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Wang Y, Kang SY, Socal MP, Dusetzina SB. Manufacturer-sponsored drug coupon use and drug-switching behavior among patients with type 2 diabetes. J Manag Care Spec Pharm 2024; 30:903-907. [PMID: 39213140 PMCID: PMC11365561 DOI: 10.18553/jmcp.2024.30.9.903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Patients often use manufacturer-sponsored coupons to reduce their out-of-pocket spending. However, little is known whether coupon use is associated with medication-switching behaviors. OBJECTIVE To examine if using a manufacturer-sponsored coupon to initiate a medication is associated with patterns of medication-switching behaviors among patients with type 2 diabetes. METHODS Using IQVIA's retail pharmacy claims data from October 2017 to September 2019, we analyzed commercially insured patients with type 2 diabetes who had newly started taking the following noninsulin diabetes drugs: generic metformin (nearly no coupon use), Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors (SGLT2, high coupon use), and dipeptidyl peptidase IV inhibitors (DPP-IV inhibitors, moderate coupon use). We assessed if drug-switching behaviors, defined as no switching, switching to a same-class drug, or switching to a drug in a different class, differed among patients who did and did not use coupons to initiate treatments. We performed multinomial logistic regression to estimate the probability of each switching type associated with patients' initial coupon use. RESULTS Among 9,781 patients in our sample, 83.7% of them initiated treatments with metformin, 8.2% with SGLT2, and 8.1% with DPP-IV inhibitors. The overall switching rate was the lowest for generic metformin (40%) than brand-name drugs (56%-57%). Among the brand-name drug users, patients who used a coupon to initiate these drugs were less likely to switch to any drug compared with patients without coupon use (SGLT2 = -18% [95% CI = -24% to -13%]; DPP-IV inhibitors = -9% [-16% to -2%]). These patients were also less likely to switch to drugs in other competing classes (SGLT2 = -16% [95% CI = -22% to -10%]; DPP-IV inhibitors = -9% [-16% to -2%]). CONCLUSIONS Patients who started their treatment with generic metformin had the lowest rate of drug switching. Using coupons to initiate brand-name drugs in classes with prevalent coupons was associated with reduced medication switching to other class drugs.
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Affiliation(s)
- Yang Wang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - So-Yeon Kang
- Georgetown University School of Health, Department of Health Management and Policy, Washington, DC
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Gidwani R, Yank V, Burgette L, Kofner A, Asch SM, Wagner Z. The impact of telehealth cost-sharing on healthcare utilization: Evidence from high-deductible health plans. Health Serv Res 2024. [PMID: 39135532 DOI: 10.1111/1475-6773.14343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024] Open
Abstract
OBJECTIVE Evaluate whether cost-sharing decreases led high-deductible health plans (HDHP) enrollees to increase their use of healthcare. DATA SOURCES, STUDY SETTING National sample of chronically-ill patients age 18-64 from 2018 to 2020 (n = 1,318,178). STUDY DESIGN Difference-in-differences analyses using entropy-balancing weights were used to evaluate the effect of a policy shift to $0 cost-sharing for telehealth on utilization for HDHP compared with non-HDHP enrollees. Due to this shock, HDHP enrollees experienced substantial declines in cost-sharing for telehealth, while non-HDHP enrollees experienced small declines. Event study models were also used to evaluate changes over time. DATA COLLECTION/EXTRACTION METHODS Outcomes included use of any outpatient care; use of $0 telehealth; use of $0 telehealth as a proportion of all outpatient care; and use of any telehealth. To test whether any differences were due to preferences for care modality versus cost-sharing, we further evaluated use of non-$0 telehealth as a placebo test. PRINCIPAL FINDINGS There was no difference in change in overall outpatient visits (p = 0.84), with chronicall-ill HDHP enrollees using less care both before and after the policy shift. However, compared with non-HDHP enrollees, HDHP enrollees increased their use of $0 telehealth by 0.08 visits over a 9-month period, a 27% increase (95% CI 0.07-0.09, p < 0.001) and shifted 1.2 percentage points more of their care to $0 telehealth, a 15% increase (ß = 0.01, 95% CI 0.01, 0.01, p < 0.001). However, HDHP enrollees had lower uptake of non-$0 telehealth than non-HDHP enrollees (ß = -0.01, 95%CI -0.02, 0.00, p = 0.04). CONCLUSIONS Recent-but-expiring federal legislation exempts telehealth from HDHP deductibles for care provided in 2023 and 2024. Our results indicate that extending the protections provided by this legislation could help reduce the gap in access to care for chronically-ill persons enrolled in HDHPs.
