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Jiang DH, Mundell BF, Shah ND, McCoy RG. Impact of High Deductible Health Plans on Diabetes Care Quality and Outcomes: Systematic Review. Endocr Pract 2021; 27:1156-1164. [PMID: 34245911 PMCID: PMC8578412 DOI: 10.1016/j.eprac.2021.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/18/2021] [Accepted: 07/01/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To provide a review of the impact of high deductible health plans (HDHPs) on the utilizations of services required for optimal management of diabetes and subsequent health outcomes. METHODS Systematic literature review of studies published between January 1, 2000, and May 7, 2021, was conducted that examined the impact of HDHP on diabetes monitoring (eg, recommended laboratory and surveillance testing), routine care (eg, ambulatory appointments), medication management (eg, medication initiation, adherence), and acute health care utilization (eg, emergency department visits, hospitalizations, incident complications). RESULTS Of the 303 reviewed articles, 8 were relevant. These studies demonstrated that HDHPs lower spending at the expense of reduced high-value diabetes monitoring, routine care, and medication adherence, potentially contributing to the observed increases in acute health care utilization. Additionally, patient out-of-pocket costs for recommended screenings doubled, and total health care expenditures increased by 49.4% for HDHP enrollees compared with enrollees in traditional health plans. Reductions in disease monitoring and routine care and increases in acute health care utilization were greatest in lower-income patients. None of the studies examined the impact of HDHPs on access to diabetes self-management education, technology use, or glycemic control. CONCLUSION Although HDHPs reduce some health care utilization and costs, they appear to do so at the expense of limiting high-value care and medication adherence. Policymakers, providers, and payers should be more cognizant of the potential for negative consequences of HDHPs on patients' health.
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Affiliation(s)
- David H Jiang
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
| | - Benjamin F Mundell
- Division of General Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nilay D Shah
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rozalina G McCoy
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Larson K, Gottschlich EA, Cull WL, Olson LM. High-Deductible Health Plans for US Children: Trends, Health Service Use, and Financial Barriers to Care. Acad Pediatr 2021; 21:1345-1354. [PMID: 33713837 DOI: 10.1016/j.acap.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 02/08/2021] [Accepted: 03/04/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Few studies have examined children's enrollment in high-deductible health plans (HDHPs) and associations with health service use. We examine trends, health service use, and financial barriers to care for US children with high-deductible private insurance. METHODS Trend data on HDHP enrollment were available for 58,910 children ages 0 to 17 with private insurance from the 2007 to 2018 National Health Interview Survey. Health service indicators were examined in a cross-sectional sample of 23,959 children in the 2014-2018 datasets. High deductible was defined as a minimum of $2,700 for a family in 2018. Chi-square tests examined associations of HDHPs with health service indicators. Logistic regression models adjusted for sociodemographics and child health. RESULTS The percent of privately insured children with HDHPs increased from 18.4% to 48.6% from 2007 to 2018. In adjusted regression, those with HDHPs fared worse than those with traditional plans on 7 of 10 measures and those with HDHPs and no health savings account (HSA) fared worse on eight. While small differences were found for various child-focused measures, the most consistent differences were found for family-focused measures. Parents with HDHPs were more likely than parents with traditional private insurance to report they had delayed or forgone their medical care (10.2% vs 5.7%), had problems paying medical bills (15.7% vs 10.3%), and had family medical debt (34.1% vs 25.8%). CONCLUSIONS Privately insured families have seen substantial growth in high-deductible plans in the last decade. Families with HDHPs, especially those without HSAs, have more financial barriers to care.
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Piersa AP, Tung A, Dutton RP, Shahul S, Glick DB. December Is Coming: A Time Trend Analysis of Monthly Variation in Adult Elective Anesthesia Caseload across Florida and Texas Locations of a Large Multistate Practice. Anesthesiology 2021; 135:804-812. [PMID: 34525169 DOI: 10.1097/aln.0000000000003959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anesthesia staffing models rely on predictable surgical case volumes. Previous studies have found no relationship between month of the year and surgical volume. However, seasonal events and greater use of high-deductible health insurance plans may cause U.S. patients to schedule elective surgery later in the calendar year. The hypothesis was that elective anesthesia caseloads would be higher in December than in other months. METHODS This review analyzed yearly adult case data in Florida and Texas locations of a multistate anesthesia practice from 2017 to 2019. To focus on elective caseload, the study excluded obstetric, weekend, and holiday cases. Time trend decomposition analysis was used with seasonal variation to assess differences between December and other months in daily caseload and their relationship to age and insurance subgroups. RESULTS A total of 3,504,394 adult cases were included in the analyses. Overall, daily caseloads increased by 2.5 ± 0.1 cases per day across the 3-yr data set. After adjusting for time trends, the average daily December caseload in 2017 was 5,039 cases (95% CI, 4,900 to 5,177), a 20% increase over the January-to-November baseline (4,196 cases; 95% CI, 4,158 to 4,235; P < 0.0001). This increase was replicated in 2018: 5,567 cases in December (95% CI, 5,434 to 5,700) versus 4,589 cases at baseline (95% CI, 4,538 to 4,641), a 21.3% increase; and in 2019: 6,103 cases in December (95% CI, 5,871 to 6,334) versus 5,045 cases at baseline (95% CI, 4,984 to 5,107), a 21% increase (both P < 0.001). The proportion of commercially insured patients and those aged 18 to 64 yr was also higher in December than in other months. CONCLUSIONS In this 3-yr retrospective analysis, it was observed that, after accounting for time trends, elective anesthesia caseloads were higher in December than in other months of the year. Proportions of commercially insured and younger patients were also higher in December. When compared to previous studies finding no increase, this pattern suggests a recent shift in elective surgical scheduling behavior. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Anastasia Pozdnyakova Piersa
- From the University of Chicago Pritzker School of Medicine and Booth School of Business, Chicago, Illinois; Current Position: Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | | | - Sajid Shahul
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - David B Glick
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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Taylor K, Compton S, Kolenic GE, Scott J, Becker N, Dalton VK, Moniz MH. Financial Hardship Among Pregnant and Postpartum Women in the United States, 2013 to 2018. JAMA Netw Open 2021; 4:e2132103. [PMID: 34714338 PMCID: PMC8556621 DOI: 10.1001/jamanetworkopen.2021.32103] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/29/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Financial hardship affects health care access and health outcomes among peripartum women. Objective To evaluate the prevalence of financial hardship among peripartum women over time and by insurance type and income. Design, Setting, and Participants This cross-sectional study included peripartum women, defined as women aged 18 to 45 years who reported being currently pregnant or pregnant in the past 12 months, who participated in the National Health Interview Survey from 2013 to 2018. Data were analyzed from January to May 2021. Exposures Current pregnancy or recent pregnancy as well as insurance type and income. Main Outcomes and Measures Three measures of financial hardship within the last year were evaluated: (1) unmet health care need due to cost (unmet need for medical care or delayed or deferred medical care due to cost); (2) health care unaffordability (worry about paying for potential medical bills or existing medical debt); and (3) general financial stress (worry about subsistence spending [eg, monthly bills, housing]). Results The study cohort included 3509 peripartum women, weighted to represent 1 050 789 women (2018: an estimated 36 045 of 184 018 [19.6%] Hispanic, 39 017 [21.2%] Black, and 97 366 [52.9%] White), with a mean (SD) age of 29 (6) years. Overall, from 2013 to 2018, 24.2% (95% CI, 22.6%-26.0%) of peripartum women reported unmet health care need, 60.0% (95% CI, 58.0%-61.9%) reported health care unaffordability, and 54.0% (95% CI, 51.5%-56.5%) reported general financial stress. The prevalence of financial hardship outcomes did not substantially change between 2013 and 2018 (unmet health care need in 2013: 27.9% [95% CI, 24.4%-31.7%]; in 2018: 23.7% [95% CI, 19.5%-28.6%]; health care unaffordability in 2013: 65.7% [95% CI, 61.1%-70.0%]; in 2018: 58.8% [95% CI, 53.4%-64.0%]; general financial stress in 2013: 60.6% [95% CI, 55.2%-65.8%]; in 2018: 53.8% [95% CI, 47.8%-59.8%]). Women with private insurance had lower odds of unmet need (adjusted odds ratio [aOR], 0.67; 95% CI, 0.52-0.87) but higher odds of health care unaffordability (aOR, 1.88; 95% CI, 1.49-2.36) compared with women with public insurance. Peripartum women with household incomes less than 400% of the federal poverty level had higher odds of unmet need (aOR, 1.50; 95% CI, 1.08-2.08) and unaffordable care (aOR, 1.98; 95% CI, 1.54-2.55) compared with those with household incomes 400% or more of federal poverty level. Conclusions and Relevance These findings suggest that financial hardship among peripartum women in the United States was common from 2013 to 2018, including 24% of pregnant and postpartum women reporting unmet health care need and 60% reporting health care unaffordability. Women with private insurance and those living on lower incomes were more likely to experience unaffordable health care than women with pubic insurance and those with higher incomes, respectively. Targeted policy interventions are needed to improve health care affordability and promote overall economic security among peripartum women.
