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Ilkhani S, Naus AE, Pinkes N, Rafaqat W, Grobman B, Valverde MD, Sanchez SE, Hwabejire JO, Ranganathan K, Scott JW, Herrera-Escobar JP, Salim A, Anderson GA. The invisible scars: Unseen financial complications worsen every aspect of long-term health in trauma survivors. J Trauma Acute Care Surg 2024; 96:893-900. [PMID: 38227675 DOI: 10.1097/ta.0000000000004247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Trauma survivors are susceptible to experiencing financial toxicity (FT). Studies have shown the negative impact of FT on chronic illness outcomes. However, there is a notable lack of data on FT in the context of trauma. We aimed to better understand prevalence, risk factors, and impact of FT on trauma long-term outcomes. METHODS Adult trauma patients with an Injury Severity Score (ISS) ≥9 treated at Level I trauma centers were interviewed 6 months to 14 months after discharge. Financial toxicity was considered positive if patients reported any of the following due to the injury: income loss, lack of care, newly applied/qualified for governmental assistance, new financial problems, or work loss. The Impact of FT on Patient Reported Outcome Measure Index System (PROMIS) health domains was investigated. RESULTS Of 577 total patients, 44% (254/567) suffered some form of FT. In the adjusted model, older age (odds ratio [OR], 0.4; 95% confidence interval [95% CI], 0.2-0.81) and stronger social support networks (OR, 0.44; 95% CI, 0.26-0.74) were protective against FT. In contrast, having two or more comorbidities (OR, 1.81; 95% CI, 1.01-3.28), lower education levels (OR, 1.95; 95% CI, 95%, 1.26-3.03), and injury mechanisms, including road accidents (OR, 2.69; 95% CI, 1.51-4.77) and intentional injuries (OR, 4.31; 95% CI, 1.44-12.86) were associated with higher toxicity. No significant relationship was found with ISS, sex, or single-family household. Patients with FT had worse outcomes across all domains of health. There was a negative linear relationship between the severity of FT and worse mental and physical health scores. CONCLUSION Financial toxicity is associated with long-term outcomes. Incorporating FT risk assessment into recovery care planning may help to identify patients most in need of mitigative interventions across the trauma care continuum to improve trauma recovery. Further investigations to better understand, define, and address FT in trauma care are warranted. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Saba Ilkhani
- From the Center for Surgery and Public Health (S.I., N.P., M.D.V., K.R., J.P.H.-E., G.A.A.), Brigham and Women's Hospital, Harvard Medical School, Boston; Beth Israel Lahey Health, Lahey Hospital and Medical Center (A.E.N.), Burlington; Division of Trauma, Emergency Surgery (W.R., JOH), and Surgical Critical Care, Massachusetts General Hospital, School of Medicine (B.G.), Harvard Medical School; Tufts University School of Medicine (M.D.V.), Boston; Division of Trauma, Acute Care Surgery & Surgical Critical Care (S.E.S.), Boston Medical Center, Boston University School of Medicine; Division of Plastic and Reconstructive Surgery (K.R.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, University of Washington (J.W.S.), Harborview Medical Center, Seattle, Washington; and Division of Trauma, Burn, and Surgical Critical Care (J.P.H.-E., A.S., G.A.A.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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DeMartini SJ, Pereira DE, Dy CJ. Disparities Exist in the Experience of Financial Burden Among Orthopedic Trauma Patients: A Systematic Review. Curr Rev Musculoskelet Med 2024; 17:129-135. [PMID: 38491251 PMCID: PMC11068702 DOI: 10.1007/s12178-024-09890-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 03/18/2024]
Abstract
PURPOSE OF REVIEW There are substantial costs associated with orthopedic injury and management. These costs are likely not experienced equally among patients. At the level of the healthcare and hospital systems, disparities in financial burden and patient demographics have already been identified among orthopedic trauma patients. Accordingly, disparities may also arise at the level of the patient and how they experience the cost of their care. We sought to determine (1) how patient demographics are associated with financial burden/toxicity and (2) if patients experience disproportionate financial burden/toxicity and social support secondary to their economic standing. RECENT FINDINGS It has been described that there is an inequitable experience in clinical and economic outcomes in certain socioeconomic demographics leading to disparities in financial burden. It has been further reported that orthopedic injury, management, and outcomes are not experienced equitably among all demographic and socioeconomic groups. Ten articles met inclusion criteria, among which financial burden was disproportionately experienced amid orthopedic trauma patients across age, gender, race, education, and marital status. Financial hardship was also unequally distributed among different levels of income, employment, insurance status, and social deprivation. Younger, female, non-White, and unmarried patients experience increased financial burden. Patients with less education, lower income, limited or no insurance, and greater social deprivation disproportionately experienced financial toxicity compared to patients of improved economic standing. Further investigation into policy changes, social support, and barriers to appropriate care should be addressed to prevent unnecessary financial burden and promote greater patient welfare.
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Affiliation(s)
- Stephen J DeMartini
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 Euclid Avenue, St. Louis, MO, 63110, USA
| | - Daniel E Pereira
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 Euclid Avenue, St. Louis, MO, 63110, USA
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 Euclid Avenue, St. Louis, MO, 63110, USA.
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Olateju OA, Shen C, Thornton JD. The Affordable Care Act and income-based disparities in health care coverage and spending among nonelderly adults with cancer. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae050. [PMID: 38812986 PMCID: PMC11135644 DOI: 10.1093/haschl/qxae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/12/2024] [Accepted: 04/23/2024] [Indexed: 05/31/2024]
Abstract
The Patient Protection and Affordable Care Act (ACA) significantly reduced uninsured individuals and improved financial protection; however, escalating costs of cancer treatment has led to substantial out-of-pocket expenses, causing severe financial and mental health distress for individuals with cancer. Mixed evidence on the ACA's ongoing impact highlights the necessity of assessing health-spending changes across income groups for informed policy interventions. In our nationally representative survey evaluating the early- and long-term effects of the ACA on nonelderly adult patients with cancer, we categorized individuals-based income subgroups defined by the ACA for eligibility. We found that ACA implementation increased insurance coverage, which was particularly evident after 2 years of implementation. Early post-ACA (within two years of implementation), there were declines in out-of-pocket spending for the lowest and low-income groups by 26.52% and 38.31%, respectively, persisting long-term only for the lowest-income group. High-income groups experienced continuously increased out-of-pocket and premium spending by 25.39% and 34.28%, respectively, with a notable 122% increase in the risk of high-burden spending. This study provides robust evidence of income-based disparities in financial burden for cancer care, emphasizing the need for health care policies promoting equitable care and addressing spending disparities across income brackets.
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Affiliation(s)
- Olajumoke A Olateju
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX 77204-5000, United States
| | - Chan Shen
- Departments of Surgery and Public Health Sciences, Penn State Cancer Institute, Hershey, PA 17033, United States
| | - James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX 77204-5000, United States
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Dwivedi S, Cichocki MN, Wu H, Kettaneh CA, Wang L, Chung KC. Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act. JAMA Surg 2024; 159:404-410. [PMID: 38294792 PMCID: PMC10831625 DOI: 10.1001/jamasurg.2023.7189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/01/2023] [Indexed: 02/01/2024]
Abstract
Importance Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear. Objective To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA. Design, Setting, and Participants This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023. Exposures Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods. Main Outcomes and Measures Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA. Results Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (-70.5 [95% CI, -112.6 to -28.3] days; P < .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P < .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P < .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P < .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change. Conclusions and Relevance Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.