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Affiliation(s)
- Risha Gidwani
- Economics, Sociology, and Statistics (ESS), RAND Corporation, Santa Monica, California, USA
- Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California, USA
| | - Veronica Yank
- School of Medicine, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Lane Burgette
- Economics, Sociology, and Statistics (ESS), RAND Corporation, Arlington, Virginia, USA
| | - Aaron Kofner
- Economics, Sociology, and Statistics (ESS), RAND Corporation, Arlington, Virginia, USA
| | - Steven M Asch
- Department of Medicine at Stanford, Stanford University, Palo Alto, California, USA
| | - Zachary Wagner
- Economics, Sociology, and Statistics (ESS), RAND Corporation, Santa Monica, California, USA
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Eddelbuettel JCP, Kennedy-Hendricks A, Meiselbach MK, Stuart EA, Huskamp HA, Busch AB, Hollander MAG, Schilling C, Barry CL, Eisenberg MD. Changes in Healthcare Spending Attributable to High Deductible Health Plan Offer Among Enrollees with Comorbid Substance Use Disorder and Cardiovascular Disease. J Gen Intern Med 2024; 39:1993-2000. [PMID: 38459412 PMCID: PMC11306437 DOI: 10.1007/s11606-024-08700-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/23/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND The rise in prevalence of high deductible health plans (HDHPs) in the United States may raise concerns for high-need, high-utilization populations such as those with comorbid chronic conditions. In this study, we examine changes in total and out-of-pocket (OOP) spending attributable to HDHPs for enrollees with comorbid substance use disorder (SUD) and cardiovascular disease (CVD). METHODS We used de-identified administrative claims data from 2007 to 2017. SUD and CVD were defined using algorithms of ICD 9 and 10 codes and HEDIS guidelines. The main outcome measures of interest were spending measure for all non-SUD/CVD-related services, SUD-specific services, and CVD-specific services, for all services and medications specifically. We assessed both total and OOP spending. We used an intent-to-treat two-part model approach to model spending and computed the marginal effect of HDHP offer as both the dollar change and percent change in spending attributable to HDHP offer. RESULTS Our sample included 33,684 enrollee-years and was predominantly white and male with a mean age of 53 years. The sample had high demonstrated substantial healthcare utilization with 94% using any non-SUD/CVD services, and 84% and 78% using SUD and CVD services, respectively. HDHP offer was associated with a 17.0% (95% CI = [0.07, 0.27] increase in OOP spending for all non-SUD/CVD services, a 21.1% (95% CI = [0.11, 0.31]) increase in OOP spending for all SUD-specific services, and a 13.1% (95% CI = [0.04, 0.23]) increase in OOP spending for all CVD-specific services. HDHP offer was also associated with a significant increase in OOP spending on non-SUD/CVD-specific medications and SUD-specific medications, but not CVD-specific medications. CONCLUSIONS This study suggests that while HDHPs do not change overall levels of annual spending among enrollees with comorbid CVD and SUD, they may increase the financial burden of healthcare services by raising OOP costs, which could negatively impact this high-need and high-utilization population.
