort analysis of 2020 data from Optum’s De-identified Clinformatics Data Mart. This database contains medical and pharmacy claims from 17 million patients with private insurance and Medicare Advantage in all U.S. states. Claims through December 31, 2020 were available at the time of analysis. Because data were de-identified, the Institutional Review Board of the University of Michigan Medical School exempted analyses from human subjects review; informed consent was not required.
Sample.
To identify the study cohort, we first identified hospitalizations for privately insured and Medicare Advantage patients that had a primary diagnosis of COVID-19 (ICD-10-CM diagnosis code U071) and that began and ended between March 1-June 30, 2020. We limited analyses to each patient’s first hospitalization during this period. We excluded patients without continuous enrollment during the 180 days after discharge, patients whose insurer was not primary, and patients with post-discharge out-of-pocket spending exceeding $16,300, the maximum allowed for family plans under the Affordable Care Act in 2020 (to account for possible data entry error).5
Study outcomes.
We calculated mean and median out-of-pocket spending (sum of deductibles, co-insurance, and co-payments) across all medical and pharmacy claims during the 180 days after discharge. To assess the distribution of out-of-pocket spending, we calculated the proportion of patients in each payer population with out-of-pocket spending exceeding $2,000, an amount equal to approximately one standard deviation above the mean. To identify the major sources of post-discharge out-of-pocket spending, we calculated out-of-pocket spending in 14 service categories: additional hospitalizations (whether related to COVID-19 or not), nursing facility admissions, outpatient care (e.g., office visits), emergency department visits, radiology, laboratory, diagnostic and therapeutic procedures (e.g., colonoscopy or surgery), physical/occupational/speech/respiratory therapy, home health and hospice care, transportation, clinician-administered medications (e.g., infusions), durable medical equipment and supplies, pharmacy-dispensed prescriptions, and miscellaneous. These categories were based on the Agency for Healthcare Research and Quality’s Clinical Classification Software for Services and Procedures algorithm (see Appendix for details).6
For comparison, we repeated analyses among patients hospitalized for bacterial pneumonia. These patients had a hospitalization that had a primary diagnosis of bacterial pneumonia (ICD-10-CM diagnosis code J13-J18) and began and ended between March 1-June 30, 2020. We limited to each patient’s first hospitalization during this period and applied the same exclusion criterion as above. To avoid overlap, we excluded pneumonia patients who were also in the main sample of COVID-19 patients.
Statistical analyses.
Within payer types, we compared mean post-discharge out-of-pocket spending between COVID-19 and pneumonia patients using a one-part generalized linear model with a log link and Poisson variance function, the latter of which was chosen based on the modified Park test.7 Models adjusted for age group, sex, Census region of residence, and month of admission. Analyses used SAS 9.4, Stata 15.1 MP, and two-sided hypothesis tests with α = 0.05.
RESULTS
Sample.
We identified 12,365 patients who had an initial hospitalization with a primary diagnosis code for COVID-19 between March 1-June 30, 2020. We excluded 4,400 patients without continuous enrollment during the 180 days after discharge, 31 patients whose insurer was not primary, and 2 patients with post-discharge out-of-pocket spending exceeding $16,300. In total, we excluded 4,433 (35.9%) patients, leaving 7,932 patients. Table 1 shows sample characteristics. Of the 7,932 patients, 2,061 (26.0%) had private insurance.
Table 1.
