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Background: The Diabetes Health Plan (DHP), a value-based insurance plan that reduces cost sharing, was previously shown to modestly increase employer-level medication adherence. However, it is unclear whether the DHP has a larger impact on individual-level medication adherence among lower- or higher-income beneficiaries. Methods: An employer-level propensity score match was done to identify suitable control employers, followed by individual-level propensity score weighting. These weights were applied to difference-in-difference (DID) models examining 1) the effect of the DHP and 2) the effect of income on changes in adherence to metformin, statins, and ACE/ARBs. The weights were then applied to a differences-in-differences-in-differences (DDD) model to estimate the differential impact of DHP status on changes in adherence by income group. This is a retrospective, quasi-experimental study.Results: There were no significant differences in changes to adherence for any medications between beneficiaries enrolled in the DHP versus standard plans. However, changes in adherence were higher for all medications among those in the highest income strata (>$75,000) versus those in the lowest income strata (Conclusion: We did not find significant associations between the DHP and changes in individual-level medication adherence, even for low-income beneficiaries. New strategies to improve consumer engagement may be needed in order to translate value-based insurance designs into changes in patient behavior.

Background The extent to which a surgeon's risk aversion influences their clinical decisions remains unknown. We assessed whether a surgeon's attitude toward risk (“risk aversion”) influences their surgical decisions and whether the relationship can be explained by differences in surgeons’ perception of treatment risks and benefits. Materials and methods We presented a series of detailed clinical vignettes to a national sample of surgeons (n = 1,769; 13.4% adjusted response rate) and asked them to complete an instrument that measured how risk averse they are within their clinical practice (scale 6-36; higher number indicates greater risk aversion). For each vignette, participants rated their likelihood of recommending an operation and judged the likelihood of complications or full recovery. We examined whether differences in perceived likelihood of complications versus recovery could explain why risk-averse surgeons may be less likely to recommend an operation. Results Surgeons varied in their self-reported risk aversion score (median = 25, interquartile range[22,28]). Scores did not differ by level of surgeon experience or gender. Risk-averse surgeons were significantly less likely to recommend an operation for patients with exactly the same condition (65.5% for surgeons in highest quartile of risk aversion versus 62.3% for lowest quartile; P = 0.02). However, after controlling for surgeons’ perception of the likelihood of complications versus recovery, there was no longer a significant association between surgeons’ risk aversion and the decision to recommend an operation (64.7% versus 64.8%; P = 0.96). Conclusions Surgeons vary widely in their self-reported risk aversion. Risk-averse surgeons were significantly less likely to recommend an operation, a finding that was explained by a higher perceived probability of post-operative complications than their colleagues.

Objectives To examine changes in carve-out financial requirements (copayments, coinsurance, use of deductibles, and out-of-pocket maxima) following the Mental Health Parity and Addiction Equity Act (MHPAEA). Data source/study setting Specialty mental health benefit design information for employer-sponsored carve-out plans from a national managed behavioral health organization's claims processing engine (2008-2013). Study design This pre-post study reports linear and logistic regression as the main analysis. Data collection/extraction methods NA. Principal findings Copayments for in-network emergency room (-$44.9, 95% CI: -78.3, -11.5; preparity mean: $56.2), outpatient services (eg, individual psychotherapy: -$7.4, 95% CI: -10.5, -4.2; preparity mean: $17.8), and out-of-network coinsurance for emergency room (-11 percentage points, 95% CI: -16.7, -5.4; preparity mean: 38.8 percent) and outpatient (eg, individual psychotherapy: -5.8 percentage points, 95% CI: -10.0, -1.6; preparity mean 41.0 percent) decreased. Probability of family OOP maxima use (29 percentage points, 95% CI: 19.3, 38.6; preparity mean: 36 percent) increased. In-network outpatient coinsurance increased (eg, individual psychotherapy: 4.5 percentage points, 95% CI: 1.1, 7.9; preparity mean: 2.7 percent), as did probability of use of family deductibles (15 percentage points, 95% CI: 6.1, 23.3; preparity mean: 38 percent). Conclusions MHPAEA was associated with increased generosity in most financial requirements observed here. However, increased use of deductibles may have reduced generosity for some patients.

Author(s): Duru, O Kenrik; Harwood, Jessica; Moin, Tannaz; Jackson, Nicholas J; Ettner, Susan L; Vasilyev, Arseniy; Mosley, David G; O'Shea, Donna L; Ho, Sam; Mangione, Carol M | Abstract: BackgroundMedical, behavioral, and social determinants of health are each associated with high levels of emergency department (ED) visits and hospitalizations.ObjectiveThe objective of this study was to evaluate a care coordination program designed to provide combined "whole-person care," integrating medical, behavioral, and social support for high-cost, high-need Medicaid beneficiaries by targeting access barriers and social determinants.Research designIndividual-level interrupted time series with a comparator group, using person-month as the unit of analysis.SubjectsA total of 42,214 UnitedHealthcare Medicaid beneficiaries (194,834 person-months) age 21 years or above with diabetes, with Temporary Assistance to Needy Families, Medicaid expansion, Supplemental Security Income without Medicare, or dual Medicaid/Medicare.MeasuresOur outcome measures were any hospitalizations and any ED visits in a given month. Covariates of interest included an indicator for intervention versus comparator group and indicator and spline variables measuring changes in an outcome's time trend after program enrollment.ResultsOverall, 6 of the 8 examined comparisons were not statistically significant. Among Supplemental Security Income beneficiaries, we observed a larger projected decrease in ED visit risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -6.6%; 95% confidence interval: -11.2%, -2.1%). Among expansion beneficiaries, we observed a greater decrease in hospitalization risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -5.8%; 95% confidence interval: -11.4%, -0.2%).ConclusionA care coordination program designed to reduce utilization among high-cost, high-need Medicaid beneficiaries was associated with fewer ED visits and hospitalizations for patients with diabetes in selected Medicaid programs but not others.

Author(s): Moin, Tannaz; Harwood, Jessica M; Mangione, Carol M; Jackson, Nicholas; Ho, Sam; Ettner, Susan L; Duru, O Kenrik | Abstract: Background/objectivesMedicaid beneficiaries with diabetes have complex care needs. The Accountable Care Communities (ACC) Program is a practice-level intervention implemented by UnitedHealthcare to improve care for Medicaid beneficiaries. We examined changes in costs and utilization for Medicaid beneficiaries with diabetes assigned to ACC versus usual care practices.Research designInterrupted time series with concurrent control group analysis, at the person-month level. The ACC was implemented in 14 states, and we selected comparison non-ACC practices from those states to control for state-level variation in Medicaid program. We adjusted the models for age, sex, race/ethnicity, comorbidities, seasonality, and state-by-year fixed effects. We examined the difference between ACC and non-ACC practices in changes in the time trends of expenditures and hospital and emergency room utilization, for the 4 largest categories of Medicaid eligibility [Temporary Assistance to Needy Families, Supplemental Security Income (without Medicare), Expansion, Dual-Eligible].Subjects/measuresEligibility and claims data from Medicaid adults with diabetes from 14 states between 2010 and 2016, before and after ACC implementation.ResultsAnalyses included 1,200,460 person-months from 66,450 Medicaid patients with diabetes. ACC implementation was not associated with significant changes in outcome time trends, relative to comparators, for all Medicaid categories.ConclusionsMedicaid patients assigned to ACC practices had no changes in cost or utilization over 3 years of follow-up, compared with patients assigned to non-ACC practices. The ACC program may not reduce costs or utilization for Medicaid patients with diabetes.