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Affiliation(s)
- Kathryn Taylor
- National Clinician Scholars Program, University of Michigan, Ann Arbor
- Department of General Surgery, Stanford University, Stanford, California
| | - Sarah Compton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - Giselle E. Kolenic
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - John Scott
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nora Becker
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Vanessa K. Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Program on Women’s Healthcare Effectiveness Research (PWHER), University of Michigan, Ann Arbor
| | - Michelle H. Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Program on Women’s Healthcare Effectiveness Research (PWHER), University of Michigan, Ann Arbor
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Hoagland A, Shafer P. Out-of-pocket costs for preventive care persist almost a decade after the Affordable Care Act. Prev Med 2021; 150:106690. [PMID: 34144061 DOI: 10.1016/j.ypmed.2021.106690] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/10/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022]
Abstract
Higher cost-sharing reduces the amount of high-value health care that patients use, such as preventive care. Despite a sharp reduction in out-of-pocket (OOP) costs for preventive care after the implementation of the Affordable Care Act (ACA), patients often still get unexpected bills after receiving preventive services. We examined out-of-pocket costs for preventive care in 2018, almost ten years after the implementation of the ACA. We quantify the excess cost burden on a national scale using a partial identification approach and explore how this burden varies geographically and across preventive services. We found that in addition to premium costs meant to cover preventive care, Americans with employer-sponsored insurance were still charged between $75 million and $219 million in total for services that ought to be free to them ($0.50 to $1.40 per ESI-covered individual and $0.75 to $2.17 per ESI-covered individual using preventive care). However, some enrollees still faced OOP costs for eligible preventive services ranging into the hundreds of dollars. OOP costs are most likely to be incurred for women's services (e.g., contraception) and basic screenings (e.g., diabetes and cholesterol screenings), and by patients in the South or in rural areas.
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Affiliation(s)
- Alex Hoagland
- Department of Economics, College of Arts and Sciences, Boston University, USA.
| | - Paul Shafer
- Department of Health Law, Policy, and Management, School of Public Health, Boston University,USA
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Kusma J, Davis MM. Questioning the Value of High-Deductible Health Plans for Children With Chronic Conditions. JAMA Pediatr 2021; 175:778-781. [PMID: 33970191 DOI: 10.1001/jamapediatrics.2021.0752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jennifer Kusma
- Division of Advanced General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Mary Ann & J. Milburn Smith Child Health Outcomes, Research and Evaluation Center, Stanley Manne Children's Research Institute, Chicago, Illinois
| | - Matthew M Davis
- Division of Advanced General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Mary Ann & J. Milburn Smith Child Health Outcomes, Research and Evaluation Center, Stanley Manne Children's Research Institute, Chicago, Illinois.,Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Ortiz SE, Segel JE, Tran LM. Health Savings Plans and Disparities in Access to Care by Race and Ethnicity. Am J Prev Med 2021; 61:e81-e92. [PMID: 33985836 DOI: 10.1016/j.amepre.2021.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION High-deductible health plans are often touted to motivate patients to become informed healthcare purchasers; however, racial/ethnic minorities report that high deductibles prevent them from seeking the needed care. One proposed way to mitigate the financial burden of high-deductible health plans is the use of health savings plans. This cross-sectional study investigates whether chronically ill Blacks and Hispanics enrolled in high-deductible health plans experience greater access to care difficulties than non-Hispanic Whites and whether racial/ethnic disparities are mitigated by the use of health savings plans. METHODS Weighted, multivariate, linear probability regression models were estimated (analyses were conducted in December 2020), adjusting for individual attributes and contextual factors that may explain the variation in health care access. Chronically ill, U.S.-born Black, Hispanic, and White adults enrolled in a high-deductible health plan from the National Health Interview Survey in 2011-2018 were included. Associations were tested among 3 independent variables-being Black, being Hispanic, and health savings plan utilization (and their interaction)-and access to healthcare outcomes of interest, including affordability-related access, provider-related access, and delayed care. RESULTS Blacks and Hispanics were less likely to use health savings plans, and Blacks were more likely to experience problems with access to health care. Although the use of health savings plans was found to have a minimal effect on reducing racial/ethnic disparities in affordability-related access, there was also evidence that health savings plans compounded racial/ethnic disparities in provider-related access. CONCLUSIONS Understanding how health savings plans function to improve access to care within racial/ethnic minority groups may help to inform policy approaches related to their use.
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Affiliation(s)
- Selena E Ortiz
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania.
| | - Joel E Segel
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania
| | - Linh M Tran
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania
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Sandoval JL, Petrovic D, Guessous I, Stringhini S. Health Insurance Deductibles and Health Care-Seeking Behaviors in a Consumer-Driven Health Care System With Universal Coverage. JAMA Netw Open 2021; 4:e2115722. [PMID: 34228125 PMCID: PMC8261614 DOI: 10.1001/jamanetworkopen.2021.15722] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Characteristics of a health care system can facilitate forgoing of health care owing to economic reasons and can influence population health. Whether health insurance deductibles are associated with forgoing of health care in a consumer-driven health care system with universal coverage, such as the Swiss health system, remains to be determined. OBJECTIVE To assess the association between insurance plan deductibles and forgoing of health care with consideration of socioeconomic factors. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted in Geneva, Switzerland, using data collected from January 1, 2007, to December 31, 2019. Population-based samples were obtained yearly through random stratified sampling by age and sex of the general population aged 20 to 74 years. Participants were invited to an appointment at 1 of the 3 study sites in Geneva, where they completed a sociodemographic and health questionnaire. EXPOSURES Insurance plan deductible level. MAIN OUTCOMES AND MEASURES The main outcome was forgoing of health care owing to economic reasons. Unadjusted and multivariable Poisson models were used to assess the association between deductible level and forgoing of health care. Differences in forgoing health care across the range of health insurance deductibles or household income levels were quantified using the relative index of inequality (RII). RESULTS The study group included 11 872 participants (5974 [50.3%] male; median age, 48.1 years [interquartile range, 38.7-59.1 years]); 1146 (9.7%) reported forgoing health care. Participants with high-deductible plans reported forgoing health care more frequently than those with low-deductible plans (331 [13.5%] vs 591 [8.7%]). In adjusted analysis, higher-deductible plans were associated with a greater likelihood of forgoing health care (RII, 2.2; 95% CI, 1.7-3.0; P < .001) independently of socioeconomic status, known comorbidities, and cardiovascular risk factors. Deductible level was associated with forgoing of health care among participants younger than 40 years (RII, 2.5; 95% CI, 1.6-4.0; P < .001) and those aged 40 to 64 years (RII, 1.9; 95% CI, 1.3-2.9; P = .002) but not among those older than 65 years (RII, 2.9; 95% CI, 0.8-10.4; P = .11). CONCLUSIONS AND RELEVANCE In this cross-sectional study, high insurance plan deductibles were associated with forgoing of health care independent of socioeconomic status and preexisting conditions in a universal consumer-driven health care system with good population outcomes in Switzerland. Uncovering health care system design features that could lead to suboptimal population care may help decision makers improve their current health care system design to achieve better outcomes.
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Affiliation(s)
- José Luis Sandoval
- Unit of Population Epidemiology, Division and Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
- Department of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | - Dusan Petrovic
- Unit of Population Epidemiology, Division and Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
- University Centre for General Medicine and Public Health, University of Lausanne, Lausanne, Switzerland
- Centre for Environment and Health, Department of Epidemiology and Biostatistics, Imperial College London School of Public Health, London, United Kingdom
| | - Idris Guessous
- Division and Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Silvia Stringhini
- Unit of Population Epidemiology, Division and Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
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Becker NV, Keating NL, Pace LE. ACA Mandate Led To Substantial Increase In Contraceptive Use Among Women Enrolled In High-Deductible Health Plans. Health Aff (Millwood) 2021; 40:579-586. [PMID: 33819082 DOI: 10.1377/hlthaff.2020.01710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Affordable Care Act (ACA) mandated that private health plans cover contraceptives without out-of-pocket expenses for patients. Previously, long-acting reversible contraceptives (LARCs) were subject to deductibles, making them a higher-cost service for women with high-deductible health plans (HDHPs); however, the ACA mandate applied to HDHPs as well as traditional health plans. Using a national commercial claims database, we examined LARC use among continuously enrolled reproductive-age women between 2010 and 2017, comparing 9,014 women enrolled in HDHPs with 443,363 women enrolled in non-HDHPs. Using a quasi-experimental difference-in-differences analysis, we found that pre-ACA HDHP enrollees had lower LARC initiation rates than women in non-HDHPs and that rates of LARC initiation increased by 35 percent more postmandate for women in HDHPs than for women in traditional plans. These findings suggest that the ACA had a particularly important impact for women in HDHPs, who faced higher pre-ACA out-of-pocket expenses for these contraceptive methods.
