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Importance: Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost.Objectives: To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity.Evidence Review: Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings.Findings: The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress.Conclusions and Relevance: The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress. [ABSTRACT FROM AUTHOR]

With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity. [ABSTRACT FROM AUTHOR]

Wellness programs constitute central components of disease prevention efforts under the Affordable Care Act and are likely to remain a component of employer provided health insurance. This paper evaluates the impact of such programs on medical utilization 4 to 7 years after enrollment in the plan. Using a unique suited data provided by a large private employer, I analyze medical expenditure and utilization for individuals enrolled in a wellness plan. The analysis compares expenditures and visits between wellness members and nonmembers who are matched through propensity score methods. The results show that although the wellness program increases utilization of preventive and outpatient care, by as much as 1.57 visits per year, there is no comparable decline in emergency or inpatient care, resulting in an overall increase in medical expenditure of around $507 per person per year. The increase in medical expenditure persists even 6 to 7 years of continued enrollment in wellness. I find some evidence of improved health, as diagnoses of diabetes decline 0.8 percentage points among wellness members. The results suggest that employer savings stemming from improved health and more judicious use of medical services are not likely to materialize in this wellness program. [ABSTRACT FROM AUTHOR]

Objective: To explore the sexual and reproductive health (SRH) behaviors, health insurance coverage and use of SRH services of women in the United States (U.S.) by nativity, disaggregated by race and ethnicity.Study Design: We analyzed publicly available and restricted data from the National Survey of Family Growth to assess differences and similarities between foreign-born and U.S.-born women, both overall and within Hispanic, non-Hispanic (NH) white, NH black and NH Asian groups.Results: A larger proportion of foreign-born women than U.S.-born women lacked health insurance coverage. Foreign-born women utilized SRH services at lower rates than U.S.-born women; this effect diminished at the multivariate level, although race and ethnicity differences remained. Overall, foreign-born women were less likely to pay for SRH services with private insurance than U.S.-born women. Foreign-born women were less likely to use the most effective contraceptive methods than U.S.-born women, with some variation across race and ethnicity: NH white and NH black foreign-born women were less likely to use highly effective contraceptive methods than their U.S.-born counterparts, but among Hispanic women, the reverse was true.Conclusion: Our findings demonstrate that the SRH behaviors, needs and outcomes of foreign-born women differ from those of U.S-born women within the same race/ethnic group.Implications: This paper contributes to the emergent literature on immigrants in the U.S. by laying the foundation for further research on the SRH of the foreign-born population in the country, which is critical for developing public health policies and programs to understand better and serve this growing and diverse population. [ABSTRACT FROM AUTHOR]

Policymakers are increasingly interested in reducing healthcare costs and inefficiencies through innovative payment strategies. These strategies may have heterogeneous impacts across geographic areas, potentially reducing or exacerbating geographic variation in healthcare spending. In this paper, we exploit a major payment reform for home health care to examine whether reductions in reimbursement lead to differential changes in treatment intensity and provider costs depending on the level of competition in a market. Using Medicare claims, we find that while providers in more competitive markets had higher average costs in the pre-reform period, these markets experienced larger proportional reductions in treatment intensity and costs after the reform relative to less competitive markets. This led to a convergence in spending across geographic areas. We find that much of the reduction in provider costs is driven by greater exit of "high-cost" providers in more competitive markets. [ABSTRACT FROM AUTHOR]

This paper examines the extensive margin of selection into employer-sponsored health insurance (ESHI) using data from the Medical Expenditures Panel Survey 2001-2010 and 2014-2016 and the National Longitudinal Survey of Youth'97 in 2010. Controlling for a large set of firm and job characteristics, I find that before the implementation of the Affordable Care Act (ACA) in 2014, workers aged 25-40 who declined ESHI and remained privately uninsured had significantly higher health risk than those who enrolled. No correlation between health and insurance take-up is found in the 41-64 age group. These results are partly explained by differences in income and Medicaid crowding out ESHI for high risk workers. The paper sheds light on the characteristics of uninsured workers, their incentives for declining insurance and the interaction between private and public health insurance. The allocation of ESHI remained unchanged after the ACA was introduced due to the provisions' counteracting effects. [ABSTRACT FROM AUTHOR]

