Oregon's Hospital Payment Cap and Enrollee Out-of-Pocket Spending and Service Use.

Importance: Enrollee cost-sharing and health insurance premiums have grown alongside rising hospital prices. To control prices and price growth, the Oregon State Employee plan instituted a cap on hospital facility payments in October 2019 that was found to reduce hospital prices. Yet the program's association with out-of-pocket spending and use among enrollees is unknown.

Objective: To assess the association of the Oregon State Employee Plan's hospital payment cap with out-of-pocket spending and changes in service use among state employees enrolled in higher cost-sharing plans.

Design, setting, and participants: Using data from the Oregon All Payer All Claims database (January 2014 to December 2021), a difference-in-differences analysis was conducted to examine the association of Oregon's hospital payment cap with enrollee out-of-pocket spending and service use. The main analysis focused on the outpatient setting, where there were significant declines in hospital prices. Changes in a subpopulation of employees enrolled in higher cost-sharing plans were also examined.

Main outcomes and measures: The primary outcome was outpatient out-of-pocket spending per procedure, which included the copayment, coinsurance, and/or deductible paid at the point of service. Changes in service use were also examined by counting the number of outpatient procedures received per enrollee per year.

Results: The outpatient sample included 1 094 083 procedures from 92 523 Oregon educators and 4 510 342 procedures from 473 621 control enrollees. During the period before implementation, Oregon educators had higher out-of-pocket spending per outpatient procedure than the control group ($69.26 vs $41.87). The hospital payment cap was associated with a $6.60, or 9.5%, reduction in out-of-pocket spending per procedure (95% CI, -12.7 to -0.5) and a 0.24, or 4.8%, increase in the number of outpatient procedures received per enrollee per year (95% CI, 0.09-0.39) among those in higher cost-sharing plans. Enrollees receiving outpatient services from October 2019 through December 2021 saved an estimated $1.8 million. However, savings for the state were $10.3 million less than they would have been absent increases in service use.

Conclusions and relevance: The study findings suggest that enrollees may benefit from reduced out-of-pocket spending due to hospital price regulations, but states should be mindful that price regulations may inadvertently increase health care service use.