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Bin Abdul Baten R, Noman A, Rahman MN. Affordable Care Act Medicaid expansion, access to health care, and financial behavior of the United States adults. J Public Health Policy 2024:10.1057/s41271-024-00522-0. [PMID: 39313587 DOI: 10.1057/s41271-024-00522-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2024] [Indexed: 09/25/2024]
Abstract
The access to care benefits of Affordable Care Act (ACA) Medicaid expansions are important for 45-64-year-old adults who are living below 100% of the Federal Poverty Level, a particularly vulnerable group in the United States (US). Gaining coverage from Medicaid expansions should improve access to healthcare and affect social determinants of health, including financial behavior. We analyzed data from 2009 to 2018 from the National Financial Capability Survey (NFCS) and utilize a difference-in-differences model to compare outcomes changes in states with and without expansion before and after the ACA Medicaid expansions. Overall, Medicaid expansion was associated with increased healthcare access for 45-64-year-olds, potentially resulting in better healthcare experience. Results indicate effects of the Medicaid expansion on the financial behavior of 45-64-year-olds, with evidence of credit card bills being paid in full, higher banking activities, and better financial preparedness. These findings have important implications for financial regulators and healthcare policymakers.
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Affiliation(s)
- Redwan Bin Abdul Baten
- Department of Health Management and Policy, College of Health and Human Services, University of North Carolina at Charlotte, 9201 University City Blvd., Charlotte, NC, 28223, USA.
| | - Abdullah Noman
- Thomas College of Business and Economics, University of North Carolina at Pembroke, Pembroke, NC, 28372, USA
| | - Mohammad Nakibur Rahman
- Thomas College of Business and Economics, University of North Carolina at Pembroke, Pembroke, NC, 28372, USA
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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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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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Clark NM, Agoubi LL, Gibbs S, Stewart BT, De Grauw X, Vavilala MS, Rivara FP, Arbabi S, Pham TN. Impact of Tele-Triage Pathways on Short-Stay Admission after Transfer to a Regional Burn Center for Acute Burn Injury. J Am Coll Surg 2023; 237:799-807. [PMID: 37694925 DOI: 10.1097/xcs.0000000000000854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Regionalized care for burn-injured patients requires accurate triage. In 2016, we implemented a tele-triage system for acute burn consultations. We evaluated resource utilization following implementation, hypothesizing that this system would reduce short-stay admissions and prioritize inpatient care for those with higher burn severity. STUDY DESIGN We conducted a retrospective study of all transferred patients with acute burn injuries from January 1, 2010 to December 31, 2015, and January 1, 2017 to December 31, 2019. We evaluated the proportions of short-stay admissions (discharges less than 24 hours without operative intervention, ICU admission, or concern for nonaccidental trauma) among patients transferred before (2010 to 2015) and after (2017 to 2019) triage system implementation. Multivariable Poisson regression was used to evaluate factors associated with short-stay admissions. Interrupted time series analysis was used to evaluate the effect of the triage system. RESULTS There were 4,688 burn transfers (3,244 preimplementation and 1,444 postimplementation) in the study periods. Mean age was higher postimplementation (32 vs 29 years, p < 0.001). Median hospital length of stay (LOS) and ICU LOS were both 1 day higher, more patients underwent operative intervention (19% vs 16%), and median time to first operation was 1 day lower postimplementation. Short-stay admissions decreased from 50% (n = 1,624) to 39% (n = 561), and patients were 17% less likely to have a short-stay admission after implementation (adjusted relative risk [aRR], 0.83; 95% CI, 0.8 to 0.9). Pediatric patients younger than 15 years old composed 43% of all short-stay admissions and were much more likely than adult patients to have a short-stay admission independent of transfer timing (aRR, 2.36; 95% CI, 1.84 to 3.03). CONCLUSIONS Tele-triage burn transfer center protocols reduced short-stay admissions and prioritized inpatient care for patients with more severe injuries. Pediatric patients remain more likely to have short-stay admission after transfer.