In many markets, including the new U.S. Marketplaces, health insurance plans are paid by risk-adjusted capitation, sometimes combined with reinsurance and other payment mechanisms. This paper proposes a framework for evaluating the de facto insurer incentives embedded in these complex payment systems. We discuss fit, power and balance, each of which addresses a distinct market failure in health insurance. We implement empirical metrics of fit, power, and balance in a study of Marketplace payment systems. Using data similar to that used to develop the Marketplace risk adjustment scheme, we quantify tradeoffs among the three classes of incentives. We show that an essential tradeoff arises between the goals of limiting costs and limiting cream skimming because risk adjustment, which is aimed at discouraging cream-skimming, weakens cost control incentives in practice. A simple reinsurance system scores better on our measures of fit, power and balance than the risk adjustment scheme in use in the Marketplaces. [ABSTRACT FROM AUTHOR]

Job loss in the United States is associated with reductions in income and long-term increases in mortality rates. This paper examines the short-run changes in health, health care access, and health care utilization after job loss that lead to these long-term effects. Using a sample with more than 10,000 individual job losses and longitudinal data on a wide variety of health-related outcomes, we show that job loss results in worse self-reported health, activity limitations, and worse mental health, but is not associated with statistically significant increases in a variety of specific chronic conditions. Among the full sample of workers, we see reductions in insurance coverage, but little evidence of reductions in health care utilization after job loss. Among the subset of displaced workers with chronic conditions and those for whom the lost job was their primary source of insurance we do see reductions in doctor's visits and prescription drug usage. [ABSTRACT FROM AUTHOR]

Using the 2007 to 2016 Medical Expenditure Panel Survey-Household Component, this study analyzes trends in per capita health expenditures among nonelderly adults from the Great Recession to the period following full implementation of the Affordable Care Act. We find that the growth in total per capita spending-and specifically for prescription drug and emergency room spending-from 2007-2009 to 2014-2016 was largely driven by increases in expenditures per unit, that is, increases in per unit prices, quality, and/or intensity of treatment. We also find that changes in the health insurance distribution were the largest driver behind the increase in total per capita expenditures over this period, while changes in prevalence of chronic conditions explained a smaller portion of the increase. Identifying policies for containing health care spending growth requires a detailed understanding of the sources of that growth, particularly during periods of economic fluctuations, policy changes, and technological developments. [ABSTRACT FROM AUTHOR]

Low-income children are less likely to receive recommended health services than their high-income counterparts. This paper examines whether the design of parental Medicaid benefit packages could serve as a mechanism for reducing income-based disparities in unmet health care needs, considering dental benefits as a case study. Leveraging state-level changes to adult dental benefits over time, I find that coverage is associated with increases of 14 and 5 percentage points, respectively, in the likelihood of a recent dental visit among parents and children directly exposed to the policy. Child effects appear to be concentrated among younger children under age 12. [ABSTRACT FROM AUTHOR]

