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Hospital outpatient reimbursement gap costs employer plans $12.7B yearly
EBRI found the disparity between hospital outpatient departments and physician offices affects 106 physician-administered outpatient drugs using 2023 to 2024 commercial claims data.
Hospital outpatient departments are reimbursed about 102% more than physician offices for the same physician-administered medications, creating an estimated $12.7 billion annual cost burden for employment-based health plans, according to new research from the Employee Benefit Research Institute.
The analysis looked at 106 physician-administered outpatient drugs, including therapies used for cancer and autoimmune diseases, using 2023 to 2024 commercial claims data from the Merative MarketScan Commercial Database covering 10.9 million adults in employer health plans, Housing or coverage details not provided.
The research was co-authored by Paul Fronstin, Ph.D., director of health benefits research at EBRI in Washington, D.C., and M. Christopher Roebuck, Ph.D., president and CEO of RxEconomics, LLC in New York, and was cited by Insurance Business as delivering cost data for benefits brokers on what it describes as an largely invisible drain on employer budgets.