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Lin S, Qi Q, Liu H, Deng X, Trees I, Yuan X, Gallant MP. The Joint Effects of Thunderstorms and Power Outages on Respiratory-Related Emergency Visits and Modifying and Mediating Factors of This Relationship. ENVIRONMENTAL HEALTH PERSPECTIVES 2024; 132:67002. [PMID: 38829734 PMCID: PMC11166412 DOI: 10.1289/ehp13237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 04/27/2024] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND While limited studies have evaluated the health impacts of thunderstorms and power outages (POs) separately, few have assessed their joint effects. We aimed to investigate the individual and joint effects of both thunderstorms and POs on respiratory diseases, to identify disparities by demographics, and to examine the modifications and mediations by meteorological factors and air pollution. METHODS Distributed lag nonlinear models were used to examine exposures during three periods (i.e., days with both thunderstorms and POs, thunderstorms only, and POs only) in relation to emergency department visits for respiratory diseases (2005-2018) compared to controls (no thunderstorm/no PO) in New York State (NYS) while controlling for confounders. Interactions between thunderstorms and weather factors or air pollutants on health were assessed. The disparities by demographics and seasons and the mediative effects by particulate matter with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ) and relative humidity (RH) were also evaluated. RESULTS Thunderstorms and POs were independently associated with total and six subtypes of respiratory diseases in NYS [highest risk ratio (RR) = 1.12; 95% confidence interval (CI): 1.08, 1.17], but the impact was stronger when they co-occurred (highest RR = 1.44; 95% CI: 1.22, 1.70), especially during grass weed, ragweed, and tree pollen seasons. The stronger thunderstorm/PO joint effects were observed on chronic obstructive pulmonary diseases, bronchitis, and asthma (lasted 0-10 d) and were higher among residents who lived in rural areas, were uninsured, were of Hispanic ethnicity, were 6-17 or over 65 years old, and during spring and summer. The number of comorbidities was significantly higher by 0.299-0.782/case. Extreme cold/heat, high RH, PM 2.5 , and ozone concentrations significantly modified the thunderstorm-health effect on both multiplicative and additive scales. Over 35% of the thunderstorm effects were mediated by PM 2.5 and RH. CONCLUSION Thunderstorms accompanied by POs showed the strongest respiratory effects. There were large disparities in thunderstorm-health associations by demographics. Meteorological factors and air pollution levels modified and mediated the thunderstorm-health effects. https://doi.org/10.1289/EHP13237.
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Affiliation(s)
- Shao Lin
- Department of Environmental Health Sciences, School of Public Health, University at Albany, State University of New York, Albany, New York, USA
- Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, State University of New York, Albany, New York, USA
| | - Quan Qi
- Department of Economics, University at Albany, State University of New York, Albany, New York, USA
| | - Han Liu
- Population Studies and Training Center, Brown University, Providence, Rhode Island, USA
| | - Xinlei Deng
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Durham, North Carolina, USA
| | - Ian Trees
- Epidemiology Branch, Division of Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland, USA
| | - Xiaojun Yuan
- Department of Information Sciences and Technology, College of Emergency Preparedness, Homeland Security and Cybersecurity, University at Albany, State University of New York, Albany, New York, USA
| | - Mary P. Gallant
- Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, Massachusetts, 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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3
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Boone J. Pricing above value: Selling to a market with selection problems. JOURNAL OF HEALTH ECONOMICS 2024; 94:102868. [PMID: 38447245 DOI: 10.1016/j.jhealeco.2024.102868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 02/23/2024] [Accepted: 02/28/2024] [Indexed: 03/08/2024]
Abstract
This paper shows that selection incentives in downstream markets distort upstream prices. It is possible for inputs to be priced above the value that the good has for final consumers. We apply this idea to pharmaceutical companies selling drugs to a health insurance market with selection problems. We specify the conditions under which drugs are sold at prices exceeding treatment value. Another feature of the model is an excessive private incentive to reduce market size, e.g. in the form of personalized medicine.
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Affiliation(s)
- Jan Boone
- Tilburg University, Department of Economics, Tilec, Netherlands; CEPR, United Kingdom.
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4
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Schikowski EM, Swabe G, Chan SY, Magnani JW. Association Between Copayment and Adherence to Medications for Pulmonary Arterial Hypertension. J Am Heart Assoc 2022; 11:e026620. [PMID: 36370005 PMCID: PMC9750087 DOI: 10.1161/jaha.122.026620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Pharmacologic treatment for pulmonary arterial hypertension (PAH) improves exercise capacity, functional class, and hemodynamic indexes. However, monthly prescription costs often exceed $4000. We examined associations between (1) medication copayment and (2) annual household income with adherence to pulmonary vasodilator therapy among individuals with PAH. Methods and Results We used administrative claims data from an insured population in the United States to identify individuals diagnosed with PAH between 2015 and 2020. All individuals had ≥1 medication claim for endothelin receptor antagonists, phosphodiesterase type-5 inhibitors, prostanoids or prostacyclin receptor agonists, or the soluble guanylate cyclase stimulator riociguat. We defined copayments as low, medium, or high, as determined by their distributions for each medication class. Annual household income was categorized as <$40 000, $40 000 to $74 999, and ≥$75 000. The primary outcome was medication adherence, defined by proportion of days covered ≥80%. We studied 4025 adults (aged 65.9±13.3 years; 71.2% women). Compared with those with annual household income ≥$75 000, individuals in the <$40 000 and $40 000 to $74 999 categories had no significant differences in medication adherence. Compared with those with low copayments, individuals with high copayments had decreased adherence to prostanoids (odds ratio [OR], 0.36 [95% CI, 0.20-0.65]; P<0.001) and combination therapy with endothelin receptor antagonist and phosphodiesterase type-5 inhibitor (OR, 0.61 [95% CI, 0.38-0.97]; P=0.03). Conclusions We identified associations between copayment and adherence to prostanoids and combination therapy among individuals with PAH. Copayment may be a structural barrier to medication adherence and merits inclusion in studies examining access to pharmacotherapy among individuals with PAH.
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Affiliation(s)
- Erin M Schikowski
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA
| | - Gretchen Swabe
- School of Medicine University of Pittsburgh Pittsburgh PA
| | - Stephen Y Chan
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA.,Vascular Medicine Institute University of Pittsburgh School of Medicine Pittsburgh PA
| | - Jared W Magnani
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA.,Center for Research on Health Care, Department of Medicine University of Pittsburgh Pittsburgh PA
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Kenawy DM, Ackah RL, Abdel-Rasoul M, Tamimi MM, Thomas GM, Roach TA, D'Souza DM, Merritt RE, Kneuertz PJ. Preventable operating room delays in robotic-assisted thoracic surgery: Identifying opportunities for cost reduction. Surgery 2022; 172:1126-1132. [PMID: 35970610 PMCID: PMC10020819 DOI: 10.1016/j.surg.2022.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 05/23/2022] [Accepted: 06/30/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study aimed to characterize the types of intraoperative delays during robotic-assisted thoracic surgery, operating room staff awareness/perceptions of delays, and cost impact of delays on overall operative costs. METHODS Robotic-assisted thoracic surgery cases from May to August 2019 were attended by 3 third-party observers to record intraoperative delays. The postoperative surveys were given to operating room staff to elicit perceived delays. Observed versus perceived delays were compared using the McNemar test. Direct costs and charges per delay were calculated. RESULTS Forty-four cases were observed, of which a majority were lobectomies (n = 38 [86%]). A total of 71 delays were recorded by observers, encompassing 75% of cases (n = 33), with an average delay length of 3.6 minutes (±5.3 minutes). The following delays were observed: equipment failure (n = 40, average delay length 5.0 minutes (±6.5 minutes), equipment missing (n = 15, 2.2 minutes [±1.4 minutes]), staff unfamiliarity with equipment (n = 4, 3.4 minutes [± 1.5 minutes]), and other (n = 12, 4.5 minutes [±5.3 minutes]). The detection rates for any intraoperative delay were consistently lower for all of the operating room team members compared with observers, including surgeons (34.3% vs 77.1%; P = .0003), first assistants (41.9% vs 74.2%; P = .0075), surgical technologists (39.4% vs 72.7%; P = .0045), and circulating nurses (41.18% vs 76.47% minutes; P = .0013). The average operating room variable direct cost of delays based on the average total delay length per case was $225.52 (±$350.18) and was 1.6% (range 0-10.6%) of the total case charges. CONCLUSION The lack of perception of intraoperative delays hinders operating teams from effectively closing the variable cost gaps. Future studies are needed to explore methods of increasing perception of delays and opportunities to improve operating room efficiency.