Background: Episode-based payment (EBP) is gaining traction among payers as an alternative to fee-for-service reimbursement. However, there is concern that EBP could influence the number of episodes.Objective: To examine how procedure volume changed after the introduction of EBP in 2013 and 2014 under the Arkansas Health Care Payment Improvement Initiative.Design: Using 2011-2016 commercial claims data, we estimate a difference-in-differences model to assess the impact of EBP on the probability of a beneficiary having an episode for four procedures that were reimbursed under EBP in Arkansas: total joint replacement, cholecystectomy, colonoscopy, and tonsillectomy.Participants: Commercially insured beneficiaries in Arkansas serve as our treatment group, while commercially insured beneficiaries in neighboring states serve as our comparison group.Interventions: Statewide implementation of EBP for various clinical conditions by two of Arkansas' largest commercial insurers.Main Measures: For a given procedure type, the primary outcomes are the annual rate of procedures (number of procedures per 1000 beneficiaries) and the probability of a beneficiary undergoing that procedure in a given quarter.Key Results: The relationship between EBP and procedure volume varies across procedures. After EBP was implemented, the probability of undergoing colonoscopy increased by 17.2% (point estimate, 2.63; 95% CI, 1.18 to 4.08; p < 0.001; Arkansas pre-period mean, 15.29). The probability of undergoing total joint replacement increased by 9.9% (point estimate, 0.091; 95% CI, - 0.011 to 0.19; p = 0.08; Arkansas pre-period mean, 0.91), though this effect is not significant. There is no discernable impact on cholecystectomy or tonsillectomy volume.Conclusions: We do not find clear evidence of deleterious volume expansion. However, because the impact of EBP on procedure volume may vary by procedure, payers planning to implement EBP models should be aware of this possibility. [ABSTRACT FROM AUTHOR]

Using a novel data set from a major credit bureau, we examine the early effects of the Affordable Care Act Medicaid expansions on personal finance. We analyze less common events such as personal bankruptcy, and more common occurrences such as medical collection balances, and change in credit scores. We estimate triple-difference models that compare individual outcomes across counties that expanded Medicaid versus counties that did not, and across expansion counties that had more uninsured residents versus those with fewer. Results demonstrate financial improvements in states that expanded their Medicaid programs as measured by improved credit scores, reduced balances past due as a percent of total debt, reduced probability of a medical collection balance of $1,000 or more, reduced probability of having one or more recent medical bills go to collections, reduction in the probability of experiencing a new derogatory balance of any type, reduced probability of incurring a new derogatory balance equal to $1,000 or more, and a reduction in the probability of a new bankruptcy filing. [ABSTRACT FROM AUTHOR]

Background: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy.Objective: To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities.Conclusions: Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion. [ABSTRACT FROM AUTHOR]

Objective: To estimate health care utilization and costs incurred by homeless Veterans relative to nonhomeless Veterans and to examine the impact of a VA homelessness program on these outcomes.Data Sources/study Setting: Combined Department of Veterans Affairs (VA) administrative and Medicare claims data.Study Design: Observational study using longitudinal data from Veterans engaged with the VA system and enrolled in Medicare. Veterans with administrative evidence of homelessness at any point during 2006-2010 were matched on period of military service to Veterans with no evidence of homelessness.Principal Findings: Experience of homelessness was associated with 1.37 (95 percent CI = 1.34-1.40) and 0.16 (95 percent CI = 0.14-0.17) more outpatient encounters per quarter in VA and non-VA settings, respectively, and 1.31 (95 percent CI = 1.30-1.32) and 0.49 (95 percent CI = 0.48-0.49) more inpatient days per quarter in VA and non-VA hospitals, respectively. These were associated with higher costs. Relative to stably housed Veterans less than 65 years of age, those enrolled in a VA homelessness program had 94.4 percent (95 percent CI = 90.7 percent-98.1 percent) more VA outpatient visits but 5.5 percent (95 percent CI = 3.0 percent-7.9 percent) fewer Medicare outpatient visits.Conclusions: Homelessness was associated with an increase in VA and Medicare utilization and cost. A VA homelessness program decreased use of Medicare outpatient services. [ABSTRACT FROM AUTHOR]