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Affiliation(s)
- Shashank Dwivedi
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Meghan N. Cichocki
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Hao Wu
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Celeste A. Kettaneh
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Lu Wang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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Scott JW, Anderson GA, Conatser A, de Souza C, Evans E, Goodwin Z, Jakubus JL, Kelm J, Mekled I, Monahan J, Oh EJ, Oliphant BW, Hemmila MR. Multicenter evaluation of financial toxicity and long-term health outcomes after injury. J Trauma Acute Care Surg 2024; 96:54-61. [PMID: 37867247 DOI: 10.1097/ta.0000000000004161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Despite the growing awareness of the negative financial impact of traumatic injury on patients' lives, the association between financial toxicity and long-term health-related quality of life (hrQoL) among trauma survivors remains poorly understood. METHODS Patients from nine trauma centers participating in a statewide trauma quality collaborative had responses from longitudinal survey data linked to inpatient trauma registry data. Financial toxicity was defined based on patient-reported survey responses regarding medical debt, work or income loss, nonmedical financial strain, and forgone care due to costs. A financial toxicity score ranging from 0 to 4 was calculated. Health-related quality of life was assessed using the EuroQol 5 Domain tool. Multivariable regression models evaluated the association between financial toxicity and hrQoL outcomes while adjusting for patient demographics, injury severity and inpatient treatment intensity, and health systems variables. RESULTS Among the 403 patients providing 510 completed surveys, rates of individual financial toxicity elements ranged from 21% to 46%, with 65% of patients experiencing at least one element of financial toxicity. Patients with any financial toxicity had worse summary measures of hrQoL and higher rates of problems in all five EuroQol 5 Domain domains ( p < 0.05 for all). Younger age, lower household income, lack of insurance, more comorbidities, discharge to a facility, and air ambulance transportation were independently associated with higher odds of financial toxicity ( p < 0.05 for all). Injury traits and inpatient treatment intensity were not independently associated with financial toxicity. CONCLUSION A majority of trauma survivors in this study experienced some level of financial toxicity, which was independently associated with worse risk-adjusted health outcomes across all hrQoL measures. Risk factors for financial toxicity are not related to injury severity or treatment intensity but rather to sociodemographic variables and measures of prehospital and posthospital health care resource utilization. Targeted interventions and policies are needed to address financial toxicity and ensure optimal recovery for trauma survivors. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- John W Scott
- From the Department of Surgery (J.W.S.), Harborview Medical Center, University of Michigan, Ann Arbor, Michigan; Department of Surgery (J.W.S., A.C., C.d.S., Z.G., J.L.J., J.K., I.M., J.M., E.J.O., M.R.H.), Center for Healthcare Outcomes and Policy (J.W.S., E.J.O., B.W.O., M.R.H.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (G.A.A.), Brigham and Women's Hospital, Boston, Massachusetts; University of Michigan Medical School (E.E.); and Department of Orthopedic Surgery (B.W.O.), University of Michigan, Ann Arbor, Michigan
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Taylor KK, Neiman PU, Bonner S, Ranganathan K, Tipirneni R, Scott JW. Unmet Social Health Needs as a Driver of Inequitable Outcomes After Surgery: A Cross-sectional Analysis of the National Health Interview Survey. Ann Surg 2023; 278:193-200. [PMID: 36017938 PMCID: PMC10122453 DOI: 10.1097/sla.0000000000005689] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aims to identify opportunities to improve surgical equity by evaluating unmet social health needs by race, ethnicity, and insurance type. BACKGROUND Although inequities in surgical care and outcomes based on race, ethnicity, and insurance have been well documented for decades, underlying drivers remain poorly understood. METHODS We used the 2008-2018 National Health Interview Survey to identify adults age 18 years and older who reported surgery in the past year. Outcomes included poor health status (self-reported), socioeconomic status (income, education, employment), and unmet social health needs (food, housing, transportation). We used logistic regression models to progressively adjust for the impact of patient demographics, socioeconomic status, and unmet social health needs on health status. RESULTS Among a weighted sample of 14,471,501 surgical patients, 30% reported at least 1 unmet social health need. Compared with non-Hispanic White patients, non-Hispanic Black, and Hispanic patients reported higher rates of unmet social health needs. Compared with private insurance, those with Medicaid or no insurance reported higher rates of unmet social health needs. In fully adjusted models, poor health status was independently associated with unmet social health needs: food insecurity [adjusted odds ratio (aOR)=2.14; 95% confidence interval (CI): 1.89-2.41], housing instability (aOR=1.69; 95% CI: 1.51-1.89), delayed care due to lack of transportation (aOR=2.58; 95% CI: 2.02-3.31). CONCLUSIONS Unmet social health needs vary significantly by race, ethnicity, and insurance, and are independently associated with poor health among surgical populations. As providers and policymakers prioritize improving surgical equity, unmet social health needs are potential modifiable targets.
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Affiliation(s)
- Kathryn K Taylor
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, Stanford University, Stanford, CA
| | - Pooja U Neiman
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Sidra Bonner
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kavitha Ranganathan
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Renuka Tipirneni
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - John W Scott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
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Impact of the Affordable Care Act on Presentation, Treatment, and Outcomes of Intrahepatic Cholangiocarcinoma. J Gastrointest Surg 2023; 27:262-272. [PMID: 36400904 DOI: 10.1007/s11605-022-05496-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/20/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) transformed the US healthcare system, expanding healthcare insurance coverage. However, its impact on rare malignancies that lack an established screening strategy such as intrahepatic cholangiocarcinoma (ICC) remains ill-defined. METHODS Patients diagnosed with ICC were identified from the National Cancer Database and divided relative to ACA implementation. Multivariate logistic regression analyses were performed to evaluate association with stage at diagnosis, receipt of surgical and multimodal treatments, and survival. RESULTS Among the 9095 patients, 5636 (62.0%) were diagnosed before and 3459 (38.0%) after the implementation of the ACA. Across US regions, rates of early-stage diagnosis increased in the post-ACA era (Northeast, 62.9% vs. 85.2%; South, 63.7% vs. 78.5%; Midwest, 62.1% vs. 83.4%; West, 55.5% vs. 75.4%; p < 0.001). On multivariate analyses, the post-ACA era was associated with increased early-stage diagnosis (OR = 2.19; 95% CI 1.79-2.69), and receipt of surgical treatment (OR = 1.19, 95% CI 1.03-1.38) (both p < 0.01). Furthermore, the ACA's Medicaid expansion (ME) was also associated with improved overall survival (HR = 0.89, 95% CI 0.80-0.99, p = 0.038). Of note, although the odds of receiving surgical treatment increased after ACA for non-Hispanic White patients (OR = 1.34; 95% CI 1.20-1.49; p < 0.001), no such effect was observed in non-Hispanic Black (OR = 1.01, 95% CI 0.71-1.45), Hispanic (OR = 1.44, 95% CI 0.99-2.09), or others (OR = 1.43, 95% CI 0.98-2.10) (all p > 0.05). CONCLUSIONS The implementation of the ACA increased rates of early diagnosis and receipt of surgical treatment. Additionally, ME improved short- and long-term outcomes. However, racial and socioeconomic disparities persist, resulting in inequitable access to care and outcomes for patients with ICC.
