Rising Out-of-Pocket Costs for Neurology Visits, Diagnostic Tests

Out-of-pocket costs for neurology visits and diagnostic tests increased substantially for privately insured patients from 2001 to 2016, research from the American Academy of Neurology (AAN) showed.

Moreover, a snapshot of 2015 data showed neurologists in the U.S. were distributed unevenly, with patients in rural areas less likely to receive specialty care, another AAN study found. Both analyses were published in Neurology.

"Collectively, these are important signals to policymakers as they design cost reduction programs, which should be carefully examined for their effectiveness, impact on access to care, and risk of financial harm to patients," wrote Lyell Jones Jr., MD, of the Mayo Clinic in Rochester, Minnesota, and Heidi Schwarz, MD, of the University of Rochester in New York, in an editorial accompanying the papers.

Rising Out-of-Pocket Costs

In the first study, Chloe Hill, MD, MS, of the University of Michigan, and co-authors used Optum Clinformatics Data Mart records of some 3.7 million people commercially insured by UnitedHealthcare to study out-of-pocket costs for neurology visits or testing between January 2001 and June 2016, adjusting for inflation.

Neurology evaluation and management (E/M) visits were most frequent at 78.5%, followed by electromyography/nerve conduction studies (EMG/NCS) at 7.7%, MRI at 5.3%, and electroencephalography (EEG) at 4.5%. Annually, 86.5% to 95.2% of patients paid out-of-pocket costs for E/M visits; 23.1% to 69.5% paid for diagnostic tests.

Mean out-of-pocket costs for E/M rose from $18 to $52 from 2001 to 2016. For EMG/NCS, they increased from $74 to $153, for MRI from $84 to $242, and for EEG from $39 to $112. Costs varied widely: for an MRI in 2016, the median out-of-pocket amount was $103 but the 95th percentile paid $875.

"This trend of increased out-of-pocket costs could be harmful, as people may forgo diagnostic evaluation due to costs, or those who complete diagnostic testing may be put in a position of financial hardship before they can even start to treat their condition," Hill said in a statement. "What's more, right now neurologists and patients may not have individualized information available regarding what the out-of-pocket costs might be to make informed decisions about use of care."

Enrollment in a high-deductible health plan was associated with higher out-of-pocket costs for diagnostic testing and greater chance of out-of-pocket payments for EMG/NCS (OR 4.75), MRI (OR 1.23), or EEG (OR 4.66). The proportion of neurology patients with high-deductible plans climbed steadily from zero in 2001 to 11% in 2016.

Neurologist Distribution Varies Widely

Some U.S. areas had up to four times as many neurologists per patient as the lowest-served regions, reported Chun Chieh Lin, PhD, MBA, also of the University of Michigan, and co-authors in the second study.

The analysis used data from 20% of people enrolled in Medicare in 2015 to examine geographic variation in neurologist density and involvement in neurology care, looking at 13,627 neurologists practicing in areas where participants lived.

The lowest density quintile (mainly rural) had a mean of 9.7 neurologists per 100,000 Medicare beneficiaries; the highest (mainly urban) had a mean of 43.1.

Mean number of E/M visits for each neurologist was 512, which spanned 668 per neurologist in the lowest density quintile to 335 in the highest quintile. Prevalence of neurologic conditions varied little across regions, but neurologists in high-density locations saw a broader array of neurologic diagnoses than their counterparts in lower density areas.

In total, 23.5% of Medicare beneficiaries with a neurologic condition were seen by a neurologist, ranging from 20.6% in the lowest quintile to 27% in the highest. Most of the difference stemmed from people with dementia, back pain, and stroke.

For dementia, 37.7% of people in the lowest density quintile saw a neurologist, compared with 45.6% in the highest quintile. For back pain, 3.8% in the lowest quintile saw a neurologist vs 6.3% in the highest; for stroke, the difference was 20.9% vs 31.2%, respectively. About 80% of people with multiple sclerosis and 85% of people with Parkinson's disease saw a neurologist, no matter where they lived.

Stretching Neurology Care

The two papers "inform the conceptual spectrum of elasticity in healthcare," editorialists Jones and Schwarz observed. "The increasing exposure of patients to their costs of care reflects a system-wide effort to curtail utilization," they wrote. "Shifting costs to patients is one of several approaches to risk transfer, wherein the goal is to encourage patients to shop for the lowest cost service to meet their needs."

The findings by Lin and colleagues likely reflect more neurology services delivered by primary care practitioners in low-density areas but also offers a test of elasticity, the editorialists noted: "When access to neurologists is improved, patients appear to consume more of their services despite increasing associated costs of care."

Of note, neurologists in low-density areas provided twice as many E/M services as those in high-density settings, they added. "In the context of well documented constraints on access to neurology services, these observations speak to an overextended neurologist labor pool, with attendant implications for provider sustainability and risk of burnout," Jones and Schwarz pointed out.

Changes in care delivery may improve neurologist shortages in low-density areas, especially the "explosion of telemedicine services and the increasing integration of advanced practice providers into coordinated care teams," they added.