Objective: To assess the issue of nonrepresentative sampling in Medicare Advantage (MA) risk adjustment.Data Sources: Medicare enrollment and claims data from 2008 to 2011.Data Extraction: Risk adjustment predictor variables were created from 2008 to 2010 Part A and B claims and the Medicare Beneficiary Summary File. Spending is based on 2009-2011 Part A and B, Durable Medical Equipment, and Home Health Agency claims files.Study Design: A propensity-score matched sample of Traditional Medicare (TM) beneficiaries who resembled MA enrollees was created. Risk adjustment formulas were estimated using multiple techniques, and performance was evaluated based on R2 , predictive ratios, and formula coefficients in the matched sample and a random sample of TM beneficiaries.Principal Findings: Matching improved balance on observables, but performance metrics were similar when comparing risk adjustment formula results fit on and evaluated in the matched sample versus fit on the random sample and evaluated in the matched sample.Conclusions: Fitting MA risk adjustment formulas on a random sample versus a matched sample yields little difference in MA plan payments. This does not rule out potential improvements via the matching method should reliable MA encounter data and additional variables become available for risk adjustment. [ABSTRACT FROM AUTHOR]

Objective: The concept of shifting from volume (i.e., billing for as many patients and services as possible) to value (i.e., reducing costs while improving quality) has been a key underpinning of the development of accountable care organizations (ACOs), yet the cultural change necessary to make this shift has been previously unexplored.Data Sources/study Setting: Primary data collected through site visits to four private sector ACOs.Study Design: Cross-sectional, semi-structured interview study with analysis done at the ACO level to learn about ACO development.Data Collection: One hundred and forty-eight interviews recorded and transcribed verbatim followed by rigorous qualitative analysis using a grounded theory approach.Principal Findings: The importance of shifting organizational culture from volume to value was emphasized across sites and interviewees, particularly when defining an ACO; describing the shift in organizational focus to value; and discussing how to create value by emphasizing quality over volume. Value was viewed as more than cost-benefit, but rather encapsulated a paradigmatic cultural change in the way care is provided.Conclusions: We found that moving from volume to value is central to the culture change required of an ACO. Our findings can inform future efforts that aim to create a more effective value-based health care system. [ABSTRACT FROM AUTHOR]

Objective: To assess frequency, type, and extent of behavioral health (BH) nonquantitative treatment limits (NQTLs) before and after implementation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).Data Sources: Secondary administrative data for Optum carve-out and carve-in plans.Study Design: Cross-tabulations and "two-part" regression models were estimated to assess associations of parity period with NQTLs.Data Collection/extraction Methods: Optum provided four proprietary BH databases, including 2008-2013 data for 40 carve-out and 385 carve-in employers from Optum's claims processing databases and 2010 data from interviews conducted by Optum's parity compliance team with 49 carve-out employers.Principal Findings: Preparity, carve-out plans required preauthorization for in-network inpatient/intermediate care; otherwise coverage was denied. Postparity, 73 percent would review later by request and half charged no penalty for late authorization. Outpatient visit authorization requirements virtually disappeared. For carve-out out-of-network inpatient/intermediate care, and for carve-ins, plans changed penalties to match medical service policies, but this did not necessarily lead to fewer requirements or lower penalties.Conclusion: After 2011, MHPAEA was associated with the transformation of BH care management, including much less restrictive preauthorization requirements, especially for in-network care provided by carve-out plans. [ABSTRACT FROM AUTHOR]

Objective: To test whether underwriting modifies the effect of state-based incentives on individuals' purchase of long-term care insurance.Data Source: Health and Retirement Study (HRS), 1996-2012.Study Design: We estimated difference-in-difference regression models with an interaction of state policy indicators with individuals' probabilities of being approved for long-term care insurance.Data Extraction: We imputed probabilities of underwriting approval for respondents in the HRS using a model developed with underwriting decisions from two U.S. insurance firms. We measured the elasticity response to long-term care insurance price using changes in simulated after-tax price as an instrumental variable for premium price.Principal Findings: Tax incentives and Partnership programs increased insurance purchase by 3.62 percentage points and 1.8 percentage points, respectively, among those with the lowest risk (highest approval probability). Neither had any statistically significant effects among the highest risk individuals.Conclusions: We show that ignoring the effects of underwriting may lead to biased estimates of the potential state budget savings of long-term care insurance tax incentives. If the private market is to play a role in financing long-term care, policies need to address the underlying adverse selection problems. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data.Data Sources/study Setting: One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool.Study Design: We used a generalized estimating equation model with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days.Principal Findings: With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs.Conclusions: The relationship between cost and quality depends on facility size and current level of performance. [ABSTRACT FROM AUTHOR]