IntroductionTo examine the association of a novel disease-specific health plan, known as the Diabetes Health Plan (DHP), with emergency room (ER) and hospital utilization among patients with diabetes and pre-diabetes.Research design and methodsQuasi-experimental design, with employer group as the unit of analysis, comparing changes in any ER and inpatient hospital utilization over a 3-year period. Inverse probability weighting was used to control for differences between employers purchasing DHP versus standard plans. Estimated differences in utilization are calculated as average treatment effects on the treated. We used employees and dependents from employer groups contracting with a large, national private insurer between 2009 and 2012. Eligibility and claims data from continuously covered employees and dependents with diabetes and pre-diabetes (n=74 058) were aggregated to the employer level. The analysis included 9 DHP employers (n=7004) and 183 control employers (n=67 054).ResultsDHP purchase was associated with 2.4 and 1.8 percentage points absolute reduction in mean rates of any ER utilization, representing 13% and 10% relative reductions at 1 and 2 years post-DHP (p=0.012 and p=0.046, respectively). There was no significant association between DHP purchase and hospital utilization.ConclusionEmployers purchasing diabetes-specific health benefit designs may experience lower rates of resource-intensive services such as ER utilization.

ObjectiveThe aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures.Summary background dataReducing surgical costs is paramount to the viability of hospitals.MethodsRetrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.ResultsThe number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.ConclusionsSurgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

ObjectiveThe study objective was to examine the association between mental health staffing at health centers funded by the Health Resources and Services Administration (HRSA) and patients' receipt of mental health treatment.MethodsData were from the 2014 HRSA-funded Health Center Patient Survey and the 2013 Uniform Data System. Colocation of any mental health staff, including psychiatrists, psychologists, and other licensed staff, was examined. The outcomes of interest were whether a patient received any mental treatment and received any such treatment on site (at the health center). Analyses were conducted with multilevel generalized structural equation logistic regression models for 4,575 patients ages 18-64.ResultsPatients attending health centers with at least one mental health full-time equivalent (FTE) per 2,000 patients had a higher predicted probability of receiving mental health treatment (32%) compared with those attending centers with fewer than one such FTE (24%) or no such staffing (22%). Among patients who received this treatment, those at health centers with no staffing had a significantly lower predicted probability of receiving such treatment on site (28%), compared with patients at health centers with fewer than one such FTE (49%) and with at least one such FTE (65%). The predicted probability of receiving such treatment on site was significantly higher if there was a colocated psychiatrist versus no psychiatrist (58% versus 40%).ConclusionsColocating mental health staff at health centers increases the probability of patients' access to such treatment on site as well as from off-site providers.

Background To determine if requiring Dual Eligible Special Need Plans (D-SNPs) to receive approval from the National Committee of Quality Assurance and contract with state Medicaid agencies impacts healthcare utilization. Methods We use a Multiple Interrupted Time Series to examine the association of D-SNP regulations with dichotomized measures of emergency room (ER) and hospital utilization. Our treatment group is elderly D-SNP enrollees. Our comparison group is near-elderly (ages 60–64) beneficiaries enrolled in Medicaid Managed Care plans (N = 360,405). We use segmented regression models to estimate changes in the time-trend and slope of the outcomes associated with D-SNP regulations, during the post-implementation (2012–2015) period, relative to the pre-implementation (2010–2011) period. Models include a treatment-status indicator, a monthly time-trend, indicators and splines for the post-period and the interactions between these variables. We conduct the following sensitivity analyses: (1) Re-estimating models stratified by state (2) Estimating models including interactions of D-SNP implementation variables with comorbidity count to assess for differential D-SNP regulation effects across comorbidity level. (3) Re-estimating the models stratifying by race/ethnicity and (4) Including a transition period (2012–2013) in the model. Results We do not find any statistically significant changes in ER or hospital utilization associated with D-SNP regulation implementation in the broad D-SNP population or among specific racial/ethnic groups; however, we do find a reduction in hospitalizations associated with D-SNP regulations in New Jersey (DD level = − 3.37%; p = 0.02)/(DD slope = − 0.23%; p = 0.01) and among individuals with higher, relative to lower levels of co-morbidity (DDD slope = − 0.06%; p = 0.01). Conclusions These findings suggest that the impact of D-SNP regulations varies by state. Additionally, D-SNP regulations may be particularly effective in reducing hospital utilization among beneficiaries with high levels of co-morbidity.

OBJECTIVE: Adverse selection in medical insurance is well documented; however, little is known about the role of behavioral health. This study’s objective was to examine the probability of being enrolled in the lowest-deductible plan among commercially insured patients, according to psychiatric diagnosis. METHODS: This cross-sectional study used 2012–2013 benefit design and plan choice data linked to 2011–2012 behavioral health claims for a national sample of individuals (N=116,975) and different family types (couple with at least one dependent, N=59,237; single subscriber with at least one dependent, N=19,066; couple with no dependents, N=40,917) with Optum, UnitedHealth Group “carve-in” plans. Analyses included multiple logistic regressions examining whether the individual (or family) was enrolled in the plan with the lowest-deductible as functions of whether individuals (or family members) had any psychiatric diagnosis, the number of psychiatric diagnoses they had, and whether they had individual major psychiatric diagnoses. RESULTS: For individuals, having any psychiatric diagnosis was associated with an increase of about 10% in the probability of being enrolled in the lowest-deductible plan compared with having no psychiatric diagnosis (44.9% vs. 40.7%, p=0.04). Each additional psychiatric diagnosis increased this probability by three percentage points (p=0.02). A diagnosis of depression was associated with the largest increase. CONCLUSIONS: When individuals were offered the choice of a health insurance plan, having a prior psychiatric diagnosis (specifically depression) was associated with being enrolled in the lowest-deductible plans. Individuals with depression may anticipate future expenditures and select plans accordingly.

BackgroundPre-diabetes affects one-third of adults in the USA and a subset will progress to type 2 diabetes. Our objective was to determine whether a disease-specific health plan, known as the Diabetes Health Plan (DHP), designed to improve care for persons with pre-diabetes and diabetes also led to lower rates of incident diabetes among adults with pre-diabetes.MethodsWe examined eligibility and claims data from a large payer who offered the DHP to a national sample of employers. We included adult employees and dependents who were continuously covered by the DHP over a 4-year study window. The primary outcome was incident diabetes. We conducted propensity score matching at the employer level to find comparable control employer groups offering standard plans. Using an adjusted logistic regression model at the individual level, we tested the association between DHP employer group status and incident diabetes diagnosis during the 3 years of postbaseline follow-up.FindingsOur analysis included data from 11 965 continuously enrolled adults with pre-diabetes (n=1538 from nine employers offering DHP; n=10 427 from 105 control employers offering standard plans). DHP employees and covered dependents with pre-diabetes had an 8% lower absolute predicted probability of incident diabetes compared with individuals from employer groups offering standard benefit plans (29% predicted probability of incident diabetes for DHP vs 37% for controls, pConclusionsA pre-diabetes-specific health benefit design was associated with lower rates of incident diabetes and represents an area of needed future study.

Life chaos, the perceived inability to plan for and anticipate the future, may be a barrier to the HIV care continuum for people living with HIV who experience incarceration. Between December 2012 and June 2015, we interviewed 356 adult cisgender men and transgender women living with HIV in Los Angeles County Jail. We assessed life chaos using the Confusion, Hubbub, and Order Scale (CHAOS)and conducted regression analyses to estimate the association between life chaos and care continuum. Forty-eight percent were diagnosed with HIV while incarcerated, 14% were engaged in care 12months prior to incarceration, mean antiretroviral adherence was 65%, and 68% were virologically suppressed. Adjusting for sociodemographics, HIV-related stigma, and social support, higher life chaos was associated with greater likelihood of diagnosis while incarcerated, lower likelihood of engagement in care, and lower adherence. There was no statistically significant association between life chaos and virologic suppression. Identifying life chaos in criminal-justice involved populations and intervening on it may improve continuum outcomes.

