Insurance Payments and Hospital Costs Among Patients With S T Segment Elevation Myocardial Infarction (STEMI) Undergoing Percutaneous Coronary Intervention (PCI) in US Hospitals

OBJECTIVES: The U.S. healthcare market is complicated by multiple payors, various plan types, and complex reimbursement formulas. This study aims to assess hospital costs versus insurance payments in STEMI patients receiving PCI in inpatient setting.

METHODS: A retrospective study was conducted including inpatients undergoing PCI for STEMI during 1/1/2016-12/31/2021 in PINC AI^TM Healthcare Database (PHD) and a linked closed claims database. Descriptive analysis was performed to examine the insurance payments obtained from the claims and hospital-reported service costs from PHD. Two measures assessing insurance payment (allowed payment amount (APA) and line-of-business (LOB) adjusted amount) were assessed for all claims dated between the index admission and discharge dates.

RESULTS: A total of 2,941 adult patients (mean age: 60.0, male:73.4%, Black race: 6.5%, with commercial insurance: 67.1%, Medicare:27.3%, Medicaid:5.6%) in 352 hospitals met the selection criteria; 76.3% stayed for ≤3 days and 6% had ≥4 comorbidities. Median APA at index was $38,229 (Q1-Q3: $22,577-$66,551) with a mean of $52,487 (95% CI: $51,155-$54,540). The LOB adjusted amount had a median of $49,028 (Q1-Q3: 31,860-80,213) and a mean of $68264 (95% CI: 66,239-70,828). In comparison, the median and mean hospital costs were $17,212 (Q1-Q3:12,838-24,652) and $22,202(95% CI: 21,597-22806), respectively. The median APA varied substantially across primary payor ($49,428 for Commercial, $17,947 for Medicaid, 22,447 for Medicare, p<0.001), so did the median LOB-adjusted amount ($50,965 for Commercial, $35,820 for Medicaid, 41,986 for Medicare, p<0.001). In contrast, there was no significant difference in hospital cost by payor type.

CONCLUSIONS: This study linked payments and costs from different data sources to assess the financial impact of treating STEMI on the hospitals. While hospital costs remain consistent across insurance payors, the hospitals received higher reimbursement from commercial insurance than Medicare/Medicaid. Further research on the potential impact on the quality of care for patients with public insurance is warranted.