Importance: Bundled payments are an increasingly common alternative payment model for Medicare, yet there is limited evidence regarding their effectiveness.Objective: To report interim outcomes from the first year of implementation of a bundled payment model for lower extremity joint replacement (LEJR).Design, Setting, and Participants: As part of a 5-year, mandatory-participation randomized trial by the Centers for Medicare & Medicaid Services, eligible metropolitan statistical areas (MSAs) were randomized to the Comprehensive Care for Joint Replacement (CJR) bundled payment model for LEJR episodes or to a control group. In the first performance year, hospitals received bonus payments if Medicare spending for LEJR episodes was below the target price and hospitals met quality standards. This interim analysis reports first-year data on LEJR episodes starting April 1, 2016, with data collection through December 31, 2016.Exposure: Randomization of MSAs into the CJR bundled payment model group (75 assigned; 67 included) or to the control group without the CJR model (121 assigned; 121 included). Instrumental variable analysis was used to evaluate the relationship between inclusion of MSAs in the CJR model and outcomes.Main Outcomes and Measures: The primary outcome was share of LEJR admissions discharged to institutional postacute care. Secondary outcomes included the number of days in institutional postacute care, discharges to other locations, Medicare spending during the episode (overall and for institutional postacute care), net Medicare spending during the episode, LEJR patient volume and patient case mix, and quality-of-care measures.Results: Among the 196 MSAs and 1633 hospitals, 131 285 eligible LEJR procedures were performed during the study period (mean volume, 110 LEJR episodes per hospital) among 130 343 patients (mean age, 72.5 [SD, 0.91] years; 65% women; 90% white). The mean percentage of LEJR admissions discharged to institutional postacute care was 33.7% (SD, 11.2%) in the control group and was 2.9 percentage points lower (95% CI, -4.95 to -0.90 percentage points) in the CJR group. Mean Medicare spending for institutional postacute care per LEJR episode was $3871 (SD, $1394) in the control group and was $307 lower (95% CI, -$587 to -$27) in the CJR group. Mean overall Medicare spending per LEJR episode was $22 872 (SD, $3619) in the control group and was $453 lower (95% CI, -$909 to $3) in the CJR group, a statistically nonsignificant difference. None of the other secondary outcomes differed significantly between groups.Conclusions and Relevance: In this interim analysis of the first year of the CJR bundled payment model for LEJR among Medicare beneficiaries, MSAs covered by CJR, compared with those that were not, had a significantly lower percentage of discharges to institutional postacute care but no significant difference in total Medicare spending per LEJR episode. Further evaluation is needed as the program is more fully implemented.Trial Registration: ClinicalTrials.gov Identifier: NCT03407885; American Economic Association Registry Identifier: AEARCTR-0002521. [ABSTRACT FROM AUTHOR]

Many insurers incurred financial losses in individual markets for health insurance during 2014, the first year of Affordable Care Act mandated changes. This analysis looks at key financial ratios of insurers to compare profitability in 2014 and 2013, identify factors driving financial performance, and contrast the financial performance of health insurers operating in state-run exchanges versus the federal exchange. Overall, the median loss of sampled insurers was -3.9%, no greater than their loss in 2013. Reduced administrative costs offset increases in medical losses. Insurers performed better in states with state-run exchanges than insurers in states using the federal exchange in 2014. Medical loss ratios are the underlying driver more than administrative costs in the difference in performance between states with federal versus state-run exchanges. Policy makers looking to improve the financial performance of the individual market should focus on features that differentiate the markets associated with state-run versus federal exchanges. [ABSTRACT FROM AUTHOR]