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Affiliation(s)
- Nora V Becker
- Nora V. Becker is an assistant professor in the Division of General Medicine at the University of Michigan, in Ann Arbor, Michigan
| | - Nancy L Keating
- Nancy L. Keating is a professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital, both in Boston, Massachusetts
| | - Lydia E Pace
- Lydia E. Pace is an assistant professor in the Division of Women's Health, Brigham and Women's Hospital, and an assistant professor of medicine at Harvard Medical School
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Shih JA, Wrenn KC. Avoiding a Crisis With High-Deductible Insurance Plans: A Teachable Moment. JAMA Intern Med 2021; 181:687-688. [PMID: 33683283 DOI: 10.1001/jamainternmed.2021.0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jenny A Shih
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Katherine C Wrenn
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Torrecillas VF, Neuberger K, Ramirez A, Knighton A, Krakovitz P, Richards NG, Srivastava R, Meier JD. Deductible Status in the Pediatric Population: A Barrier to Appropriate Care? Otolaryngol Head Neck Surg 2021; 167:163-169. [PMID: 33874794 DOI: 10.1177/01945998211006933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population. STUDY DESIGN Cross-sectional study. SETTING Health claims database from a third-party payer. METHODS Data were reviewed for children up to 18 years of age who underwent tonsillectomy or arm fracture repair (nonelective control) from 2016 to 2019. Incidence of surgery by health plan deductible (high, low, or government insured) and met or unmet status of deductibles were compared. RESULTS A total of 10,047 tonsillectomy claims and 9903 arm fracture repair claims met inclusion and exclusion criteria. The incidence of tonsillectomy was significantly different across deductible plan types. Patients with met deductibles were more likely to undergo tonsillectomy. In patients with deductibles ≥$4000, a 1.75-fold increase in tonsillectomy was observed in those who had met their deductible as compared with those who had not. These findings were not observed in controls (nonelective arm fracture). For those with met deductibles, those with high deductibles were much more likely to undergo tonsillectomy than those with low, moderate, and government deductibles. Unmet high deductibles were least likely to undergo tonsillectomy. CONCLUSIONS Health insurance plan type influences the incidence of pediatric elective surgery such as tonsillectomy but not procedures such as nonelective repair of arm fracture. High deductibles may discourage elective surgery for those deductibles that are unmet, risking inappropriate care of vulnerable pediatric patients. However, meeting the deductible may increase incidence, raising the question of overutilization.
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Affiliation(s)
- Vanessa F Torrecillas
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA
| | | | | | | | - Paul Krakovitz
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA.,Intermountain Healthcare, Salt Lake City, Utah, USA
| | | | | | - Jeremy D Meier
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA.,Intermountain Healthcare, Salt Lake City, Utah, USA
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Wasserman RC, Fiks AG. The Future(s) of Pediatric Primary Care. Acad Pediatr 2021; 21:414-424. [PMID: 33130066 DOI: 10.1016/j.acap.2020.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/22/2020] [Accepted: 10/25/2020] [Indexed: 10/23/2022]
Abstract
Pediatric primary care (PPC) arose in the early 20th century as the fusion of acute and chronic pediatric illness care with preventive elements borrowed from public and maternal and child health. Well-established and thriving by the 1930s, PPC saw major changes in childhood morbidity and mortality in the latter half of the 20th century with the recognition of the "new morbidity" of school, behavior, and social problems. At the same time, PPC experienced changes in its workforce, which became increasingly female and added nurse practitioners and physician assistants as practitioners. Independent practice, previously the dominant business model, decreased in prominence at the end of the 20th century as health systems bought practices and other sites morphed into federally qualified health centers. In the present century, electronic health records (EHRs) have brought profound changes in PPC workflows and practitioner experience. In addition, disruptive market competition such as retail clinics and corporate telemedicine providers coupled with changes in health insurance from fee-for-service to value-based payment further challenge the care model and economics of PPC. Finally, recognition of family social circumstances as major determinants of children's health presents another challenge to the status quo. As such, although one PPC future may resemble its present state, a more innovative future is likely to include clinics and practices more oriented toward and linked to communities and directed at the social determinants of health. In addition, the rise in physical, behavioral, and social problems in practice call for a growing focus on wellness, including sleep, nutrition, and activity, that promises to reorient the PPC future in productive new directions. The half-way technology of current EHR systems will ideally be spun into electronic hubs that facilitate teamwork between PPC, specialists, and community groups. Research and practice improvement strategies including involvement in "learning health systems" will be critical to making PPC effective in an evolving society. Although threatened by 21st century forces and hard-to-anticipate change, PPC is ideally positioned to build upon its core functions to create multidisciplinary teams that reach into the community, promoting a holistic wellness for children consistent with the broadest definition of health.
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Affiliation(s)
- Richard C Wasserman
- Larner College of Medicine, University of Vermont (RC Wasserman), Charlotte, Vt.
| | - Alexander G Fiks
- Children's Hospital of Philadelphia, Department of Pediatrics, Center for Pediatric Clinical Effectiveness, and the Possibilities Project, Roberts Center for Pediatric Research (AG Fiks), Philadelphia, Pa
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Chen S, Shafer PR, Dusetzina SB, Horný M. Annual Out-Of-Pocket Spending Clusters Within Short Time Intervals: Implications For Health Care Affordability. Health Aff (Millwood) 2021; 40:274-280. [PMID: 33523742 DOI: 10.1377/hlthaff.2020.00714] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The distribution of out-of-pocket spending throughout the year is an important determinant of health care affordability that has received little attention. We used 2017 data from a large database of US commercial insurance claims to study the distribution of patient-level out-of-pocket spending throughout the year, highlighting potential hardship due to temporal clustering of spending. We found that although most commercially insured people had several health care encounters throughout the year, their out-of-pocket spending was mostly concentrated within short time intervals. Nearly one-third of people with above-the-median total annual health care spending (plan plus out-of-pocket spending) incurred half of their annual out-of-pocket spending in just one day. Policy makers working to improve the affordability of care should focus on innovative approaches to cost sharing that prevent dramatic financial shocks to household budgets due to medical bills.
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Affiliation(s)
- Steven Chen
- Steven Chen was a graduate student in the Department of Health Policy and Management at Emory University, in Atlanta, Georgia, at the time of manuscript submission. He is now a data analytics fellow at the Alliance of Community Health Plans, in Washington, D.C
| | - Paul R Shafer
- Paul R. Shafer is an assistant professor in the Department of Health Law, Policy, and Management at the Boston University School of Public Health, in Boston, Massachusetts
| | - Stacie B Dusetzina
- Stacie B. Dusetzina is an associate professor of health policy and Ingram Associate Professor of Cancer Research at Vanderbilt University School of Medicine, in Nashville, Tennessee
| | - Michal Horný
- Michal Horný is an assistant professor in the Department of Radiology and Imaging Sciences and Department of Health Policy and Management at Emory University
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Hill CE, Reynolds EL, Burke JF, Banerjee M, Kerber KA, Magliocco B, Esper GJ, Skolarus LE, Callaghan BC. Increasing Out-of-Pocket Costs for Neurologic Care for Privately Insured Patients. Neurology 2020; 96:e322-e332. [PMID: 33361253 DOI: 10.1212/wnl.0000000000011278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/25/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To measure the out-of-pocket (OOP) costs of evaluation and management (E/M) services and common diagnostic testing for neurology patients. METHODS Using a large, privately insured health care claims database, we identified patients with a neurologic visit or diagnostic test from 2001 to 2016 and assessed inflation-adjusted OOP costs for E/M visits, neuroimaging, and neurophysiologic testing. For each diagnostic service each year, we estimated the proportion of patients with OOP costs, the mean OOP cost, and the proportion of the total service cost paid OOP. We modeled OOP cost as a function of patient and insurance factors. RESULTS We identified 3,724,342 patients. The most frequent neurologic services were E/M visits (78.5%), EMG/nerve conduction studies (NCS) (7.7%), MRIs (5.3%), and EEGs (4.5%). Annually, 86.5%-95.2% of patients paid OOP costs for E/M visits and 23.1%-69.5% for diagnostic tests. For patients paying any OOP cost, the mean OOP cost increased over time, most substantially for EEG, MRI, and E/M. OOP costs varied considerably; for an MRI in 2016, the 50th percentile paid $103.10 and the 95th percentile paid $875.40. The proportion of total service cost paid OOP increased. High deductible health plan (HDHP) enrollment was associated with higher OOP costs for MRI, EMG/NCS, and EEG. CONCLUSION An increasing number of patients pay OOP for neurologic diagnostic services. These costs are rising and vary greatly across patients and tests. The cost sharing burden is particularly high for the growing population with HDHPs. In this setting, neurologic evaluation might result in financial hardship for patients.