Background To assess whether implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) was associated with: 1. Reduced differences in financial requirements (i.e., copayments and coinsurance) for substance use disorder (SUD) versus specialty mental health (MH) care and 2. Reductions in the level of cost-sharing for SUD-specific services. Methods MH and SUD copayments and coinsurance, 2008–2013, were obtained from benefits databases for carve-in and carve-out plans from Optum®. Linear regression was used to estimate the association of MHPAEA with differences between MH and SUD care financial requirements among carve-in and carve-out plans. A two-part regression model investigated whether MHPAEA was associated with changes in the use or level of financial requirements for SUD-specific services among carve-out plans. Results MHPAEA was not associated with significant changes in the difference between SUD and MH copayments or coinsurance levels among either carve-in or carve-out plans. MHPAEA was associated with decreases in the levels of inpatient (in-network: −$51.17; out-of-network: −$34.39) and outpatient (in-network: −$10.26) detox copayments, but increases in the levels of in-network outpatient detox coinsurance (6 percentage points) among all carve-out plans. Conclusion Even if SUD benefits had been historically less generous than MH benefits, SUD financial requirements were already at parity with MH financial requirements by the time MHPAEA was passed, among Optum® plans. MHPAEA’s SUD parity mandate reduced cost-sharing for detox services via copayments, but, for outpatient detox, the law simultaneously increased cost-sharing via coinsurance.

Fear of crime has been associated with mental health outcomes. Yet, causal relationships have not been established. We examined the relationship between fear and mental health while accounting for potential endogeneity. A sample of 2329 adolescents from the Project on Human Development in Chicago Neighborhoods dataset was analyzed to assess the effect of fear of neighborhood violent crime on anxiety/depression. Instrumental variable (IV) methods were used to address endogeneity. There is evidence that the estimated effect of fear on depressive symptoms does not suffer from endogeneity bias in single-equation models. Adolescents who were more fearful had higher anxiety/depression scores. In adjusted analyses, for each one unit increase in fear (in this case, a move from one level of fear to the next), anxiety/depression scores increased by 1.32 points. There is support for the hypothesis that fear of neighborhood violent crime caused an increase in anxiety/depression scores among adolescents. Many programs address exposure to violence as a potential cause of depression, however few address the fear of violent victimization as a cause. Interventions and services should address fear as a root cause of anxiety/depression among adolescents.

This study surveys surgeons’ cost knowledge and ability to distinguish subtle price variations between surgical tools with similar functions or indications.

IMPORTANCE: Suicide deaths are a leading cause of maternal mortality in the US, yet the prevalence and trends in suicidality (suicidal ideation and/or intentional self-harm) among childbearing individuals remain poorly described. OBJECTIVE: To characterize trends in suicidality among childbearing individuals. DESIGN, SETTING, AND PARTICIPANTS: This serial cross-sectional study analyzed data from a medical claims database for a large commercially insured population in the US from January 2006 to December 2017. There were 2714 diagnoses of suicidality 1 year before or after 698 239 deliveries among 595 237 individuals aged 15 to 44 years who were continuously enrolled in a single commercial health insurance plan. Data were analyzed from October 2019 to September 2020. MAIN OUTCOMES AND MEASURES: The primary outcome was diagnosis of suicidality in childbearing individuals 1 year before or after birth based on the identification of relevant International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes during at least 1 inpatient or 2 outpatient visits. RESULTS: Of 595 237 included childbearing individuals, the mean (SD) age at delivery was 31.9 (6.4) years. A total of 40 568 individuals (6.8%) were Asian, 52 613 (8.6%) were Black, 73 172 (12.1%) were Hispanic, 369 501 (63.1%) were White, and 59 383 (9.5%) had unknown or missing race/ethnicity data. A total of 2683 individuals were diagnosed with suicidality 1 year before or after giving birth for a total of 2714 diagnoses. The prevalence of suicidal ideation increased from 0.1% per 100 individuals in 2006 to 0.5% per 100 individuals in 2017 (difference, 0.4%; SE, 0.03; P

The aim of this study was to determine whether exposure to data from a risk calculator influences surgeons' assessments of risk and in turn, their decisions to operate.Little is known about how risk calculators inform clinical judgment and decision-making.We asked a national sample of surgeons to assess the risks (probability of serious complications or death) and benefits (recovery) of operative and nonoperative management and to rate their likelihood of recommending an operation (5-point scale) for 4 detailed clinical vignettes wherein the best treatment strategy was uncertain. Surgeons were randomized to the clinical vignettes alone (control group; n = 384) or supplemented by data from a risk calculator (risk calculator group; n = 395). We compared surgeons' judgments and decisions between the groups.Surgeons exposed to the risk calculator judged levels of operative risk that more closely approximated the risk calculator value (RCV) compared with surgeons in the control group [mesenteric ischemia: 43.7% vs 64.6%, P0.001 (RCV = 25%); gastrointestinal bleed: 47.7% vs 53.4%, P0.001 (RCV = 38%); small bowel obstruction: 13.6% vs 17.5%, P0.001 (RCV = 14%); appendicitis: 13.4% vs 24.4%, P0.001 (RCV = 5%)]. Surgeons exposed to the risk calculator also varied less in their assessment of operative risk (standard deviations: mesenteric ischemia 20.2% vs 23.2%, P = 0.01; gastrointestinal bleed 17.4% vs 24.1%, P0.001; small bowel obstruction 10.6% vs 14.9%, P0.001; appendicitis 15.2% vs 21.8%, P0.001). However, averaged across the 4 vignettes, the 2 groups did not differ in their reported likelihood of recommending an operation (mean 3.7 vs 3.7, P = 0.76).Exposure to risk calculator data leads to less varied and more accurate judgments of operative risk among surgeons, and thus may help inform discussions of treatment options between surgeons and patients. Interestingly, it did not alter their reported likelihood of recommending an operation.

OBJECTIVE: To estimate expenditures for fall-related injuries (FRIs) among older Medicare beneficiaries. DATA SOURCES: The 2007-2009 Medicare claims and 2008 Health and Retirement Study (HRS) data for 5,497 (228 FRI and 5,269 non-FRI) beneficiaries. STUDY DESIGN: FRIs were indicated by inpatient/outpatient ICD-9 diagnostic codes for fractures, trauma, dislocations, and by e-codes. A pre-post comparison group design was used to estimate the differential change in pre-post expenditures for the FRI relative to the non-FRI cohort (FRI expenditures). Out-of-pocket (OOP) costs, service category total annual FRI-related Medicare expenditures, expenditures related to the type of initial FRI treatment (inpatient, ED, outpatient), and the risk of persistently high expenditures (4th quartile for each post-FRI quarter) were estimated. PRINCIPAL FINDINGS: Estimated FRI expenditures were $9,389 (95 percent CI: $5,969-$12,808). Inpatient, physician/outpatient, skilled nursing facility, and home health comprised 31, 18, 39, and 12 percent of the total. OOP costs were $1,363.0 (95 percent CI: $889-$1,837). Expenditures for FRIs initially treated in inpatient/ED/outpatient settings were $21,424/$6,142/$8,622. The FRI cohort had a 64 percent increased risk of persistently high expenditures. Total Medicare expenditures were $13 billion (95 percent CI: $9-$18 billion). CONCLUSIONS: FRIs are associated with substantial, persistent Medicare expenditures. Cost-effectiveness of multifactorial falls prevention programs should be assessed using these expenditure estimates.© Health Research and Educational Trust. Language: en