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Affiliation(s)
- Nina M Clark
- From the Department of Surgery (Clark, Agoubi), University of Washington, Seattle, WA
- the Surgical Outcomes Research Center (Clark), University of Washington, Seattle, WA
| | - Lauren L Agoubi
- From the Department of Surgery (Clark, Agoubi), University of Washington, Seattle, WA
- the Harborview Injury Prevention and Research Center, Seattle, WA (Agoubi, De Grauw, Vavilala, Rivara, Arbabi)
| | - Sarah Gibbs
- the Surgical Outcomes Research Center (Clark), University of Washington, Seattle, WA
| | - Barclay T Stewart
- the Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery (Stewart, Arbabi, Pham), University of Washington, Seattle, WA
| | - Xinyao De Grauw
- the Harborview Injury Prevention and Research Center, Seattle, WA (Agoubi, De Grauw, Vavilala, Rivara, Arbabi)
| | - Monica S Vavilala
- the Department of Anesthesiology (Vavilala), University of Washington, Seattle, WA
- the Department of Pediatrics (Vavilala, Rivara), University of Washington, Seattle, WA
- the Harborview Injury Prevention and Research Center, Seattle, WA (Agoubi, De Grauw, Vavilala, Rivara, Arbabi)
| | - Frederick P Rivara
- the Department of Pediatrics (Vavilala, Rivara), University of Washington, Seattle, WA
- the Harborview Injury Prevention and Research Center, Seattle, WA (Agoubi, De Grauw, Vavilala, Rivara, Arbabi)
| | - Saman Arbabi
- the Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery (Stewart, Arbabi, Pham), University of Washington, Seattle, WA
- the Harborview Injury Prevention and Research Center, Seattle, WA (Agoubi, De Grauw, Vavilala, Rivara, Arbabi)
| | - Tam N Pham
- the Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery (Stewart, Arbabi, Pham), University of Washington, Seattle, WA
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Breeding T, Ngatuvai M, Rosander A, Maka P, Davis J, Knowlton LM, Hoops H, Elkbuli A. Trends in disparities research on trauma and acute care surgery outcomes: A 10-year systematic review of articles published in The Journal of Trauma and Acute Care Surgery. J Trauma Acute Care Surg 2023; 95:806-815. [PMID: 37405809 DOI: 10.1097/ta.0000000000004067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
ABSTRACT This is a 10-year review of The Journal of Trauma and Acute Care Surgery (JTACS) literature related to health care disparities, health care inequities, and patient outcomes. A retrospective review of articles published in JTACS between January 1, 2013, and July 15, 2022, was performed. Articles screened included both adult and pediatric trauma populations. Included articles focused on patient populations related to trauma, surgical critical care, and emergency general surgery. Of the 4,178 articles reviewed, 74 met the inclusion criteria. Health care disparities related to gender (n = 10), race/ethnicity (n = 12), age (n = 14), income status (n = 6), health literacy (n = 6), location and access to care (n = 23), and insurance status (n = 13) were described. Studies published on disparities peaked in 2016 and 2022 with 13 and 15 studies respectively but dropped to one study in 2017. Studies demonstrated a significant increase in mortality for patients in rural geographical regions and in patients without health insurance and a decrease in patients who were treated at a trauma center. Gender disparities resulted in variable mortality rates and studied factors, including traumatic brain injury mortality and severity, venous thromboembolism, ventilator-associated pneumonia, firearm homicide, and intimate partner violence. Under-represented race/ethnicity was associated with variable mortality rates, with one study demonstrating increased mortality risk and three finding no association between race/ethnicity and mortality. Disparities in health literacy resulted in decreased discharge compliance and worse long-term functional outcomes. Studies on disparities in JTACS over the last decade primarily focused on location and access to health care, age, insurance status, and race, with a specific emphasis on mortality. This review highlights the areas in need of further research and funding in the Journal of Trauma and Acute Care Surgery regarding health care disparities in trauma aimed at interventions to reduce disparities in patient care, ensure equitable care, and inform future approaches targeting health care disparities. LEVEL OF EVIDENCE Systematic Review; Level IV.