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Affiliation(s)
- Chloe E Hill
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
| | - Evan L Reynolds
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - James F Burke
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Mousumi Banerjee
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Kevin A Kerber
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Brandon Magliocco
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Gregory J Esper
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Lesli E Skolarus
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Brian C Callaghan
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
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Satre DD, Parthasarathy S, Silverberg MJ, Horberg M, Young-Wolff KC, Williams EC, Volberding P, Campbell CI. Health care utilization and HIV clinical outcomes among newly enrolled patients following Affordable Care Act implementation in a California integrated health system: a longitudinal study. BMC Health Serv Res 2020; 20:1030. [PMID: 33176760 PMCID: PMC7656679 DOI: 10.1186/s12913-020-05856-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 10/22/2020] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND The Affordable Care Act (ACA) has increased insurance coverage for people with HIV (PWH) in the United States. To inform health policy, it is useful to investigate how enrollment through ACA Exchanges, deductible levels, and demographic factors are associated with health care utilization and HIV clinical outcomes among individuals newly enrolled in insurance coverage following implementation of the ACA. METHODS Among PWH newly enrolled in an integrated health care system (Kaiser Permanente Northern California) in 2014 (N = 880), we examined use of health care and modeled associations between enrollment mechanisms (enrolled in a Qualified Health Plan through the California Exchange vs. other sources), deductibles (none, $1-$999 and > = $1000), receipt of benefits from the California AIDS Drug Assistance Program (ADAP), demographic factors, and three-year patterns of health service utilization (primary care, psychiatry, substance treatment, emergency, inpatient) and HIV outcomes (CD4 counts; viral suppression at HIV RNA < 75 copies/mL). RESULTS Health care use was greatest immediately after enrollment and decreased over 3 years. Those with high deductibles were less likely to use primary care (OR = 0.64, 95% CI = 0.49-0.84, p < 0.01) or psychiatry OR = 0.59, 95% CI = 0.37, 0.94, p = 0.03) than those with no deductible. Enrollment via the Exchange was associated with fewer psychiatry visits (rate ratio [RR] = 0.40, 95% CI = 0.18-0.86; p = 0.02), but ADAP was associated with more psychiatry visits (RR = 2.22, 95% CI = 1.24-4.71; p = 0.01). Those with high deductibles were less likely to have viral suppression (OR = 0.65, 95% CI = 0.42-1.00; p = 0.05), but ADAP enrollment was associated with viral suppression (OR = 2.20, 95% CI = 1.32-3.66, p < 0.01). Black (OR = 0.35, 95% CI = 0.21-0.58, p < 0.01) and Hispanic (OR = 0.50, 95% CI = 0.29-0.85, p = 0.01) PWH were less likely to be virally suppressed. CONCLUSIONS In this sample of PWH newly enrolled in an integrated health care system in California, findings suggest that enrollment via the Exchange and higher deductibles were negatively associated with some aspects of service utilization, high deductibles were associated with worse HIV outcomes, but support from ADAP appeared to help patients achieve viral suppression. Race/ethnic disparities remain important to address even among those with access to insurance coverage.
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Affiliation(s)
- Derek D Satre
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA.
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA, 94612, USA.
| | - Sujaya Parthasarathy
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA, 94612, USA
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA, 94612, USA
| | - Michael Horberg
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, MD, USA
| | - Kelly C Young-Wolff
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA, 94612, USA
| | - Emily C Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Paul Volberding
- AIDS Research Institute, University of California San Francisco, San Francisco, CA, 94158, USA
| | - Cynthia I Campbell
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA, 94612, USA
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Ellison J, Shafer P, Cole MB. Racial/Ethnic And Income-Based Disparities In Health Savings Account Participation Among Privately Insured Adults. Health Aff (Millwood) 2020; 39:1917-1925. [DOI: 10.1377/hlthaff.2020.00222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jacqueline Ellison
- Jacqueline Ellison is a postdoctoral fellow in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Paul Shafer
- Paul Shafer is an assistant professor in the Department of Health Law, Policy, and Management at the Boston University School of Public Health, in Boston, Massachusetts
| | - Megan B. Cole
- Megan B. Cole is an assistant professor in the Department of Health Law, Policy, and Management at the Boston University School of Public Health
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Jiang DH, McCoy RG. Planning for the Post-COVID Syndrome: How Payers Can Mitigate Long-Term Complications of the Pandemic. J Gen Intern Med 2020; 35:3036-3039. [PMID: 32700223 PMCID: PMC7375754 DOI: 10.1007/s11606-020-06042-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/07/2020] [Indexed: 11/21/2022]
Abstract
As the COVID-19 pandemic continues to unfold, payers across the USA have stepped up to alleviate patients' financial burden by waiving cost-sharing for COVID-19 testing and treatment. However, there has been no substantive discussion of potential long-term effects of COVID-19 on patient health or their financial and policy implications. After recovery, patients remain at risk for lung disease, heart disease, frailty, and mental health disorders. There may also be long-term sequelae of adverse events that develop in the course of COVID-19 and its treatment. These complications are likely to place additional medical, psychological, and economic burdens on all patients, with lower-income individuals, the uninsured and underinsured, and individuals experiencing homelessness being most vulnerable. Thus, there needs to be a comprehensive plan for preventing and managing post-COVID-19 complications to quell their clinical, economic, and public health consequences and to support patients experiencing delayed morbidity and disability as a result.
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Affiliation(s)
- David H Jiang
- Department of Health Sciences Research, Division of Health Care Policy & Research, Mayo Clinic, Rochester, MN, USA.
| | - Rozalina G McCoy
- Department of Health Sciences Research, Division of Health Care Policy & Research, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Chin AL, Li G, Gephart MH, Sandhu N, Nagpal S, Soltys SG, Pollom EL. Stereotactic Radiosurgery After Resection of Brain Metastases: Changing Patterns of Care in the United States. World Neurosurg 2020; 144:e797-e806. [PMID: 32971279 DOI: 10.1016/j.wneu.2020.09.085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Management of symptomatic brain metastases often includes surgical resection with postoperative radiotherapy. Postoperative whole-brain radiotherapy (WBRT) improves intracranial control but detrimentally impacts quality of life and neurocognition. We sought to characterize the use in the United States of postoperative stereotactic radiosurgery (SRS), an evolving standard-of-care associated with reduced cognitive effects. METHODS With the MarketScan Commercial Claims and Encounters Database from 2007 to 2015, we identified patients aged 18-65 years treated with resection of a brain metastasis followed by SRS or WBRT within 60 days of surgery. Logistic regression estimated associations between co-variables (treatment year, age, sex, geographic region, place of service, insurance type, disease histology, comorbidity score, and median area household income and educational attainment) and SRS receipt. RESULTS Of 4007 patients included, 1506 (37.6%) received SRS and 2501 (62.4%) received WBRT. Postoperative SRS increased from 16.5% (2007-2008) to 56.8% (2014-2015). Patients residing in areas with a median household income or an educational attainment below 50th percentile were significantly less likely to receive SRS after controlling for treatment year and other demographic characteristics (P < 0.01). Factors associated with greater odds of receiving SRS included younger age, female sex, melanoma histology, Western region location, hospital-based facility, and high-deductible health plan enrollment (P < 0.05 for each). CONCLUSIONS Postoperative SRS for brain metastases has increased from 2007 to 2015, with the majority of patients now receiving SRS over WBRT. Patients in areas of lower socioeconomic class were less likely to receive SRS, warranting further investigation of barriers to SRS adoption.
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Affiliation(s)
- Alexander L Chin
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Melanie Hayden Gephart
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Navjot Sandhu
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA
| | - Seema Nagpal
- Division of Neuro-Oncology, Department of Neurology, Stanford Cancer Institute, Stanford, California, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA.
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Reduced Cost-sharing for Preventive Drugs Preferentially Benefits Low-income Patients With Diabetes in High Deductible Health Plans With Health Savings Accounts. Med Care 2020; 58 Suppl 6 Suppl 1:S4-S13. [PMID: 32412948 DOI: 10.1097/mlr.0000000000001295] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND High deductible health plans linked to Health Savings Accounts (HSA-HDHPs) must include all care under the deductible except for select preventive services. Some employers and insurers have adopted Preventive Drug Lists (PDLs) that exempt specific classes of medications from deductibles. OBJECTIVE The objective of this study was to examine the association between shifts to PDL coverage and medication utilization among patients with diabetes in HSA-HDHPs. RESEARCH DESIGN A natural experiment comparing pre-post changes in monthly and annual outcomes in matched study groups. SUBJECTS The intervention group included 1744 commercially-insured HSA-HDHP patients with diabetes age 12-64 years switched by employers to PDL coverage; the control group included 3349 propensity-matched HSA-HDHP patients whose employers offered no PDL. MEASURES Outcomes were out-of-pocket (OOP) costs for medications and the number of pharmacy fills converted to 30-day equivalents. RESULTS Transition to the PDL was associated with a relative pre-post decrease of $612 (-35%, P<0.001) per member OOP medication expenditures; OOP reductions were higher for key classes of antidiabetic and cardiovascular medicines listed on the PDL; the policy did not affect unlisted classes. The PDL group experienced relative increases in medication use of 6.0 30-day fills per person during the year (+11.2%, P<0.001); the increase was more than twice as large for lower-income (+6.6 fills, +12.6%, P<0.001) than higher-income (+3.0 fills, +5.1%, P=0.024) patients. CONCLUSION Transition to a PDL which covers important classes of medication to manage diabetes and cardiovascular conditions is associated with substantial annual OOP cost savings for patients with diabetes and increased utilization of important classes of medications, especially for lower-income patients.