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Affiliation(s)
- Dahlia M Kenawy
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH. https://twitter.com/DahliaKenawy
| | - Ruth L Ackah
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH. https://twitter.com/RuthAckah
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Muna M Tamimi
- College of Medicine, The Ohio State University, Columbus, OH
| | | | - Tyler A Roach
- College of Medicine, The Ohio State University, Columbus, OH. https://twitter.com/troach2023
| | - Desmond M D'Souza
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Robert E Merritt
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Peter J Kneuertz
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
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Karim MA, Singal AG, Ohsfeldt RL, Morrisey MA, Kum HC. Health services utilization, out-of-pocket expenditure, and underinsurance among insured non-elderly cancer survivors in the United States, 2011-2015. Cancer Med 2021; 10:5513-5523. [PMID: 34327859 PMCID: PMC8366084 DOI: 10.1002/cam4.4103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND High out-of-pocket (OOP) expenditure and inadequate insurance coverage may adversely affect cancer survivors. We aimed to characterize the extent and correlates of healthcare utilization, OOP expenditures, and underinsurance among insured cancer survivors. METHODS We used 2011-2015 Medical Expenditure Panel Survey data to identify a nationally representative sample of insured non-elderly adult (age 18-64 years) cancer survivors. We used negative binomial, two-part (logistic and Generalized Linear Model with log link and gamma distribution), and logistic regression models to quantify healthcare utilization, OOP expenditures, and underinsurance, respectively, and identified sociodemographic correlates for each outcome. RESULTS We identified 2738 insured non-elderly cancer survivors. Adjusted average utilization of ambulatory, non-ambulatory, prescription medication, and dental services was 14.4, 0.51, 24.9, and 1.4 events per person per year, respectively. Higher ambulatory and dental services utilization were observed in older adults, females, non-Hispanic Whites, survivors with a college degree and high income, compared to their counterparts. Nearly all (97.7%) survivors had some OOP expenditures, with a mean adjusted OOP expenditure of $1552 per person per year. Adjusted mean OOP expenditures for ambulatory, non-ambulatory, prescription medication, dental, and other health services were $653, $161, $428, $194, and $83, respectively. Sociodemographic variations in service-specific OOP expenditures were generally consistent with respective utilization patterns. Overall, 8.8% of the survivors were underinsured. CONCLUSION Many insured non-elderly cancer survivors allocate a substantial portion of their OOP expenditure for healthcare-related services and experience financial vulnerability, resulting in nearly 8.8% of the survivors being underinsured. Utilization of healthcare services varies across sociodemographic groups.
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Affiliation(s)
- Mohammad A Karim
- Population Informatics Laboratory, Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Amit G Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert L Ohsfeldt
- Population Informatics Laboratory, Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Michael A Morrisey
- Population Informatics Laboratory, Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Hye-Chung Kum
- Population Informatics Laboratory, Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
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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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Abstract
The Affordable Care Act (ACA) is at the crossroads. It is important to evaluate the effectiveness of the ACA in order to make rational decisions about the ongoing healthcare reform, but existing research into its effect on health insurance status in the United States is insufficient and descriptive. Using data from the National Health Interview Surveys from 2009 to 2015, this study examines changes in health insurance status and its determinants before the ACA in 2009, during its partial implementation in 2010–2013, and after its full implementation in 2014 and 2015. The results of trend analysis indicate a significant increase in national health insurance rate from 82.2% in 2009 to 89.4% in 2015. Logistic regression analyses confirm the similar impact of age, gender, race, marital status, nativity, citizenship, education, and poverty on health insurance status before and after the ACA. Despite similar effects across years, controlling for other variables, youth aged 26 or below, the foreign-born, Asians, and other races had a greater probability of gaining health insurance after the ACA than before the ACA; however, the odds of obtaining health insurance for Hispanics and the impoverished rose slightly during the partial implementation of the ACA, but somewhat declined after the full implementation of the ACA starting in 2014. These findings should be taken into account by the U.S. Government in deciding the fate of the ACA.
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Jones JR, Kogan MD, Ghandour RM, Minkovitz CS. Out-of-Pocket Health Care Expenditures Among United States Children: Parental Perceptions and Past-Year Expenditures, 2016 to 2017. Acad Pediatr 2021; 21:480-487. [PMID: 33221493 DOI: 10.1016/j.acap.2020.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 11/10/2020] [Accepted: 11/14/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the association between parental perceptions of out-of-pocket (OOP) health care costs for their child and the total amount of OOP health care expenditures for that child during the past year. METHODS We used data from the 2016 and 2017 National Surveys of Children's Health, cross-sectional, parent-reported, and nationally representative surveys of noninstitutionalized US children, ages 0 to 17 years. We conducted bivariate analyses to assess characteristics associated with the amount of OOP expenditures and parental perceptions of these costs. We estimated adjusted prevalence ratios for parental perceptions of OOP costs using logistic regression. RESULTS Based on parent report, nearly two thirds (65.7%) of children incurred some amount of past-year OOP expenditures, with 13.3% of children incurring expenditures of ≥$1000. Parents reported that costs were unreasonable for 35.3% of children with past-year expenditures. The amount of OOP spending was associated with parents' perceptions that costs were unreasonable, with 16.5% of those with $1 to 249 in expenditures reporting unreasonable costs compared to 77.5% of those with >$5,000 in expenditures (P < .05). In adjusted analyses, high OOP expenditures, non-Hispanic white race/ethnicity, lack of health insurance, low household income, parental education levels less than a college degree, and foreign-born nativity status were associated with reports of unreasonable costs (P < .05). CONCLUSIONS This study demonstrates an association between attitudinal and economic measures of health care expenditures for children while demonstrating differences in the perception of costs by measures of family economic vulnerability. Results may inform efforts to assess adequacy of health insurance coverage.
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Affiliation(s)
- Jessica R Jones
- Health Resources and Services Administration, Maternal and Child Health Bureau (JR Jones, MD Kogan, and RM Ghandour), Rockville, Md.
| | - Michael D Kogan
- Health Resources and Services Administration, Maternal and Child Health Bureau (JR Jones, MD Kogan, and RM Ghandour), Rockville, Md
| | - Reem M Ghandour
- Health Resources and Services Administration, Maternal and Child Health Bureau (JR Jones, MD Kogan, and RM Ghandour), Rockville, Md
| | - Cynthia S Minkovitz
- Departments of Population, Family and Reproductive Health and Pediatrics, Johns Hopkins Bloomberg School of Public Health (CS Minkovitz), Baltimore, Md
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10
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Hsiang W, Han X, Jemal A, Nguyen KA, Shuch B, Park H, Yu JB, Gross CP, Davidoff AJ, Leapman MS. The Association Between the Affordable Care Act and Insurance Status, Stage and Treatment in Patients with Testicular Cancer. UROLOGY PRACTICE 2020; 7:252-258. [PMID: 34017908 PMCID: PMC8130174 DOI: 10.1097/upj.0000000000000109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE We aimed to determine whether insurance expansions implemented through the Affordable Care Act (ACA) were associated with changes in coverage status, disease stage, and treatment of younger adults with testicular germ cell tumors (GCT). MATERIALS AND METHODS We identified men aged 18-64 diagnosed with testicular GCTs between 2010 and 2015 in the National Cancer Data Base. We defined time periods as: pre-ACA (2010-2013) and post-ACA (2014-2015) and used difference-in-differences (DID) modeling to examine associations between state Medicaid expansion status and changes in insurance, stage at diagnosis, and treatment. RESULTS Following the ACA, the proportion of patients with any health insurance increased 3.7% (95% CI 3-4.5) in Medicaid expansion states and 3.0% (95% CI 1.5-4.5) in non-expansion states, mainly by gaining Medicaid and private insurance, respectively. The largest increases occurred in low-income patients, where Medicaid expansion was associated with an adjusted increase of 14.5 percentage points (95% CI 7.2-21.8) in Medicaid coverage following the ACA. We did not observe reductions in late-stage diagnoses during the observation period. Changes in the proportion of patients receiving chemotherapy or radiation for advanced-stage cancers were ongoing prior to the ACA and differed between expansion and non-expansion states, limiting assessment of ACA-related effects on individual treatments. CONCLUSIONS Post-ACA, the proportion of newly diagnosed testicular cancer patients with health insurance increased, with the largest effects seen among lowest income individuals. Our findings that changes in practice preceded the ACA and differed by expansion status highlight the need for caution in assessing the legislation's impact.
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Affiliation(s)
| | - Xuesong Han
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, Georgia
| | - Kevin A. Nguyen
- David Geffen School of Medicine, University of California Los Angeles
| | - Brian Shuch
- University of California Los Angeles, Department of Urology
| | - Henry Park
- Yale University School of Medicine, Department of Therapeutic Radiology
- Yale Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center
| | - James B. Yu
- Yale University School of Medicine, Department of Therapeutic Radiology
- Yale Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center
| | - Cary P. Gross
- Yale Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center
- Yale University School of Medicine, Department of Medicine
| | - Amy J. Davidoff
- Yale Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center
- Yale University School of Public Health
| | - Michael S. Leapman
- Yale Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center
- Yale University School of Medicine, Department of Urology
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11
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Withrow DR, Berrington de González A, Spillane S, Freedman ND, Best AF, Chen Y, Shiels MS. Trends in Mortality Due to Cancer in the United States by Age and County-Level Income, 1999-2015. J Natl Cancer Inst 2020; 111:863-866. [PMID: 31199459 DOI: 10.1093/jnci/djz123] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/17/2019] [Accepted: 06/06/2019] [Indexed: 12/15/2022] Open
Abstract
Disparities in cancer mortality by county-level income have increased. It is unclear whether these widening disparities have affected older and younger adults equally. National death certificate data were utilized to ascertain cancer deaths during 1999-2015. Average annual percent changes in mortality rates and mortality rate ratios (RRs) were estimated by county-level income quintile and age (25-64 vs ≥65 years). Among 25- to 64-year-olds, cancer mortality rates were 30% higher (RR = 1.30, 95% confidence interval [CI] = 1.29 to 1.31) in the lowest-vs the highest-income counties in 1999-2001 and 56% higher (RR = 1.56, 95% CI = 1.55 to 1.57) in 2013-2015; the disparities among those 65 years and older were smaller but also widened over time (RR1999-2001 = 1.04, 95% CI = 1.03 to 1.05; RR2013-2015 = 1.14, 95% CI = 1.13 to 1.14). Widening disparities occurred across cancer sites. If all counties had the mortality rates of the highest-income counties, 21.5% of cancer deaths among 25- to 64-year-olds and 7.3% of cancer deaths in those 65 years and older would have been avoided in 2015. These results highlight an ongoing need for equity-focused interventions, particularly among younger adults.