RESEARCH OBJECTIVE: Policy makers, clinicians, researchers, and the general public are all paying increasing attention to disturbing trends regarding growing rates of maternal mortality. Suicide deaths are a significant contributor to maternal mortality and continue to rise. In this context, we sought to identify trends in suicidal ideation and self‐harm in a large national cohort of privately insured delivering women. STUDY DESIGN: The MAternal Behavioral Health PoLicy Evaluation (MAPLE: R01 MH120124) study uses administrative health plan data to develop predictors and health service utilization outcomes associated with suicidal ideation and self‐harm in this high‐risk patient population. We will present the baseline characteristics of our study population in addition to trends. POPULATION STUDIED: This study includes 1 750 000 privately insured delivering women between 2005 and 2017 using data from a large national database of multiple health plans. The study sample includes women aged 15‐44 continuously enrolled in a single health insurance plan for one year before and one year after delivery. We identified suicidal ideation, self‐harm, depression, and anxiety using ICD‐9 and ICD‐10 diagnosis codes. PRINCIPAL FINDINGS: We found that rates of suicidal ideation rose from 34.8 per 100 000 women in 2005 to 318.7 per 100 000 women in 2017. Rates of intentional self‐harm rose from 34.8 per 100 000 women in 2005 to 122.2 per 100 000 women in 2017. Rates of either suicidal ideation or self‐harm rose from 69.6 per 100 000 women in 2005 to 440.9 per 100 000 women in 2017. Among women with a diagnosis of perinatal depression or anxiety, rates of either suicidal ideation or self‐harm rose from 123.9 per 100 000 women in 2005 to 909.1 per 100 000 women in 2017. Among women without a diagnosis of perinatal depression or anxiety disorder (PMAD), rates of either suicidal ideation or self‐harm rose from 58.2 per 100 000 women in 2005 to 307.9 per 100 000 women in 2017. Stated another way, suicidal ideation rose over eightfold during the observation period, self‐harm increased 2.5 times, and ideation or self‐harm increased over fivefold. Among women with PMAD, ideation or self‐harm among women increased 6.3 times compared to those without PMAD, for whom ideation and self‐harm increased 4.3 times. CONCLUSIONS: Rates of suicidal ideation and self‐harm increased substantially over a thirteen‐year period. Even accounting for potential coding changes associated with conversion from diagnosis using ICD‐9 to ICD‐10, changes in access to mental health care due to mental health parity and the Affordable Care Act during the observation period, these increases remain alarming. Given that publicly insured women typically face higher rates of morbidity and mortality than do those who are privately insured, these statistics likely underrepresent the burden of severe mental distress among all perinatal women. IMPLICATIONS FOR POLICY OR PRACTICE: Policy makers, health plans, and clinicians should ensure access to screening and appropriate treatment for high‐risk delivering and postpartum women and to seek additional health system and policy avenues to mitigating this growing public health crisis. PRIMARY FUNDING SOURCE: National Institutes of Health.

The effects of witnessing and experiencing crime have seldom been disaggregated. Little research has assessed the effect of multiple exposures to crime. We assess independent contributions of self-reported crime and area-level crime to adolescent behavioral health outcomes. Cross sectional data on 5519 adolescents from the Comprehensive Community Mental Health Services for Children and their Families Program was linked to FBI crime rate data to assess associations of mutually exclusive categories of self-reported crime exposure and area-level crime rates with mental health and substance abuse. Self-reported crime exposure was significantly associated with poorer behavioral health. Violent victimization had the largest association with all outcomes except internalizing scores. All self-reported crime variables were significantly associated with three of the outcomes. Area-level crime rates were associated with one mental health outcome. Providers should assess direct and indirect crime exposure rather than only focusing on violent victimization.

Background At-risk drinking, defined as alcohol use that is excessive or potentially harmful in combination with select comorbidities or medications, affects about 10% of older adults in the United States and is associated with higher mortality. The Project SHARE intervention, which uses patient and provider educational materials, physician counseling, and health educator support, was designed to reduce at-risk drinking among this vulnerable population. Although an earlier study showed that this intervention was successful in reducing rates of at-risk drinking, it is unknown whether these reductions translate into improved health and health-related quality of life (HRQL). Objective The aim of this study was to examine changes in health and HRQL of older adult at-risk drinkers resulting from a patient–provider educational intervention. Research design A randomized controlled trial to compare the health and HRQL outcomes of patients assigned to the Project SHARE intervention vs. care as usual at baseline, 6- and 12-months post assignment. Control patients received usual care, which may or may not have included alcohol counseling. Intervention group patients received a personalized patient report, educational materials on alcohol and aging, a brief provider intervention, and a telephone health educator intervention. Subjects Current drinkers 60years and older accessing primary care clinics around Santa Barbara, California ( N =1049). Measurements Data were collected from patients using baseline, 6- and 12-month mail surveys. Health and HRQL measures included mental and physical component scores (MCS and PCS) based on the Short Form-12v2 (SF-12v2), the SF-6D, which is also based on the SF-12, and the Geriatric Depression Scale (GDS). Adjusted associations of treatment assignment with these outcomes were estimated using generalized least squares regressions with random provider effects. Regressions controlled for age group, sex, race/ethnicity, marital status, education, household income, home ownership and the baseline value of the dependent variable. Results After regression adjustment, the intervention was associated with a 0.58 point (95% CI: −0.06, 1.21) increase in 6-month MCS and a 0.14 point (95% CI: 0.01, 0.26) improvement in 12-month GDS score, compared to the control group. The intervention also increased adjusted SF-6D scores by 0.01 points at both 6 and 12months (6-month 95% CI: 0.01, 0.02; 12-month 95% CI: 0.01, 0.01). Conclusions Despite the previously shown effectiveness of the Project SHARE intervention to reduce at-risk drinking among older adults, this effect translated into effects on health and HRQL that were statistically but not necessarily clinically significant. Effects were most prominent for patients who received physician discussions, suggesting that provider counseling may be a critical component of primary care-based interventions targeting at-risk alcohol use.

© 2015, American Psychiatric Association. All rights reserved. Objective: The study assessed racial-ethnic differences in receipt of mental health services among children enrolled in systems of care under the Children's Mental Health Initiative (CMHI). Methods: Survey data for 3,920 CMHI enrollees were used to estimate the association between race-ethnicity and the number of days in the 12 months postenrollment during which the child received individual psychotherapy, family and group psychotherapy, medication monitoring, assessment and evaluation, case management, residential treatment, and inpatient care. Two-part regressionswith fixedsiteeffectswereestimated to adjust for geography and baseline population differences, including child and caregiver characteristics. Results: Compared with white non-Latino children, African Americans had lower odds of using any individual psychotherapy (odds ratio [OR]=.73, p=.019), family and group psychotherapy (OR=.79, p=.043), and medication monitoring (OR=.51, p

Objective: To compare community engage­ment and planning (CEP) for coalition support to implement depression quality improvement (QI) to resources for services (RS) effects on service-use costs over a 12-month period. Design: Matched health and community programs (N=93) were cluster-randomized within communities to CEP or RS. Setting: Two Los Angeles communities. Participants: Adults (N=1,013) with depressive symptoms (Patient Health Questionnaire (PHQ-8) ≥10); 85% African American and Latino. Interventions: CEP and RS to support pro­grams in depression QI. Main outcome measures: Intervention training and service-use costs over 12 months. Results: CEP planning and training costs were almost 3 times higher than RS, largely due to greater CEP provider training partici­pation vs RS, with no significant differences in 12-month service-use costs. Conclusions: Compared with RS, CEP had higher planning and training costs with simi­lar service-use costs. Ethn Dis. 2018;28(Sup­pl 2):349-356; doi:10.18865/ed.28.S2.349.

Background The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between behavioral health and medical health insurance benefits among the commercially insured. This study determines whether MHPAEA was associated with increased BH expenditures and utilization among a population with substance use disorder (SUD) diagnoses. Methods Claims and eligibility data from 5,987,776 enrollees, 2008–2013, were obtained from a national, commercial, managed behavioral health organization. An interrupted time series study design with segmented regression analysis estimated time trends of per-member-per-month (PMPM) spending and use before (2008–2009), during (2010), and after (2011−2013) MHPAEA compliance. The study sample contained individuals with drug or alcohol use disorder diagnosis during study period (N=2,716,473 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits; medication management; individual, group and family psychotherapy, and structured outpatient care); intermediate care utilization (day treatment; recovery home and residential); and inpatient utilization. Results Starting at the beginning of the post-parity period, MHPAEA was associated with increased levels of PMPM total and plan spending ($25.80 [p=0.01]; $28.33 [p=0.00], respectively), as well as the number of PMPM assessment/evaluation, individual psychotherapy, and group psychotherapy visits, and inpatient days (0.01 visits [p=0.01]; 0.02 visits [p=0.01]; 0.01 visits [p=0.03]; 0.01days [p=0.01], respectively). Following these initial level changes, MHPAEA was also associated with monthly increases in PMPM total, plan, and patent out-of-pocket spending ($2.56/month [p=0.00]; $2.25/month [p=0.00]; $0.27 [p=0.03], respectively), as well as structured outpatient visits and inpatient days (0.0012 visits/month [p=0.01]; 0.0012days/month [p=0.00]). Conclusion MHPAEA was associated with modest increases in total, plan, and patient out-of-pocket spending and outpatient and inpatient utilization. These increases, while modest in magnitude, are larger in magnitude than increases detected among a sample of all enrollees (i.e. not only those with SUD diagnoses).