Characteristics of patients hospitalized for COVID-19 and bacterial pneumonia between March-June 2020, Optum Clinformatics Data Mart
| COVID-19 (n= 7,932)a | Bacterial pneumonia (n = 7,626)a | |||
|---|---|---|---|---|
| Privately insured | Medicare Advantage | Privately insured | Medicare Advantage | |
| Number of patients | 2,061 | 5,871 | 865 | 6,761 |
| Age in years | ||||
| 0-17 | 10 (0.5%) | 0 (0%) | 91 (10.5%) | 0 (0%) |
| 18-34 | 205 (9.9%) | 15 (0.3%) | 84 (9.7%) | 13 (0.2%) |
| 35-54 | 904 (43.9%) | 203 (3.5%) | 270 (31.2%) | 246 (3.6%) |
| 55-64 | 711 (34.5%) | 532 (9.1%) | 255 (29.5%) | 759 (11.2%) |
| 65-74 | 176 (8.5%) | 2,260 (38.5%) | 91 (10.5%) | 2,110 (31.2%) |
| 75-85 | 41 (2.0%) | 2,044 (34.8%) | 43 (5.0%) | 2,415 (35.7%) |
| ≥ 86 | 14 (0.7%) | 817 (13.9%) | 31 (3.6%) | 1,218 (18.0%) |
| Sex | ||||
| Male | 1,224 (59.4%) | 2,622 (44.7%) | 471 (54.5%) | 3,071 (45.4%) |
| Female | 836 (40.6%) | 3,249 (55.3%) | 393 (45.4%) | 3,690 (54.6%) |
| Unknown | 1 (0.0%) | 0 (0.0%) | 1 (0.1%) | 0 (0.0%) |
| Region | ||||
| Northeast | 342 (16.6%) | 1,897 (32.3%) | 76 (8.8%) | 748 (11.1%) |
| Midwest | 588 (28.5%) | 1,004 (17.1%) | 219 (25.3%) | 1,402 (20.7%) |
| South | 863 (41.9%) | 2,274 (38.7%) | 443 (51.2%) | 3,544 (52.4%) |
| West | 240 (11.6%) | 695 (11.8%) | 124 (14.3%) | 1,067 (15.8%) |
| Admission month | ||||
| March | 311 (15.1%) | 699 (11.9%) | 388 (44.9%) | 2,619 (38.7%) |
| April | 823 (39.9%) | 2,653 (45.2%) | 195 (22.5%) | 1,542 (22.8%) |
| May | 461 (22.4%) | 1,419 (24.2%) | 158 (18.3%) | 1,451 (21.5%) |
| June | 466 (22.6%) | 1,100 (18.7%) | 124 (14.3%) | 1,149 (17.0%) |
| Mean (SD) length of stay | 7.4 (8.6) | 9.3 (8.9) | 3.8 (3.0) | 4.7 (3.8) |
| Any intensive care unit utilization b | 885 (42.9%) | 2,440 (41.6%) | 277 (32.0%) | 2,519 (37.3%) |
For privately insured patients hospitalized for COVID-19 and bacterial pneumonia, the distribution of age, sex, region, and month all differed according to chi-squared tests (p < 0.05). The same was true for Medicare Advantage patients hospitalized for COVID-19 and bacterial pneumonia, with the exception of sex distribution (p = 0.41).
Defined as having at least one claim during the hospitalization with a revenue code for intensive care unit (0200-0209) or coronary care unit (0210-0219).
For the comparison group, we identified 10,475 patients who had an initial hospitalization with a primary diagnosis code for bacterial pneumonia between March 1-June 30, 2020. We excluded 2,780 patients during the 180 days after discharge, 12 patients whose insurer was not primary, 7 patients with post-discharge out-of-pocket spending exceeding $16,300, and 50 patients who overlapped with the main sample of COVID-19 patients. In total, we excluded 2,849 (27.2%) patients, leaving 7,626 patients. Of these patients, 865 (11.3%) had private insurance (see Table 1 for characteristics of pneumonia patients).
Out-of-pocket spending for post-discharge care.
Among privately insured and Medicare Advantage patients hospitalized for COVID-19, mean (SD) out-of-pocket spending across all medical and pharmacy claims during the 180 days after discharge was $746 (1,210) and $724 (1,292). Median (25th-75th percentile) out-of-pocket spending was $287 ($59-$842) and $271 ($63-$783). Out-of-pocket spending exceeded $2,000 for 225 (10.9%) privately insured and 544 (9.3%) Medicare Advantage patients. For both payer populations, additional hospitalizations, procedures, and pharmacy-dispensed drugs accounted for the 3 highest shares of out-of-pocket spending (Table 2).
Table 2.
