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BACKGROUND: E-health services may improve the quality and efficiency of care; however, there is little quantitative data on e-health use. OBJECTIVE: The objective of this study was to examine trends in e-health use and user characteristics. RESEARCH DESIGN: This was a longitudinal study of e-health use (1999-2002) within an integrated delivery system (IDS). We classified 4 e-health services into transactional (drug refills and appointment scheduling) and care-related (medical and medication advice) services. SUBJECTS: Approximately 3.3 million members of a large, prepaid IDS. MEASUREMENTS: Amount and frequency of e-health use over time and characteristics of users. RESULTS: The number of members registered for access to e-health increased from 20,617 (0.7% of all members) in Q1 1999 to 270,987 (8.6%) in Q3 2002. Between Q1 and Q3 2002, 42,845 members (1.3%) used the drug refill service and 55,901 (1.7%) used the appointment scheduling service compared with 10,756 members (0.3%) who used the medical advice service and 3069 (0.1%) who used the medication advice service. Over the same period, transactional service users averaged 3.5 uses/user versus 1.6 uses/user among care-related service users. Members most likely to use e-health services had a high level of clinical need, a regular primary care provider, were 30 to 64 years old, female, white, and lived in a nonlow socioeconomic status neighborhood. These findings were consistent across e-health service types. CONCLUSIONS: Although use of all e-health services grew rapidly, use of care-related services lagged significantly behind use of transactional services. Subjects with greater clinical need and better ties to the health system were more likely to use both types of e-health services. [ABSTRACT FROM AUTHOR]

Background: Patients are increasingly paying for more of their medical care through cost-sharing, yet little is known about how patients change the ways that they seek care in response.Objective: We sought to assess how patients change their care-seeking behavior in response to emergency department (ED) copayments.Research Design: Telephone interviews with a stratified random sample of adult members of a large integrated delivery system.Subjects: There were 932 respondents (72% response rate).Measures: We examined participants' knowledge of their copayment level for ED services, and measures of how the cost-sharing affected their decisions about where or when to seek care.Results: Overall, 82% of participants faced a copayment for ED services (ranging between 5 US dollars and 100 US dollars), and 41% correctly reported the amount of this copayment. In response to the perceived copayment amount, 19% reported changing their care-seeking behavior within the previous 12 months: 12% sought care from an alternate delivery site, 12% contacted a provider by telephone or the Internet, 9% delayed going to the ED, and 2% avoided medical care altogether. In multivariate models, the ED cost-sharing amount was significantly associated with reporting changes in care-seeking behavior.Conclusions: When faced with an ED copayment, patients in the health system most commonly shifted toward seeking care from other available alternatives, and rarely avoid medical care altogether. [ABSTRACT FROM AUTHOR]

Background: Physicians often receive lower payments for dual-eligible Medicare-Medicaid beneficiaries versus nondual Medicare beneficiaries because of state reimbursement caps. The Affordable Care Act (ACA) primary care fee bump temporarily eliminated this differential in 2013-2014., Objective: To examine how dual payment policy impacts primary care physicians' (PCP) acceptance of duals., Research Design: We assessed differences in the likelihood that PCPs had dual caseloads of ≥10% or 20% in states with lower versus full dual reimbursement using linear probability models adjusted for physician and area-level traits. Using a triple-difference approach, we examined changes in dual caseloads for PCPs versus a control group of specialists in states with fee bumps versus no change during years postbump versus prebump., Subjects: PCPs and specialists (cardiologists, orthopedic surgeons, general surgeons) that billed fee-for-service Medicare., Measures: State dual payment policies and physicians' dual caseloads as a percentage of their Medicare patients., Results: In 2012, 81% of PCPs had dual caseloads of ≥10% and this was less likely among PCPs in states with lower versus full dual reimbursement (eg, difference=-4.52 percentage points; 95% confidence interval, -6.80 to -2.25). The proportion of PCPs with dual caseloads of ≥10% or 20% decreased significantly between 2012 and 2017 and the fee bump was not consistently associated with increases in dual caseloads., Conclusions: Pre-ACA, PCPs' participation in the dual program appeared to be lower in states with lower reimbursement for duals. Despite the ACA fee bump, dual caseloads declined over time, raising concerns of worsening access to care., Competing Interests: J.P.N. discloses that he was a director of Aetna until May 2018, held Aetna stock until November 2018, and currently owns stock in Novartis and Medtronic. There are no other relevant disclosures. The remaining authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Online access to health records and the ability to exchange secure messages with physicians can improve patient engagement and outcomes; however, the digital divide could limit access to web-based portals among disadvantaged groups., Objectives: To understand whether sociodemographic differences in patient portal use for secure messaging can be explained by differences in internet access and care preferences., Research Design: Cross-sectional survey to examine the association between patient sociodemographic characteristics and internet access and care preferences; then, the association between sociodemographic characteristics and secure message use with and without adjusting for internet access and care preference., Subjects: One thousand forty-one patients with chronic conditions in a large integrated health care delivery system (76% response rate)., Measures: Internet access, portal use for secure messaging, preference for in-person or online care, and sociodemographic and health characteristics., Results: Internet access and preference mediated some of the differences in secure message use by age, race, and income. For example, using own computer to access the internet explained 52% of the association between race and secure message use and 60% of the association between income and use (Sobel-Goodman mediation test, P<0.001 for both). Education and sex-related differences in portal use remained statistically significant when controlling for internet access and preference., Conclusions: As the availability and use of patient portals increase, it is important to understand which patients have limited access and the barriers they may face. Improving internet access and making portals available across multiple platforms, including mobile, may reduce some disparities in secure message use.