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Choksi EJ, Mukherjee K, Sadigh G, Duszak R. Out-of-Pocket Expenditures for Imaging Examinations: Perspectives From National Patient Surveys Over Two Decades. J Am Coll Radiol 2023; 20:18-28. [PMID: 36210041 DOI: 10.1016/j.jacr.2022.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/20/2022] [Accepted: 07/30/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Using national surveys, we longitudinally studied imaging costs-and specifically those paid out-of-pocket (OOP) by patients-over two decades. METHODS Using 2000 to 2019 Medical Expenditure Panel Survey data, we identified all imaging-focused encounters (mammography, radiography, ultrasonography, and CT and MR [surveyed together in Medical Expenditure Panel Survey]) and calculated mean overall and OOP encounter costs. Effects of sociodemographic, personal, and clinical factors were measured using logistic regression and generalized linear modeling. RESULTS We identified 102,717 patients (mean 45.6 years; 64.8% female; 58.8% White) undergoing 229,010 imaging-focused encounters. Between 2000 and 2019, mean costs of mammography, radiography, and ultrasonography increased 14.5%, 24.5%, and 40% and total mean cost of CT or MR decreased by 15.1%. OOP costs were incurred by 51%. Overall mean OOP costs increased 89.8% from 2000 to 2019. Mean OOP costs for mammography decreased by 32.9%; mean OOP costs for radiography, ultrasonography, and CT or MR increased 81%, 123.2%, and 61%, respectively. Patients were less likely to incur OOP costs when older, of racial and ethnic minorities, female, or recipients of public only (versus private) insurance. Among those with OOP costs, the presence of comorbidities, lack of insurance, younger age, and history of cancer significantly increased OOP costs. CONCLUSION Mean overall patient OOP costs for imaging examinations increased significantly and substantially over the last two decades. Lack of insurance, younger age, history of cancer, and other comorbidities were associated with higher OOP costs. As diagnostic imaging utilization increases, patient financial hardship considerations merit further attention.
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Affiliation(s)
- Eshani J Choksi
- Medical Student, Rowan University School of Osteopathic Medicine, Stratford, New Jersey. https://twitter.com/EshaniChoksi
| | - Kumar Mukherjee
- Associate Professor, Pharmacy Practice, Philadelphia College of Osteopathic Medicine, Suwanee, Georgia.
| | - Gelareh Sadigh
- Director, Health Services and Comparative Effectiveness Outcome Research, University of California Irvine, Irvine California; Division of Neuroradiology, Department of Radiological Sciences, Orange, California; and Associate Editor, JACR. https://twitter.com/GelarehSadigh
| | - Richard Duszak
- Professor and Chair, Department of Radiology, University of Mississippi Medical Center, Jackson, Mississippi; and Chair, Commission of Leadership and Practice Development, ACR. https://twitter.com/RichDuszak
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Liew CH, Shabaruddin FH, Dahlui M. The Burden of Out-of-Pocket Expenditure Related to Gynaecological Cancer in Malaysia. Healthcare (Basel) 2022; 10:healthcare10102099. [PMID: 36292545 PMCID: PMC9601824 DOI: 10.3390/healthcare10102099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 01/09/2023] Open
Abstract
This study aimed to estimate the economic burden on gynaecological cancer patients and their households, in terms of out-of-pocket expenditure, catastrophic health expenditure (CHE) and poverty impact. A cross-sectional study was conducted at an academic tertiary-care health centre in an upper-middle-income country. Data were obtained via structured interviews of 120 gynaecological cancer patients alongside review of medical charts. Mean (SD) and median (IQR) annual household out-of-pocket expenditures were USD 2780 (SD = USD 3926) and USD 1396 (IQR = 3013), respectively. Two thirds (n = 77/120, 64%) of households experienced CHE and 17% (n = 20/120) were impoverished due to out-of-pocket expenditure related to gynaecological cancer. Factors associated with CHE, explored using multivariate logistic regression analysis, estimated that the highest income quintile households, Q5, were 90% less likely to incur CHE compared to the lowest income quintile households, Q1 (adjusted odds ratio = 0.100; p-value < 0.05) and that patients who were not receiving chemotherapy were 88% less likely to incur CHE compared to those receiving chemotherapy (adjusted odds ratio = 0.120; p-value < 0.05). These results indicate the necessity to broaden the coverage of existing financial assistance for patients from low- and middle-income households, such as extending coverage to adult patients of all ages and to those treated in all public hospitals, including academic health centres.
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Affiliation(s)
- Chee Hui Liew
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia
- Department of Pharmacy, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur 50586, Malaysia
| | - Fatiha Hana Shabaruddin
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur 50603, Malaysia
- Correspondence:
| | - Maznah Dahlui
- Centre of Population Health, Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia
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Katabogama JB, Mpirimbanyi C, Cyuzuzo T, Muvunyi V, Urimubabo C, Rickard J. Costs Associated With Surgical Infections at a Tertiary Referral Hospital in Rwanda. J Surg Res 2022; 280:94-102. [PMID: 35964487 DOI: 10.1016/j.jss.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 06/04/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In low-income and middle-income countries, there is a high demand for surgical care, although many individuals lack access due to its affordability, availability, and accessibility. Costs are an important metric in healthcare and can influence healthcare access and outcomes. The aim of this study was to determine the financial impact of infections in acute care surgery patients and factors associated with inability to pay the hospital bill at a Rwandan referral hospital. MATERIALS AND METHODS This was a prospective observational study of acute care surgery patients at a tertiary referral hospital in Rwanda with infections. Data were collected on demographics, clinical features, hospital charges, and expenses. Factors associated with inability to pay the hospital bill were analyzed using Chi-squared and Wilcoxon rank sum tests. RESULTS Over 14 mo, 191 acute care surgery patients with infections were enrolled. Most (n = 174, 91%) patients had health insurance. Median total hospital charges were 414.24 United States Dollars (interquartile range [IQR]: 268.20, 797.48) and median patient charges were 41.53 USD (IQR: 17.15, 103.09). At discharge, 53 (28%) patients were unable to pay their hospital bill. On a univariate analysis actors associated with inability to pay the bill included transportation via ambulance, occupation as a farmer, diagnosis, complications, surgical site infection, and length of hospital stay. On a multivariable analysis, intestinal obstruction (adjusted odds ratio 4.56, 95% confidence interval 1.16, 17.95, P value 0.030) and length of hospital stay more than 7 d (adjusted odds ratio 2.95, 95% confidence interval 1.04, 8.34, P value 0.042) were associated with inability to pay the final hospital bill. CONCLUSIONS Although there is broad availability of health insurance in Rwanda, hospital charges and other expenses remain a financial burden for many patients seeking surgical care. Further innovative efforts are needed to mitigate expenses and minimize financial risk.