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Affiliation(s)
- Diana R Withrow
- See the Notes section for the full list of authors' affiliations
| | | | - Susan Spillane
- See the Notes section for the full list of authors' affiliations
| | - Neal D Freedman
- See the Notes section for the full list of authors' affiliations
| | - Ana F Best
- See the Notes section for the full list of authors' affiliations
| | - Yingxi Chen
- See the Notes section for the full list of authors' affiliations
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12
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Impact of the Affordable Care Act Insurance Marketplaces on Out-of-Pocket Spending Among Surgical Patients. Ann Surg 2020; 274:e1252-e1259. [PMID: 32221119 DOI: 10.1097/sla.0000000000003823] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the association between the introduction of the Affordable Care Act (ACA) Health Insurance Marketplaces ("Marketplaces") and financial protection for patients undergoing surgery. BACKGROUND The ACA established Marketplaces through which individuals could purchase subsidized insurance coverage. However, the effect of these Marketplaces on surgical patients' healthcare spending remains largely unknown. METHODS We analyzed a nationally representative sample of adults aged 19-64 who underwent surgery in 2010-2017, using the Medical Expenditure Panel Survey. Low-income patients eligible for cost-sharing and premium subsidies in the Marketplaces [income 139%-250% federal poverty level (FPL)] and middle-income patients eligible only for premium subsidies (251%-400% FPL) were compared to high-income controls ineligible for subsidies (>400% FPL) using a quasi-experimental difference-in-differences approach. We evaluated 3 main outcomes: (1) out-of-pocket spending, (2) premium contributions, and (3) likelihood of experiencing catastrophic expenditures, defined as out-of-pocket plus premium spending exceeding 19.5% of family income. RESULTS Our sample included 5450 patients undergoing surgery, representing approximately 69 million US adults. Among low-income patients, Marketplace implementation was associated with $601 lower [95% confidence interval (CI): -$1169 to -$33; P = 0.04) out-of-pocket spending; $968 lower (95% CI: -$1652 to -$285; P = 0.006) premium spending; and 34.6% lower probability (absolute change: -8.3 percentage points; 95% CI: -14.9 to -1.7; P = 0.01) of catastrophic expenditures. We found no evidence that health expenditures changed for middle-income surgical patients. CONCLUSIONS The ACA's insurance Marketplaces were associated with improved financial protection among low-income surgical patients eligible for both cost-sharing and premium subsidies, but not in middle-income patients eligible for only premium subsidies.
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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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Erickson KF, Shen JI, Zhao B, Winkelmayer WC, Chertow GM, Ho V, Bhattacharya J. Safety-Net Care for Maintenance Dialysis in the United States. J Am Soc Nephrol 2020; 31:424-433. [PMID: 31857351 PMCID: PMC7003304 DOI: 10.1681/asn.2019040417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 10/18/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Although most American patients with ESKD become eligible for Medicare by their fourth month of dialysis, some never do. Information about where patients with limited health insurance receive maintenance dialysis has been lacking. METHODS We identified patients initiating maintenance dialysis (2008-2015) from the US Renal Data System, defining patients as "safety-net reliant" if they were uninsured or had only Medicaid coverage at dialysis onset and had not qualified for Medicare by the fourth dialysis month. We examined four dialysis facility ownership categories according to for-profit/nonprofit status and ownership (chain versus independent). We assessed whether patients who were safety-net reliant were more likely to initiate dialysis at certain facility types. We also examined hospital-based affiliation. RESULTS The proportion of patients <65 years initiating dialysis who were safety-net reliant increased significantly over time, from 11% to 14%; 73% of such patients started dialysis at for-profit/chain-owned facilities compared to 76% of all patients starting dialysis. Patients who were safety-net reliant had a 30% higher relative risk of initiating dialysis at nonprofit/independently owned versus for-profit/independently owned facilities (odds ratio, 1.30; 95% CI, 1.24 to 1.36); they had slightly lower relative risks of initiating dialysis at for-profit and non-profit chain-owned facilities, and were more likely to receive dialysis at hospital-based facilities. These findings primarily reflect increased likelihood of dialysis among patients without insurance at certain facility types. CONCLUSIONS Although most patients who were safety-net reliant received care at for-profit/chain-owned facilities, they were disproportionately cared for at nonprofit/independently owned and hospital-based facilities. Ongoing loss of market share of nonprofit/independently owned outpatient dialysis facilities may affect safety net-reliant populations.
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Affiliation(s)
- Kevin F Erickson
- Selzman Institute for Kidney Health, Section of Nephrology, and
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
| | - Jenny I Shen
- Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Bo Zhao
- Selzman Institute for Kidney Health, Section of Nephrology, and
| | | | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Vivian Ho
- Baker Institute for Public Policy, Rice University, Houston, Texas
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
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Beck J, Wignall J, Jacob-Files E, Tchou MJ, Schroeder A, Henrikson NB, Desai AD. Parent Attitudes and Preferences for Discussing Health Care Costs in the Inpatient Setting. Pediatrics 2019; 144:peds.2018-4029. [PMID: 31270139 DOI: 10.1542/peds.2018-4029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To explore parent attitudes toward discussing their child's health care costs in the inpatient setting and to identify strategies for health care providers to engage in cost discussions with parents. METHODS Using purposeful sampling, we conducted semistructured interviews between October 2017 and February 2018 with parents of children with and without chronic disease who received care at a tertiary academic children's hospital. Researchers coded the data using applied thematic analysis to identify salient themes and organized them into a conceptual model. RESULTS We interviewed 42 parents and identified 2 major domains. Categories in the first domain related to factors that influence the parent's desire to discuss health care costs in the inpatient setting, including responsibility for out-of-pocket expenses, understanding their child's insurance coverage, parent responses to financial stress, and their child's severity of illness on hospital presentation. Categories in the second domain related to parent preference regarding the execution of cost discussions. Parents felt these discussions should be optional and individualized to meet the unique values and preferences of families. They highlighted concerns regarding physician involvement in these discussions; their preference instead was to explore financial issues with a financial counselor or social worker. CONCLUSIONS Parents recommended that cost discussions in the inpatient setting should be optional and based on the needs of the family. Families expressed a desire for physicians to introduce rather than conduct cost discussions. Specific recommendations from parents for these discussions may be used to inform the initiation and improvement of cost discussions with families during inpatient encounters.
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Affiliation(s)
- Jimmy Beck
- Department of Pediatrics, University of Washington, Seattle, Washington;
| | - Julia Wignall
- Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, Washington
| | | | - Michael J Tchou
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Alan Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
| | - Nora B Henrikson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington
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Health Insurance Coverage Before and After the Affordable Care Act. SCI 2019. [DOI: 10.3390/sci1010030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Affordable Care Act (ACA) is at the crossroads. It is important to evaluate the effectiveness of the ACA in order to make rational decisions about the ongoing healthcare reform, but existing research into its effect on health insurance status in the United States is insufficient and descriptive. Using data from the National Health Interview Surveys from 2009 to 2015, this study examines changes in health insurance status and its determinants before the ACA in 2009, during its partial implementation in 2010–2013, and after its full implementation in 2014 and 2015. The results of trend analysis indicate a significant increase in national health insurance rate from 82.2% in 2009 to 89.4% in 2015. Logistic regression analyses confirm the similar impact of age, gender, race, marital status, nativity, citizenship, education, and poverty on health insurance status before and after the ACA. Despite similar effects across years, controlling for other variables, youth aged 26 or below, the foreign-born, Asians, and other races had a greater probability of gaining health insurance after the ACA than before the ACA; however, the odds of obtaining health insurance for Hispanics and the impoverished rose slightly during the partial implementation of the ACA but somewhat declined after the full implementation of the ACA starting in 2014. These findings should be taken into account by the U.S. government in deciding the fate of the ACA.
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Schickedanz AB, Escarce JJ, Halfon N, Sastry N, Chung PJ. Adverse Childhood Experiences and Household Out-of-Pocket Healthcare Costs. Am J Prev Med 2019; 56:698-707. [PMID: 30905486 PMCID: PMC6475485 DOI: 10.1016/j.amepre.2018.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/13/2018] [Accepted: 11/14/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Adverse childhood experiences are associated with higher risk of common chronic mental and physical illnesses in adulthood, but little evidence exists on whether this influences medical costs or expenses. This study estimated increases in household medical expenses associated with adults' reported adverse childhood experience scores. METHODS Household out-of-pocket medical cost and adverse childhood experience information was collected in the 2011 and 2013 waves of the Panel Study of Income Dynamics and its linked 2014-2015 Panel Study of Income Dynamics Childhood Retrospective Circumstances Study supplement and analyzed in 2017. Generalized linear regression models estimated adjusted annual household out-of-pocket medical cost differences by retrospective adverse childhood experience count and compared costs by family type and size. Logistic models estimated odds of out-of-pocket costs that were >10% of household income or >100% of savings, as well as odds of household debt. RESULTS Adverse childhood experience scores were associated with higher out-of-pocket costs. Annual household total out-of-pocket medical costs were $184 (95% CI=$90, $278) or 1.18-fold higher when respondents reported one to two adverse childhood experiences and $311 (95% CI=$196, $426) or 1.30-fold higher when three or more adverse childhood experiences were reported by an adult in the household. Odds of household medical costs >10% of income, >100% of savings, and the presence of household medical debt were 2.48-fold (95% CI=1.40, 4.38), 2.25-fold (95% CI=1.69, 2.99), and 2.29-fold (95% CI=1.56, 3.34) higher when an adult in the household reported three or more adverse childhood experiences compared with none. CONCLUSIONS Greater exposure to adverse childhood experiences is associated with higher household out-of-pocket medical costs and financial burden in adulthood.