Medicaid expansions through the Affordable Care Act began in January 2014, but we have little information about what is happening in rural areas where provider access and patient resources might be more limited. In 2008, Oregon held a lottery for restricted access to its Medicaid program for uninsured low-income adults not otherwise eligible for public coverage. The Oregon Health Insurance Experiment used this opportunity to conduct the first randomized controlled study of a public insurance expansion. This analysis builds off of previous work by comparing rural and urban survey outcomes and adds qualitative interviews with 86 rural study participants for context. We examine health care access and use, personal finances, and self-reported health. While urban and rural populations have unique demographic profiles, rural populations appear to have benefited from Medicaid as much as urban. Qualitative interviews revealed the distinctive challenges still facing low-income uninsured and newly insured rural populations. [ABSTRACT FROM AUTHOR]

As the health insurance industry becomes more consolidated, hospitals and health systems have started to enter the insurance business. Insurers are also rapidly acquiring providers. Although these "vertically" integrated plan providers are small players in the insurance market, they are becoming more numerous. The health insurance marketplaces (HIMs) offer a unique setting to study integrated plan providers relative to other insurer types because the HIMs were designed to promote competition. In this descriptive study, the authors compared the premiums of the lowest priced silver plans of integrated plan providers with other insurer types on the 2015 and 2016 HIMs. Integrated plan providers were associated with modestly lower premiums relative to most other insurer types. This study provides early insights into premium competition on the HIMs. Examining integrated plan providers as a separate insurer type has important policy implications because they are a growing segment of the marketplaces and their pricing behavior may influence future premium trends. [ABSTRACT FROM AUTHOR]

Objective: Evaluating the potential of the high-dimensional propensity score (HDPS) to control for residual confounding in studies analyzing quality of care based on administrative health insurance data.Data Source: Secondary data from 2004 to 2009 from three German statutory health insurance providers.Study Design: We conducted a retrospective cohort study in patients with elective percutaneous coronary interventions (PCIs) and compared the mortality risk between the in- and outpatient setting using Cox regression. Adjustment for predefined confounders was performed using conventional propensity score (PS) techniques. Further, an HDPS was calculated based on predefined and empirically selected confounders from the database.Principal Findings: Conventional PS methods showed a decreased mortality risk for outpatient compared to inpatient PCIs, while trimming of patients with nonoverlap in the HDPS distribution and weighting resulted in a comparable risk. Most comorbidities were less prevalent in the HDPS-trimmed population compared to the original one.Conclusion: The HDPS methodology may reduce residual confounding by rendering the studied cohort more comparable through restriction. However, results cannot be generalized for the entire study population. To provide unbiased results, full assessment of all unmeasured confounders from proxy information in the database would be necessary. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of Enroll America's field outreach activities on the number of individuals enrolled in Marketplace coverage during the first open enrollment period.Data Sources/study Setting: Marketplace enrollment for the initial open enrollment period linked with data on Enroll America's field activities and baseline local-area demographic, economic, and health services characteristics.Study Design: We used a quasi-experimental design, comparing Marketplace enrollment during the first open enrollment period in local areas drawn from Enroll America field states to a comparison group of local areas drawn from states that were not served by Enroll America's field effort, but that otherwise match up well with Enroll America states.Principal Findings: We find evidence of a large, positive effect of Enroll America's field outreach on Marketplace enrollment in non-Medicaid expansion states. Across model specifications, the Enroll America effects on Marketplace enrollment ranged between 10 and 15 percent, with most estimates statistically significant at the 5 percent level.Conclusions: Enroll America played an important role in the success of individual states' efforts to boost Marketplace enrollment. Enroll American's evidence-driven, grassroots approach could serve as a model for others interested in conducting similar outreach campaigns for Affordable Care Act-related coverage. [ABSTRACT FROM AUTHOR]