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Affiliation(s)
- Tessa Breeding
- From the Kiran Patel College of Allopathic Medicine (T.B., M.N.), NOVA Southeastern University, Fort Lauderdale, Florida; Arizona College of Osteopathic Medicine, Midwestern University (A.R.), Glendale, Arizona; John A. Burns School of Medicine (P.M.), Honolulu, Hawaii; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (J.D.), The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Trauma and Surgical Critical Care, Department of Surgery (L.M.K.), Stanford University Medical Center, Palo Alto, California; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (H.H.), Oregon Health & Sciences University, Portland, Oregon; Division of Trauma and Surgical Critical Care, Department of Surgery (A.E.), and Department of Surgical Education (A.E.), Orlando Regional Medical Center, Orlando, Florida
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Billig JI, Law JM, Brody M, Cavanaugh KE, Dy CJ. Catastrophic Health Expenditures Associated With Open Reduction Internal Fixation of Distal Radius Fractures. J Hand Surg Am 2023; 48:977-983. [PMID: 37480916 DOI: 10.1016/j.jhsa.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/17/2023] [Accepted: 06/07/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE Distal radius fracture is one of the most common upper-extremity traumatic injuries. These injuries result in time off work and potential financial consequences for patients. Therefore, we aimed to understand the risk of catastrophic health expenditures (CHEs) after open reduction and internal fixation of distal radius fractures and examine the association between patient characteristics and the risk of CHE. METHODS We used data from patients undergoing open reduction and internal fixation of a distal radius fracture from a large, urban, level I trauma center (2018-2020). The risk of CHE was defined as out-of-pocket expenses of ≥40% of postsubsistence income. We used multivariable logistic regression to assess the impact of age, sex, race, and insurance status on the risk of CHE. RESULTS In our cohort of 394 patients, 121 patients (30.7%) were at risk of CHE after their distal radius fracture. After controlling for patient characteristics and insurance status, patients aged 26-34 years were 5.7 times more likely to be at risk of CHE (odds ratio, 5.73; 95% CI, 1.81-18.13) than patients aged ≥65 years. Patients who were uninsured were six times more likely to be at risk of CHE than patients with employer-sponsored health insurance (odds ratio, 6.02; 95% CI, 1.94-18.66). Lastly, non-White patients were at a higher risk of CHE (odds ratio, 3.63; 95% CI, 1.70-7.79) than White patients. CONCLUSIONS Distal radius fractures are unexpected and place patients at risk of financial harm, with one in three patients at risk of CHEs. Policies aimed at minimizing cost-sharing after traumatic injury may help alleviate the financial consequences of health care delivery and reduce disparities. TYPE OF STUDY/LEVEL OF EVIDENCE Economic and Decision Analysis II.
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Affiliation(s)
- Jessica I Billig
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO
| | - Jody M Law
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO
| | - Madison Brody
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO
| | - Katherine E Cavanaugh
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO.
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Kay HF, Buss JL, Keller MR, Olsen MA, Brogan DM, Dy CJ. Catastrophic Health Care Expenditure Following Brachial Plexus Injury. J Hand Surg Am 2023; 48:354-360. [PMID: 36725391 PMCID: PMC10079640 DOI: 10.1016/j.jhsa.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/25/2022] [Accepted: 12/08/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Brachial plexus injuries (BPIs) are devastating to patients not only functionally but also financially. Like patients experiencing other traumatic injuries and unexpected medical events, patients with BPIs are at risk of catastrophic health expenditure (CHE) in which out-of-pocket health spending exceeds 40% of postsubsistence income (income remaining after food and housing expenses). The individual financial strain after BPIs has not been previously quantified. The purpose of this study was to assess the proportion of patients with BPIs who experience risk of CHE after reconstructive surgery. METHODS Administrative databases were used from 8 states to identify patients who underwent surgery for BPIs. Demographics including age, sex, race, and insurance payer type were obtained. Inpatient billing records were used to determine the total surgical and inpatient facility costs within 90 days after the initial surgery. Due to data constraints, further analysis was only conducted for privately-insured patients. The proportion of patients with BPIs at risk of CHE was recorded. Predictors of CHE risk were determined from a multivariable regression analysis. RESULTS Among 681 privately-insured patients undergoing surgery for BPIs, nearly one-third (216 [32%]) were at risk of CHE. Black race and patients aged between 25 and 39 years were significant risk factors associated with CHE. Sex and the number of comorbidities were not associated with risk of CHE. CONCLUSIONS Nearly one-third of privately-insured patients met the threshold for being at risk of CHE after BPI surgery. CLINICAL RELEVANCE Identifying those patients at risk of CHE can inform strategies to minimize long-term financial distress after BPIs, including detailed counseling regarding anticipated health care expenditures and efforts to optimize access to appropriate insurance policies for patients with BPIs.
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Affiliation(s)
- Harrison F Kay
- Department of Orthopaedic Surgery, Washington University in St Louis School of Medicine, St Louis, MO
| | - Joanna L Buss
- Center for Administrative Data Research, Washington University in St Louis School of Medicine, St Louis, MO
| | - Matthew R Keller
- Center for Administrative Data Research, Washington University in St Louis School of Medicine, St Louis, MO
| | - Margaret A Olsen
- Center for Administrative Data Research, Washington University in St Louis School of Medicine, St Louis, MO
| | - David M Brogan
- Department of Orthopaedic Surgery, Washington University in St Louis School of Medicine, St Louis, MO
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University in St Louis School of Medicine, St Louis, MO.
