Nonindicated pelvic examinations during contraceptive encounters: Prevalence and provider variations

The Patient Protection and Affordable Care Act and Pediatric Medical Clinicians' Application of Fluoride Varnish

Importance

Fluoride varnish reduces children's tooth decay, yet few clinicians provide it. Most state Medicaid programs have covered this service during medical visits for children aged 1 to 5 years, but private insurers began covering it only in 2015 due to the Patient Protection and Affordable Care Act (ACA) mandate that they cover a set of recommended preventive services without cost-sharing. Evidence on clinicians' behavior change postmandate is limited.

Objective

To examine monthly changes in fluoride varnish applications among pediatric clinicians following the ACA mandate.

Design, Setting, and Participants

Using all-payer claims data from Massachusetts, this cohort study applied an interrupted time-series approach with linear regression models comparing changes in monthly clinician-level outcomes before and after the mandate. Participants included clinicians who billed at least 5 well-child visits for patients aged 1 to 5 years and were observed at least once premandate. Adjusted for clinician fixed effects, models were assessed overall and separately for clinicians categorized by their monthly share of well-child visits paid by private insurers before the mandate: mostly private (>66% of visits paid by private insurers), mostly public (<33% of visits paid by private insurers), or mixed (33%-66% of visits paid by private insurers) insurance types. Analysis was performed from June 1, 2022, to July 31, 2023.

Exposure

Preenactment and postenactment of the ACA mandate for private insurers to cover fluoride varnish applications without cost-sharing.

Main Outcomes and Measures

Clinician-month measures of whether fluoride varnish was provided during at least 1 well-child visit and the share of such visits, analyzed separately for clinicians who did and did not apply fluoride varnish premandate.

Results

The sample included 2405 clinicians, with 107 841 clinician-months. Premandate, 10.48% of the visits included fluoride varnish applications. Two years postmandate, the likelihood of ever applying fluoride varnish was 13.64 (95% CI, 10.97-16.32) percentage points higher. For clinicians providing fluoride varnish premandate, the share of visits with fluoride varnish increased by 9.22 (95% CI, 5.41-13.02) percentage points. This increase was observed in clinicians who treated children with insurance that was mostly mixed and mostly private; no substantial change was observed among those treating children with mostly public insurance.

Conclusions and Relevance

In this cohort study of pediatric primary care clinicians, an association between the ACA mandate and an increase in fluoride varnish application was observed, especially among clinicians primarily treating privately insured patients and those applying it premandate. However, application remains infrequent, suggesting persistent barriers.

Effects of the COVID-19 pandemic on family planning services

PURPOSE OF REVIEW

The COVID-19 pandemic has highlighted existing healthcare disparities worldwide and has challenged access to family planning (FP) services.

RECENT FINDINGS

Research has identified ways in which government regulations and healthcare programs have inhibited or increased access to FP services, as well as how the pandemic has changed individuals' sexual and reproductive health behaviors and intentions.

SUMMARY

The pandemic has had both positive and negative effects on access to FP services. Innovations in various delivery services, extended use of contraception, telehealth for medication abortion, and a no-test medication abortion protocol have decreased the need for in-person visits and improved access to FP services.

Utilization of Women’s Preventive Health Services During the COVID-19 Pandemic

Question

How has utilization of preventive health services among commercially insured women changed during the COVID-19 pandemic?

Findings

In this cross-sectional study of 685 373 women enrolled in a large commercial health maintenance organization plan in Michigan, rates of breast cancer screening, cervical cancer screening, sexually transmitted infection screening, and prescriptions and new insertions for contraceptives all significantly declined in 2020 compared with 2019. For some services, there were small declines in utilization among women residing in zip codes that are lower income with higher proportions of non-White and non–English-speaking residents.

Meaning

The pandemic has disrupted the utilization of women’s preventive health services and may be associated with increased disparities in access to these services.

Importance

The association of the COVID-19 pandemic with women’s preventive health care use is unknown.

Objective

To describe utilization of women’s preventive health services.

Design, Setting, and Participants

Cross-sectional study of women aged 18 to 74 years enrolled in a commercial health maintenance organization in Michigan.

Exposures

COVID-19 pandemic (2019-2020).

Main Outcomes and Measures

Adjusted odds ratios (AORs) of receiving breast cancer screening, cervical cancer screening, sexually transmitted infection (STI) screening, long-acting reversible contraception (LARC) insertions, and pharmacy-obtained contraception, adjusted for month, age, county, zip code characteristics (per-capita income, non-White percentage of population, non–English-proficient percentage of population), and plan designation (primary plan holder vs dependent).

Results

The study population included 685 373 women aged 18 to 74 years, enrolled for 13 000 715 person-months, of whom 10 061 275 person-months (77.4%) were among women aged 25 to 64 years and 8 020 215 (61.7%) were the primary plan holder, with mean zip code per capita income of $33 708, 20.2% mean zip code non-White population, and 3.4% mean zip code non–English-speaking population. For services requiring an in-person visit (breast cancer screening, cervical cancer screening, STI testing, and LARC insertions), utilization declined by 60% to 90% during the spring of 2020, with a nadir in April 2020, after which utilization for all services recovered to close to 2019 levels by July 2020. Claims for pharmacy-obtained hormonal contraceptives in 2020 were consistently 15% to 30% lower than 2019. The AORs of a woman receiving a given preventive service in 2020 compared with 2019 were significantly lower for breast cancer screening (AOR, 0.80; 95% CI, 0.79-0.80), cervical cancer screening (AOR, 0.80; 95% CI, 0.80-0.81), STI screening (AOR, 0.83; 95% CI, 0.82-0.84), LARC insertion (AOR, 0.87; 95% CI, 0.84-0.90), and pharmacy-obtained contraception (AOR, 0.73; 95% CI, 0.72-0.74) (all P < .001).

Conclusions and Relevance

In this cross-sectional study of women enrolled in a large US commercial health maintenance organization plan, the COVID-19 pandemic was associated with large but transient declines in rates of breast cancer screening, cervical cancer screening, STI screening, and LARC insertions, and moderate persistent declines in pharmacy-obtained hormonal contraceptives. The overall odds of a woman receiving a given preventive service in 2020 was 20% to 30% lower than 2019. Further research into disparities in access to care and the health outcomes of decreased use of these key health services is warranted.