Background: Decision makers are increasingly tasked with reducing health care costs, but the public may be mistrustful of these efforts. Public deliberation helps gather input on these types of issues by convening a group of diverse individuals to learn about and discuss values-based dilemmas.Objective: To explore public perceptions of health care costs and how they intersect with medical mistrust.Design and Participants: This mixed-methods study analyzed data from a randomized controlled trial including four public deliberation groups (n = 96) and a control group (n = 348) comprising English-speaking adults aged 18 years and older. Data were collected in 2012 in four U.S. regions.Approach: We used data from four survey items to compare attitude shifts about costs among participants in deliberation groups to participants in the control group. We qualitatively analyzed deliberation transcripts to identify themes related to attitude shifts and to provide context for quantitative results about attitude shifts.Key Results: Deliberation participants were significantly more likely than control group participants to agree that doctors and patients should consider cost when making treatment decisions (β = 0.59; p < 0.01) and that people should consider the effect on group premiums when making treatment decisions (β = 0.48; p < 0.01). Qualitatively, participants mistrusted the health care system's profit motives (e.g., that systems prioritize making money over patient needs); however, after grappling with patient/doctor autonomy and learning about and examining their own views related to costs during the process of deliberation, they largely concluded that payers have the right to set some boundaries to curb costs.Conclusions: Individuals who are informed about costs may be receptive to boundaries that reduce societal health care costs, despite their mistrust of the health care system's profit motives, especially if decision makers communicate their rationale in a transparent manner. Future work should aim to develop transparent policies and practices that earn public trust. [ABSTRACT FROM AUTHOR]

Background: Adherence and persistence to therapy, or how well a patient follows provider directions on frequency and time to discontinuation of prescribed medications, is associated with positive health outcomes, including decreased healthcare costs and patient mortality. A clear literature gap exists assessing adherence and persistence to antidepressants (ADs) in the major depressive disorder (MDD) population at clinically relevant time points and at the therapeutic class level.Objective: This study assessed adherence and persistence to specific ADs, therapeutic classes, and AD therapy overall at multiple time points among US individuals from commercial, Medicare supplemental, and Medicaid insurance plans.Methods: Patients with MDD without AD or MDD claims in the prior 6 months who initiated therapy in 2003-2014 with a selective serotonin reuptake inhibitor (SSRI), serotonin and norepinephrine reuptake inhibitor (SNRI), tricyclic AD (TCA), monoamine oxidase inhibitor (MAOI), or other AD were identified using MarketScan® databases. These databases contain information on diagnoses, billing codes, and dates of service. Adherence (proportion of days covered) and persistence (days until a 30-day gap in therapy) were calculated to AD medication, AD therapeutic class, and AD therapy overall over the first 3, 6, 9, and 12 months from the index prescription date. Multivariable logistic regression estimated the adjusted odds ratios (ORs) of adherence to initial AD medication comparing AD therapeutic classes.Results: For 527,907 patients, adherence to initial AD medication decreased over 3, 6, 9, and 12 months (41, 31, 24, and 21%, respectively). Similar patterns were observed for adherence to initial AD therapeutic class, AD therapy overall, and all three persistence calculations. The odds of adherence to SNRIs versus SSRIs were 20-27% greater at 3, 6, 9, and 12 months (ORs 1.20, 1.23, 1.25, 1.27, respectively; p-values all <0.0001). Similar or significantly lower odds of adherence were demonstrated for other classes versus SSRIs at 3, 6, 9, and 12 months [ORs for other ADs 0.80, 0.77, 0.74, 0.72, respectively (p-values all <0.0001); ORs for TCAs 0.46, 0.45, 0.47, 0.49, respectively (p-values all <0.0001); ORs for MAOIs 1.13, 1.0, 0.77, 0.69, respectively (p-values all >0.05)].Conclusion: We found low adherence and persistence to ADs in the MDD population. Within the limitations of the insurance claims data we analysed, our results suggest that adherence may differ based on therapeutic class, as patients initiating SNRI therapy appeared to have a higher likelihood of adherence versus SSRIs over the year assessed, while the odds of adherence appeared similar or lower for other classes versus SSRIs. Further prospective research is needed to confirm these findings and determine additional drivers of these apparent differences by AD therapeutic class. [ABSTRACT FROM AUTHOR]