ObjectiveThe Mental Health Parity and Addiction Equity Act (MHPAEA) significantly changed regulations governing behavioral health benefits for large, commercially insured employers. Pre-MHPAEA, many plans covered only a specific number of behavioral health treatment days or visits; post-MHPAEA, such quantitative treatment limits (QTLs) were allowed only if they were "at parity" with medical-surgical limits. This study assessed MHPAEA's effect on the prevalence of behavioral health QTLs.MethodsAnalyses used 2008-2013 specialty behavioral health benefit design data for Optum large-group plans, both carve-outs (N=2,257 plan-years, corresponding to 1,527 plans and 40 employers) and carve-ins (N=11,644 plan-years, 3,569 plans, and 340 employers). Descriptive statistics were calculated for limits existing at parity implementation, distinguished by accumulation period (annual or lifetime), level of care (inpatient, intermediate, or outpatient), unit (days, visits, or courses), condition, and network level. Proportions of plans using specific limits during the preparity (2008-2009), transition (2010), and postparity (2011-2013) periods were compared with Fisher's exact tests.ResultsPreparity, the most common QTLs were annual visit or day limits. Accounting for overlap in limit types, 89% of regular carve-out plans, 90% of in-network-only carve-outs, and 77% of carve-in plans limited outpatient visits; 66% of regular carve-out plans, 74% of in-network-only carve-outs, and 73% of carve-ins limited inpatient or intermediate days. Postparity, QTLs almost entirely disappeared (p

Rationale Falls are common among older adults and may be related to depressive symptoms (DS). With advancing age, there is an onset of chronic conditions, sensory impairments, and activity limitations that are associated with falls and with depressive disorders. Prior cross-sectional studies have observed significant associations between DS and subsequent falls as well as between fractures and subsequent clinical depression and DS. Objective The directionality of these observed relationship between falls and DS is in need of elaboration given that cross-sectional study designs can yield biased estimates of the DS-falls relationship. Methods Using 2006–2010 Health and Retirement Study data, cross-lagged panel structural equation models were used to evaluate associations between falls and DS among 7233 community-dwelling adults ages ≥65. Structural coefficients between falls and DS (in 2006→2008, 2008→2010) were estimated. Results A good-fitting model was found: Controlling for baseline (2006) physical functioning, vision, chronic conditions, and social support and neighborhood social cohesion, falls were not associated with subsequent DS, but a 0.5 standard deviation increase in 2006 DS was associated with a 30% increase in fall risk two years later. This DS-falls relationship was no longer significant when use of psychiatric medications, which was positively associated with falls, was included in the model. Conclusion Using sophisticated methods and a large U.S. sample, we found larger magnitudes of effect in the DS-falls relationship than in prior studies—highlighting the risk of falls for older adults with DS. Medical providers might assess older individuals for DS as well as use of psychotropic medications as part of a broadened falls prevention approach. National guidelines for fall risk assessments as well as quality indicators for fall prevention should include assessment for clinical depression.

BackgroundFalls and fall-related injuries (FRI) are common and costly occurrences among older adults living in the community, with increased risk for those with physical and cognitive limitations. Caregivers provide support for older adults with physical functioning limitations, which are associated with fall risk.DesignUsing the 2004-2012 waves of the Health and Retirement Study, we examined whether receipt of low (0-13 weekly hours) and high levels (≥14 weekly hours) of informal care or any formal care is associated with lower risk of falls and FRIs among community-dwelling older adults. We additionally tested whether serious physical functioning (≥3 activities of daily living) or cognitive limitations moderated this relationship.ResultsCaregiving receipt categories were jointly significant in predicting noninjurious falls (P=0.03) but not FRIs (P=0.30). High levels of informal care category (P=0.001) and formal care (P

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Objective: The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees. Methods: We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in selfinsured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N = 179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization. Results: MHPAEA was associated with increases in monthly permember total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P = 0.02); $0.88 (P = 0.04); 0.00045 visits (P = 0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P = 0.00) and additional increases of 0.00017 visits/mo (P = 0.03)]. Conclusions: MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.

Objectives To compare the strength of the association between depression and mortality between elderly and younger individuals with diabetes mellitus. Design A survival analysis conducted in a longitudinal cohort study of persons with diabetes mellitus to test the association between depression and mortality in older (≥65) and younger (18-65) adults. Setting Managed care. Participants Persons aged 18 and older with diabetes mellitus who participated in the Wave 2 survey of the Translating Research Into Action for Diabetes (TRIAD) Study (N = 3,341). Measurements The primary outcome was mortality risk, which was measured as days until death using linked data from the National Death Index. Depression was measured using the Patient Health Questionnaire. Results After controlling for age, sex, race and ethnicity, income, and other comorbidities, mortality risk in persons with diabetes mellitus was 49% higher in those with depression than in those without, although results varied according to age. After controlling for the same variables, mortality risk in persons aged 65 and older with depression was 78% greater than in those without. For those younger than 65, the effect of depression on mortality was smaller and not statistically significant. Conclusion This analysis suggests that the effect of depression on mortality in persons with diabetes mellitus is most significant for older adults. Because there is evidence in the literature that treatment of depression in elderly adults can lead to lower mortality, these results may suggest that older adults with diabetes mellitus should be considered a high-priority population for depression screening and treatment. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Objectives: To compare 12-month outpatient healthcare expenditures of at-risk and not-at-risk drinkers aged 60 and older. Design: Secondary analysis of data from Project Senior Health and Alcohol Risk Education, a cluster, randomized trial to test the efficacy of an intervention to reduce at-risk drinking. Setting: Seven primary care clinics in or near Santa Barbara, California. Participants: Current drinkers aged 60 and older who completed a baseline survey (N = 2,779) and did not receive the study intervention, including 628 at-risk drinkers and 2,151 not-at-risk drinkers. Measurements: Comparisons of at-risk and not-at-risk drinkers for baseline demographic characteristics, health indicators, alcohol consumption, and adjusted and unadjusted outpatient healthcare expenditures incurred over 12 months after baseline. Results: At-risk drinkers were younger, more often male, and more likely to be married and had higher education and incomes than not-at-risk drinkers. Unadjusted 12-month mean outpatient healthcare expenditures were $1,333 ± 2,973 for at-risk drinkers and $1,417 ± 2,952 for the not-at-risk drinkers. There were no statistically significant differences in expenditures between groups before and after controlling for sociodemographic and health characteristics. Conclusion: In this short-term study, no adjusted differences in healthcare expenditures were observed between at-risk and not-at-risk older drinkers. Future study is warranted to determine the role of at-risk drinking in long-term healthcare expenditures in older adults.