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Law JM, Brody M, Cavanaugh KE, Dy CJ. Catastrophic Health Expenditure in Patients with Lower-Extremity Orthopaedic Trauma. J Bone Joint Surg Am 2023; 105:363-368. [PMID: 36729433 DOI: 10.2106/jbjs.22.00623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Health-care expenditures are a leading contributor to financial hardship in the United States. Traumatic orthopaedic injuries are unpredictable and result in substantial expense. Our objectives were to quantify the catastrophic health expenditure (CHE) risk of patients with orthopaedic trauma and to examine the impact of insurance status, socioeconomic status, sex, and race on CHE. METHODS We identified all isolated lower-extremity orthopaedic trauma cases at a safety-net, Level-1 trauma center from 2018 to 2020. We queried an institutional charge database to obtain total hospital charges, insurance status, and ZIP Code to determine out-of-pocket (OOP) expenditures. To evaluate financial hardship, we calculated the CHE risk as defined by the World Health Organization's threshold of OOP expenditures, ≥40% of estimated household post-subsistence income. RESULTS In our cohort of 2,535 patients, 33% experienced a risk of CHE. A risk of CHE was experienced by 99% of patients who were uninsured, 35% of patients with private insurance, 2% of patients with Medicare, and 0% of patients with Medicaid. Multivariable regression modeling showed that patients who were uninsured were significantly more likely to experience a risk of CHE compared with patients with private insurance (odds ratio, 107.68 [95% confidence interval, 37.20 to 311.68]; p < 0.001). CONCLUSIONS One-third of patients with lower-extremity orthopaedic trauma experience a risk of CHE, with patients who are uninsured facing a disproportionately higher risk of CHE compared with patients who are insured. Our results suggest that the expansion of public insurance options may provide substantial financial protection for those at the greatest risk for CHE. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jody M Law
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
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Gulamhussein MA, Sawe HR, Kilindimo S, Mfinanga JA, Mussa R, Hyuha GM, Rwegoshora S, Shayo F, Mdundo W, Sadiq AM, Weber EJ. Out-of-pocket cost for medical care of injured patients presenting to emergency department of national hospital in Tanzania: a prospective cohort study. BMJ Open 2023; 13:e063297. [PMID: 36720574 PMCID: PMC9890776 DOI: 10.1136/bmjopen-2022-063297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE We aimed to determine the out-of-pocket (OOP) costs for medical care of injured patients and the proportion of patients encountering catastrophic costs. DESIGN Prospective cohort study SETTING: Emergency department (ED) of a tertiary-level hospital in Dar es Salaam, Tanzania. PARTICIPANTS Injured adult patients seen at the ED of Muhimbili National Hospital from August 2019 to March 2020. METHODS During alternating 12-hour shifts, consecutive trauma patients were approached in the ED after stabilisation. A case report form was used to collect social-demographics and patient clinical profile. Total charges billed for ED and in-hospital care and OOP payments were obtained from the hospital billing system. Patients were interviewed by phone to determine the measures they took to pay their bills. PRIMARY OUTCOME MEASURE The primary outcome was the proportion of patients with catastrophic health expenditure (CHE), using the WHO definition of OOP expenditures ≥40% of monthly income. RESULTS We enrolled 355 trauma patients of whom 51 (14.4%) were insured. The median age was 32 years (IQR 25-40), 238 (83.2%) were male, 162 (56.6%) were married and 87.8% had ≥2 household dependents. The majority 224 (78.3%) had informal employment with a median monthly income of US$86. Overall, 286 (80.6%) had OOP expenses for their care. 95.1% of all patients had an Injury Severity Score <16 among whom OOP payments were US$176.98 (IQR 62.33-311.97). Chest injury and spinal injury incurred the highest OOP payments of US$282.63 (84.71-369.33) and 277.71 (191.02-874.47), respectively. Overall, 85.3% had a CHE. 203 patients (70.9%) were interviewed after discharge. In this group, 13.8% borrowed money from family, and 12.3% sold personal items of value to pay for their hospital bills. CONCLUSION OOP costs place a significant economic burden on individuals and families. Measures to reduce injury and financial risk are needed in Tanzania.