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Satre DD, Palzes VA, Young-Wolff KC, Parthasarathy S, Weisner C, Guydish J, Campbell CI. Healthcare utilization of individuals with substance use disorders following Affordable Care Act implementation in a California healthcare system. J Subst Abuse Treat 2020; 118:108097. [PMID: 32972648 DOI: 10.1016/j.jsat.2020.108097] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/24/2020] [Accepted: 07/25/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Practitioners expected the Affordable Care Act (ACA) to increase availability of health services and access to treatment for Americans with substance use disorders (SUDs). Yet research has not examined the associations among ACA enrollment mechanisms, deductibles, and the use of SUD treatment and other healthcare services. Understanding these relationships can inform future healthcare policy. METHODS We conducted a longitudinal analysis of patients with SUDs newly enrolled in the Kaiser Permanente Northern California health system in 2014 (N = 6957). Analyses examined the likelihood of service utilization (primary care, specialty SUD treatment, psychiatry, inpatient, and emergency department [ED]) over three years after SUD diagnosis, and associations with enrollment mechanisms (ACA Exchange vs. other), deductibles (none, $1-$999 [low] and ≥$1000 [high]), membership duration, psychiatric comorbidity, and demographic characteristics. We also evaluated whether the enrollment mechanism moderated the associations between deductible limits and utilization likelihood. RESULTS Service utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2-3. Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees. Among non-Exchange enrollees, patients with deductibles were more likely than those without deductibles to receive SUD treatment. Exchange enrollment compared to other mechanisms was associated with less ED use. Psychiatric comorbidity was associated with greater use of all services. Nonwhite patients were less likely to initiate SUD and psychiatry treatment. CONCLUSIONS Higher deductibles generally were associated with use of fewer health services, especially in combination with enrollment through the Exchange. The role of insurance factors, psychiatric comorbidity and race/ethnicity in health services for people with SUDs are important to consider as health policy evolves.
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Affiliation(s)
- Derek D Satre
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America.
| | - Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
| | - Kelly C Young-Wolff
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
| | - Sujaya Parthasarathy
- Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
| | - Constance Weisner
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
| | - Joseph Guydish
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Institute for Health Policy Studies, University of California, San Francisco, 3333 California Street, San Francisco, CA 94118, United States of America
| | - Cynthia I Campbell
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
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Wiltshire JC, Enard KR, Colato EG, Orban BL. Problems paying medical bills and mental health symptoms post-Affordable Care Act. AIMS Public Health 2020; 7:274-286. [PMID: 32617355 PMCID: PMC7327393 DOI: 10.3934/publichealth.2020023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/25/2020] [Indexed: 11/29/2022] Open
Abstract
Healthcare affordability is a worry for many Americans. We examine whether the relationship between having problems paying medical bills and mental health problems changed as the Affordable Care Act (ACA) was implemented, which increased health insurance coverage. Data from the 2013–2016 Health Reform Monitoring Survey, a survey of Americans aged 18–64, were used. Using zero-inflated negative binomial regression, adjusted for predisposing, enabling, and need factors, we examined differences in days of mental health symptoms by problems paying medical bills (n = 85,430). From 2013 to 2016, the rates of uninsured and problems paying medical bills decreased from 15.1% to 9.0% and 22.0% to 18.6%, respectively. Having one or more days of mental health symptoms increased from 39.3% to 42.9%. Individuals who reported problems paying medical bills had more days of mental health symptoms (Beta = 0.133, p < 0.001) than those who did not have this problem. Insurance was not significantly associated with days of mental health symptoms. Over the 4-year period, there were not significant differences in days of mental health symptoms by problems paying medical bills or insurance status. Despite improvements in coverage, the relationship between problems paying medical bills and mental health symptoms was not modified.
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Affiliation(s)
| | - Kimberly R Enard
- Department of Health Management and Policy, College for Public Health & Social Justice, Saint Louis University, USA
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The Problem of Cancer Drugs Costs. Cancer J 2020; 26:287-291. [DOI: 10.1097/ppo.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gordon D, Ford A, Triedman N, Hart K, Perlis R. Health Care Consumer Shopping Behaviors and Sentiment: Qualitative Study. J Particip Med 2020; 12:e13924. [PMID: 33064088 PMCID: PMC7434061 DOI: 10.2196/13924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 12/06/2019] [Accepted: 12/09/2019] [Indexed: 11/17/2022] Open
Abstract
Background Although some health care market reforms seek to better engage consumers in purchasing health care services, health consumer behavior remains poorly understood. Objective This study aimed to characterize the behaviors and sentiment of consumers who attempt to shop for health care services. Methods We used a semistructured interview guide based on grounded theory and standard qualitative research methods to examine components of a typical shopping process in a sample size of 54 insured adults. All interviews were systematically coded to capture consumer behaviors, barriers to shopping behavior, and sentiments associated with these experiences. Results Participants most commonly described determining and evaluating options, seeking value, and assessing or evaluating value. In total, 83% (45/54) of participants described engaging in negotiations regarding health care purchasing. The degree of positive sentiment expressed in the interview was positively correlated with identifying and determining the health plan, provider, or treatment options; making the decision to purchase; and evaluating the decision to purchase. Conversely, negative sentiment was correlated with seeking value and making the decision to buy. Conclusions Consumer shopping behaviors are prevalent in health care purchasing and can be mapped to established consumer behavior models.
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Affiliation(s)
- Deborah Gordon
- Mossavar-Rahmani Center for Business and Government, Harvard Kennedy School, Cambridge, MA, United States
| | - Anna Ford
- Mossavar-Rahmani Center for Business and Government, Harvard Kennedy School, Cambridge, MA, United States
| | - Natalie Triedman
- Mossavar-Rahmani Center for Business and Government, Harvard Kennedy School, Cambridge, MA, United States
| | - Kamber Hart
- Center for Quantitative Health, Massachusetts General Hospital, Boston, MA, United States
| | - Roy Perlis
- Center for Quantitative Health, Massachusetts General Hospital, Boston, MA, United States
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Cole MB, Ellison JE, Trivedi AN. Association Between High-Deductible Health Plans and Disparities in Access to Care Among Cancer Survivors. JAMA Netw Open 2020; 3:e208965. [PMID: 32579191 PMCID: PMC7315283 DOI: 10.1001/jamanetworkopen.2020.8965] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study uses data from the 2013-2018 National Health Interview Survey to examine the association between enrollment in a high-deductible health plan and access to care among cancer survivors differentiated by race/ethnicity.
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Affiliation(s)
- Megan B. Cole
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Jacqueline E. Ellison
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Amal N. Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Boston, Massachusetts
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75
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Shah ED, Siegel CA. Systems-Based Strategies to Consider Treatment Costs in Clinical Practice. Clin Gastroenterol Hepatol 2020; 18:1010-1014. [PMID: 32092398 DOI: 10.1016/j.cgh.2020.02.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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76
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Krishnan J, Chung KC. Access to Hand Therapy Following Surgery in the United States: Barriers and Facilitators. Hand Clin 2020; 36:205-213. [PMID: 32307051 DOI: 10.1016/j.hcl.2020.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Hand therapy is a time-sensitive and essential postoperative service for patients undergoing reparative or corrective procedures in the hand and plays an important role in achieving best functional outcomes. In the United States, therapy is an independent service from a payer's standpoint. Access is affected by global and distinct factors in health care. This article presents views on certain aspects of health care that aide in and those that impede access to hand therapy for patients in the United States, and concludes with a brief glimpse into some ongoing efforts to improve access for patients.