BackgroundDrug substitution is a promising approach to reducing medication costs.ObjectiveTo calculate the potential savings in a Medicare Part D plan from generic or therapeutic substitution for commonly prescribed drugs.DesignCross-sectional, simulation analysis.ParticipantsLow-income subsidy (LIS) beneficiaries (n = 145,056) and non low-income subsidy (non-LIS) beneficiaries (n = 1,040,030) enrolled in a large, national Part D health insurer in 2007 and eligible for a possible substitution.MeasurementsUsing administrative data from 2007, we identified claims filled for brand-name drugs for which a direct generic substitute was available. We also identified the 50 highest cost drugs separately for LIS and non-LIS beneficiaries, and reached consensus on which drugs had possible therapeutic substitutes (27 for LIS, 30 for non-LIS). For each possible substitution, we used average daily costs of the original and substitute drugs to calculate the potential out-of-pocket savings, health plan savings, and when applicable, savings for the government/LIS subsidy.ResultsOverall, 39 % of LIS beneficiaries and 51 % of non-LIS beneficiaries were eligible for a generic and/or therapeutic substitution. Generic substitutions resulted in an average annual savings of $160 in the case of LIS beneficiaries and $127 in the case of non-LIS beneficiaries. Therapeutic substitutions resulted in an average annual savings of $452 in the case of LIS beneficiaries and $389 in the case of non-LIS beneficiaries.ConclusionsOur findings indicate that drug substitution, particularly therapeutic substitution, could result in significant cost savings. There is a need for additional studies evaluating the acceptability of therapeutic substitution interventions within Medicare Part D.

OBJECTIVE To estimate the effect of preventing postoperative complications on readmission rates and costs. BACKGROUND Policymakers are targeting readmission for quality improvement and cost savings. Little is known regarding mutable factors associated with postoperative readmissions. METHODS Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Risk factors, procedure, and 30-day postoperative complications were determined from ACS-NSQIP. The 30-day postoperative readmission and costs were determined from Medicare. Occurrence of a postoperative complication included surgical site infections and cardiac, pulmonary, neurologic, and renal complications. Multivariate regression models predicted the effect of reducing complication rates on risk-adjusted readmission rates and costs by procedure. RESULTS The 30-day postoperative readmission rate was 12.8%. Complication rates for readmitted and nonreadmitted patients were 53% and 16% (P < 0.001). Patients with a postoperative complication had higher predicted probability of readmission and cost of readmission than patients without a complication. For the 20 procedures accounting for the greatest number of readmissions, reducing ACS-NSQIP complication rates by a relative 5% could result in prevention of 2092 readmissions per year and a savings to Medicare of $31.0 million per year. Preventing all ACS-NSQIP complications for these procedures could result in prevention of 41,846 readmissions per year and a savings of $620.3 million per year. CONCLUSIONS This study provides substantial evidence that efforts to reduce postoperative readmissions should begin by focusing on postoperative complications that can be reliably and validly measured. Such an approach will not eliminate all postoperative readmissions but will likely have a major effect on readmission rates.

OBJECTIVES: Compare expenditures of fall-related injuries (FRIs) using several methods to identify FRIs in administrative claims data. RESEARCH DESIGN: Using 2007-2009 Medicare claims and 2008 Health and Retirement Survey data, FRIs were identified using external-cause-of-injury (e-codes 880/881/882/884/885/888) only, e-codes plus a broad set of primary diagnosis codes, and a newer approach using e-codes and diagnostic and procedural codes. Linear regression models adjusted for sociodemographic, health, and geographic characteristics were used to estimate per-FRI, service component, patient cost share, expenditures by type of initial FRI treatment (inpatient, emergency department only, outpatient), and total annual FRI-related Medicare expenditures. SUBJECTS: The analysis included 5497 community-dwelling adults ≥65 (228 FRI, 5269 non-FRI individuals) with continuous Medicare coverage and alive during the 24-month study. RESULTS: The 3 FRI identification methods produced differing distributions of index FRI type and varying estimated expenditures: $12,171 [95% confidence interval (CI), $4662-$19,680], $5648 (95% CI, $3819-$7476), and $9388 (95% CI, $5969-$12,808). In all models, most spending occurred in hospital, outpatient, and skilled nursing facility (SNF) settings, but greater proportions of SNF and outpatient spending were observed with commonly used FRI identification methods. Patient cost-sharing was estimated at $691-$1900 across the 3 methods. Inpatient-treated index FRIs were more expensive than emergency department and outpatient-treated FRIs across all methods, but were substantially higher when identifying FRI using only e-codes. Estimated total FRI-related Medicare expenditures were highly variable across methods. CONCLUSIONS: FRIs are costly, with implications for Medicare and its beneficiaries. However, expenditure estimates vary considerably based on the method used to identify FRIs. Language: en

© 2016 Wolters Kluwer Health, Inc. Importance: Patients treated outside of their Medicare Shared Savings Program (MSSP) accountable care organization (ACO) likely benefit less from the ACO's integration of care. Consequently, the MSSP's open-network design may preclude ACOs from improving value in care. Objectives: Quantify out-of-ACO care in a single urban ACO and examine associations between patient-level predictors and out-of-ACO expenditures. Research Design: Secondary data analysis using Centers for Medicare and Medicaid ACO Program Claim and Claim Line Feed dataset (dates of service January 1, 2013-December 31, 2013). Two-part modeling was used to examine associations between patient-level predictors and likelihood and level of out-of-ACO expenditures. Subjects: Patients were included if they were prospectively assigned to the MSSP in 2013. Patients were excluded if they declined to share data with the ACO, were not retrospectively confirmed to be in the ACO, or had missing data on covariates. Analytic sample included 11,922 patients. Measures: Total out-of-ACO expenditures and out-of-ACO expenditures by place of service. Results: Of total expenditures, 32.9% were paid to out-of-ACO providers, and 89.8% of beneficiaries had out-of-ACO expenditures. The presence of almost all medical comorbidities increased out-of-ACO expenditures ($800-$3000 per comorbidity) across the study population. Racial/ethnic minority groups spent between $1076 and $1422 less outside of the ACO than white patients, which was driven by less out-of-ACO outpatient office expenditures ($417-$517 less for each racial/ethnic minority group). Conclusions: Out-of-ACO expenditures represented a significant portion of expenditures for the study population. Medically complex patients spent more outside of the ACO and represent an important population to study further.

To determine how surgeons' perceptions of treatment risks and benefits influence their decisions to operate.Little is known about what makes one surgeon choose to operate on a patient and another chooses not to operate.Using an online study, we presented a national sample of surgeons (N = 767) with four detailed clinical vignettes (mesenteric ischemia, gastrointestinal bleed, bowel obstruction, appendicitis) where the best treatment option was uncertain and asked them to: (1) judge the risks (probability of serious complications) and benefits (probability of recovery) for operative and nonoperative management and (2) decide whether or not they would recommend an operation.Across all clinical vignettes, surgeons varied markedly in both their assessments of the risks and benefits of operative and nonoperative management (narrowest range 4%-100% for all four predictions across vignettes) and in their decisions to operate (49%-85%). Surgeons were less likely to operate as their perceptions of operative risk increased [absolute difference (AD) = -29.6% from 1.0 standard deviation below to 1.0 standard deviation above mean (95% confidence interval, CI: -31.6, -23.8)] and their perceptions of nonoperative benefit increased [AD = -32.6% (95% CI: -32.8,--28.9)]. Surgeons were more likely to operate as their perceptions of operative benefit increased [AD = 18.7% (95% CI: 12.6, 21.5)] and their perceptions of nonoperative risk increased [AD = 32.7% (95% CI: 28.7, 34.0)]. Differences in risk/benefit perceptions explained 39% of the observed variation in decisions to operate across the four vignettes.Given the same clinical scenarios, surgeons' perceptions of treatment risks and benefits vary and are highly predictive of their decisions to operate.

Given the growing concern about CT overutilization, we provide a descriptive trend analysis of CT studies ordered in U.S. emergency departments by nonphysician health care providers and examine whether there is a significant difference in ordering patterns between nonphysicians and physicians.We used a nationally representative data sample for 2001-2008 to describe trends in CT studies ordered in U.S. emergency departments by nonphysician health care providers. We performed a multivariate logistic regression with hospital fixed effects on the most recently available data to determine whether there is a difference in ordering patterns between the two provider groups.From 2001 to 2008, the number of emergency department visits associated with CT studies managed solely by nonphysician health care providers increased from 100,626 to 620,296. Over this same period, the proportion of emergency department visits associated with CT managed solely by nonphysician providers grew from 1.5% to 3.6%. Controlling for hospital-level and patient-level variables, patient visits managed solely by nonphysician providers had 0.38 times the odds of CT utilization compared with patient visits managed by physicians.Although both the total number and the proportion of emergency department visits managed independently by nonphysician providers and associated with CT have grown rapidly in the past decade, nonphysician health care providers are less likely to order CT compared with physicians. The types of ordering providers and their differing practices should become part of the discourse regarding appropriate CT utilization.