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Affiliation(s)
- Masuma A Gulamhussein
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Hendry Robert Sawe
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Said Kilindimo
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Juma A Mfinanga
- Emergency Medicine, Muhimbili National Hospital, Dar es Salaam, Tanzania, United Republic of
| | - Raya Mussa
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Gimbo M Hyuha
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Shamila Rwegoshora
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Frida Shayo
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Winnie Mdundo
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Abid M Sadiq
- Emergency Medicine, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania, United Republic of
| | - Ellen J Weber
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
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The Role of Pericardial Window Techniques in the Management of Penetrating Cardiac Injuries in the Hemodynamically Stable Patient: Where Does It Fit in the Current Trauma Algorithm. J Surg Res 2022; 276:120-135. [PMID: 35339780 DOI: 10.1016/j.jss.2022.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/21/2021] [Accepted: 02/12/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Penetrating cardiac injuries (PCIs) have high in-hospital mortality rates. Guidelines regarding the use of pericardial window (PW) for diagnosis and treatment of suspected PCIs are not universally established. The objective of this review was to provide a critical appraisal of the current literature to determine the effectiveness and safety of PW as both a diagnostic and therapeutic technique for suspected PCIs in patients with hemodynamic stability. METHODS A review was conducted using PubMed/MEDLINE, Google Scholar, and Embase to identify literature evaluating the accuracy and therapeutic efficacy of PW and its role in a hemodynamically stable patient with penetrating thoracic or thoracoabdominal trauma. RESULTS Eleven studies evaluating diagnostic PW and two studies evaluating therapeutic PW were included. These studies ranged from (y) 1977 to 2018. Existing literature indicates that PW is highly sensitive (92%-100%) and specific (96%-100%) for the diagnosis of suspected PCIs. PW and drainage, when compared with sternotomy, may be associated with decreased total hospital stay (4.1 versus 6.5 d; P < 0.001) and intensive care unit stay (0.25 versus 2.04 d; P < 0.001) along with similar mortality and complication rates after the management of hemopericardium. CONCLUSIONS In a hemodynamically stable patient presenting with penetrating cardiac trauma with a high suspicion for PCI, PWs can (1) facilitate prompt diagnosis in the event of equivocal ultrasonography findings and (2) serve as an effective therapeutic modality with the benefit of potentially avoiding more invasive procedures. Subxiphoid, transdiaphragmatic, and laparoscopic approaches for PW have been shown to have similar efficacy and safety.
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Albright BB, Nitecki R, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Catastrophic health expenditures, insurance churn, and nonemployment among gynecologic cancer patients in the United States. Am J Obstet Gynecol 2022; 226:384.e1-384.e13. [PMID: 34597606 PMCID: PMC10016333 DOI: 10.1016/j.ajog.2021.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of nonemployment, uninsurance, and catastrophic out-of-pocket health spending. Patients with gynecologic cancer often require expensive and prolonged treatments, potentially disrupting employment and insurance coverage access, and putting patients and their families at risk for catastrophic health expenditures. OBJECTIVE This study aimed to describe the prevalence of insurance churn, nonemployment, and catastrophic health expenditures among nonelderly patients with gynecologic cancer in the United States, to compare within subgroups and to other populations and assess for changes associated with the Affordable Care Act. STUDY DESIGN We identified respondents aged 18 to 64 years from the Medical Expenditure Panel Survey, 2006 to 2017, who reported care related to gynecologic cancer in a given year, and a propensity-matched cohort of patients without cancer and patients with cancers of other sites, as comparison groups. We applied survey weights to extrapolate to the US population, and we described patterns of insurance churn (any uninsurance or insurance loss or change), catastrophic health expenditures (>10% annual family income), and nonemployment. Characteristics and outcomes between groups were compared with the adjusted Wald test. RESULTS We identified 683 respondents reporting care related to a gynecologic cancer diagnosis from 2006 to 2017, representing an estimated annual population of 532,400 patients (95% confidence interval, 462,000-502,700). More than 64% of patients reported at least 1 of 3 primary negative outcomes of any uninsurance, part-year nonemployment, and catastrophic health expenditures, with 22.4% reporting at least 2 of 3 outcomes. Catastrophic health spending was uncommon without nonemployment or uninsurance reported during that year (1.2% of the population). Compared with patients with other cancers, patients with gynecologic cancer were younger and more likely with low education and low family income (≤250% federal poverty level). They reported higher annual risks of insurance loss (8.8% vs 4.8%; P=.03), any uninsurance (22.6% vs 14.0%; P=.002), and part-year nonemployment (55.3% vs 44.6%; P=.005) but similar risks of catastrophic spending (12.6% vs 12.2%; P=.84). Patients with gynecologic cancer from low-income families faced a higher risk of catastrophic expenditures than those of higher icomes (24.4% vs 2.9%; P<.001). Among the patients from low-income families, Medicaid coverage was associated with a lower risk of catastrophic spending than private insurance. After the Affordable Care Act implementation, we observed reductions in the risk of uninsurance, but there was no significant change in the risk of catastrophic spending among patients with gynecologic cancer. CONCLUSION Patients with gynecologic cancer faced high risks of uninsurance, nonemployment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in the absence of either nonemployment or uninsurance in a given year.