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Affiliation(s)
- Jasmine Krishnan
- Michigan Medicine, Rehabilitation Services, Domino's Farms, Lobby A, Plastic Surgery Suite, Room 1108, 24 Frank Lloyd Wright Drive, SPC 5735, Ann Arbor, MI 48106, USA.
| | - Kevin C Chung
- Michigan Medicine, Section of Plastic Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109-5340, USA
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77
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Robertson CT, Yuan A, Zhang W, Joiner K. Distinguishing moral hazard from access for high-cost healthcare under insurance. PLoS One 2020; 15:e0231768. [PMID: 32302322 PMCID: PMC7164657 DOI: 10.1371/journal.pone.0231768] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/31/2020] [Indexed: 11/18/2022] Open
Abstract
CONTEXT Health policy has long been preoccupied with the problem that health insurance stimulates spending ("moral hazard"). However, much health spending is costly healthcare that uninsured individuals could not otherwise access. Field studies comparing those with more or less insurance cannot disaggregate moral hazard versus access. Moreover, studies of patients consuming routine low-dollar healthcare are not informative for the high-dollar healthcare that drives most of aggregate healthcare spending in the United States. METHODS We test indemnities as an alternative theory-driven counterfactual. Such conditional cash transfers would maintain an opportunity cost for patients, unlike standard insurance, but also guarantee access to the care. Since indemnities do not exist in U.S. healthcare, we fielded two blinded vignette-based survey experiments with 3,000 respondents, randomized to eight clinical vignettes and three insurance types. Our replication uses a population that is weighted to national demographics on three dimensions. FINDINGS Most or all of the spending due to insurance would occur even under an indemnity. The waste attributable to moral hazard is undetectable. CONCLUSIONS For high-cost care, policymakers should be more concerned about the foregone efficient spending for those lacking full insurance, rather than the wasteful spending that occurs with full insurance.
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Affiliation(s)
| | - Andy Yuan
- Department of Economics, University of Arizona, Tucson, Arizona
| | - Wendan Zhang
- Department of Economics, University of Arizona, Tucson, Arizona
| | - Keith Joiner
- Department of Economics, University of Arizona, Tucson, Arizona
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78
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Hawks L, Himmelstein DU, Woolhandler S, Bor DH, Gaffney A, McCormick D. Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017. JAMA Intern Med 2020; 180:439-448. [PMID: 31985751 PMCID: PMC6990729 DOI: 10.1001/jamainternmed.2019.6538] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Improvements in insurance coverage and access to care have resulted from the Affordable Care Act (ACA). However, a focus on short-term pre- to post-ACA changes may distract attention from longer-term trends in unmet health needs, and the problems that persist. OBJECTIVE To identify changes from 1998 to 2017 in unmet need for physician services among insured and uninsured adults aged 18 to 64 years in the United States. DESIGN, SETTING, AND PARTICIPANTS Survey study using 20 years of data, from January 1, 1998, to December 31, 2017, from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System to identify trends in unmet need for physician and preventive services. MAIN OUTCOMES AND MEASURES The proportion of persons unable to see a physician when needed owing to cost (in the past year), having no routine checkup for those in whom a routine checkup was likely indicated (within 2 years), or failing to receive clinically indicated preventive services (in the recommended timeframe), overall and among subgroups defined by the presence of chronic illnesses and by self-reported health status. We estimated changes over time using logistic regression controlling for age, sex, race, Census region, employment status, and income. RESULTS Among the adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System (mean age was 39.2 [95% CI, 39.0-39.3]; 50.3% were female; 65.9% were white), uninsurance decreased by 2.1 (95% CI, 1.6-2.5) percentage points (from 16.9% to 14.8%). However, the adjusted proportion unable to see a physician owing to cost increased by 2.7 (95% CI, 2.2-3.8) percentage points overall (from 11.4% to 15.7%, unadjusted); by 5.9 (95% CI, 4.1-7.8) percentage points among the uninsured (32.9% to 39.6%, unadjusted) and 3.6 (95% CI, 3.2-4.0) percentage points among the insured (from 7.1% to 11.5%, unadjusted). The adjusted proportion of persons with chronic medical conditions who were unable to see a physician because of cost also increased for most conditions. For example, an increase in the inability to see a physician because of cost for patients with cardiovascular disease was 5.9% (95% CI, 1.7%-10.1%), for patients with elevated cholesterol was 3.5% (95% CI, 2.5%-4.5%), and for patients with binge drinking was 3.1% (95% CI, 2.3%-3.3%). The adjusted proportion of chronically ill adults receiving checkups did not change. While the adjusted share of people receiving guideline-recommended cholesterol tests (16.8% [95% CI, 16.1%-17.4%]) and flu shots (13.2% [95% CI, 12.7%-13.8%]) increased, the proportion of women receiving mammograms decreased (-6.7% [95% CI, -7.8 to -5.5]). CONCLUSIONS AND RELEVANCE Despite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased.
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Affiliation(s)
- Laura Hawks
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - David U Himmelstein
- Harvard Medical School, Boston, Massachusetts.,Hunter College, City University of New York, New York, New York
| | - Steffie Woolhandler
- Harvard Medical School, Boston, Massachusetts.,Hunter College, City University of New York, New York, New York
| | - David H Bor
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Adam Gaffney
- Harvard Medical School, Boston, Massachusetts.,Division of Pulmonary and Critical Care, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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79
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Warner JJ, Benjamin IJ, Churchwell K, Firestone G, Gardner TJ, Johnson JC, Ng-Osorio J, Rodriguez CJ, Todman L, Yaffe K, Yancy CW, Harrington RA. Advancing Healthcare Reform: The American Heart Association's 2020 Statement of Principles for Adequate, Accessible, and Affordable Health Care: A Presidential Advisory From the American Heart Association. Circulation 2020; 141:e601-e614. [PMID: 32008369 DOI: 10.1161/cir.0000000000000759] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The mission of the American Heart Association is to be a relentless force for a world of longer, healthier lives. The American Heart Association has consistently prioritized the needs and perspective of the patient in taking positions on healthcare reform while recognizing the importance of biomedical research, providers, and healthcare delivery systems in advancing the care of patients and the prevention of disease. The American Heart Association's vision for healthcare reform describes the foundational changes needed for the health system to serve the best interests of patients and to achieve health care and coverage that are adequate, accessible, and affordable for everyone living in the United States. The American Heart Association is committed to advancing the dialogue around healthcare reform and has prepared this updated statement of our principles, placed in the context of the advances in coverage and care that have occurred after the passage of the Affordable Care Act, the rapidly changing landscape of healthcare delivery systems, and our evolving recognition that efforts to prevent cardiovascular disease can have synergistic benefit in preventing other diseases and improving overall well-being. These updated principles focus on expanding access to affordable health care and coverage; enhancing the availability of evidence-based preventive services; eliminating disparities that limit the availability and equitable delivery of health care; strengthening the public health infrastructure to respond to social determinants of health; prioritizing and accelerating investments in biomedical research; and growing a diverse, culturally competent health and healthcare workforce prepared to meet the challenges of delivering high-value health care.
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80
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Abdus S. The role of plan choice in health care utilization of high-deductible plan enrollees. Health Serv Res 2020; 55:119-127. [PMID: 31657012 PMCID: PMC6980946 DOI: 10.1111/1475-6773.13223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To study whether the negative association between enrollment in high-deductible plans and health care utilization is driven by reverse moral hazard or favorable selection, by examining adults with and without a choice of plans. DATA SOURCE 2011-2016 Medical Expenditure Panel Survey Household Component data on nonelderly adults enrolled in employer-sponsored insurance. STUDY DESIGN Four types of plans were examined: high-deductible health plans (HDHPs), consumer-directed health plans (CDHPs), low-deductible health plans (LDHPs), and no-deductible health plans (NDHPs). Multivariate logistic regressions of various measures of health care utilization were conducted to estimate the differences in utilization across plan types among those who had a choice of plans and those who did not. PRINCIPAL FINDINGS Among adults with a choice of plans, HDHP enrollees had lower levels of utilization compared with those of the NDHP enrollees for any ambulatory visit, any specialist visit, and most preventive services. Among adults without any choice of plans, the differences between HDHP enrollees and NDHP enrollees were not statistically significant. CONCLUSIONS The differences between those with and without choice of plans in the relationship between HDHP enrollment and health care utilization might possibly be explained by favorable selection.
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Affiliation(s)
- Salam Abdus
- Division of Research & ModelingCenter for Financing, Access, and Cost TrendsAgency for Healthcare Research & QualityRockvilleMaryland
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81
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Johnson M, Kishore S, Berwick DM. Medicare For All: An Analysis Of Key Policy Issues. Health Aff (Millwood) 2020; 39:133-141. [PMID: 31905054 DOI: 10.1377/hlthaff.2019.01040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare for All has emerged as a major topic in the national health reform debate. A clear understanding of the policy issues raised by Medicare for All would benefit both public discussion and policy design. In this article we identify key policy design issues for a Medicare for All system: comprehensiveness of coverage, the private sector's role, the payment approach, and financing. We analyze policy options within these domains and show that the Medicare for All bills under consideration in the 116th Congress propose a comprehensive benefit structure with a limited role for supplementary private insurance. We suggest that Medicare for All could adopt payment rates between existing Medicare rates and the average all-payer rate, or it could implement global payment starting at a level similar to current spending. We propose a financing framework that includes repurposing existing public funds, redirecting private health care spending to public spending, and implementing a mix of progressive taxes to replace the regressive financing of private insurance.