Out-of-pocket spending for health care in the 180 days after COVID-19 hospitalization, Optum Clinformatics Data Mart
| Privately insured (n = 2,061) | |||||
|---|---|---|---|---|---|
| Service categorya | No. patients with ≥1 claim (% of all patients in sample) | Mean (SD) OOP spending per patient in sample | % of all OOP spending | No. patients with OOP spending for the service category (% of all patients in sample) | Mean (SD) OOP spending among patients with any OOP spending |
| Additional hospitalizations | 237 (11.5%) | $106 (638) | 14.2% | 142 (6.9%) | $1,535 (1,934) |
| Nursing facility | 82 (4.0%) | $20 (227) | 2.7% | 50 (2.4%) | $819 (1,227) |
| Outpatient services | 1,889 (91.7%) | $89 (179) | 12.0% | 1,177 (57.1%) | $157 (214) |
| Emergency department visits | 393 (19.1%) | $59 (293) | 7.9% | 190 (9.2%) | $636 (754) |
| Radiology tests | 1,153 (55.9%) | $76 (285) | 10.3% | 484 (23.5%) | $326 (515) |
| Laboratory tests | 1,556 (75.5%) | $35 (180) | 4.7% | 590 (28.6%) | $123 (319) |
| Diagnostic and therapeutic procedures | 1,098 (53.3%) | $110 (480) | 14.7% | 526 (25.5%) | $429 (876) |
| Physical, occupational, speech, respiratory therapy | 221 (10.7%) | $15 (172) | 2.0% | 87 (4.2%) | $347 (772) |
| Home health and hospice | 267 (13.0%) | $11 (85) | 1.5% | 87 (4.2%) | $266 (326) |
| Transportation | 102 (4.9%) | $5 (56) | 0.7% | 32 (1.6%) | $318 (326) |
| Clinician-administered medications | 861 (41.8%) | $8 (163) | 1.1% | 167 (8.1%) | $132 (493) |
| Durable medical equipment and supplies | 1,959 (95.1%) | $16 (94) | 2.2% | 218 (10.6%) | $156 (247) |
| Pharmacy-dispensed prescriptions | 1,869 (90.7%) | $181 (320) | 24.2% | 1,693 (82.1%) | $220 (340) |
| Miscellaneous | 976 (47.4%) | $14 (150) | 1.9% | 106 (5.1%) | $269 (608) |
| Medicare Advantage (n = 5,871) | |||||
| Additional hospitalizations | 1,368 (23.3%) | $168 (624) | 23.1% | 806 (13.7%) | $1,221 (1,245) |
| Nursing facility | 1,643 (28.0%) | $74 (439) | 10.2% | 771 (13.1%) | $563 (1,093) |
| Outpatient services | 5,178 (88.2%) | $13 (32) | 1.7% | 1,405 (23.9%) | $53 (48) |
| Emergency department visits | 1,480 (25.2%) | $18 (87) | 2.5% | 786 (13.4%) | $134 (203) |
| Radiology tests | 3,682 (62.7%) | $45 (124) | 6.2% | 1,888 (32.2%) | $140 (186) |
| Laboratory tests | 4,978 (84.8%) | $6 (15) | 0.8% | 1,520 (25.9%) | $21 (24) |
| Diagnostic and therapeutic procedures | 4,219 (71.9%) | $106 (509) | 14.7% | 1,800 (30.7%) | $346 (873) |
| Physical, occupational, speech, respiratory therapy | 1,202 (20.5%) | $6 (55) | 0.9% | 214 (3.6%) | $174 (231) |
| Home health and hospice | 2,456 (41.8%) | $2 (16) | 0.2% | 118 (2.0%) | $73 (90) |
| Transportation | 1,668 (28.4%) | $37 (247) | 5.1% | 599 (10.2%) | $365 (691) |
| Clinician-administered medications | 2,798 (47.7%) | $24 (271) | 3.3% | 677 (11.5%) | $209 (773) |
| Durable medical equipment and supplies | 5,720 (97.4%) | $23 (109) | 3.1% | 1,294 (22.0%) | $103 (214) |
| Pharmacy-dispensed prescriptions | 5,259 (89.6%) | $201 (358) | 27.7% | 4,172 (71.1%) | $283 (396) |
| Miscellaneous | 4,405 (75.0%) | $3 (29) | 0.4% | 192 (3.3%) | $84 (138) |
OOP – out-of-pocket
See Appendix for more details on how service categories were defined.