Background: Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy. Objective: To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services. Design: Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3% (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS). Patients: U.S. transgender population starting before transitional therapy. Interventions: No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both. Main Measures: Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost. Key Results: Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000-22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints--HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85% of simulations. Conclusions: Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions. [ABSTRACT FROM AUTHOR]

Background: The implementation of the ACA has improved access to quality health insurance, a necessary first step to improving health outcomes. However, access must be supplemented by education to help individuals make informed choices for plans that meet their individual financial and health needs.Methods/design: Drawing on a model of information processing and on prior research, we developed a health insurance decision support tool called Show Me My Health Plans. Developed with extensive stakeholder input, the current tool (1) simplifies information through plain language and graphics in an educational component; (2) assesses and reviews knowledge interactively to ensure comprehension of key material; (3) incorporates individual and/or family health status to personalize out-of-pocket cost estimates; (4) assesses preferences for plan features; and (5) helps individuals weigh information appropriate to their interests and needs through a summary page with "good fit" plans generated from a tailored algorithm. The current study will evaluate whether the online decision support tool improves health insurance decisions compared to a usual care condition (the healthcare.gov marketplace website). The trial will include 362 individuals (181 in each group) from rural, suburban, and urban settings within a 90 mile radius around St. Louis. Eligibility criteria includes English-speaking individuals 18-64 years old who are eligible for the ACA marketplace plans. They will be computer randomized to view the intervention or usual care condition.Discussion: Presenting individuals with options that they can understand tailored to their needs and preferences could help improve decision quality. By helping individuals narrow down the complexity of health insurance plan options, decision support tools such as this one could prepare individuals to better navigate enrollment in a plan that meets their individual needs. The randomized trial was registered in clinicaltrials.gov (NCT02522624) on August 6, 2015. [ABSTRACT FROM AUTHOR]

Background: Risk assessment with a thorough family health history is recommended by numerous organizations and is now a required component of the annual physical for Medicare beneficiaries under the Affordable Care Act. However, there are several barriers to incorporating robust risk assessments into routine care. MeTree, a web-based patient-facing health risk assessment tool, was developed with the aim of overcoming these barriers. In order to better understand what factors will be instrumental for broader adoption of risk assessment programs like MeTree in clinical settings, we obtained funding to perform a type III hybrid implementation-effectiveness study in primary care clinics at five diverse healthcare systems. Here, we describe the study's protocol.Methods/design: MeTree collects personal medical information and a three-generation family health history from patients on 98 conditions. Using algorithms built entirely from current clinical guidelines, it provides clinical decision support to providers and patients on 30 conditions. All adult patients with an upcoming well-visit appointment at one of the 20 intervention clinics are eligible to participate. Patient-oriented risk reports are provided in real time. Provider-oriented risk reports are uploaded to the electronic medical record for review at the time of the appointment. Implementation outcomes are enrollment rate of clinics, providers, and patients (enrolled vs approached) and their representativeness compared to the underlying population. Primary effectiveness outcomes are the percent of participants newly identified as being at increased risk for one of the clinical decision support conditions and the percent with appropriate risk-based screening. Secondary outcomes include percent change in those meeting goals for a healthy lifestyle (diet, exercise, and smoking). Outcomes are measured through electronic medical record data abstraction, patient surveys, and surveys/qualitative interviews of clinical staff.Discussion: This study evaluates factors that are critical to successful implementation of a web-based risk assessment tool into routine clinical care in a variety of healthcare settings. The result will identify resource needs and potential barriers and solutions to implementation in each setting as well as an understanding potential effectiveness.Trial Registration: NCT01956773. [ABSTRACT FROM AUTHOR]