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Affiliation(s)
| | | | - Mark K Meiselbach
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth A Stuart
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD, USA
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Mara A G Hollander
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, NC, USA
| | - Cameron Schilling
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
| | - Colleen L Barry
- Brooks School of Public Policy, Cornell University, Ithaca, NY, USA
| | - Matthew D Eisenberg
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
- Optum Labs, Boston, MA, USA
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Gupta R, Yang L, Lewey J, Navathe AS, Groeneveld PW, Khatana SAM. Association of High-Deductible Health Plans With Health Care Use and Costs for Patients With Cardiovascular Disease. J Am Heart Assoc 2023; 12:e030730. [PMID: 37750565 PMCID: PMC10727247 DOI: 10.1161/jaha.123.030730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023]
Abstract
Background By increasing cost sharing, high-deductible health plans (HDHPs) aim to reduce low-value health care use. The association of HDHPs with health care use and costs in patients with chronic cardiovascular disease is unknown. Methods and Results This longitudinal cohort study analyzed 57 690 privately insured patients, aged 18 to 64 years, from a large commercial claims database with chronic cardiovascular disease from 2011 to 2019. Health care entities in which all or most beneficiaries switched from being in a traditional plan to an HDHP were identified. A difference-in-differences design was used to account for differences between individuals who remained in traditional plans and those who switched to HDHPs and to assess changes in health care use and costs. Among the 934 individuals in the HDHP group and the 56 756 in the traditional plan group, switching to an HDHP was not associated with statistically significant changes in annual outpatient visits, hospitalizations, or emergency department visits (-8.3% [95% CI, -16.8 to 1.1], -28.5% [95% CI, -62.1 to 34.6], and 11.2% [95% CI, -20.9 to 56.5], respectively). Switching to an HDHP was associated with an increase of $921 (95% CI, $743-$1099) in out-of-pocket costs but no statistically significant difference in total health care costs. Conclusions Among commercially insured patients with chronic cardiovascular disease, switching to an HDHP was not associated with a change in health care use but was associated with an increase in out-of-pocket costs. Although health care use by individuals with chronic cardiovascular disease may not be sensitive to higher cost sharing associated with HDHP enrollment, there may be a significant increase in patients' financial burden.
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Affiliation(s)
- Ravi Gupta
- Division of General Internal MedicineJohns Hopkins University School of MedicineBaltimoreMD
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
- Hopkins Business of Health Initiative, Johns Hopkins UniversityBaltimoreMD
| | - Lin Yang
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
| | - Jennifer Lewey
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Peter W. Groeneveld
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
| | - Sameed Ahmed M. Khatana
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
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Park KE, Saluja S, Kaplan CM. Alleviating Financial Hardships Associated with High-Deductible Health Plans for Adults with Chronic Conditions Through Health Savings Accounts. J Gen Intern Med 2023; 38:1593-1598. [PMID: 36600078 PMCID: PMC10212892 DOI: 10.1007/s11606-022-07985-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 12/13/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND High-deductible health plans (HDHPs) are becoming increasingly common, but their financial implications for enrollees with and without chronic conditions and the mitigating effects of health savings accounts (HSAs) are relatively unknown. OBJECTIVE Our aim was to compare financial hardship between non-HDHPs and HDHPs with and without HSAs, stratified by enrollees' number of chronic conditions. DESIGN We used data from 2015 to 2018 Medical Expenditure Panels Surveys (MEPS) to compare rates of financial hardship across individuals with HDHPs and non-HDHPs using linear and logistic regression models. PARTICIPANTS A nationally representative sample of 30,981 adults aged 18-64 enrolled in HDHPs and non-HDHPs. MAIN MEASURES We examined several measures of financial hardship, including total yearly out-of-pocket medical spending as well as rates of delaying medical care or prescriptions in the past year due to cost, forgoing medical care or prescriptions in the past year due to cost, paying medical bills over time, or having problems paying medical bills. We compared rates using the non-HDHP as the control. KEY RESULTS On most measures, HDHPs are associated with greater financial hardship compared to non-HDHPs, including average annual out-of-pocket spending of $637 for non-HDHPs, $939 for HDHPs with HSAs, and $825 for HDHPs without HSAs (p < 0.01). However, for HDHP enrollees with multiple chronic conditions, having an HSA was associated with less financial hardship (p < 0.05). CONCLUSIONS Our findings suggest that HSAs may be most beneficial for those with chronic conditions, in part due to the tax benefits they offer as well as the fact that those with chronic conditions are more likely to take advantage of their HSAs than their younger, healthier counterparts. However, as HDHPs are more likely to be correlated with worse financial outcomes regardless of health status, recent trends of increasing participation may be a reason for concern.