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Affiliation(s)
- Adam B Schickedanz
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California.
| | - José J Escarce
- Department of Internal Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Neal Halfon
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Narayan Sastry
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| | - Paul J Chung
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
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Dumont DM, Pizzonia C, Poulin S, Meddaugh P. Diabetes Quality of Care and Maintenance in New England: Can Cross-State Collaboration Move Us Forward? Prev Chronic Dis 2018; 15:E165. [DOI: 10.5888/pcd15.180250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Dora M. Dumont
- Rhode Island Department of Health, Providence, Rhode Island
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Caitlin Pizzonia
- University of Southern Maine, Portland, Maine
- Maine Center for Disease Control and Prevention, Augusta, Maine
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Dale R, Guo B. Estimating epidemiological parameters of a stochastic differential model of HIV dynamics using hierarchical Bayesian statistics. PLoS One 2018; 13:e0200126. [PMID: 30044818 PMCID: PMC6059410 DOI: 10.1371/journal.pone.0200126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 04/29/2018] [Indexed: 11/19/2022] Open
Abstract
Current estimates of the HIV epidemic indicate a decrease in the incidence of the disease in the undiagnosed subpopulation over the past 10 years. However, a lack of access to care has not been considered when modeling the population. Populations at high risk for contracting HIV are twice as likely to lack access to reliable medical care. In this paper, we consider three contributors to the HIV population dynamics: at-risk population exhaustion, lack of access to care, and usage of anti-retroviral therapy (ART) by diagnosed individuals. An extant problem in the mathematical study of this system is deriving parameter estimates due to a portion of the population being unobserved. We approach this problem by looking at the proportional change in the infected subpopulations. We obtain conservative estimates for the proportional change of the infected subpopulations using hierarchical Bayesian statistics. The estimated proportional change is used to derive epidemic parameter estimates for a system of stochastic differential equations (SDEs). Model fit is quantified to determine the best parametric explanation for the observed dynamics in the infected subpopulations. Parameter estimates derived using these methods produce simulations that closely follow the dynamics observed in the data, as well as values that are generally in agreement with prior understanding of transmission and diagnosis rates. Simulations suggest that the undiagnosed population may be larger than currently estimated without significantly affecting the population dynamics.
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Affiliation(s)
- Renee Dale
- Department of Experimental Statistics, Louisiana State University, Baton Rouge, Louisiana, United States of America
- Department of Biological Sciences, Louisiana State University, Baton Rouge, Louisiana, United States of America
- * E-mail:
| | - BeiBei Guo
- Department of Experimental Statistics, Louisiana State University, Baton Rouge, Louisiana, United States of America
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Sommers BD, McMURTRY CL, Blendon RJ, Benson JM, Sayde JM. Beyond Health Insurance: Remaining Disparities in US Health Care in the Post-ACA Era. Milbank Q 2018; 95:43-69. [PMID: 28266070 DOI: 10.1111/1468-0009.12245] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Benjamin D Sommers
- Harvard T.H. Chan School of Public Health.,Harvard Medical School.,Brigham & Women's Hospital
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Boone J. Basic versus supplementary health insurance: Access to care and the role of cost effectiveness. JOURNAL OF HEALTH ECONOMICS 2018; 60:53-74. [PMID: 29913308 DOI: 10.1016/j.jhealeco.2018.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 04/05/2018] [Accepted: 05/22/2018] [Indexed: 06/08/2023]
Abstract
In a model where patients face budget constraints that make some treatments unaffordable without health insurance, we ask which treatments should be covered by universal basic insurance and which by private voluntary insurance. We argue that next to cost effectiveness, prevalence is important if the government wants to maximize the welfare gain that it gets from its health budget. Conditions are derived under which basic insurance should cover treatments that are mainly used by high risk agents with low income.
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Affiliation(s)
- Jan Boone
- CentER, TILEC, Department of Economics, Tilburg University, P.O. Box 90153, 5000 LE Tilburg, The Netherlands; CEPR, London, UK.
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Kelly AM, Mullan PB. Designing a Curriculum for Professionalism and Ethics Within Radiology: Identifying Challenges and Expectations. Acad Radiol 2018; 25:610-618. [PMID: 29580789 DOI: 10.1016/j.acra.2018.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/17/2018] [Accepted: 02/19/2018] [Indexed: 12/17/2022]
Abstract
Although professionalism and ethics represent required competencies, they are more challenging than other competencies to design a curriculum for and teach. Reasons include variability in agreed definitions of professionalism within medicine and radiology. This competency is also framed differently whether as roles, duties, actions, skills, behavior, beliefs, and attitudes. Standardizing a curriculum in professionalism is difficult because each learner's (medical student/resident) professional experiences and interactions will be unique. Professionalism is intertwined throughout all (sub) specialties and areas and its teaching cannot occur in isolation as a standalone curriculum. In the past, professionalism was not emphasized enough or at all, with global (or no) assessments, with the potential effect of trainees not valuing it. Although we can teach it formally in the classroom and informally in small groups, much of professionalism is witnessed and learned as "hidden curricula". The formal, informal, and hidden curricula often contradict each other creating confusion, disillusion, and cynicism in trainees. The corporatization of medicine pressurizes us to increase efficiency (throughput) with less focus on aspects of professionalism that add value, creating a disjoint between what we do in practice and preach to trainees. Progressively, expectations for our curriculum include providing evidence for the impacts of our efforts on patient outcomes. Generational differences in the perception of professionalism and the increasingly diverse and multicultural society in which we live affects our interpretation of professionalism, which can add to confusion and misunderstanding. The objectives of this article are to outline challenges facing curriculum design in professionalism and to make suggestions to help educators avoid or overcome them.
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Excess Deaths Among the Uninsured Before the Affordable Care Act (ACA), and Potential Post-ACA Reductions. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 23:e18-e28. [PMID: 27598710 DOI: 10.1097/phh.0000000000000428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Despite implementation of the Affordable Care Act (ACA), as of 2015, about 25.8 million working-age Americans remained uninsured and vulnerable to premature death because of poor health care access. The ACA-mandated phasing out of disproportionate share hospital payments that supported charity care may aggravate care access for the residual uninsured. OBJECTIVES To estimate excess deaths among the uninsured and the potential ACA impact on the basis of a recent cohort's mortality experience. We hypothesized a higher uninsured mortality risk than the available pre-2000 estimate because of worsening of care disparities owing to technology-driven advances in life-saving care. DESIGN We conducted a retrospective cohort study of the 1999 to 2002 National Health and Nutrition Examination Survey respondents observed through 2011. We estimated (a) weighted Cox proportional mortality hazard of uninsured working-age adults adjusted for demographics, comorbidity, and lifestyle behaviors, (b) weighted mortality rates among the uninsured and insured within age and comorbidity strata, and (c) excess deaths because of uninsurance using the Institute of Medicine methodology. SETTING Noninstitutionalized US population. PARTICIPANTS Adults aged 20 to 64 years. MAIN OUTCOME MEASURE Mortality. RESULTS Of 7274 study-eligible respondents, 20.6% were uninsured and 478 died during follow-up, for an adjusted uninsured mortality hazard ratio of 1.57 (95% confidence interval, 1.12-2.21) versus privately insured, translating to 48 529 excess deaths among the population aged 25 to 64 years in 2011 (7.8% of total deaths in this age group). The estimated proportion of excess deaths was 52% higher than the pre-2000 cohort study. The mortality disparity increased with age and comorbidity. CONCLUSIONS Findings support our hypotheses, and indicate that post-ACA, a residual 4.7% excess mortality among working-age adults will continue, about 30 428 excess deaths annually. Restoration of disproportionate share hospital supports and continued advocacy for universal health care coverage are needed to reduce avoidable deaths.