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Affiliation(s)
- Micah Johnson
- Micah Johnson ( micah_johnson@hms. harvard. edu ) is an MD candidate at Harvard Medical School, in Boston, Massachusetts
| | - Sanjay Kishore
- Sanjay Kishore is a resident physician in the Department of Medicine, Brigham and Women's Hospital, in Boston
| | - Donald M Berwick
- Donald M. Berwick is president emeritus and senior fellow at the Institute for Healthcare Improvement, in Boston
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82
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Abstract
A well-implemented and adequately funded medical home not only is the best approach to optimize the health of the individual patient but also can function as an effective instrument for improving population health. Key financing elements to providing quality, effective, comprehensive care in the pediatric medical home include the following: (1) first dollar coverage without deductibles, copays, or other cost-sharing for necessary preventive care services as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents; (2) adoption of a uniform definition of medical necessity across payers that embraces services that promote optimal growth and development and prevent, diagnose, and treat the full range of pediatric physical, mental, behavioral, and developmental conditions, in accord with evidence-based science or evidence-informed expert opinion; (3) payment models that promote appropriate use of pediatric primary care and pediatric specialty services and discourage inappropriate, inefficient, or excessive use of medical services; and (4) payment models that strengthen the patient- and family-physician relationship and do not impose additional administrative burdens that will only erode the effectiveness of the medical home. These goals can be met by designing payment models that provide adequate funding of the cost of medical encounters, care coordination, population health services, and quality improvement activities; provide incentives for quality and effectiveness of care; and ease administrative burdens.
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Affiliation(s)
- Jonathan Price
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Mary L Brandt
- Department of Surgery, Texas Children's Hospital, Houston, Texas; and
| | - Mark L Hudak
- Department of Pediatrics, College of Medicine, University of Florida-Jacksonville, Jacksonville, Florida
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83
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Fendrick AM, Buxbaum JD, Tang Y, Vlahiotis A, McMorrow D, Rajpathak S, Chernew ME. Association Between Switching to a High-Deductible Health Plan and Discontinuation of Type 2 Diabetes Treatment. JAMA Netw Open 2019; 2:e1914372. [PMID: 31675081 PMCID: PMC6826641 DOI: 10.1001/jamanetworkopen.2019.14372] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE High-deductible health plans (HDHPs) are a common cost-savings option for employers but may lead to underuse of necessary treatments because beneficiaries bear the full cost of health care, including medications, until a deductible is met. OBJECTIVES To evaluate the association between switching from a non-HDHP to an HDHP and discontinuation of antihyperglycemic medication and to assess whether the association differs in patients using branded vs generic antihyperglycemic medications. DESIGN, SETTING, AND PARTICIPANTS This retrospective matched cohort study used administrative claims from MarketScan databases to identify commercially insured adult patients with type 2 diabetes who used at least 1 antihyperglycemic medication in 2013. Patients in the HDHP cohort (n = 1490) were matched by propensity scores to a non-HDPH control cohort (n = 1490). Data were collected and analyzed from January 1, 2013, through December 31, 2014. EXPOSURES Switching from a non-HDHP in 2013 to a full replacement HDHP in 2014 (no non-HDHP option offered) vs staying on a non-HDHP. MAIN OUTCOMES AND MEASURES Difference-in-differences models estimated discontinuation of branded and generic antihyperglycemic medications. RESULTS Among the 2980 patients included in the analysis (1932 men [64.8%]; mean [SD] age, HDHP cohort: 52.6 [6.9] years; non-HDHP cohort: 52.7 [7.3] years), no difference between the HDHP and non-HDHP cohorts was found in unadjusted follow-up discontinuation rates for all antihyperglycemic medications (255 [22.7%] vs 255 [23.3%]; P = .72); however, among patients using branded medication, a significantly greater proportion of patients in the HDHP group did not refill branded medications (81 of 396 [20.5%] vs 61 of 437 [14.0%]; P = .009). Difference-in-differences models were not statistically significant. CONCLUSIONS AND RELEVANCE These findings suggest switching to an HDHP is associated with discontinuation specifically of branded medications. Unintended health consequences may result and should be considered by employers making health care benefit decisions.
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Affiliation(s)
- A. Mark Fendrick
- Center for Value-Based Insurance Design, University of Michigan, Ann Arbor
| | - Jason D. Buxbaum
- Center for Value-Based Insurance Design, University of Michigan, Ann Arbor
| | - Yuexin Tang
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey
| | | | | | - Swapnil Rajpathak
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey
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84
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Zheng Z, Jemal A, Banegas MP, Han X, Yabroff KR. High-Deductible Health Plans and Cancer Survivorship: What Is the Association With Access to Care and Hospital Emergency Department Use? J Oncol Pract 2019; 15:e957-e968. [DOI: 10.1200/jop.18.00699] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: To examine the associations among high-deductible health plan (HDHP) enrollment, cancer survivorship, and access to care and utilization. MATERIALS AND METHODS: The 2010 to 2017 National Health Interview Survey was used to identify privately insured adults ages 18 to 64 years (cancer survivors, n = 4,321; individuals without a cancer history, n = 95,316). We used multivariable logistic regressions to evaluate the associations among HDHP/health savings account (HSA) status, delayed/forgone care for financial reasons, and hospital emergency department (ED) visits among cancer survivors compared with individuals without a cancer history. RESULTS: Among cancer survivors, HDHPs with or without HSA (8.9% and 13.9%, respectively; both P < .05) were associated with more delayed/forgone care compared with low-deductible health plans (LDHPs) (7.9%). HSA enrollment was associated with less delayed/forgone care among HDHP cancer survivors ( P < .05). ED visits were similar by insurance type. Among individuals without a cancer history, HDHP with or without HSA (9.5% and 10.8%, respectively; both P < .05) were both associated with more delayed/forgone care compared with LDHPs (5.9%). HSA enrollment also was associated with less delayed/forgone care among HDHP enrollees without a cancer history. A small difference in ED visits was observed between HDHPs without HSA (15.3%) and LDHPs (14.1%; P < .05) or HDHPs with HSA (13.4%; P < .05) among individuals without a cancer history. CONCLUSION: HDHP enrollment and HSA status affect access to care and hospital ED visits similarly by cancer history. HDHP enrollment may serve as a barrier to access to care among cancer survivors, although HSA enrollment coupled with an HDHP may mitigate the impact on access. HDHPs and HSA status were not associated with ED visits among cancer survivors. Improvement to care coordination efforts may be needed to reduce ED visits among privately insured cancer survivors.
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Affiliation(s)
- Zhiyuan Zheng
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
| | - Ahmedin Jemal
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
| | | | - Xuesong Han
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
| | - K. Robin Yabroff
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
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85
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Bergo CJ, Dominik B, Sanz S, Rankin K, Handler A. Persisting Gaps in Coverage and Services of Illinois Women Who Acquired Insurance After Implementation of the Affordable Care Act. Public Health Rep 2019; 134:417-422. [PMID: 31170025 DOI: 10.1177/0033354919853265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Before implementation of the Affordable Care Act, many uninsured women in Illinois received care through safety-net programs. The new law allowed them to acquire health insurance through Medicaid or the Illinois Health Exchange. We examined (1) the health care experiences of such women who previously used a safety-net program and acquired this new coverage and (2) persisting gaps in coverage for breast and cervical cancer services and other health care services. METHODS We interviewed a stratified random sample of 400 women aged 34-64 in Illinois each year during 2015-2017 (total N = 1200). We used multivariable logistic regression models to determine the association between health insurance status (Illinois Health Exchange vs Medicaid) and past 12-month gaps in coverage (ie, delaying care, not having a recent mammogram, having a medical cost, and having a medical cost not covered) for the 360 women who were former participants of the Illinois Breast and Cervical Cancer Program. We calculated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for race/ethnicity, age, income, and education. RESULTS We found no significant differences by health insurance status in the prevalence of delaying preventive, chronic, or sick care; timeliness of the most recent mammogram; and having a major medical cost. However, of women who reported a major medical cost, women with health insurance through the Illinois Health Exchange had a higher prevalence of not having a cost covered than women with Medicaid (adjusted OR = 4.86; 95% CI, 1.48-16.03). CONCLUSIONS The results of this study suggest that many women who gained health insurance lacked adequate coverage and services. Safety-net programs will likely continue to play an essential role in supporting women as they navigate a complex system.