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Affiliation(s)
- Kristen E Park
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Sonali Saluja
- The Gehr Family Center for Health Systems Science and Innovation, Department of Medicine, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Cameron M Kaplan
- The Gehr Family Center for Health Systems Science and Innovation, Department of Medicine, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, Los Angeles, CA, 90033, USA
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Reeves SL, Ng S, Dombkowski KJ, Raphael JL, Chua KP. TCD screening and spending among children with sickle cell anemia. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:e79-e84. [PMID: 36947020 PMCID: PMC10838405 DOI: 10.37765/ajmc.2023.89333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
OBJECTIVES National guidelines recommend that children with sickle cell anemia receive annual transcranial Doppler (TCD) screening to assess stroke risk. Our objectives were to estimate the rate of TCD screening among privately insured children with sickle cell anemia, estimate out-of-pocket spending for TCD screening, and evaluate the association between TCD screening and enrollment in high-deductible health plans (HDHPs). STUDY DESIGN Cross-sectional. METHODS Using the 2009-2017 IBM MarketScan Commercial Database, we identified children aged 2 to 15 years who met a validated claims-based definition of sickle cell anemia. We calculated the proportion of children receiving annual TCD screening and out-of-pocket spending per TCD screen. Using logistic regression with generalized estimating equations, we modeled the receipt of annual TCD screening as a function of HDHP enrollment, controlling for demographics and year. RESULTS The 2519 children in the analysis accounted for 7197 person-years of enrollment; 14% of person-years were from HDHP enrollees. During 2009-2017, the proportion of children receiving TCD screening ranged from 40% to 44%. Median out-of-pocket spending for TCD screening was $20 overall and $65 among HDHP enrollees. Out-of-pocket spending exceeded $100 for 27% of all screens and 42% of screens among HDHP enrollees. HDHP enrollment was not associated with TCD screening (adjusted odds ratio, 0.99; 95% CI, 0.85-1.15). CONCLUSIONS Among privately insured children with sickle cell anemia, fewer than half received annual TCD screening. Out-of-pocket spending exceeded $100 for 27% of TCD screens. Although HDHP enrollment was not associated with TCD screening, additional studies are needed to assess whether cost sharing might deter this screening.
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Affiliation(s)
- Sarah L Reeves
- University of Michigan, 2800 Plymouth Rd, Bldg 16, Ann Arbor, MI 48109.