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Goldman AL, Woolhandler S, Himmelstein DU, Bor DH, McCormick D. Out-of-Pocket Spending and Premium Contributions After Implementation of the Affordable Care Act. JAMA Intern Med 2018; 178:347-355. [PMID: 29356828 PMCID: PMC5885918 DOI: 10.1001/jamainternmed.2017.8060] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE The Affordable Care Act (ACA) was associated with a reduced number of Americans who reported being unable to afford medical care, but changes in actual health spending by households are not known. OBJECTIVES To estimate changes in household spending on health care nationwide after implementation of the ACA. DESIGN, SETTING, AND PARTICIPANTS Population-based data from the Medical Expenditure Panel Survey from January 1, 2012, through December 31, 2015, and multivariable regression were used to examine changes in out-of-pocket spending, premium contributions, and total health spending (out-of-pocket plus premiums) after the ACA's coverage expansions on January 1, 2014. The study population included a nationally representative sample of US adults aged 18 to 64 years (n = 83 431). In addition, changes were assessed in the likelihood of exceeding affordability thresholds for each outcome and spending changes for income subgroups defined under the ACA to determine program eligibility at 138% or less, 139% to 250%, 251% to 400%, and greater than 400% of the federal poverty level (FPL). EXPOSURE Implementation of the ACA's major insurance programs on January 1, 2014. MAIN OUTCOMES AND MEASURES Mean individual-level out-of-pocket spending and premium payments and the percentage of persons experiencing high-burden spending, defined as more than 10% of family income for out-of-pocket expenses, more than 9.5% for premium payments, and more than 19.5% for out-of-pocket plus premium payments. RESULTS In this nationally representative survey of 83 431 adults (weighted frequency, 49.1% men and 50.9% women; median age, 40.3 years; interquartile range, 28.6-52.4 years), ACA implementation was associated with an 11.9% decrease (95% CI, -17.1% to -6.4%; P < .001) in mean out-of-pocket spending in the full sample, a 21.4% decrease (95% CI, -30.1% to -11.5%; P < .001) in the lowest-income group (≤138% of the FPL), an 18.5% decrease (95% CI, -27.0% to -9.0%; P < .001) in the low-income group (139%-250% of the FPL), and a 12.8% decrease (95% CI, -22.1% to -2.4%; P = .02) in the middle-income group (251%-400% of the FPL). Mean premium spending increased in the full sample (12.1%; 95% CI, 1.9%-23.3%) and the higher-income group (22.9%; 95% CI, 5.5%-43.1%). Combined out-of-pocket plus premium spending decreased in the lowest-income group only (-16.0%; 95% CI, -27.6% to -2.6%). The odds of household out-of-pocket spending exceeding 10% of family income decreased in the full sample (odds ratio [OR], 0.80; 95% CI, 0.70-0.90) and in the lowest-income group (OR, 0.80; 95% CI, 0.67-0.97). The odds of high-burden premium spending increased in the middle-income group (OR, 1.28; 95% CI, 1.03-1.59). CONCLUSIONS AND RELEVANCE Implementation of the ACA was associated with reduced out-of-pocket spending, particularly for low-income persons. However, many of these individuals continue to experience high-burden out-of-pocket and premium spending. Repeal or substantial reversal of the ACA would especially harm poor and low-income Americans.
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Affiliation(s)
- Anna L Goldman
- Cambridge Health Alliance, Cambridge, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steffie Woolhandler
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, City University of New York at Hunter College, New York City, New York
| | - David U Himmelstein
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, City University of New York at Hunter College, New York City, New York
| | - David H Bor
- Cambridge Health Alliance, Cambridge, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Danny McCormick
- Cambridge Health Alliance, Cambridge, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Fang J, Wang G, Ayala C, Lucido SJ, Loustalot F. Healthcare Access Among Young Adults: Impact of the Affordable Care Act on Young Adults With Hypertension. Am J Prev Med 2017; 53:S213-S219. [PMID: 29153123 PMCID: PMC7038642 DOI: 10.1016/j.amepre.2017.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/03/2017] [Accepted: 07/14/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The Patient Protection and Affordable Care Act provision implemented policies to improve coverage for young adults. It is not known if it affected access to care among young adults with hypertension. METHODS National Health Interview Survey data from 2006 to 2009 and 2011 to 2014 were used. Young adults aged 19-25 years were assessed for potential barriers to access to health care. The authors compared the percentage of each indicator of barriers to access to health care among young adults in general, as well as those with hypertension in the two time periods and estimated the AOR. All data were self-reported. The analyses were conducted in 2016. RESULTS Among young adults, the frequencies of barrier indicators were significantly lower in 2011-2014 than 2006-2009, except "did not see doctor in the past 12 months." Among those with hypertension, the percentage reporting "no health insurance" (31.3% vs 23.3%, p=0.037); "no place to see a doctor when needed" (30.5% vs 21.6%, p=0.031); or "cannot afford prescribed medicine" (23.0% vs 15.3%, p=0.023) were significantly lower in 2011-2014 compared with that of 2006-2009. The differences maintained statistical significance after adjusting for sex, race/ethnicity, and level of education. CONCLUSIONS Significant differences in select access to care measures were found among young adults with hypertension between 2006-2009 and 2011-2014, as was found among young adults generally. Changes in extension of dependent insurance coverage in 2010 may have led to improvements in access to care among this group.
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Affiliation(s)
- Jing Fang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carma Ayala
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Salvatore J Lucido
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Fleetwood Loustalot
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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State-Level Surveillance of Underinsurance and Health Care-Related Financial Burden. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2017; 23:e10-e16. [PMID: 27997481 DOI: 10.1097/phh.0000000000000481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) has reduced uninsurance, but underinsurance, health care-related financial burden, and dental uninsurance may not follow suit. Underinsurance is associated with reduced access to care, household debt, and bankruptcy but has been difficult to track without economic data. METHODS We used readily available state-level survey data to build a model that states can adopt to implement surveillance over underinsurance and health care-related financial burden, as well as assess related disparities and health profiles. RESULTS The state prevalence of underinsurance and dental uninsurance did not change in the first year of the ACA's individual mandate. Underinsurance was associated with poorer health-related quality-of-life measures: compared with the fully insured, underinsured adults had an adjusted odds ratio of 2.40 (95% CI, 1.71-3.38) of fair or poor general health. CONCLUSION Tracking underinsurance and medical debt can help public health and health care access stakeholders evaluate which mechanisms (deductibles, co-pays, uncovered services, or is proportionately priced health care services and products) are barriers to care and improved health outcomes.
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Ellis RP, Bachman SS, Tan HR. Refining Our Understanding of Value-Based Insurance Design and High Cost Sharing on Children. Pediatrics 2017; 139:S136-S144. [PMID: 28562311 DOI: 10.1542/peds.2016-2786h] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There is significant concern about the financial burdens of new insurance plan designs on families, particularly families with children and youth with special health care needs (CYSHCN). With value-based insurance design (VBID) plans growing in popularity, this study examined the implications of selected VBID cost-sharing features on children. METHODS We studied children's health care spending patterns in 2 data sets that include high deductible and narrow network plans among others. Medical Expenditure Panel Survey data from 2007 to 2013 on 22 392 children were used to study out-of-pocket (OOP) costs according to CYSHCN, family income, and spending. MarketScan large employer insurance claims data from 2007 to 2014 (N = 4 263 452) were used to test for differences in mean total payments and OOP costs across various health plans. RESULTS Across the data sets, we found that existing health plans place significant financial burdens on families, particularly lower income households and families with CYSHCN; individuals among the top 10% of OOP spending averaged more than $2000 per child. Although high deductible and consumer-driven plans impose substantial OOP costs on children, they do not significantly reduce spending, whereas health maintenance organizations that use network restrictions and tighter management do. CONCLUSIONS Our results do not support the conclusion that high cost-sharing features that are common in VBID plans will significantly reduce health care spending on children.
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Affiliation(s)
| | - Sara S Bachman
- Schools of Social Work and Public Health, Boston University, Boston, Massachusetts
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Fang J, Zhao G, Wang G, Ayala C, Loustalot F. Insurance Status Among Adults With Hypertension-The Impact of Underinsurance. J Am Heart Assoc 2016; 5:JAHA.116.004313. [PMID: 28003253 PMCID: PMC5210449 DOI: 10.1161/jaha.116.004313] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hypertension is a major risk factor for heart disease and stroke. Health insurance coverage affects hypertension treatment and control, but limited information is available for US adults with hypertension who are classified as underinsured. Methods and Results Using Behavioral Risk Factor Surveillance System 2013 data, we identified adults with self‐reported hypertension. On the basis of self‐reported health insurance status and health care–related financial burdens, participants were categorized as uninsured, underinsured, or adequately insured. Proxies for health care received included whether they reported taking antihypertensive medications and whether they visited a doctor for a routine checkup in the past year. We assessed the association between health insurance status and health care received, adjusting for selected sociodemographic characteristics. Among 123 257 participants from 38 states and District of Columbia with self‐reported hypertension, 12% were uninsured, 26% were underinsured, and 62% were adequately insured. In adjusted models using adequately insured participants as referent, both uninsured (adjusted odds ratio, 0.39; 95% CI, 0.35–0.43) and underinsured (0.83, 0.76–0.89) participants were less likely to report using antihypertensive medication than those of adequately insured participants. Similarly, adjusted odds ratio of visiting a doctor for routine checkup in the past year were 0.25 (0.23–0.28) for those who were uninsured and 0.78 (0.72–0.84) for those who were underinsured compared to those with adequate insurance. Conclusions Uninsured and underinsured participants with hypertension were less likely to report receiving care compared to those with adequate insurance coverage. Disparities in health care coverage may necessitate targeted interventions, even among people with health insurance.
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Affiliation(s)
- Jing Fang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Guixiang Zhao
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Carma Ayala
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Fleetwood Loustalot
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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Abstract
The Patient Protection and Affordable Care Act of 2010 is the most sweeping health care legislation in a generation. The goal of the legislation is to increase access to both public and private insurance, and to improve the affordability and quality of care. Many provisions of the bill have a direct impact on the women's health care services. This paper provides an overview of the bill's provisions that have the largest impact on women's health care and provides data on the impact of the bill to date.
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Baird KE. The financial burden of out-of-pocket expenses in the United States and Canada: How different is the United States? SAGE Open Med 2016; 4:2050312115623792. [PMID: 26985389 PMCID: PMC4778086 DOI: 10.1177/2050312115623792] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/18/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This article compares the burden that medical cost-sharing requirements place on households in the United States and Canada. It estimates the probability that individuals with similar demographic features in the two countries have large medical expenses relative to income. METHOD The study uses 2010 nationally representative household survey data harmonized for cross-national comparisons to identify individuals with high medical expenses relative to income. Using logistic regression, it estimates the probability of high expenses occurring among 10 different demographic groups in the two countries. RESULTS The results show the risk of large medical expenses in the United States is 1.5-4 times higher than it is in Canada, depending on the demographic group and spending threshold used. The United States compares least favorably when evaluating poorer citizens and when using a higher spending threshold. CONCLUSION Recent health care reforms can be expected to reduce Americans' catastrophic health expenses, but it will take very large reductions in out-of-pocket expenditures-larger than can be expected-if poorer and middle-class families are to have the financial protection from high health care costs that their counterparts in Canada have.