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Affiliation(s)
- Cara Jane Bergo
- 1 Division of Epidemiology and Biostatistics, University of Illinois Chicago School of Public Health, Chicago, IL, USA
| | - Bethany Dominik
- 2 Division of Community Health Sciences, University of Illinois Chicago School of Public Health, Chicago, IL, USA
| | - Stephanie Sanz
- 2 Division of Community Health Sciences, University of Illinois Chicago School of Public Health, Chicago, IL, USA
| | - Kristin Rankin
- 1 Division of Epidemiology and Biostatistics, University of Illinois Chicago School of Public Health, Chicago, IL, USA
| | - Arden Handler
- 2 Division of Community Health Sciences, University of Illinois Chicago School of Public Health, Chicago, IL, USA
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86
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Tsega S, Cho HJ. The Reality of Accessing Transportation for Health Care in New York City. JAMA Netw Open 2019; 2:e196856. [PMID: 31251373 DOI: 10.1001/jamanetworkopen.2019.6856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Surafel Tsega
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York
| | - Hyung J Cho
- New York University School of Medicine, New York
- New York City Health and Hospitals, New York, New York
- Lown Institute, Brookline, Massachusetts
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87
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Keller D, Reynolds A. Behavioral Pediatrics Meets Behavioral Economics: Autism, Mandates, and High Deductibles. Pediatrics 2019; 143:peds.2019-0926. [PMID: 31092587 DOI: 10.1542/peds.2019-0926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- David Keller
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Ann Reynolds
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
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88
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Parsons SK, Kumar AJ. Adolescent and young adult cancer care: Financial hardship and continued uncertainty. Pediatr Blood Cancer 2019; 66:e27587. [PMID: 30556354 DOI: 10.1002/pbc.27587] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/24/2018] [Accepted: 11/16/2018] [Indexed: 02/02/2023]
Abstract
Since 2005, there has been a steady increase in the number of new cancer diagnoses among adolescents and young adults (AYA) in the United States (US), likely due to improved awareness and detection within this age group, as well as the possible contribution of insurance expansion under the Patient Protection and Affordable Care Act. AYAs with cancer remain highly vulnerable financially, a situation that will only worsen with proposed rollbacks in access to and affordability of healthcare. In this review, we will discuss existing aspects of financial hardship and highlight areas of uncertainty, based on the current US political climate.
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Affiliation(s)
- Susan K Parsons
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts.,Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Reid R. Sacco AYA Cancer Program, Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Anita J Kumar
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Reid R. Sacco AYA Cancer Program, Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
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89
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Abstract
High-deductible health plans (HDHPs) are becoming more popular owing to their potential to curb rising health care costs. Relative to traditional health insurance plans, HDHPs involve higher out-of-pocket costs for consumers, which have been associated with lower utilization of health services. We focus specifically on the impact that HDHPs have on the use of preventive services. We critique the current evidence by discussing the benefits and drawbacks of the research designs used to examine this relationship. We also summarize the findings from the most methodologically sophisticated studies. We conclude that the balance of the evidence shows that HDHPs are reducing the use of some preventive service, especially screenings. However, it is not clear if HDHPs affect all preventive services. Additional research is needed to determine why variability in conclusions exists among studies. We describe an agenda for future research that can further inform public health decision makers on the impact of HDHPs on prevention.
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Affiliation(s)
- Olena Mazurenko
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University-IUPUI, Indianapolis, Indiana 46202-2872, USA;,
| | - Melinda J.B. Buntin
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee 37203, USA
| | - Nir Menachemi
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University-IUPUI, Indianapolis, Indiana 46202-2872, USA;,
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90
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Service Utilization and Costs of Patients at a Cash-Based Physical Therapy Clinic. Health Care Manag (Frederick) 2019; 38:37-43. [PMID: 30640238 DOI: 10.1097/hcm.0000000000000247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cash-based physical therapy, a model in which the clinicians do not accept insurance payments and accept only direct payment, is quickly becoming an enticing option for clinicians who own their own practice. The purpose of this study was to describe service utilization for a single cash-based physical therapy clinic. Forty-eight charts of patients who had been discharged between 2013 and 2016 were randomly selected. The data were deidentified prior to the researchers gaining access. Chronic diagnoses were predominately prevalent (n = 28). The lumbo/pelvic region of diagnoses (39.6%) and knee/leg region of diagnoses (29.2%) encompassed the majority of the diagnoses. The mean physical therapy utilization for the cohort per episode of care was 8.0 ± 8.1 visits per episode of care, total cost of $780.19 ± 530.30 per episode of care, and $97.52 per visit. This study is the first to present data regarding costs, utilization, and patient demographics for a cash-based physical therapy clinic.
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91
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Wender RC, Brawley OW, Fedewa SA, Gansler T, Smith RA. A blueprint for cancer screening and early detection: Advancing screening's contribution to cancer control. CA Cancer J Clin 2019; 69:50-79. [PMID: 30452086 DOI: 10.3322/caac.21550] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
From the mid-20th century, accumulating evidence has supported the introduction of screening for cancers of the cervix, breast, colon and rectum, prostate (via shared decisions), and lung. The opportunity to detect and treat precursor lesions and invasive disease at a more favorable stage has contributed substantially to reduced incidence, morbidity, and mortality. However, as new discoveries portend advancements in technology and risk-based screening, we fail to fulfill the greatest potential of the existing technology, in terms of both full access among the target population and the delivery of state-of-the art care at each crucial step in the cascade of events that characterize successful cancer screening. There also is insufficient commitment to invest in the development of new technologies, incentivize the development of new ideas, and rapidly evaluate promising new technology. In this report, the authors summarize the status of cancer screening and propose a blueprint for the nation to further advance the contribution of screening to cancer control.
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Affiliation(s)
- Richard C Wender
- Chief Cancer Control Officer, American Cancer Society, Atlanta, GA
| | - Otis W Brawley
- Chief Medical Officer, American Cancer Society, Atlanta, GA
| | - Stacey A Fedewa
- Senior Principal Scientist, Department of Surveillance Research, American Cancer Society, Atlanta, GA
| | - Ted Gansler
- Strategic Director of Pathology Research, American Cancer Society, Atlanta, GA
| | - Robert A Smith
- Vice-President, Cancer Screening, Cancer Control Department, and Director, Center for Quality Cancer Screening and Research, American Cancer Society Atlanta, GA
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92
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Pauly MV. Switching to High-Deductible Health Plans: It Is Going to Be a Bumpy Ride. Ann Intern Med 2018; 169:879-880. [PMID: 30458466 DOI: 10.7326/m18-2825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Mark V Pauly
- University of Pennsylvania, Philadelphia, Pennsylvania (M.V.P.)
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93
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Miller GE, Vistnes JP, Rohde F, Keenan PS. High-Deductible Health Plan Enrollment Increased From 2006 To 2016, Employer-Funded Accounts Grew In Largest Firms. Health Aff (Millwood) 2018; 37:1231-1237. [DOI: 10.1377/hlthaff.2018.0188] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- G. Edward Miller
- G. Edward Miller is deputy director of the Division of Research and Modeling, Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality (AHRQ), in Rockville, Maryland
| | - Jessica P. Vistnes
- Jessica P. Vistnes is a senior economist in the Division of Research and Modeling, Center for Financing, Access, and Cost Trends, AHRQ
| | - Frederick Rohde
- Frederick Rohde is a survey statistician in the Division of Statistical Research and Methods, Center for Financing, Access, and Cost Trends, AHRQ
| | - Patricia S. Keenan
- Patricia S. Keenan is a senior researcher in the Division of Research and Modeling, Center for Financing, Access, and Cost Trends, AHRQ
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94
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Agarwal R, Gupta A, Fendrick AM. Value-Based Insurance Design Improves Medication Adherence Without An Increase In Total Health Care Spending. Health Aff (Millwood) 2018; 37:1057-1064. [DOI: 10.1377/hlthaff.2017.1633] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Rajender Agarwal
- Rajender Agarwal is director of the Center for Health Reform, in Southlake, Texas. At the time this work was completed, he was a Business of Medicine MBA candidate at Indiana University’s Kelley School of Business, in Indianapolis
| | - Ashutosh Gupta
- Ashutosh Gupta is associate director of the Center for Health Reform and a gastroenterologist at ProCare Gastroenterology, in Odessa, Texas
| | - A. Mark Fendrick
- A. Mark Fendrick is a professor in the Department of Internal Medicine, University of Michigan, in Ann Arbor
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95
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Cuckler GA, Sisko AM, Poisal JA, Keehan SP, Smith SD, Madison AJ, Wolfe CJ, Hardesty JC. National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth. Health Aff (Millwood) 2018; 37:482-492. [DOI: 10.1377/hlthaff.2017.1655] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Gigi A. Cuckler
- Gigi A. Cuckler is an economist in the Office of the Actuary, Centers for Medicare and Medicaid Services (CMS), in Baltimore, Maryland
| | - Andrea M. Sisko
- Andrea M. Sisko is an economist in the CMS Office of the Actuary
| | - John A. Poisal
- John A. Poisal is a deputy director of the National Health Statistics Group, CMS Office of the Actuary
| | - Sean P. Keehan
- Sean P. Keehan is an economist in the CMS Office of the Actuary
| | - Sheila D. Smith
- Sheila D. Smith is an economist in the CMS Office of the Actuary
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