Children in the child welfare system are the most expensive child population to insure for their mental health needs. The objective of this article is to estimate the amount of Medicaid expenditures incurred from the purchase of psychotropic drugs - the primary drivers of mental health expenditures - for these children.We linked a subsample of children interviewed in the first nationally representative survey of children coming into contact with U.S. child welfare agencies, the National Survey of Child and Adolescent Well-Being (NSCAW), to their Medicaid claims files obtained from the Medicaid Analytic Extract. Our data consist of children living in 14 states, and Medicaid claims for 4 years, adjusted to 2010 dollars. We compared expenditures on psychotropic medications in the NSCAW sample to a propensity score-matched comparison sample obtained from Medicaid files.Children surveyed in NSCAW had over thrice the odds of any psychotropic drug use than the comparison sample. Each maltreated child increased Medicaid expenditures by between $237 and $840 per year, relative to comparison children also receiving medications. Increased expenditures on antidepressants and amphetamine-like stimulants were the primary drivers of these increased expenditures. On average, an African American child in NSCAW received $399 less expenditure than a white child, controlling for behavioral problems and other child and regional characteristics. Children scoring in the clinical range of the Child Behavior Checklist received, on average, $853 increased expenditure on psychotropic drugs.Each child with child welfare involvement is likely to incur upwards of $1482 in psychotropic medication expenditures throughout his or her enrollment in Medicaid. Medicaid agencies should focus their cost-containment strategies on antidepressants and amphetamine-type stimulants, and expand use of instruments such as the Child Behavior Checklist to identify high-cost children. Both of these strategies can assist Medicaid agencies to better predict and plan for these expenditures.

Hospital use near the end of life is often undesirable to patients, represents considerable Medicare cost, and varies widely across regions.To concurrently examine regional and patient factors, including disability and functional decline, associated with end-of-life hospital use.We sampled decedents aged 65 and older (n = 2,493) from the Health and Retirement Study (2000-2006), and linked data from individual Medicare claims and the Dartmouth Atlas of Health Care. Two-part regression models estimated the relationship between total hospital days in the last 6 months and patient characteristics including physical function, while adjusting for regional resources and hospital care intensity (HCI).Median hospital days was 7 (range = 0-183). 53% of respondents had functional decline. Compared with decedents without functional decline, those with severe disability or decline had more regression-adjusted hospital days (range 3.47-9.05, depending on category). Dementia was associated with fewer days (-3.02); while chronic kidney disease (2.37), diabetes (2.40), stroke or transient ischemic attack (2.11), and congestive heart failure (1.74) were associated with more days. African Americans and Hispanics had more days (5.91 and 4.61, respectively). Those with family nearby had 1.62 fewer days and hospice enrollees had 1.88 fewer days. Additional hospital days were associated with urban residence (1.74) and residence in a region with more specialists (1.97) and higher HCI (2.27).Functional decline is significantly associated with end-of-life hospital use among older adults. To improve care and reduce costs, health care programs and policies should address specific needs of patients with functional decline and disability.

Diabetic patients are nearly three times as likely to have depression as their nondiabetic counterparts. Patients with diabetes are already at risk for poor cardiovascular health. Using cross-sectional data from the translating research into action for diabetes (TRIAD) study, the authors tested the association of depression with cardiovascular risk factors in diabetic patients. Depression was measured using the patient health questionnaire (PHQ8). Patients who scored greater than 9 on the PHQ8 were classified as depressed and were compared with those who were not depressed(n=2,341). Depressed patients did not have significantly different blood pressure levels than those who were not depressed. However, those who were depressed had higher HbA1c levels than those who were not depressed(P<0.01)and higher BMIs than those who were not depressed(P<0.01). These results indicate that depressed diabetic patients are at greater risk of having poor control of cardiovascular risk factors and suggest that depression screening should be a standard practice among this patient group.

Collaborative Care for Depression (CCD) in primary care redesigns care processes to incorporate evidence-based depression treatment guidelines and components of the Chronic Care Model (Wagner 2000; Wagner, Austin, and Von Korff 1996). A central element of the model is a care manager in the clinic who serves as a physician extender and conducts patient assessment, education, follow-ups, and care coordination, largely outside a patient’s visits to his/her primary care physician (PCP) (Schulberg et al. 2001). More than 30 randomized controlled trials have shown that CCD improves depression outcomes, patient adherence to treatment, and satisfaction with care (Gilbody et al. 2006; Neumeyer-Gromen et al. 2004; Williams et al. 2007). The prevailing visit-based fee-for-service physician payment system, however, constitutes a serious disincentive for providing this service (Bachman et al. 2006; Berenson, and Horvath 2003; Unutzer et al. 2006; Wolff, and Boult 2005). Recognizing the importance of a payment mechanism, several recent large-scale implementation initiatives adopted case-rate based payment models to cover the cost of delivering evidence-based CCD. The Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) initiative adopted a flat monthly case rate (Institute for Clinical Systems Improvement 2008). This monthly rate was determined based on the average monthly cost of a 12-month CCD intervention tested in a randomized controlled trial (RCT) known as IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) (Unutzer et al. 2002b). A more recent implementation of the IMPACT model to treat a broader set of behavioral health disorders among community health centers in Washington state adopted a lump sum payment to each clinic covering the cost of the yearlong program, with minimum caseload expectations and 25% of the payment retained to reward providers achieving pre-specified depression treatment and outcome targets. The CCD payment in both initiatives is intended to cover CCD program cost to the clinic that is not covered by the visit-based physician payment. The underlying goals of these pioneering efforts to pay for CCD are twofold: 1) to adequately cover the cost of providing CCD, and 2) to align incentives with the delivery of CCD in a way that leads to better outcomes. The design of such a payment should reflect meaningful variation in resource requirement for evidence-based practice of CCD. In addition, it requires a consideration of incentives associated with a given design, and ways to address or ameliorate related issues. In this paper, we used data from a large randomized controlled trial, the IMPACT study (Unutzer et al. 2002b; Unutzer et al. 2001) to investigate salient and feasible properties of a bundled case rate payment design for CCD. In IMPACT, with close monitoring and guidance from the research team, the CCD intervention protocol was implemented with high fidelity. Meanwhile, participating practices came from diverse community and organizational settings (Unutzer et al. 2001). Delivery of CCD as seen in IMPACT thus represents probably the closest to evidence-based practice in “real-world” implementation where provider adoption of financial strategies is likely to be minimal. This unique feature of the data enables us to identify factors accounting for practically significant variation in resource use of CCD, which then guided our recommendation of two case rate based payment models. We further compared implications for health care organizations in the IMPACT study of alternative payment models..

Background— Stroke is the leading cause of adult disability. Inpatient programs optimize secondary stroke prevention care at the time of hospital discharge, but such care may not be continued after hospital discharge. Methods— To improve the delivery of secondary stroke preventive services after hospital discharge, we have designed a chronic care model–based program called SUSTAIN (Systemic Use of STroke Averting INterventions). This care intervention includes group clinics, self-management support, report cards, decision support through care guides and protocols, and coordination of ongoing care. The first specific aim is to test, in a randomized, controlled trial, whether SUSTAIN improves blood pressure control among an analytic sample of 268 patients with a recent stroke or transient ischemic attack discharged from 4 Los Angeles County public hospitals. Secondary outcomes consist of control of other stroke risk factors, lifestyle habits, medication adherence, patient perceptions of care quality, functional status, and quality of life. A second specific aim is to conduct a cost analysis of SUSTAIN from the perspective of the Los Angeles County Department of Health Services by using direct costs of the intervention, cost equivalents of associated utilization of county system resources, and cost equivalents of the observed and predicted averted vascular events. Conclusions— If SUSTAIN is effective, we will have the expertise and findings to advocate for its continued support at Los Angeles County hospitals and to disseminate the SUSTAIN program to other settings serving indigent, minority populations. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00861081.