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Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Roni Nitecki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emeline M Aviki
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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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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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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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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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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Lifting the burden: State Medicaid expansion reduces financial risk for the injured. J Trauma Acute Care Surg 2020; 89:e20. [DOI: 10.1097/ta.0000000000002734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liu C, Tsugawa Y, Weiser TG, Scott JW, Spain DA, Maggard-Gibbons M. Association of the US Affordable Care Act With Out-of-Pocket Spending and Catastrophic Health Expenditures Among Adult Patients With Traumatic Injury. JAMA Netw Open 2020; 3:e200157. [PMID: 32108892 PMCID: PMC7049078 DOI: 10.1001/jamanetworkopen.2020.0157] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE Trauma is an expensive and unpredictable source of out-of-pocket spending for American families. The Patient Protection and Affordable Care Act (ACA) sought to improve financial protection by expanding health insurance coverage, but its association with health care spending for patients with traumatic injury remains largely unknown. OBJECTIVE To evaluate the association of ACA implementation with out-of-pocket spending, premiums, and catastrophic health expenditures (CHE) among adult patients with traumatic injury. DESIGN, SETTING, AND PARTICIPANTS Data from a nationally representative sample of US adults aged 19 to 64 years who had a hospital stay or emergency department visit for a traumatic injury from January 2010 to December 2017 were analyzed using the Medical Expenditure Panel Survey. Multivariable generalized linear models were used to evaluate changes in spending after ACA implementation. Additionally, 4 income subgroups were evaluated based on ACA thresholds for program eligibility: lowest-income patients (earning 138% or less of the federal poverty level [FPL]), low-income patients (earning 139% to 250% of the FPL), middle-income patients (earning 251% to 400% of the FPL), and high-income patients (earning more than 400% of the FPL). Data were analyzed from February to December 2019. EXPOSURES Implementation of the ACA, beginning January 1, 2014. MAIN OUTCOMES AND MEASURES Out-of-pocket spending, premium spending, out-of-pocket plus premium spending, and likelihood of experiencing CHE, defined as out-of-pocket plus premium spending exceeding 19.5% of family income. RESULTS Of the 6288 included patients, 2995 (weighted percentage, 51.3%) were male, and the mean (SD) age was 41.4 (12.8) years. Implementation of the ACA was associated with 31% lower odds of CHE (adjusted odds ratio, 0.69; 95% CI, 0.54 to 0.87; P = .002). Changes were greatest in lowest-income patients, who experienced 30% lower out-of-pocket spending (adjusted percentage change, -30.4%; 95% CI, -46.6% to -9.4%; P = .01), 26% lower out-of-pocket plus premium spending (adjusted percentage change, -26.3%; 95% CI, -41.0% to -8.1%; P = .01), and 39% lower odds of CHE (adjusted odds ratio, 0.61; 95% CI, 0.44 to 0.84; P = .002). Low-income patients experienced decreased out-of-pocket spending and out-of-pocket plus premium spending but no changes in CHE, while middle-income and high-income patients experienced no significant changes in any spending outcome. In the post-ACA period, 1 in 11 of all patients with traumatic injury and 1 in 5 with the lowest incomes continued to experience CHE each year. CONCLUSIONS AND RELEVANCE Implementation of the ACA was associated with improved financial protection for US adults with traumatic injury, especially lowest-income individuals targeted by the law's Medicaid expansions. Despite these gains, injured patients remain at risk of financial strain.
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Affiliation(s)
- Charles Liu
- Department of Surgery, Stanford University, Stanford, California
- National Clinician Scholars Program, University of California, Los Angeles
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, University of California, Los Angeles
- Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles
| | - Thomas G. Weiser
- Department of Surgery, Stanford University, Stanford, California
| | - John W. Scott
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor
| | - David A. Spain
- Department of Surgery, Stanford University, Stanford, California
| | - Melinda Maggard-Gibbons
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles
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