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Fusco N, Sils B, Graff JS, Kistler K, Ruiz K. Cost-sharing and adherence, clinical outcomes, health care utilization, and costs: A systematic literature review. J Manag Care Spec Pharm 2023; 29:4-16. [PMID: 35389285 PMCID: PMC10394195 DOI: 10.18553/jmcp.2022.21270] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND: US health plans are adopting benefit designs that shift greater financial burden to patients through higher deductibles, additional copay tiers, and coinsurance. Prior systematic reviews found that higher cost was associated with reductions in both appropriate and inappropriate medications. However, these reviews were conducted prior to contemporary benefit design and medication utilization. OBJECTIVE: To assess the relationship and factors associated with cost-sharing and (1) medication adherence, (2) clinical outcomes, (3) health care resource utilization (HRU), and (4) costs. METHODS: A systematic review of literature published between January 2010 and August 2020 was conducted to identify the relationship between cost-sharing and medication adherence, clinical outcomes, HRU, and health care costs. Data were extracted using a standardized template and were synthesized by key questions of interest. RESULTS: From 1,995 records screened, 79 articles were included. Most studies, 71 of 79 (90%), reported the relationship between cost-sharing and treatment adherence, persistence and/or discontinuation; 16 (20%) reported data on cost-sharing and HRU or medication initiation, 11 (14%) on costsharing and health care costs, and 6 (8%) on cost-sharing and clinical outcomes. The majority of publications found that, regardless of disease area, increased cost-sharing was associated with worse adherence, persistence, or discontinuation. The aggregate data suggested the greater the magnitude of cost-sharing, the worse the adherence. Among studies examining clinical outcomes, cost-sharing was associated with worse outcomes in 1 study and the remaining 3 found no significant differences. Regarding HRU, higher-cost-sharing trended toward decreased outpatient and increased inpatient utilization. The available evidence suggested higher cost-sharing has an overall neutral to negative impact on total costs. Studies evaluating elimination of copays found either decreased or no impact in total costs. CONCLUSIONS: The published literature shows consistent impacts of higher cost sharing on initiation and continuation of medications, and the greater the cost-sharing, the worse the medication adherence. The evidence is limited regarding the impact of cost-sharing on clinical outcomes, HRU, and costs. Limited evidence suggests increased cost-sharing is associated with more inpatient care and less outpatient care; however, a neutral to no difference was suggested for other outcomes. Although increased costsharing is intended to decrease total costs, studies evaluating reducing or eliminating cost-sharing found that total costs did not rise. Today's growing cost-containment environment should carefully consider the broader impact cost-sharing has on treatment adherence, clinical outcomes, resource use, and total costs. It may be that cost-sharing is a blunt, rather than precise, tool to curb health care costs, affecting both necessary and unnecessary health care use. DISCLOSURES: This study and the development of this article were funded by the National Pharmaceutical Council. Mr Sils is an employee of the National Pharmaceutical Council. Dr Graff is a former employee of the National Pharmaceutical Council. Drs Fusco and Kistler and Ms Ruiz are employees of Xcenda. Xcenda received funding to conduct the literature review.
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Affiliation(s)
| | - Brian Sils
- National Pharmaceutical Council, Washington, DC
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8
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Impact of Real-Time Benefit Tools on Patients' Access to Medications: A Retrospective Cohort Study. Am J Med 2022; 135:1315-1319.e2. [PMID: 35896143 DOI: 10.1016/j.amjmed.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/23/2022]
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Wu YM, Huang J, Reed ME. Association Between High-Deductible Health Plans and Engagement in Routine Medical Care for Type 2 Diabetes in a Privately Insured Population: A Propensity Score-Matched Study. Diabetes Care 2022; 45:1193-1200. [PMID: 35290445 PMCID: PMC9375446 DOI: 10.2337/dc21-1885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE High-deductible health plans (HDHPs) are increasingly more common but can be challenging for patients to navigate and may negatively affect care engagement for chronic conditions such as type 2 diabetes. We sought to understand how higher out-of-pocket costs affect participation in provider visits, medication adherence, and routine monitoring by patients with type 2 diabetes with an HDHP. RESEARCH DESIGN AND METHODS In a retrospective cohort of 19,379 Kaiser Permanente Northern California patients with type 2 diabetes (age 18-64 years), 6,801 patients with an HDHP were compared with those with a no-deductible plan using propensity score matching. We evaluated the number of telephone and office visits with primary care, oral diabetic medication adherence, and rates of HbA1c testing, blood pressure monitoring, and retinopathy screening. RESULTS Patients with an HDHP had fewer primary care office visits compared with patients with no deductible (4.25 vs. 4.85 visits per person; P < 0.001), less retinopathy screening (49.9% vs. 53.3%; P < 0.001), and fewer A1c and blood pressure measurements (46.7% vs. 51.4%; P < 0.001 and 93.2% vs. 94.4%; P = 0.004, respectively) compared with the control group. Medication adherence was not significantly different between patients with an HDHP and those with no deductible (57.4% vs. 58.6%; P = 0.234). CONCLUSIONS HDHPs seem to be a barrier for patients with type 2 diabetes and reduce care participation in both visits with out-of-pocket costs and preventive care without out-of-pocket costs, possibly because of the increased complexity of cost sharing under an HDHP, potentially leading to decreased monitoring of important clinical measurements.