Objective: Medicare Part D provides formulary protections for antipsychotics but does not exempt these drugs from cost-sharing. We investigated the impact of Part D coverage on antipsychotic drug spending, adherence, and clinical outcomes among beneficiaries with varying indications for use., Methods: We conducted a historical cohort study of Medicare Advantage beneficiaries who received antipsychotic drugs, with diagnoses of schizophrenia or bipolar disorder or with no mental health diagnoses (N=10,190). Half had a coverage gap; half had no gap because of low-income subsidies. Using fixed effects regression models, we examined changes in spending and adherence as beneficiaries experienced cost-sharing increases after reaching the gap. We examined changes in hospitalizations and emergency department visits using proportional hazard models., Results: Across all diagnostic groups, total monthly expenditure on antipsychotic drugs decreased with cost-sharing increases in the gap compared with those with no gap (eg, schizophrenia: -$123 95% confidence interval [-$138, -$108]), and out-of-pocket spending increased (eg, schizophrenia: $104 [$98, $110]). Adherence similarly decreased, with the largest declines among those with schizophrenia (-20.6 percentage points [-22.3, -18.9] in proportion of days covered). Among beneficiaries with schizophrenia and bipolar disorder, hospitalizations and emergency department visit rates increased with cost-sharing increases (eg, schizophrenia: hazard ratio=1.32 [1.06, 1.65] for all hospitalizations), but did not among subjects without mental health diagnoses. Clinical event rates did not change among beneficiaries with low-income subsidies without gaps., Conclusions: There is evidence of interruptions in antipsychotic use attributable to Part D cost-sharing. Adverse events increased among beneficiaries with approved indications for use, but not among beneficiaries without such indications.

Background: There is limited information on patients' knowledge about their cost-sharing requirements and how that influenced their care-seeking behavior., Objective: To examine patients' knowledge of their office visit copayments, their self-reported responses to perceived and actual copayments, and discussions with physicians about costs., Research Design: Cross-sectional telephone interview study with a 71% response rate., Subjects: Stratified random sample of 479 adult members of a prepaid, integrated delivery system: equal sample of members with and without a chronic disease., Measures: Perceived and actual office visit copayment amounts, patient self-reported behavioral responses to copayments, cost discussions with a physician, and patient attitudes about discussing costs., Results: Overall, 50% of respondents correctly reported their copayment amount, with 39% underestimating and 11% overestimating. Among respondents who reported having copayments, 27% reported delaying or avoiding a visit altogether, or talking to a physician/advice nurse instead of attending an in-person visit because of their copayment. Perceived office visit copayment amounts were significantly associated with self-reported behavior changes (OR, 1.47 per $10; 95% CI, 1.06-2.05). Only 4% of respondents reported talking with their physician about their costs, with 79% believing that their providers cannot help them with their costs, and 51% believing that it is inappropriate to discuss costs with their physician., Conclusions: Patients have limited knowledge of their office visit copayment amounts, and are changing their care-seeking behavior in response to perceived costs. Moreover, most patients are making these changes without discussing their cost concerns with their physician.