Despite recent interest in how psychiatric disorders affect work outcomes, little is known about the role of personality disorders (PDs), which are poorly understood yet prevalent (15%) and impairing. We used nationally representative data for 12,457 men and 16,061 women to examine associations of PDs with any employment, full-time employment, chronic unemployment, being fired or laid off, and having trouble with a boss or co-worker. Antisocial, paranoid, and obsessive-compulsive PDs demonstrated the broadest patterns of associations with adverse outcomes. Findings suggest that PDs may have implications for the productivity of co-workers as well as that of the disordered employees themselves.

Aim The broad objective of this study was to examine multiple dimensions of depression in a large, diverse population of adults with diabetes. Specific aims were to measure the association of depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care. Methods Cross-sectional analyses were performed using survey and chart data from the Translating Research Into Action for Diabetes (TRIAD) study, including 8790 adults with diabetes, enrolled in 10 managed care health plans in 7 states. Depression was measured using the Patient Health Questionnaire (PHQ-8). Patient characteristics, outcomes and quality of care were measured using validated survey items and chart data. Results Nearly 18% of patients had major depression, with prevalence 2–3 times higher among patients with low socioeconomic status. Pain and limited mobility were strongly associated with depression, controlling for other patient characteristics. Depression was associated with slightly worse glycemic control, but not other intermediate clinical outcomes. Depressed patients received slightly fewer recommended diabetes-related processes of care. Conclusions In a large, diverse cohort of patients with diabetes, depression was most prevalent among patients with low socioeconomic status and those with pain, and was associated with slightly worse glycemic control and quality of care.

OBJECTIVES: To identify predictors of alcohol-related patient-physician discussions. DESIGN: Cross-sectional study using baseline data from a randomized controlled trial. SETTING: Community-based group practice. PARTICIPANTS: Thirty-one physicians in Project Senior Health and Alcohol Risk Education and 3,305 of their patients aged 60 and older who use alcohol and completed a survey that included the Comorbidity Alcohol Risk Evaluation Tool (CARET). MEASUREMENTS: At study baseline, older adults were asked whether alcohol-related discussions with a physician had occurred in the prior year. This outcome was modeled using logistic regression models with physician random effects. Predictor variables included patient-level variables such as demographics and seven CARET-defined risk factors, specifically a medical or psychiatric comorbidity that alcohol might worsen, a potentially alcohol-related symptom, use of a medication that may interact negatively with alcohol, excessive quantity or frequency of alcohol use, binge drinking, concern from others about drinking, and drinking and driving. Physician-level predictors (age, sex, years since graduation, specialty) were also included. RESULTS: The probability of reporting alcohol-related discussions declined with patient age (e.g., odds ratio (OR)=0.40 for patients aged ≥80) and was significantly lower for Latinos (OR=0.38). Drinking and driving (OR=1.69) or concern from others (OR=6.04) were significantly associated with alcohol-related discussions; having comorbidities or using medications that may interact with alcohol were not. CONCLUSION: Although patient demographics, including age and ethnicity, are associated with the occurrence of alcohol-related discussions, clinical factors that may negatively interact with alcohol to increase risk are not. This suggests that physicians may not be attuned to the entire spectrum of alcohol-related risks for older adults. Language: en

Empirical evidence suggests that individuals who consume relatively large amounts of alcohol are more likely to use expensive acute medical care and less likely to use preventive or ambulatory services than other individuals. The few studies that investigated the associations between heavy drinking and health promotion activities did not try to address omitted-variable biases that may confound the relationships. To fill this void in the literature, we examined the effects of heavy alcohol use on three health promotion activities (routine physical exam, flu shot, regular seatbelt use) using the US 2006 Behavioral Risk Factor Surveillance Survey. Although specification tests indicated that omitted variable bias was not present in the majority of the single-equation probit models, we cautiously interpret our findings as evidence of strong associations rather than causal effects. Among both men and women, heavy alcohol use is negatively and significantly associated with each of our three outcomes. These findings suggest that heavy drinkers may be investing less in health promotion activities relative to abstainers and other drinkers. Policy options to address the associated externalities may be warranted.

Research during the past few decades has greatly advanced our understanding of the cost, quality, and variability of medical care at the end of life. The current health-care policy debate has focused considerable attention on the unsustainable rate of spending and wide regional variation associated with medical treatments in the last year of life. New initiatives aim to standardize quality and reduce over-utilization at the end of life. We argue, however, that focusing exclusively on medical treatment at the end of life is not likely to lead to effective health-care policy reform or reduce costs. Specifically, end-of-life policy initiatives face the challenges of political feasibility, inaccurate prognostication, and gaps in the existing literature.With the ultimate aim of improving the quality and efficiency of care, we propose a research and policy agenda guided by a new conceptual framework of factors associated with treatment intensity for patients with serious and complicated medical illness. This model not only expands the population of interest to include all adults with serious illness, but also provides a blueprint for the thorough investigation of the diverse and interconnected determinants of treatment intensity.The new conceptual framework presented in this paper can be used to develop future research and policy initiatives designed to improve the quality and efficiency of care for adults with serious illness.

Importance Diagnosis of human immunodeficiency virus (HIV) infection, linkage and retention in care, and adherence to antiretroviral therapy are steps in the care continuum enabling consistent viral suppression for people living with HIV, extending longevity and preventing further transmission. While incarcerated, people living with HIV receive antiretroviral therapy and achieve viral suppression more consistently than after they are released. No interventions have shown sustained viral suppression after jail release. Objective To test the effect on viral suppression in released inmates of the manualized LINK LA (Linking Inmates to Care in Los Angeles) peer navigation intervention compared with standard transitional case management controls. Design, Setting, and Participants Randomized clinical trial conducted from December 2012 through October 2016 with people living with HIV being released from Los Angeles (LA) County Jail. All participants were (1) 18 years or older; (2) either men or transgender women diagnosed with HIV; (3) English speaking; (4) selected for the transitional case management program prior to enrollment; (5) residing in LA County; and (6) eligible for antiretroviral therapy. Main Outcomes and Measures Change in HIV viral suppression ( Interventions During the 12-session, 24-week LINK LA Peer Navigation intervention, trained peer navigators counseled participants on goal setting and problem solving around barriers to HIV care and adherence, starting while the participants were still in jail. After their release, they continued counseling while they accompanied participants to 2 HIV care visits, then facilitated communication with clinicians during visits. Results Of 356 participants randomized, 151 (42%) were black; 110 (31%) were Latino; 303 (85%) were men; 53 (15%) were transgender women; and the mean (SD) age was 39.5 (10.4) years. At 12 months, viral suppression was achieved by 62 (49.6%) of 125 participants in the peer navigation (intervention) arm compared with 45 (36.0%) of 125 in the transitional case management (control) arm, for an unadjusted treatment difference of 13.6% (95% CI, 1.34%-25.9%; P = .03). In the repeated measures, random effects, logistic model the adjusted probability of viral suppression declined from 52% at baseline to 30% among controls, while those in the peer navigation arm maintained viral suppression at 49% from baseline to 12 months, for a difference-in-difference of 22% (95% CI, 0.03-0.41; P = .02). Conclusions and Relevance The LINK LA peer navigation intervention was successful at preventing declines in viral suppression, typically seen after release from incarceration, compared with standard transitional case management. Future research should examine ways to strengthen the intervention to increase viral suppression above baseline levels. Trial Registration clinicaltrials.gov Identifier:NCT01406626