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Affiliation(s)
- You M Wu
- Department of Adult and Family Medicine, Kaiser Permanente, Santa Clara, CA
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, CA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA
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Buttorff C, Girosi F, Lai J, Taylor EA, Lewis SE, Ma S, Eibner C. Do Financial Incentives Affect Utilization for Chronically Ill Medicare Beneficiaries? Med Care 2022; 60:302-310. [PMID: 35213426 DOI: 10.1097/mlr.0000000000001695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to examine the price sensitivity for provider visits among Medicare Advantage beneficiaries. DATA SOURCES We used Medicare Advantage encounter data from 2014 to 2017 accessed as part of an evaluation for the Center for Medicare & Medicaid Innovation. STUDY DESIGN We analyzed the effect of cost-sharing on the utilization of 2 outcome categories: number of visits (specialist and primary care) and the probability of any visit (specialist and primary care). Our main independent variable was the size of the copayment for the visit, which we regressed on the outcomes with several beneficiary-level and plan-level control variables. DATA COLLECTION/EXTRACTION METHODS We included beneficiaries with at least 1 of 4 specific chronic conditions and matched comparison beneficiaries. We did not require beneficiaries to be continuously enrolled from 2014 to 2017, but we required a full year of data for each year they were observed. This resulted in 371,140 beneficiary-year observations. PRINCIPAL FINDINGS Copay reductions were associated with increases in utilization, although the changes were small, with elasticities <-0.2. We also found evidence of substitution effects between primary care provider (PCP) and specialist visits, particularly cardiology and endocrinology. When PCP copays declined, visits to these specialists also declined. CONCLUSIONS We find that individuals with chronic conditions respond to changes in copays, although these responses are small. Reductions in PCP copays lead to reduced use of some specialists, suggesting that lowering PCP copays could be an effective way to reduce the use of specialist care, a desirable outcome if specialists are overused.
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Affiliation(s)
| | | | | | | | - Sarah E Lewis
- Center for Medicare & Medicaid Innovation, Baltimore, MD
| | - Sai Ma
- Clinical Transformation, Humana, Washington, DC
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Kennedy-Hendricks A, Schilling CJ, Busch AB, Stuart EA, Huskamp HA, Meiselbach MK, Barry CL, Eisenberg MD. Impact of High Deductible Health Plans on Continuous Buprenorphine Treatment for Opioid Use Disorder. J Gen Intern Med 2022; 37:769-776. [PMID: 34405345 PMCID: PMC8904661 DOI: 10.1007/s11606-021-07094-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD. OBJECTIVE To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending. DESIGN Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group). PARTICIPANTS Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment. MAIN MEASURES Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits. KEY RESULTS HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services. CONCLUSIONS HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population.
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Affiliation(s)
- Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 408, Baltimore, MD, 21205, USA.
- Johns Hopkins Center for Mental Health and Addiction Policy, Baltimore, MD, USA.
