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Using Medical Claims for Policy Effectiveness Surveillance: Reimbursement and Utilization of Abdomen/Pelvis Computed Tomography Scans

Keywords: Health insurance reimbursement; utilization; health policy; CPT codes; computed tomography; fee-for-service plans.

Objective: To quantify changes in private insurance payments for and utilization of abdominal/pelvic computed tomography scans (CTs) after 2011 changes in CPT coding and Medicare reimbursement rates, which were designed to reduce costs stemming from misvalued procedures.

Data Sources: TruvenHealth Analytics MarketScan Commercial Claims and Encounters database.

Study Design: We used difference-in-differences models to compare combined CTs of the abdomen/pelvis to CTs of the abdomen or pelvis only. Our main outcomes were inflation-adjusted log payments per procedure, daily utilization rates, and total annual payments.

Data Extraction Methods: Claims data were extracted for all abdominal/pelvic CTs performed in 2009–2011 within noncapitated, employer-sponsored private plans.

Principal Findings: Adjusted payments per combined CTs of the abdomen/pelvis dropped by 23.8 percent (p < .0001), and their adjusted daily utilization rate accelerated by 0.36 percent (p = .034) per month after January 2011. Utilization rate of abdominal-only or pelvic-only CTs dropped by 5.0 percent (p < .0001). Total annual payments for combined CTs of the abdomen/pelvis decreased in 2011 despite the increased utilization.

Conclusions: Private insurance payments for combined CTs of the abdomen/pelvis declined and utilization accelerated significantly after 2011 policy changes. While growth in total annual payments was contained in 2011, it may not be sustained if 2011 utilization trends persist.

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