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Affiliation(s)
| | | | - Thierry Cyuzuzo
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Vital Muvunyi
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Christian Urimubabo
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda; Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jennifer Rickard
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda; Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda; Department of Surgery, University of Minnesota, Minneapolis, Minnesota.
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Kassim SA, Gartner JB, Labbé L, Landa P, Paquet C, Bergeron F, Lemaire C, Côté A. Benefits and limitations of business process model notation in modelling patient healthcare trajectory: a scoping review protocol. BMJ Open 2022; 12:e060357. [PMID: 35636803 PMCID: PMC9152926 DOI: 10.1136/bmjopen-2021-060357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The adoption of business process model notation (BPMN) in modelling healthcare trajectory can enhance the efficiency and efficacy of healthcare organisations, improve patient outcomes while restraining costs. Existing systematic reviews have been inconclusive regarding the effectiveness of BPMN in modelling healthcare trajectory. The aims of this scoping review are to map and aggregate existing evidence on the benefits and limitations associated with BPMN in healthcare trajectory, highlighting areas of improvement on BPMN and its extensions in healthcare. We will assess BPMN's ability to model key dimensions or concepts of the healthcare process and to meet the needs of stakeholders. The review will highlight the advantages of this approach to support clinical activities and decision-making processes associated with the healthcare trajectory, proposing a conceptual framework for improving the use of BPMN in healthcare. METHODS AND ANALYSIS This study will be performed in accordance with the methodological framework suggested by Arksey and O'Malley. A wide range of electronic databases and grey literature sources will be systematically searched using predefined keywords. The review will include any study design focusing on the application of the BPMN approach for optimising healthcare trajectories, published in either English or French from 1 January 2004 to 9 December 2021. Two reviewers will independently screen titles, abstracts and full-text articles and select articles meeting the inclusion criteria. A customised data extraction form will be used to extract data. The results will be presented using descriptive statistics and thematic analysis on qualitative data. ETHICS AND DISSEMINATION Research ethics approval is not required. Review findings will be used to advance understanding about BPMN, its extensions and application in healthcare trajectory optimisation. The review will develop recommendations on tailoring BPMN strategies for optimising care pathways and decision-making processes. Findings will be disseminated in peer-reviewed journals, conferences and discussions with relevant organisations and stakeholders.
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Affiliation(s)
- Said Abasse Kassim
- Département de management, Faculté des sciences de l'administration, Universite Laval, Quebec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Quebec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- VITAM Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
| | - Jean-Baptiste Gartner
- Département de management, Faculté des sciences de l'administration, Universite Laval, Quebec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Quebec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- VITAM Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, CISSS de Chaudière-Appalaches, Québec, QC, Canada
| | - Laurence Labbé
- Département de management, Faculté des sciences de l'administration, Universite Laval, Quebec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Quebec, QC, Canada
| | - Paolo Landa
- Département d'opérations et systèmes de décision, Faculté des sciences de l'administration, Université Laval, Québec, QC, Canada
- Centre de Recherche CHU de Québec, Université Laval, Québec, QC, Canada
| | - Catherine Paquet
- Centre de Recherche CHU de Québec, Université Laval, Québec, QC, Canada
- Département de Marketing, Faculté des sciences de l'administration, Université Laval, Québec, QC, Canada
- Centre Nutrition, santé et société (NUTRISS), INAF, Université Laval, Québec, QC, Canada
| | - Frédéric Bergeron
- Bibliothèque, Direction des services-conseils, Université Laval, Québec, QC, Canada
| | - Célia Lemaire
- Laboratoire Humanis, EM Strasbourg-Business School, Université de Strasbourg, Strasbourg, France
| | - André Côté
- Département de management, Faculté des sciences de l'administration, Universite Laval, Quebec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Quebec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- VITAM Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, CISSS de Chaudière-Appalaches, Québec, QC, Canada
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Shah CH, Onukwugha E. Direct medical and indirect absenteeism costs among working adult ADHD patients in the United States. Expert Rev Pharmacoecon Outcomes Res 2022; 22:1013-1020. [PMID: 35502641 DOI: 10.1080/14737167.2022.2073223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE This study investigated the direct medical and indirect (i.e. absenteeism) costs among working adults diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) in the United States. METHODS This study utilized 2017-2018 Medical Expenditure Panel Survey data. Attribution and regression-based incremental cost approaches were utilized to estimate direct medical costs, i.e. prescription drug costs and total costs. The regression-based approach was utilized to estimate absenteeism cost. RESULTS The study sample consisted of 32,222 observations (weighted: 187,207,896). Of these, 459 (weighted: 3,175,033) had ADHD. The mean annual per person ADHD-attributable prescription drug cost was 2018 US $1,248 (standard error (SE): 97) and the ADHD-attributable total cost was $2,031 (SE: 371). This contributed to a mean overall annual spending of $3.96 (SE: 0.42) billion on ADHD-attributable prescription drugs and $6.45 (SE: 1.26) billion on ADHD-attributable total direct medical costs among adult ADHD patients. Based on the regression-based approach, the mean annual incremental cost for ADHD was $1,641 (SE: 164) and $4,328 (SE: 862) per person for prescription medication costs and total costs, respectively. The mean indirect cost of ADHD was estimated at $512 (SE: 91) per year, per person among working adults with ADHD in the United States. CONCLUSIONS There is a significant direct and indirect economic burden on working adults with ADHD. EXPERT OPINION There is a significant economic burden of ADHD in terms of direct medical (including out-of-pocket) cost as well as indirect absenteeism cost. The per person annual costs estimated using a regression approach were approximately twice as much as the costs using the sum disease-specific approach, suggesting a potential role for 'spillover' costs among working adults with ADHD. Prescription drug costs were top-ranked contributors to the direct medical costs. As a group, working adults with ADHD are relatively understudied and more research is needed to better understand the burden of ADHD in this group.
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Affiliation(s)
- Chintal H Shah
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Data Resources for Evaluating the Economic and Financial Consequences of Surgical Care in the United States. J Trauma Acute Care Surg 2022; 93:e17-e29. [PMID: 35358106 DOI: 10.1097/ta.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
LEVEL OF EVIDENCE V.