| | - Cameron J Schilling
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 408, Baltimore, MD, 21205, USA
- Johns Hopkins Center for Mental Health and Addiction Policy, Baltimore, MD, USA
| | - Alisa B Busch
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- McLean Hospital, Belmont, MA, USA
| | - Elizabeth A Stuart
- Johns Hopkins Center for Mental Health and Addiction Policy, Baltimore, MD, USA
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Mark K Meiselbach
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 408, Baltimore, MD, 21205, USA
| | - Colleen L Barry
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 408, Baltimore, MD, 21205, USA
- Johns Hopkins Center for Mental Health and Addiction Policy, Baltimore, MD, USA
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Matthew D Eisenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 408, Baltimore, MD, 21205, USA
- Johns Hopkins Center for Mental Health and Addiction Policy, Baltimore, MD, USA
- OptumLabs, Cambridge, MA, USA
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12
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Khanijahani A, Akinci N, Iezadi S, Priore D. Impacts of high-deductible health plans on patients with diabetes: A systematic review of the literature. Prim Care Diabetes 2021; 15:948-957. [PMID: 34400113 DOI: 10.1016/j.pcd.2021.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES High-deductible health plans (HDHPs) as a type of consumer-directed health insurance plan aim to control unnecessary service utilization and share the responsibility in payments and care with the patient. Our objective was to systematically pool the medical and non-medical impacts of HDHPs on patients with diabetes. METHODS We searched databases, including PubMed, Scopus, Embase, and Wiley, to identify relevant published studies. We outlined the eligibility criteria based on the study population, intervention, comparison, outcome, and types of studies (PICOT). We included peer-reviewed quantitative studies published in English, including quasi-experimental, observational, and cross-sectional studies in this review. We used the narrative data synthesis method to categorize and interpret the results. RESULTS Initial search yielded 149 results. After removing duplicates and screening for relevant titles and abstracts, and reviewing full texts, 11 studies met eligibility criteria. Overall, diabetic patients with HDHP were less likely to adhere to treatment and prescription refills, utilize fewer healthcare services and medications, and more likely to have acute emergency visits than their counterparts enrolled in low-deductible plans. However, the results on overall healthcare costs and the final health outcome were unclear. CONCLUSIONS It appears that HDHPs negatively impact low-income diabetic patients by leading them to forgo preventive and primary care services and experience excessive preventable emergency department visits. The socioeconomic characteristics of patients must be considered when developing HDHP policies, and adjustments should be made to HDHPs accordingly.
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Affiliation(s)
- Ahmad Khanijahani
- Department of Health Administration and Public Health, John G. Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA, USA.
| | - Nesli Akinci
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Shabnam Iezadi
- Hospital Management Research Center, Iran University of Medical Science, Tehran, Iran
| | - Dreux Priore
- Department of Health Administration and Public Health, John G. Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA, USA
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13
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Impact of High Deductible Health Plans on Diabetes Care Quality and Outcomes: Systematic Review. Endocr Pract 2021; 27:1156-1164. [PMID: 34245911 DOI: 10.1016/j.eprac.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [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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14
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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: 3] [Impact Index Per Article: 1.0] [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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15
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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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16
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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: 6.8] [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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17
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Guitron S, Pianykh OS, Succi MD, Lang M, Brink J. COVID-19: Recovery Models for Radiology Departments. J Am Coll Radiol 2020; 17:1460-1468. [PMID: 32979322 PMCID: PMC7476574 DOI: 10.1016/j.jacr.2020.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 10/28/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has greatly affected demand for imaging services, with marked reductions in demand for elective imaging and image-guided interventional procedures. To guide radiology planning and recovery from this unprecedented impact, three recovery models were developed to predict imaging volume over the course of the COVID-19 pandemic: (1) a long-term volume model with three scenarios based on prior disease outbreaks and other historical analogues, to aid in long-term planning when the pandemic was just beginning; (2) a short-term volume model based on the supply-demand approach, leveraging increasingly available COVID-19 data points to predict examination volume on a week-to-week basis; and (3) a next-wave model to estimate the impact from future COVID-19 surges. The authors present these models as techniques that can be used at any stage in an unpredictable pandemic timeline.
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Affiliation(s)
- Steven Guitron
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Oleg S Pianykh
- Director of Medical Analytics Group, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Marc D Succi
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Director, Medically Engineered Solutions in Healthcare Incubator, Massachusetts General Hospital, Boston, Massachusetts
| | - Min Lang
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James Brink
- Juan M. Taveras Professor of Radiology, Harvard Medical School, Boston, Massachusetts; Radiologist-in-Chief, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
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