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Affiliation(s)
- Katherine E Baird
- The Division of Politics, Philosophy and Public Affairs, University of Washington Tacoma, Tacoma, WA, USA
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Diaz R, Behr J, Kumar S, Britton B. MODELING CHRONIC DISEASE PATIENT FLOWS DIVERTED FROM EMERGENCY DEPARTMENTS TO PATIENT-CENTERED MEDICAL HOMES. IIE TRANSACTIONS ON HEALTHCARE SYSTEMS ENGINEERING 2016; 5:268-285. [PMID: 26770663 PMCID: PMC4709841 DOI: 10.1080/19488300.2015.1095824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chronic Disease is defined as a long lasting health condition, which can develop and/or worsen over an extended time, but which can also be controlled. The monetary and budgetary toll due to its persistent nature has become unsustainable and requires pressing actions to limit their incidence and burden. This paper demonstrates the utility of the System Dynamics approach to simulate the behavior of key factors involved in the implementation of chronic disease management. We model the patient flow diversion from emergency departments (ED) to patient-centered medical homes (PCMH), with emphasis on the visit rates, as well as the effect of insurance coverage, in an effort to assure continuity of quality care for Asthma patients at lower costs. The model is used as an evaluative method to identify conditions of a maintained health status through adequate policy planning, in terms of resources and capacity. This approach gives decision makers the ability to track the level of implementation of the intervention and generate knowledge about dynamics between population demands and the intervention effectiveness. The functionality of the model is demonstrated through the consideration of hypothetical scenarios executed using sensitivity analysis.
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Affiliation(s)
- Rafael Diaz
- Old Dominion University, Virginia Modeling, Analysis, and Simulation Center, Norfolk, United States
| | - Joshua Behr
- Old Dominion University, Virginia Modeling, Analysis, and Simulation Center, Suffolk, 23435 United States
| | - Sameer Kumar
- University of St. Thomas, Minneapolis, United States
| | - Bruce Britton
- Eastern Virginia Medical School, Norfolk, United States
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Jackson CR, Eavey RD, Francis DO. Surgeon Awareness of Operating Room Supply Costs. Ann Otol Rhinol Laryngol 2015; 125:369-77. [PMID: 26522468 DOI: 10.1177/0003489415614864] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The extent to which surgeons understand costs associated with expensive operative procedures remains unclear. The goal of the study was to better understand surgeon cost awareness of operating room supplies and implants. METHODS This was a cross-sectional study of faculty (n = 24) and trainees (fellow and residents, n = 27) in the Department of Otolaryngology. Participants completed surveys to assess opinions on importance of cost and ease in accessing cost data and were asked to estimate the costs of operating room (OR) supplies and implants. Estimates within 20% of actual cost were considered correct. Analyses were stratified into faculty and trainee surgeons. RESULTS Cost estimates varied widely, with a low percentage of correct estimations (25% for faculty, 12% for trainees). Surgeons tended to underestimate the cost of high-cost items (55%) and overestimate the cost of low-cost items (77%). Attending surgeons were more accurate at correctly estimating costs within their own subspecialty (33% vs 16%, P < .001). Self-rated cost knowledge and years in practice did not correlate with cost accuracy (P < .05). CONCLUSIONS A majority of surgeons were unable to correctly estimate the costs of items/implants used in their OR. An opportunity exists to improve the mechanisms by which cost data are fed back to physicians to help promote value-based decision making.
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Affiliation(s)
- Christopher R Jackson
- Department of Otolaryngology, Bill Wilkerson Center for Otolaryngology and Communication Disorders, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Roland D Eavey
- Department of Otolaryngology, Bill Wilkerson Center for Otolaryngology and Communication Disorders, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David O Francis
- Department of Otolaryngology, Bill Wilkerson Center for Otolaryngology and Communication Disorders, Vanderbilt University Medical Center, Nashville, Tennessee, USA Vanderbilt Voice Center, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA Department of Otolaryngology, Bill Wilkerson Center for Otolaryngology and Communication Disorders, Center for Surgical Quality and Outcomes Research, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Ward BW, Martinez ME. Health Insurance Status and Psychological Distress among U.S. Adults Aged 18-64 Years. Stress Health 2015; 31:324-35. [PMID: 24403273 PMCID: PMC4658514 DOI: 10.1002/smi.2559] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 11/06/2013] [Accepted: 11/20/2013] [Indexed: 11/07/2022]
Abstract
The purpose of this research was to examine the relationship between psychological distress and aspects of health insurance status, including lack of coverage, types of coverage and disruption in coverage, among US adults. Data from the 2001-2010 National Health Interview Survey were used to conduct analyses representative of the US adult population aged 18-64 years. Multivariate analyses regressed psychological distress on health insurance status while controlling for covariates. Adults with private or no health insurance coverage had lower levels of psychological distress than those with public/other coverage. Adults who recently (≤1 year) experienced a change in health insurance status had higher levels of distress than those who had not recently experienced a change. An interaction effect indicated that the relationship between recent change in health insurance status and distress was not dependent on whether an adult had private versus public/other coverage. However, for adults who had not experienced a change in status in the past year, the average absolute level of distress is higher among those with no coverage versus private coverage. Although significant relationships between psychological distress and health insurance status were identified, their strength was modest, with other demographic and health condition covariates also being potential sources of distress. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Brian W. Ward
- Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, United States,Correspondence: Brian W. Ward, Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, 3311 Toledo Road, Room 2330, Hyattsville, MD 20782, United States
| | - Michael E. Martinez
- Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, United States
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Nipp RD, Zullig LL, Samsa G, Peppercorn JM, Schrag D, Taylor DH, Abernethy AP, Zafar SY. Identifying cancer patients who alter care or lifestyle due to treatment‐related financial distress. Psychooncology 2015; 25:719-25. [DOI: 10.1002/pon.3911] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 05/09/2015] [Accepted: 06/12/2015] [Indexed: 11/07/2022]
Affiliation(s)
| | - Leah L. Zullig
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical Center Durham NC USA
- Division of General Internal Medicine, Department of MedicineDuke University Durham NC USA
| | - Gregory Samsa
- Division of Medical Oncology, Department of MedicineDUMC Durham NC USA
| | | | | | | | - Amy P. Abernethy
- Division of Medical Oncology, Department of MedicineDUMC Durham NC USA
| | - S. Yousuf Zafar
- Division of Medical Oncology, Department of MedicineDUMC Durham NC USA
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Austin S, Ramamonjiarivelo Z, Qu H, Ellis-Griffith G. Acupuncture Use in the United States: Who, Where, Why, and at What Price? Health Mark Q 2015; 32:113-128. [PMID: 26075541 DOI: 10.1080/07359683.2015.1033929] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Despite the increase in acupuncture uses and greater than ever before interest of funding agencies to fund biomedical research in acupuncture, little is known about the profile of acupuncture users. We examined who these individuals are, where they reside, why they use acupuncture, and what price they pay. The increased use and high costs associated with each acupuncture visit poses questions to health care insurers regarding its coverage. Profiling will help conventional providers identify the segment of the population who are more likely to use acupuncture and educate them on the possible risks and benefits of using it with conventional medicine.
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Affiliation(s)
- Shamly Austin
- a Department of Critical Care Medicine , University of Pittsburgh , Pittsburgh , Pennsylvania
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36
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Houle JN, Keene DE. Getting sick and falling behind: health and the risk of mortgage default and home foreclosure. J Epidemiol Community Health 2014; 69:382-7. [PMID: 25430548 DOI: 10.1136/jech-2014-204637] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND An emerging literature shows that mortgage strain can lead to poor health outcomes, but less work has focused on whether and how health shocks influence mortgage distress. We examine the link between changes in health status and default/foreclosure risk among older middle-aged adults. METHOD We used National Longitudinal Study of Youth 1979 data and multivariate logistic regression models to examine the relationship between changes in health limitations and chronic conditions across survey waves and risk of mortgage default and foreclosure. RESULTS We found that changes in health limitations and chronic conditions increased the risk of default and foreclosure between 2007 and 2010. These associations were partially mediated by changes in family income and loss of health insurance. CONCLUSIONS From a policy perspective, the strong link between the onset of illness and foreclosure suggests a need to re-examine the safety-nets that are available to individuals who become ill or disabled.