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Newsome K, Autrey C, Sen-Crowe B, Ang D, Elkbuli A. The Affordable Care Act and its Effects on Trauma Care Access, Short- and Long-term Outcomes and Financial Impact: A Review Article. ANNALS OF SURGERY OPEN 2022; 3:e145. [PMID: 37600113 PMCID: PMC10431310 DOI: 10.1097/as9.0000000000000145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/07/2022] [Indexed: 11/26/2022] Open
Abstract
Objective The purpose of this study is to evaluate the current evidence regarding the impact of the ACA on trauma outcomes and the financial impact on trauma patients and trauma systems. Background Traumatic injuries are the leading cause of death and disability between the ages of 1 to 47 years. Uninsured status has been associated with worse outcomes and higher financial strain. The Affordable Care Act (ACA) was signed into law with the aim of increasing health insurance coverage. Despite improvements in insured status, it is unclear how the ACA has affected trauma. Methods We conducted a literature search using PubMed and Google Scholar for peer-reviewed studies investigating the impact of the ACA on trauma published between January 2017 and April 2021. Results Our search identified 20 studies that evaluated the impact of ACA implementation on trauma. The evidence suggests ACA implementation has been associated with increased postacute care access but not significant changes in trauma mortality. ACA implementation has been associated with a decreased likelihood of catastrophic health expenditures for trauma patients. ACA was also associated with an increase in overall reimbursement and amount billed for trauma visits, but a decrease in Medicaid reimbursement. Conclusions Some improvements on the financial impact of ACA implementation on trauma patients and trauma systems have been shown, but studies are limited by methods of calculating costs and by inconsistent pre-/post-ACA timeframes. Further studies on cost-effectiveness and cost-benefit analysis will need to be conducted to definitively determine the impact of ACA on trauma.
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Affiliation(s)
- Kevin Newsome
- From the Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Cody Autrey
- From the Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Brendon Sen-Crowe
- Dr. Kiran C. Patel College of Allopathic Medicine, NSU NOVA Southeastern University, Fort Lauderdale, FL
| | - Darwin Ang
- Department of Surgery, Ocala Regional Medical Center, Ocala, FL
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL
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Fu SJ, Arnow K, Trickey A, Spain DA, Morris A, Knowlton L. Financial Burden of Traumatic Injury Amongst the Privately Insured. Ann Surg 2022; 275:424-432. [PMID: 34596072 DOI: 10.1097/sla.0000000000005225] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to evaluate the overall financial burden associated with traumatic injury amongst patients with private insurance and assess the effect of high deductible plans on out-of-pocket costs (OOPCs). SUMMARY OF BACKGROUND DATA Traumatic injury can be a source of unexpected financial burden for households. However, the effect of increasing participation in higher cost-sharing private health insurance plans remains unknown. METHODS We conducted a retrospective cohort observational study, using the Clinformatics Data Mart Database, a nationwide single-payer administrative claims database to identify US adults who required emergency department services or hospital admission for single traumatic injury from 2008 to 2018. A 2-part model using a logistic regression and a generalized linear model with gamma distribution and log link was used to evaluate 12-month OOPCs after traumatic injury. Multivariable logistic regression was used to evaluate the likelihood of catastrophic health expenditure (CHE) after injury. RESULTS Of 426,945 included patients, 53% were male, 71% were white, and median age was 42 years. Patients faced monthly OOPC of $660 at the time of their injury. High deductible plan enrollment was associated with an increase of $1703 in 12-month OOPC after trauma, compared to those covered by traditional health plans. In addition to high deductible health plan enrollment, worsening injury severity and longer hospital stays were also associated with increased 12-month OOPC after trauma. Non-white minorities paid less 12-month OOPC after trauma compared to non-Hispanic white patients, but also used fewer services. Overall, the incidence of CHE was 5%; however high-deductible health plan enrollees faced a 13% chance of CHE. CONCLUSIONS Privately insured trauma patients face substantial OOPCs at the time of their injuries. High-deductible health plans are associated with increased financial vulnerability after trauma.
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Affiliation(s)
- Sue J Fu
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
- Health Research and Development, Veteran Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Katherine Arnow
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Amber Trickey
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - David A Spain
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Arden Morris
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Lisa Knowlton
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
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Liu C, Scannell CA, Kenison T, Wren SM, Saliba D. Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act. J Gen Intern Med 2022; 37:573-581. [PMID: 33959882 PMCID: PMC8101607 DOI: 10.1007/s11606-021-06807-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans' financial risk protection has not been explored. OBJECTIVE To evaluate whether ACA implementation was associated with changes in veterans' risk of catastrophic health expenditures, and to characterize drivers of catastrophic health spending among veterans post-ACA. DESIGN Using multivariable linear probability regression, we examined changes in likelihood of catastrophic health spending after ACA implementation, stratifying by age (18-64 vs 65+), household income tercile, and payer (VHA vs non-VHA). Among veterans with catastrophic spending post-ACA, we evaluated sources of out-of-pocket spending. PARTICIPANTS Nationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey. INTERVENTION ACA implementation, January 1, 2014. MAIN MEASURES Likelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income. KEY RESULTS Among veterans aged 18-64, ACA implementation was associated with a 26% decrease in likelihood of catastrophic health expenditures (absolute change, -1.4 percentage points [pp]; 95% CI, -2.6 to -0.2; p=0.03), which fell from 5.4% pre-ACA to 3.9% post-ACA. This was driven by a 38% decrease in catastrophic spending among veterans with non-VHA coverage (absolute change, -1.8pp; 95% CI, -3.0 to -0.6; p=0.003). In contrast, catastrophic expenditure rates among veterans aged 65+ remained high, at 13.0% pre- and 12.5% post-ACA. Major drivers of veterans' spending post-ACA include dental care, prescription drugs, and home care. CONCLUSIONS ACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans' financial protection and areas amenable to policy intervention.
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Affiliation(s)
- Charles Liu
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA.
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Christopher A Scannell
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Tiffany Kenison
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Health Administration, Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Debra Saliba
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Borun Center for Gerontological Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Gheysvandi E, Mohammadi SZ, Amirkiyasar MN, Rad EH, Kouchakinejad-Eramsadati L, Mohtasham-Amiri Z. Measuring Catastrophic Costs in Families Facing Traumatic Brain Injury in Iran. Korean J Neurotrauma 2022; 19:53-62. [PMID: 37051037 PMCID: PMC10083442 DOI: 10.13004/kjnt.2022.18.e46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/04/2022] [Accepted: 08/15/2022] [Indexed: 11/11/2022] Open
Abstract
Objectives Traumatic brain injury (TBI) is preventable and expensive. The medical costs of TBI can be too high for some households and might lead to poverty, malnutrition, and loss of assets, which are called catastrophic expenditures. In this study, we investigated the incidence of catastrophic costs associated with TBI caused by road accidents in a province in northern Iran. Methods This prospective study involved a 1-year follow-up after the accident. Data of 220 patients were collected from the medical records of the Poursina Hospital, Rasht, Iran from March 2018 to February 2020. Direct and indirect costs faced by the households of patients with TBI and catastrophic costs related to TBI were calculated. Regression models were obtained and sensitivity analyses were performed at the end of the study. Results In total, the prevalence of households TBI-related catastrophic costs (TBICC) was 45.5% . Households of female patients (odds ratio [OR]: 0.289, p=0.042), households of retired patients (OR: 0.053, p=0.005), and households falling in the fifth quintile of wealth (OR: 0.370, p=0.050) faced lower TBICC compared to other groups. The Activities of Daily Living scores had a significant negative relationship with TBICC. Conclusions Political interventions such as implementation of insurance schemes, exemptions from payment for certain groups, identification of poor households, and coverage of assistance services can protect households from catastrophic health expenditures.