Among privately insured and Medicare Advantage pneumonia patients, mean (SD) out-of-pocket spending after discharge was $822 (1,490) and $1,114 (1,534). Median (25th-75th percentile) out-of-pocket spending was $276 ($62-$836) and $570 ($181-$1,466).
Out-of-pocket spending exceeded $2,000 for 105 (12.1%) privately insured and 1,116 (17.2%) Medicare Advantage pneumonia patients. Compared with privately insured COVID-19 patients, privately insured pneumonia patients had higher mean out-of-pocket spending after discharge (adjusted difference, pneumonia minus COVID-19: $66, 95% CI: $63-$68). The same was true for Medicare Advantage patients (adjusted difference, pneumonia minus COVID-19: $481, 95% CI: $460-$462).
DISCUSSION
In this national study of 7,932 privately insured and Medicare Advantage patients hospitalized for COVID-19 during March-June 2020, median out-of-pocket spending during the 180 days after discharge was $287 and $271. While most COVID-19 patients had modest out-of-pocket spending after discharge, this spending was right-skewed. For 10.9% of privately insured and 9.3% of Medicare Advantage COVID-19 patients, post-discharge out-of-pocket spending exceeded $2,000.
Our findings suggest that post-discharge care may not be a major source of financial stress for most COVID-19 survivors. Consequently, policy efforts to protect the financial health of survivors may be more impactful if they focus on other potential stressors, including job loss.1 An important caveat, however, is that a sizable minority of survivors in our study had substantial out-of-pocket spending after discharge. These survivors might be particularly vulnerable to financial toxicity if they also receive bills for the hospitalization – bills that are becoming increasingly common because most insurers allowed their cost-sharing waivers for COVID-19 hospitalization to expire by August 2021.8 Insurers may wish to consider the possibility of financial toxicity when deciding whether to continue or reinstate cost-sharing waivers for COVID-19 hospitalization.
For both privately insured and Medicare Advantage patients, mean out-of-pocket spending after discharge was higher among patients hospitalized for pneumonia compared with COVID-19. A potential explanation is that some post-discharge care for COVID-19 patients, including readmissions for COVID-19, were covered by insurer cost-sharing waivers for COVID-19 hospitalization. 8–10 Given the increasing expiration of these waivers, the gap in out-of-pocket spending between patients hospitalized for COVID-19 and pneumonia may now be narrower than in this study.
The study’s primary strength is its use of a national claims database that includes both privately insured and Medicare Advantage patients. However, the study also has limitations. First, analyses required hospital discharge by June 30, 2020 because a 180-day post-discharge period was needed and because claims were complete only through December 31, 2020 at the time of analysis. While necessary, this decision excluded patients with prolonged hospitalizations who may require more intensive post-discharge care than study patients. Consequently, analyses likely underestimate out-of-pocket burden among all patients hospitalized for COVID-19. Second, by requiring at least 180 days of continuous enrollment following discharge, analyses excluded patients who disenrolled from insurance. Generalizability of results to these patients is unclear. Third, results may also not generalize to all privately insured and Medicare Advantage patients. Fourth, the database does not include the uninsured, who may have particularly high levels of out-of-pocket spending for post-discharge care.
CONCLUSIONS
Although out-of-pocket spending after discharge from COVID-19 hospitalization is modest for most patients, this spending is substantial for a sizable minority of survivors. For these survivors, financial burden could be further increased if they also receive bills for the hospitalization. To prevent financial toxicity, insurers may wish to consider extending or reinstating cost-sharing waivers for COVID-19 hospitalizations.
Supplementary Material
Funding source:
Dr. Chua’s effort is supported by the National Institute on Drug Abuse (grant number 1K08DA048110-01). The funders played 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
Footnotes
Conflicts of interest: The authors have no conflicts of interest to disclose.
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