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Affiliation(s)
- Jason N Houle
- Department of Sociology, Dartmouth College, Hanover, New Hampshire, USA
| | - Danya E Keene
- Social Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
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Wisk LE, Gangnon R, Vanness DJ, Galbraith AA, Mullahy J, Witt WP. Development of a novel, objective measure of health care-related financial burden for U.S. families with children. Health Serv Res 2014; 49:1852-74. [PMID: 25328073 DOI: 10.1111/1475-6773.12248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To develop and validate a theoretically based and empirically driven objective measure of financial burden for U.S. families with children. DATA SOURCES The measure was developed using 149,021 families with children from the National Health Interview Survey, and it was validated using 18,488 families with children from the Medical Expenditure Panel Survey. STUDY DESIGN We estimated the marginal probability of unmet health care need due to cost using a bivariate tensor product spline for family income and out-of-pocket health care costs (OOPC; e.g., deductibles, copayments), while adjusting for confounders. Recursive partitioning was performed on these probabilities, as a function of income and OOPC, to establish thresholds demarcating levels of predicted risk. PRINCIPAL FINDINGS We successfully generated a novel measure of financial burden with four categories that were associated with unmet need (vs. low burden: midlow OR: 1.93, 95 percent CI: 1.78-2.09; midhigh OR: 2.78, 95 percent CI: 2.49-3.10; high OR: 4.38, 95 percent CI: 3.99-4.80). The novel burden measure demonstrated significantly better model fit and less underestimation of financial burden compared to an existing measure (OOPC/income ≥ 10 percent). CONCLUSION The newly developed measure of financial burden establishes thresholds based on different combinations of family income and OOPC that can be applied in future studies of health care utilization and expenditures and in policy development and evaluation.
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Affiliation(s)
- Lauren E Wisk
- Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; Department of Population Health Sciences, School of Medicine and Public Health University of Wisconsin, Madison, Madison, WI
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Fletcher RA. Keeping up with the Cadillacs: What Health Insurance Disparities, Moral Hazard, and the Cadillac Tax Mean to The Patient Protection and Affordable Care Act. Med Anthropol Q 2014; 30:18-36. [PMID: 25132244 DOI: 10.1111/maq.12120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A major goal of The Patient Protection and Affordable Care Act is to broaden health care access through the extension of insurance coverage. However, little attention has been given to growing disparities in access to health care among the insured, as trends to reduce benefits and increase cost sharing (deductibles, co-pays) reduce affordability and access. Through a political economic perspective that critiques moral hazard, this article draws from ethnographic research with the United Steelworkers (USW) at a steel mill and the Retail, Wholesale and Department Store Union (RWDSU) at a food-processing plant in urban Central Appalachia. In so doing, this article describes difficulties of health care affordability on the eve of reform for differentially insured working families with employer-sponsored health insurance. Additionally, this article argues that the proposed Cadillac tax on high-cost health plans will increase problems with appropriate health care access and medical financial burden for many families.
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Li R, Barker LE, Shrestha S, Zhang P, Duru OK, Pearson-Clarke T, Gregg EW. Changes over time in high out-of-pocket health care burden in U.S. adults with diabetes, 2001-2011. Diabetes Care 2014; 37:1629-35. [PMID: 24667459 PMCID: PMC4914036 DOI: 10.2337/dc13-1997] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE High out-of-pocket (OOP) costs can be an obstacle to health care access and treatment compliance. This study investigated trends in high OOP health care burden in people with diabetes. RESEARCH DESIGN AND METHODS Using Medical Expenditure Panel Survey 2001-2011 data, we examined trends in the proportion of people aged 18-64 years with diabetes facing a high OOP burden. We also examined whether the trend differed by insurance status (private insurance, public insurance, or no insurance) or by income level (poor and near poor, low income, middle income, or high income). RESULTS In 2011, 23% of people with diabetes faced high OOP burden. Between 2001-2002 and 2011, the proportion of people facing high OOP burden fell by 5 percentage points (P < 0.01). The proportion of those who were publicly insured decreased by 22 percentage points (P < 0.001) and of those who were uninsured by 12 percentage points (P = 0.01). Among people with diabetes who were poor and near poor and those with low income, the proportion facing high OOP burden decreased by 21 (P < 0.001) and 13 (P = 0.01) percentage points, respectively; no significant change occurred in the proportion with private insurance or middle and high incomes between 2001-2002 and 2011. CONCLUSIONS The past decade has seen a narrowing of insurance coverage and income-related disparities in high OOP burden in people with diabetes; yet, almost one-fourth of all people with diabetes still face a high OOP burden.
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Affiliation(s)
- Rui Li
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lawrence E Barker
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sundar Shrestha
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - O Kenrick Duru
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Tony Pearson-Clarke
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Edward W Gregg
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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Abstract
BACKGROUND Many young women have turned to illness blogs to describe their lived experience with cancer. Blogs represent an untapped source of knowledge for researchers and clinicians. OBJECTIVE The purpose of this qualitative, exploratory study was to describe the life disruptions caused by cancer among young women, as well as to understand the facilitators and barriers in accessing healthcare services during and after active treatment. METHODS Sixteen Internet illness blogs were analyzed among women, aged between 20 and 39 years, diagnosed with cancer. These blogs were analyzed based on phenomenological qualitative methods and thematic analysis. RESULTS There were 4 dimensions of persistent problems that were articulated in the narratives of the young women without any relief. They included pain and fatigue, insurance and financial barriers, concerns related to fertility, and symptoms of posttraumatic stress and anxiety. CONCLUSION The young women's narratives capture fear, uncertainty, anger, and the debilitating nature of these persistent issues. Many of the women expressed their lingering physical, psychosocial, and emotional problems. IMPLICATIONS FOR PRACTICE Online illness narratives are a naturalistic form of inquiry that allows nurses to understand the experience of the patient through their own words and accounts. This study provides a foundation for nursing-based interventions that transcend traditional clinic experiences.
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Horton S, Abadía C, Mulligan J, Thompson JJ. Critical Anthropology of Global Health "takes a stand" statement: a critical medical anthropological approach to the U.S.'s Affordable Care Act. Med Anthropol Q 2014; 28:1-22. [PMID: 24395630 DOI: 10.1111/maq.12065] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The Affordable Care Act (ACA) of 2010--the U.S.'s first major health care reform in over half a century-has sparked new debates in the United States about individual responsibility, the collective good, and the social contract. Although the ACA aims to reduce the number of the uninsured through the simultaneous expansion of the private insurance industry and government-funded Medicaid, critics charge it merely expands rather than reforms the existing fragmented and costly employer-based health care system. Focusing in particular on the ACA's individual mandate and its planned Medicaid expansion, this statement charts a course for ethnographic contributions to the on-the-ground impact of the ACA while showcasing ways critical medical anthropologists can join the debate. We conclude with ways that anthropologists may use critiques of the ACA as a platform from which to denaturalize assumptions of "cost" and "profit" that underpin the global spread of market-based medicine more broadly.
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Affiliation(s)
- Sarah Horton
- Department of Anthropology, University of Colorado, Denver
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Parikh PB, Yang J, Leigh S, Dorjee K, Parikh R, Sakellarios N, Meng H, Brown DL. The impact of financial barriers on access to care, quality of care and vascular morbidity among patients with diabetes and coronary heart disease. J Gen Intern Med 2014; 29:76-81. [PMID: 24078406 PMCID: PMC3889957 DOI: 10.1007/s11606-013-2635-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/23/2013] [Accepted: 09/03/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The prevalence and consequences of financial barriers to health care among patients with multiple chronic diseases are poorly understood. OBJECTIVE We sought to assess the prevalence of self-reported financial barriers to health care among individuals with diabetes and coronary heart disease (CHD) and to determine their association with access to care, quality of care and clinical outcomes. DESIGN The 2007 Centers for Disease Control Behavioral Risk Factor Surveillance Survey. PARTICIPANTS Diabetic patients with CHD. MAIN MEASURES Financial barriers to health care were defined by a self-reported time in the past 12 months when the respondent needed to see a doctor but could not because of cost. The primary clinical outcome was vascular morbidity—a composite of stroke, retinopathy, nonhealing foot sores or bilateral foot amputations. KEY RESULTS Among the 11,274 diabetics with CHD, 1,541 (13.7 %) reported financial barriers to health care. Compared to individuals without financial barriers, those with financial barriers had significantly reduced rates of medical assessments within the past 2 years, hemoglobin (Hgb) A1C measurements in the past year, cholesterol measurements at any time, eye and foot examinations within the past year, diabetic education, antihypertensive treatment, aspirin use and a higher prevalence of vascular morbidity. In multivariable analyses, financial barriers to health care were independently associated with reduced odds of medical checkups (Odds Ratio [OR], 0.61; 95 % Confidence Intervals [CI], 0.55–0.67), Hgb A1C measurement (OR, 0.85; 95 % CI, 0.77–0.94), cholesterol measurement (OR, 0.76; 95 % CI, 0.67–0.86), eye (OR, 0.85; 95 % CI, 0.79–0.92) and foot (OR, 0.92; 95 % CI, 0.84–1.00) examinations, diabetic education (OR, 0.93; 95 % CI, 0.87–0.99), aspirin use (OR, 0.88; 95 % CI, 0.81–0.96) and increased odds of vascular morbidity (OR, 1.23; 95 % CI, 1.14–1.33). CONCLUSIONS In diabetic adults with CHD, financial barriers to health care were associated with impaired access to medical care, inferior quality of care and greater vascular morbidity. Eliminating financial barriers and adherence to guideline-based recommendations may improve the health of individuals with multiple chronic diseases.
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Affiliation(s)
- Puja B. Parikh
- />Department of Medicine, Division of Cardiovascular Medicine, State University of New York, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Jie Yang
- />Department of Preventive Medicine, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Steven Leigh
- />Department of Medicine, Division of Cardiovascular Medicine, State University of New York, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Kunchok Dorjee
- />Department of Preventive Medicine, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Roopali Parikh
- />Department of Medicine, Division of Cardiovascular Medicine, State University of New York, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Nicholas Sakellarios
- />Department of Medicine, Division of Cardiovascular Medicine, State University of New York, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Hongdao Meng
- />Department of Preventive Medicine, Stony Brook University Medical Center, Stony Brook, NY USA
| | - David L. Brown
- />Department of Medicine, Division of Cardiovascular Medicine, State University of New York, Stony Brook University Medical Center, Stony Brook, NY USA
- />Department of Medicine, Division of Cardiovascular Medicine, Health Sciences Center, T16-080, Stony Brook, NY 11794-8160 USA
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Guevara JP, Moon J, Hines EM, Fremont E, Wong A, Forrest CB, Silber JH, Pati S. Continuity of Public Insurance Coverage. Med Care Res Rev 2013; 71:115-37. [DOI: 10.1177/1077558713504245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.