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Affiliation(s)
- Elham Gheysvandi
- School of Medical Sciences, Khomein University of Medical Sciences, Khomein, Iran
- Molecular and Medicine Research Center, Khomein University of Medical Sciences, Khomein, Iran
| | - Seyedeh Zahra Mohammadi
- Student Research Committee, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | | | - Enayatollah Homaie Rad
- Social Determinants of Health Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | | | - Zahra Mohtasham-Amiri
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
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Neiman PU, Mouli VH, Taylor KK, Ayanian JZ, Dimick JB, Scott JW. The Impact of Medicare Coverage on Downstream Financial Outcomes for Adults Who Undergo Surgery. Ann Surg 2022; 275:99-105. [PMID: 34914661 PMCID: PMC10088463 DOI: 10.1097/sla.0000000000005272] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the effects of gaining access to Medicare on key financial outcomes for surgical patients. SUMMARY BACKGROUND DATA Surgical care poses a significant financial burden, especially among patients with insufficient financial risk protection. Medicare may mitigate the risk of these adverse circumstances, but the impact of Medicare eligibility on surgical patients remains poorly understood. METHODS Regression discontinuity analysis of national, cross-sectional survey and cost data from the 2008 to 2018 National Health Interview Survey and Medical Expenditure Panel Survey. Patients were between the ages of 57 to 72 with surgery in the past 12 months. The primary outcomes were the presence of medical debt, delay/deferment of care due to cost, total annual out-of-pocket costs, and experiencing catastrophic health expenditures. RESULTS Among 45,982,243 National Health Interview Survey patients, Medicare eligibility was associated with a 6.6 percentage-point decrease (95% confidence interval [CI]: -9.0% to -4.3) in being uninsured (>99% relative reduction), 7.6 percentage-point decrease (24% relative reduction) in having medical debt (95%CI: -14.1% to -1.1%), and 4.9 percentage-point decrease (95%CI: -9.4% to -0.4%) in deferrals/delays in medical care due to cost (28% relative reduction). Among 33,084,967 Medical Expenditure Panel Survey patients, annual out-of-pocket spending decreased by $1199 per patient (95%CI: -$1633 to -$765), a 33% relative reduction, and catastrophic health expenditures decreased by 7.3 percentage points (95%CI: -13.6% to -0.1%), a 55% relative reduction. CONCLUSIONS Medicare may reduce the economic burden of healthcare spending and delays in care for older adult surgical patients. These findings have important implications for policy discussions regarding changing insurance eligibility thresholds for the older adult population.
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Affiliation(s)
- Pooja U Neiman
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Vibav H Mouli
- University of Michigan Medical School, Ann Arbor, MI
| | - Kathryn K Taylor
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, Stanford University, Stanford, CA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - John Z Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - John W Scott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
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Dalton MK, Riviello R, Kubasiak JC, Sokas CM, Osman SY, Jin G, Nitzschke SL, Ortega G. The impact of the Affordable Care Act's medicaid expansion on patients admitted for burns: An analysis of national data. Burns 2021; 48:1340-1346. [PMID: 34903411 DOI: 10.1016/j.burns.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 10/24/2021] [Accepted: 10/29/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The first states began implementing the Medicaid expansion provisions of the Patient Protection and Affordable Care Act (ACA) in 2014. Studies have yet to address its impact on burn patients. METHODS Burn patients in geographic regions that expanded Medicaid coverage were compared to patients in regions that did not expand Medicaid before and after implementation of the ACA using bivariate statistics and a difference-in-differences model. A multivariable logistic regression was used to identify factors associated with having Medicaid insurance. The primary outcome of this study was the rate of Medicaid insurance. RESULTS Of 25,331 discharges, we found greater increases in Medicaid coverage after the ACA in the Medicaid expander regions (23.4-40.2%) compared to the non-expander regions (18.5-20.1%). The difference-in-differences estimate between the expander and non-expander regions was 0.15 (95% CI: 0.11-0.18, p < 0.001). Patients admitted in expander regions were more likely to be insured by Medicaid (OR 1.57 [95%CI 1.21-2.05]), as were patients of Black race (OR 1.25 [95%CI 1.19-1.32), Hispanic ethnicity (OR 1.29 [95%CI 1.14-1.46]), and female sex (OR 1.59 [95%CI 1.11-2.27]). We also found a significant interaction between time period (pre-ACA/post-ACA) and expander region location (OR 2.10 [95%CI 1.67-2.62]). CONCLUSIONS The Medicaid expansion provision of the ACA led to increased Medicaid coverage among burn patients which was significantly higher in areas with widespread implementation of the expansion.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Robert Riviello
- Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - John C Kubasiak
- Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Claire M Sokas
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Samia Y Osman
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Ginger Jin
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Gezzer Ortega
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Albright BB, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Medicaid Expansion Reduced Uninsured Surgical Hospitalizations And Associated Catastrophic Financial Burden. Health Aff (Millwood) 2021; 40:1294-1303. [PMID: 34339246 PMCID: PMC10077516 DOI: 10.1377/hlthaff.2020.02496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An important function of health insurance is protecting enrollees from excessively burdensome charges for unanticipated medical events. Unexpected surgery can be financially catastrophic for uninsured people. By targeting the low-income uninsured population, Medicaid expansion had the potential to reduce the financial risks associated with these events. We used two data sources (state-level data for forty-four states and patient-level data for four states) to estimate the association of Medicaid expansion with uninsured surgical hospitalizations among nonelderly adults. Uninsured surgery cases were typically admitted through the emergency department-often for common emergency procedures-and 99 percent of them were estimated to be associated with financially catastrophic visit charges. We found that Medicaid expansion was associated with reductions in both the share (6.20 percent) and the population rate (7.85 per 10,000) of uninsured surgical discharges in expansion versus nonexpansion states. Our estimates suggest that in 2019 alone, adoption of Medicaid expansion in nonexpansion states could have prevented more than 50,000 incidences of catastrophic financial burden resulting from uninsured surgery.