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Affiliation(s)
| | - Jeanhee Moon
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Ettya Fremont
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Angie Wong
- Stony Brook Long Island Children’s Hospital, Stony Brook, NY, USA
| | | | | | - Susmita Pati
- Stony Brook Long Island Children’s Hospital, Stony Brook, NY, USA
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Abstract
BACKGROUND Millions of adults will gain Medicaid or private insurance in 2014 under the Affordable Care Act, and prior research shows that underinsurance is common among middle-income adults. Less is known about underinsurance among low-income adults, particularly those with public insurance. OBJECTIVE To compare rates of underinsurance among low-income adults with private versus public insurance, and to identify predictors of being underinsured. DESIGN Descriptive and multivariate analysis of data from the 2005-2008 Medical Expenditure Panel Survey. PARTICIPANTS Adults 19-64 years of age with family income less than 125 % of the Federal Poverty Level (FPL) and full-year continuous coverage in one of four mutually exclusive insurance categories (N = 5,739): private insurance, Medicaid, Medicare, and combined Medicaid/Medicare coverage. MAIN MEASURES Prevalence of underinsurance among low-income adults, defined as out-of-pocket expenditures greater than 5 % of household income, delays/failure to obtain necessary medical care due to cost, or delays/failure to obtain necessary prescription medications due to cost. KEY RESULTS Criteria for underinsurance were met by 34.5 % of low-income adults. Unadjusted rates of underinsurance were 37.7 % in private coverage, 26.0 % in Medicaid, 65.1 % in Medicare, and 45.1 % among Medicaid/Medicare dual enrollees. Among underinsured adults, household income averaged $6,181 and out-of-pocket spending averaged $1,115. Due to cost, 8.1 % and 12.8 % deferred or delayed obtaining medical care or prescription medications, respectively. Predictors of underinsurance included being White, unemployed, and in poor health. After multivariate adjustment, Medicaid recipients were significantly less likely to be underinsured than privately insured adults (OR 0.22, 95 % CI 0.17-0.28). CONCLUSIONS Greater than one-third of low-income adults nationally were underinsured. Medicaid recipients were less likely to be underinsured than privately insured adults, indicating potential benefits of expanded Medicaid under health care reform. Nonetheless, more than one-quarter of Medicaid recipients were underinsured, highlighting the importance of addressing cost-related barriers to care even among those with public coverage.
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Affiliation(s)
- Hema Magge
- Division of General Pediatrics,, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Buell R, Gesme D. Survey of provider perspectives on patient assistance programs. J Oncol Pract 2013; 5:184-7. [PMID: 20856634 DOI: 10.1200/jop.0942005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2009] [Indexed: 11/20/2022] Open
Abstract
This survey attempts to quantify the costs of applying for patient assistance programs, which oncologists say too often involves weeks of paperwork, repeated telephone calls, and bureaucratic delays.
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Affiliation(s)
- Roberta Buell
- Sausalito Healthcare Partners; E-Expert Reimbursement Partners, Sausalito, CA; and Minnesota Oncology, US Oncology, Minneapolis, MN
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Kubik MY, Lee J. Parent interest in a school-based, school nurse-led weight management program. J Sch Nurs 2013; 30:68-74. [PMID: 23598566 DOI: 10.1177/1059840513485091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Because one in three children is already overweight or obese, school-based interventions targeting secondary obesity prevention merit consideration. This study assessed parent interest in participating in a school-based, school nurse-led weight management program for young school-aged children. A random sample of parents (n = 122) of second and fourth grade students in one large midwestern suburban school district completed a mailed survey. Associations between parent and child characteristics and interest in a school nurse-led after school weight management program for children, parent support group, and school nurse meeting with parent and child for weight management education were assessed using multivariate logistic regression. Non-White parents, parents concerned about their child's weight, and parents of girls were significantly more likely to express interest in program components than their counterparts. Future studies that develop, implement, and evaluate school-based, school nurse-led weight management programs targeting children who are overweight and obese merit attention.
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Affiliation(s)
- Martha Y Kubik
- 1School of Nursing, University of Minnesota, Minneapolis, MN, USA
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Galbraith AA, Sinaiko AD, Soumerai SB, Ross-Degnan D, Dutta-Linn MM, Lieu TA. Some families who purchased health coverage through the Massachusetts Connector wound up with high financial burdens. Health Aff (Millwood) 2013; 32:974-83. [PMID: 23595500 DOI: 10.1377/hlthaff.2012.0864] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health insurance exchanges created under the Affordable Care Act will offer coverage to people who lack employer-sponsored insurance or have incomes too high to qualify for Medicaid. However, plans offered through an exchange may include high levels of cost sharing. We surveyed families participating in unsubsidized plans offered in the Massachusetts Commonwealth Health Insurance Connector Authority, an exchange created prior to the 2010 national health reform law, and found high levels of financial burden and higher-than-expected costs among some enrollees. The financial burden and unexpected costs were even more pronounced for families with greater numbers of children and for families with incomes below 400 percent of the federal poverty level. We conclude that those with lower incomes, increased health care needs, and more children will be at particular risk after they obtain coverage through exchanges in 2014. Policy makers should develop strategies to further mitigate the financial burden for enrollees who are most susceptible to encountering higher-than-expected out-of-pocket costs, such as providing cost calculators or price transparency tools.
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Affiliation(s)
- Alison A Galbraith
- Department of Population Medicine at Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.
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Bruning J, Arif AA, Rohrer JE. Medical cost and frequent mental distress among the non-elderly US adult population. J Public Health (Oxf) 2013; 36:134-9. [PMID: 23554508 DOI: 10.1093/pubmed/fdt029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Frequent mental distress (FMD) is an important measure of perceived poor mental health. With the rising cost of health care, it is not uncommon for working adults to delay seeking care. The objective of this study was to determine the relationship between avoidance of medical care due to cost and FMD among the non-elderly US population. METHODS We analyzed data from 282 044 non-elderly US population from a 2008 Behavioral Risk Factor Surveillance System survey. Multivariable logistic regression models were used to assess the association between avoidance of medical care due to cost and FMD adjusted for covariates. RESULTS The overall prevalence of FMD in the non-elderly population was 11.1%; whereas it was 24.2% for those reporting avoiding medical care due to cost. Approximately 18% of the population had no health insurance coverage and the prevalence of FMD was significantly greater in this group. The odds of FMD were >2-fold elevated for respondents who were unable to see a doctor because of cost (adjusted odds ratio: 2.40, 99% confidence interval: 2.19, 2.63). CONCLUSIONS These findings highlight the need for affordable medical care for reducing mental distress and improving population health.
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Affiliation(s)
- John Bruning
- District Health Department No. 4, Alpena Michigan, USA
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Ravi B, Croxford R, Reichmann WM, Losina E, Katz JN, Hawker GA. The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007. Best Pract Res Clin Rheumatol 2013; 26:637-47. [PMID: 23218428 DOI: 10.1016/j.berh.2012.07.014] [Citation(s) in RCA: 163] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND The rates of total joint arthroplasty (TJA) of the hip and knee have increased in North America over the last decade. While initially designed for elderly patients (>70 years of age), several reports suggest that an increasing number of younger patients are undergoing joint replacements. This suggests that more people are meeting the indication for TJA earlier in their lives. Alternatively, it might indicate a broadening of the indications for TJA. METHODS We used the administrative databases available at the Healthcare Cost and Utilization Project (HCUP) and the Institute for Clinical Evaluative Sciences (ICES) to determine the rates of TJA of the hip and knee in the United States, and Ontario, Canada, respectively. We determined the crude rates of THA and TKA in both areas for four calendar years (2001, 2003, 2005 and 2007). We also calculated the age- and sex-standardised rates of THA and TKA in both areas for each time period. We compared the age distribution of TJA recipients between the US and Ontario, and within each area over time. RESULTS The crude and standardised rates of THA and TKA increased over time in both the US and Ontario. The crude rates of THA were higher in the US in 2001 and 2003, but were not significantly different from the rate in Ontario in 2005 and 2007. The crude rates of TKA were consistently higher in the US for all time periods. In addition, the US consistently had more THA and TKA recipients in 'younger' age categories (<60 years of age). While the age- and sex-standardised rates of TKA were greater in the US in all time periods, the relative increase in rates from 2001 to 2007 was greater in Ontario (US - 59%, Ontario - 73%). For both the US and Ontario, there was a significant shift in the demographic of THA and TKA recipients to younger patients (p < 0.0001). CONCLUSIONS The utilisation of primary hip and knee arthroplasty has increased substantially in both the US and Ontario in the period from 2001 to 2007. This increase has been predominantly in knee replacements. The demographics of joint replacement recipients has become younger, with substantial increases in the prevalence of patients <60 years old amongst TJA recipients, and significant increases in the incidence of TJA in these age groups in the general population, in both the US and Ontario.
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Affiliation(s)
- Bheeshma Ravi
- Department of Surgery, University of Toronto, Toronto, Canada
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