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Affiliation(s)
- Benjamin B Albright
- Benjamin B. Albright is a gynecologic oncology fellow in the Department of Obstetrics and Gynecology, Duke University Medical Center, in Durham, North Carolina
| | - Fumiko Chino
- Fumiko Chino is an assistant attending in the Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, in New York, New York
| | - Junzo P Chino
- Junzo P. Chino is an associate professor in the Department of Radiation Oncology, Duke University Medical Center
| | - Laura J Havrilesky
- Laura J. Havrilesky is a professor in the Department of Obstetrics and Gynecology, Duke University Medical Center
| | - Emeline M Aviki
- Emeline M. Aviki is an assistant attending in the Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Haley A Moss
- Haley A. Moss is an assistant professor in the Department of Obstetrics and Gynecology, Duke University Medical Center
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Neiman PU, Taylor KK, Sinco B, Anderson GA, Sangji NF, Hemmila MR, Scott JW. Insult to injury: National analysis of return to work and financial outcomes of trauma patients. J Trauma Acute Care Surg 2021; 91:121-129. [PMID: 34144560 DOI: 10.1097/ta.0000000000003135] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While much of trauma care is rightly focused on improving inpatient survival, the ultimate goal of recovery is to help patients return to their daily lives after injury. Although the overwhelming majority of trauma patients in the United States survive to hospital discharge, little is known nationally regarding the postdischarge economic burden of injuries among trauma survivors. METHODS We used the National Health Interview Survey from 2008 to 2017 to identify working-age trauma patients, aged 18 to 64 years, who sustained injuries requiring hospitalization. We used propensity score matching to identify noninjured respondents. Our primary outcome measure was postinjury return to work among trauma patients. Our secondary outcomes included measures of food insecurity, medical debt, accessibility and affordability of health care, and disability. RESULTS A nationally weighted sample of 319,580 working-age trauma patients were identified. Of these patients, 51.7% were employed at the time of injury, and 58.9% of them had returned to work at the time of interview, at a median of 47 days postdischarge. Higher rates of returning to work were associated with shorter length of hospital stay, higher education level, and private health insurance. Injury was associated with food insecurity at an adjusted odds ratio (aOR) of 1.8 (95% confidence interval, 1.40-2.37), with difficulty affording health care at aOR of 1.6 (1.00-2.47), with medical debt at aOR of 2.6 (2.11-3.20), and with foregoing care due to cost at aOR of 2.0 (1.52-2.63). Working-age trauma patients had disability at an aOR of 17.6 (12.93-24.05). CONCLUSION The postdischarge burden of injury among working-age US trauma survivors is profound-patients report significant limitations in employment, financial security, disability, and functional independence. A better understanding of the long-term impact of injury is necessary to design the interventions needed to optimize postinjury recovery so that trauma survivors can lead productive and fulfilling lives after injury. LEVEL OF EVIDENCE Economic & Value-Based Evaluations, level II; Prognostic, level II.
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Affiliation(s)
- Pooja U Neiman
- From the National Clinician Scholars Program (P.U.N., K.K.T.), Institute for Healthcare Policy and Innovation and Center for Healthcare Outcomes and Policy (P.U.N., K.K.T., B.S., N.F.S., M.R.H., J.W.S.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (P.U.N., G.A.A.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery (K.K.T.), Stanford University, Stanford, California; Center for Surgery and Public Health (G.A.A.), Brigham and Women's Hospital, Boston, Massachusetts; and Department of Surgery (N.F.S., M.R.H., J.W.S.), University of Michigan, Ann Arbor, Michigan
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22
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Liu C, Gotanda H, Khullar D, Rice T, Tsugawa Y. The Affordable Care Act's Insurance Marketplace Subsidies Were Associated With Reduced Financial Burden For US Adults. Health Aff (Millwood) 2021; 40:496-504. [PMID: 33646874 DOI: 10.1377/hlthaff.2020.01106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Research suggests that the Affordable Care Act (ACA) Medicaid expansions improved financial protection for the poor. However, evidence is limited on whether subsidies offered through the ACA Marketplaces, the law's other major coverage expansion, were associated with reduced financial burden. Using national survey data from the period 2008-17, we examined changes in household health care spending among low-income adults eligible for both Marketplace premium subsidies and cost-sharing reductions (139-250 percent of the federal poverty level) and middle-income adults eligible only for premium subsidies (251-400 percent of the federal poverty level), using high-income adults ineligible for subsidies (greater than 400 percent of the federal poverty level) as controls. Among low-income adults, Marketplace subsidy implementation was associated with 17 percent lower out-of-pocket spending and 30 percent lower probability of catastrophic health expenditures. In contrast, middle-income adults did not experience reduced financial burden by either measure. These findings highlight the successes and limitations of Marketplace subsidies as debate continues over the ACA's future.
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Affiliation(s)
- Charles Liu
- Charles Liu is a general surgery resident in the Department of Surgery, Stanford University School of Medicine, in Stanford, California
| | - Hiroshi Gotanda
- Hiroshi Gotanda is an assistant professor of medicine at Cedars-Sinai Medical Center, in Los Angeles, California
| | - Dhruv Khullar
- Dhruv Khullar is a physician and an assistant professor in the Departments of Medicine and Population Health Sciences, Weill Cornell Medical Center, in New York, New York
| | - Thomas Rice
- Thomas Rice is a distinguished professor in the Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), in Los Angeles, California
| | - Yusuke Tsugawa
- Yusuke Tsugawa is an assistant professor in the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and the Department of Health Policy and Management, Fielding School of Public Health, UCLA
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23
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Scott JW, Neiman PU, Ayanian JZ. Threats to the Affordable Care Act and surgical care: What has been gained, and what could be lost. Surgery 2021; 169:1285-1287. [PMID: 33653613 DOI: 10.1016/j.surg.2021.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Affiliation(s)
- John W Scott
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.
| | - Pooja U Neiman
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Surgery, Brigham and Women's Hospital, Boston, MA. https://twitter.com/PoojaNeiman
| | - John Z Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI; Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI. https://twitter.com/jzayanian
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Treatment of Facial Fractures at Safety-Net Hospitals: A National Analysis of Inpatient Burden and Cost. J Craniofac Surg 2021; 32:1413-1416. [PMID: 34842403 DOI: 10.1097/scs.0000000000007573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Safety-net hospitals (SNHs) are vital in the care of trauma populations, but little is known about the burden of facial trauma presenting to SNHs. The authors sought to characterize the presentation and treatment of facial fractures across SNHs and determine the association between SNH care and healthcare utilization in patients undergoing fracture repair. METHODS Adult patients presenting with a facial fracture as their primary admitting diagnosis from the year 2012 to 2015 were identified in the National Inpatient Sample. The "safety-net burden" of each hospital was defined based on the proportion of Medicaid and self-pay discharges. Patient factors analyzed were sex, race, age, income level, insurance status, fracture location, and comorbidities. Hospital factors analyzed were safety-net burden, teaching status, geographic region, bed size, and ownership status. The main outcomes were length of stay (LOS), hospital costs, time to repair, and postoperative complications. RESULTS Of 78,730 patients, 27,080 (34.4%) were treated at SNHs and 24,844 (31.6%) were treated at non-SNHs. Compared to non-SNHs, patients treated at SNHs were more likely to undergo operative repair at SNHs (65.8% versus 53.9%, P < 0.001). Overall mean LOS was comparable between non-SNH and SNH (3.43 versus 3.38 days, P = 0.611), as was mean hospital cost ($15,487 versus $15,169, P = 0.434). On multivariate linear regression, safety-net status was not a predictor of increased LOS, cost, or complications. However, safety-net status was significantly associated with lower odds of undergoing repair within 48 hours of admission (odds ratio 0.783, 95% confidence interval = 0.680-0.900, P = 0.001). CONCLUSIONS Safety-net hospitals are able to treat facial trauma patients with greater injury burden and lower socioeconomic resources without increased healthcare utilization. Healthcare reform must address the financial challenges that endanger these institutions to ensure timely treatment of all patients.
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25
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Neiman PU, Tsai TC, Bergmark RW, Ibrahim A, Nathan H, Scott JW. The Affordable Care Act at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future. J Surg Res 2021; 263:102-109. [PMID: 33640844 DOI: 10.1016/j.jss.2020.12.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/06/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.
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Affiliation(s)
- Pooja U Neiman
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Regan W Bergmark
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - John W Scott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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26
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Schatman ME, Shapiro H, Fudin J. The Repeal of the Affordable Care Act and Its Likely Impact on Chronic Pain Patients: "Have You No Shame?". J Pain Res 2020; 13:2757-2761. [PMID: 33154666 PMCID: PMC7608115 DOI: 10.2147/jpr.s289114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 10/28/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Michael E Schatman
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA.,Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Hannah Shapiro
- McLean Hospital, Division of Alcohol, Drugs, and Addiction, Harvard Medical School, Boston, MA, USA
| | - Jeffrey Fudin
- Remitigate Therapeutics, Delmar, NY, USA.,Department of Pharmacy Practice, Albany College of Pharmacy, Albany, NY, USA.,Department of Pharmacy Practice, Western New England University, Springfield, MA, USA.,Stratton VA Medical Center, Albany, NY, USA
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27
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Wisk LE, Peltz A, Galbraith AA. Changes in Health Care-Related Financial Burden for US Families With Children Associated With the Affordable Care Act. JAMA Pediatr 2020; 174:1032-1040. [PMID: 32986093 PMCID: PMC7522777 DOI: 10.1001/jamapediatrics.2020.3973] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/04/2020] [Indexed: 01/25/2023]
Abstract
Importance The Affordable Care Act (ACA) sought to improve access and affordability of health insurance. Although most ACA policies targeted childless adults, the extent to which these policies also impacted families with children remains unclear. Objective To examine changes in health care-related financial burden for US families with children before and after the ACA was implemented based on income eligibility for ACA policies. Design, Setting, and Participants Data used for this cohort study were obtained from the 2000-2017 Medical Expenditure Panel Survey, a nationally representative, population-based survey. Multivariable regression with a difference-in-differences estimator was used to examine changes in family financial burden before and after ACA implementation according to income-based ACA eligibility groups (≤138% [lowest-income], 139%-250% [low-income], 251%-400% [middle-income], and >400% [high-income] federal poverty level). The cohort included 92 165 families with 1 or more children (age ≤18 years) and 1 or more adult parents/guardians. Exposures Income-based eligibility groups during post-ACA years (calendar years 2014-2017) vs pre-ACA years (calendar years 2000-2013). Main Outcomes and Measures Family annual out-of-pocket (OOP) health care and premium cost burden relative to income. High OOP burden was determined based on a previously validated algorithm with relative cost thresholds that vary across incomes, and extreme OOP burden was defined as costs exceeding 10% of income. Premiums exceeding 9.5% of income were classified as burdensome and premiums relative to median household income defined an unaffordability index. Results Compared with high-income families who experienced a lesser change post-ACA implementation (high OOP burden, 1.1% pre-ACA vs 0.9% post-ACA), the lowest-income families saw the greatest reduction in high OOP burden (35.6% pre-ACA vs 23.7% post-ACA; difference-in-differences: -11.4%; 95% CI, -13.2% to -9.5%) followed by low-income families (24.6% pre-ACA vs 17.3% post-ACA, difference-in-differences: -6.8%; 95% CI, -8.7% to -4.9%) and middle-income families (6.1% pre-ACA vs 4.6% post-ACA, difference-in-differences: -1.2%; 95% CI, -2.3% to -0.01%). Although premiums rose for all groups, premium unaffordability was the least exacerbated for the lowest-, low-, and middle-income families compared with higher-income families. Conclusions and Relevance The findings of this study suggest that low- and middle-income families with children who were eligible for ACA Medicaid expansions and Marketplace subsidies experienced greater reductions in health care-related financial burden after the ACA was implemented compared with families with higher incomes. However, despite ACA policies, many low- and middle-income families with children appear to continue to face considerable financial burden from premiums and OOP costs.
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Affiliation(s)
- Lauren E. Wisk
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles (UCLA)
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alon Peltz
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Alison A. Galbraith
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Associate Editor, JAMA Pediatrics
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28
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Scott JW, Ayanian JZ, Dimick JB. Medicaid Expansion and Surgical Care-Evaluating the Evidence. JAMA Surg 2020:2770718. [PMID: 32965486 DOI: 10.1001/jamasurg.2020.1995] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- John W Scott
- Department of Surgery, University of Michigan, Ann Arbor
| | - John Z Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Surgical Innovation Editor
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29
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Liu C, Rahman AS, Chao TE. Catastrophic expenditures in California trauma patients after the Affordable Care Act: reduced financial risk and racial disparities. Am J Surg 2020; 220:511-517. [DOI: 10.1016/j.amjsurg.2020.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/23/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
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30
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Authors’ reply: Understanding state-level Medicaid expansion in the context of nationwide data. J Trauma Acute Care Surg 2020; 89:e20-e21. [DOI: 10.1097/ta.0000000000002733] [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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O'Neill KM, Jean RA, Gross CP, Becher RD, Khera R, Elizondo JV, Nasir K. Financial Hardship After Traumatic Injury: Risk Factors and Drivers of Out-of-Pocket Health Expenses. J Surg Res 2020; 256:1-12. [PMID: 32663705 DOI: 10.1016/j.jss.2020.05.095] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/27/2020] [Accepted: 05/25/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Trauma-related disorders rank among the top five most costly medical conditions to the health care system. However, the impact of out-of-pocket (OOP) health expenses for traumatic conditions is not known. In this cross-sectional study, we use nationally representative data to investigate whether patients with a traumatic injury experienced financial hardship from OOP health expenses. METHODS Using data from the Medical Expenditure Panel Survey from 2010 to 2015, we analyzed the financial burden associated with a traumatic injury. Primary outcomes were excess financial burden (OOP>20% of annual income) and catastrophic medical expenses (OOP>40% of annual income). A multivariable logistic regression analysis evaluated whether these outcomes were associated with traumatic injury, adjusting for demographic, socioeconomic, and health care factors. We then completed a descriptive analysis to elucidate drivers of total OOP expenses. RESULTS Of the 90,964 families in the cohort, 6434 families had a traumatic injury requiring a visit to the emergency room and 668 families had a traumatic injury requiring hospitalization. Overall 1 in 8 households with an injured family member requiring hospitalization experienced financial hardship. These families were more likely to experience excess financial burden (OR: 2.04, 95% CI: 1.13-3.64) and catastrophic medical expenses (OR: 3.08, 95% CI: 1.37-6.9). The largest burden of OOP expenses was due to prescription drug costs, with inpatient costs as a major driver of OOP expenses for those requiring hospitalization. CONCLUSIONS Households with an injured family member requiring hospitalization are significantly more vulnerable to financial hardship from OOP health expenses than the noninjured population. Prescription drug and inpatient costs were the most significant drivers of OOP health expenses.
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Affiliation(s)
- Kathleen M O'Neill
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut; National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut.
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut; National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut
| | - Cary P Gross
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert D Becher
- Section of General Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Javier Valero Elizondo
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist, Houston, Texas
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist, Houston, Texas
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