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Background Individuals with psychotic symptoms experience substantial morbidity and have shortened life expectancies; early treatment may mitigate the worst effects. Understanding care preceding a first psychotic disorder diagnosis is critical to inform early detection and intervention. Study Design In this observational cohort study using comprehensive information from the Massachusetts All-Payer Claims Database, we identified the first psychotic disorder diagnosis in 2016, excluding those with historical psychotic disorder diagnoses in the prior 48 months among those continuous enrollment data. We reviewed visits, medications, and hospitalizations 2012–2016. We used logistic regression to examine characteristics associated with pre-diagnosis antipsychotic use. Study Results There were 2505 individuals aged 15–35 years (146 per 100 000 similarly aged individuals in the database) with a new psychotic disorder diagnosis in 2016. Most (97%) had at least one outpatient visit in the preceding 48 months; 89% had a prior mental health diagnosis unrelated to psychosis (eg, anxiety [60%], depression [60%]). Many received psychotropic medications (77%), including antipsychotic medications (46%), and 68% had a visit for injury or trauma during the preceding 48 months. Characteristics associated with filling an antipsychotic medication before the psychotic disorder diagnosis included male sex and Medicaid insurance at psychosis diagnosis. Conclusions In this insured population of Massachusetts residents with a new psychotic disorder diagnosis, nearly all had some healthcare utilization, visits for injury or trauma were common, and nearly half filled an antipsychotic medication in the preceding 48 months. These patterns of care could represent either pre-disease signals, delays, or both in receiving a formal diagnosis. [ABSTRACT FROM AUTHOR]

Objective: The authors used a large clinical data set to determine which index diagnoses of schizophrenia spectrum disorder were new diagnoses.Methods: Using the Massachusetts All-Payer Claims Database (2012–2016), the authors identified patients with a schizophrenia spectrum disorder diagnosis in 2016 (index diagnosis) and then reviewed patients’ care histories for the previous 12, 24, 36, and 48 months to identify previous diagnoses. Logistic regression was used to examine patient characteristics associated with the index diagnosis being a new diagnosis.Results: Overall, 7,217 individuals ages 15–35 years had a 2016 diagnosis of schizophrenia spectrum disorder; 67.7% had at least 48 months of historical data. Among those with at least 48 months of care history, 23% had no previous diagnoses. Diagnoses from inpatient psychiatric admissions or among female or younger patients were more likely to represent new diagnoses, compared with diagnoses from most other diagnosis locations or among males or older age groups, and outpatient diagnoses were less likely to represent new diagnoses than were most other diagnosis settings. Reviewing 48 instead of 12 months of data reduced estimated rates of new diagnoses from 112 to 66 per 100,000 persons; historical diagnoses were detected for 61% and 77% of patients with 12 or 48 months of care history, respectively.Conclusions: Examining multiple years of patient history spanning all payers and providers is critical to identifying new schizophrenia spectrum disorder diagnoses in large data sets. Review of 48 months of care history resulted in lower rates of new schizophrenia spectrum disorder diagnoses than previously reported. [ABSTRACT FROM AUTHOR]

Objective: The Affordable Care Act (ACA) introduced reforms to mitigate adverse selection into and within the individual insurance market. We examined the traits and predicted medical spending of enrollees in California post-ACA.Data Sources: Survey of 2,103 enrollees in individual market plans, on- and off-exchange, in 2014.Study Design: We compared actual versus potential participants using data from the 2014 California Health Interview Survey on respondents who were individually insured or uninsured. We predicted annual medical spending for each group using age, sex, self-rated health, body mass index, smoking status, and income.Principal Findings: Average predicted spending was similar for actual ($3,377, 95 percent CI [$3,280-$3,474]) and potential participants ($3,257 [$3,060-$3,454]); however, some vulnerable subgroups were underrepresented. On- versus off-exchange enrollees differed in sociodemographic and health traits with modest differences in spending ($3,448 [$3,330-$3,565] vs. $3,175 [$3,012-$3,338]).Conclusions: We did not find evidence of selection into the overall insurance pool in 2014; however, differences by exchange status reflect the importance of including off-exchange enrollees in analyses and the pool for risk adjustment. California's post-ACA individual market has been a relative success, highlighting the importance of state policies and outreach efforts to encourage participation in the market. [ABSTRACT FROM AUTHOR]

Objective: To examine changes in children's albuterol use and out-of-pocket (OOP) costs in response to increased copayments after the Food and Drug Administration banned inhalers with chlorofluorocarbon (CFC) propellants.Setting: Four health maintenance organizations (HMOs), two that increased copayments for albuterol inhalers that went from generic CFC-containing to branded CFC-free versions, and two that retained generic copayments for CFC-free inhalers (controls). We included children with asthma aged 4-17 years with commercial coverage from 2007 to 2010.Design: Interrupted time series with comparison series.Data: We obtained enrollee and plan characteristics from enrollment files, and utilization data from pharmacy and medical claims; OOP expenditures were extracted from pharmacy claims for two HMOs with cost data available.Findings: There were no significant differences in albuterol use between the group with increased cost-sharing and controls with respect to changes after the policy change. There was a postpolicy increase of $6.11 OOP per month per child using albuterol among those with increased cost-sharing versus $0.36 in controls; the difference between groups was significant (p < .01).Conclusions: Increased copayments for brand-name CFC-free albuterol after the CFC ban did not lead to a decrease in children's albuterol use, but it led to a modest increase in OOP costs. [ABSTRACT FROM AUTHOR]

Objectives: To study the impact of eliminating cost sharing for screening mammography on mammography rates in a large Medicare Advantage (MA) health plan which in 2010 eliminated cost sharing in anticipation of the Affordable Care Act mandate.Study Setting: Large MA health maintenance organization offering individual-subscriber MA insurance and employer-supplemented group MA insurance.Study Design: We investigated the impact on breast cancer screening of a policy that eliminated a $20 copayment for screening mammography in 2010 among 53,188 women continuously enrolled from 2007 to 2012 in an individual-subscriber MA plan, compared with 42,473 women with employer-supplemented group MA insurance in the same health maintenance organization who had full screening coverage during this period. We used differences-in-differences analysis to study the impact of cost-sharing elimination on mammography rates.Principal Findings: Annual screening rates declined over time for both groups, with similar trends pre-2010 and a slower decline after 2010 among women whose copayments were eliminated. Among women aged 65-74 years in the individual-subscriber MA plan, 44.9 percent received screening in 2009 compared with 40.9 percent in 2012, while 49.5 percent of women in the employer-supplemented MA plan received screening in 2009 compared with 44.1 percent in 2012, that is, a difference-in-difference effect of 1.4 percentage points less decline in screening among women experiencing the cost-sharing elimination. Effects were concentrated among women without recent screening. There were no differences by neighborhood socioeconomic status or race/ethnicity.Conclusions: Eliminating cost sharing for screening mammography was associated with modesty lower decline in screening rates among women with previously low screening adherence. [ABSTRACT FROM AUTHOR]

This study uses national survey data to assess the prevalence and health-related correlates of housing problems among community health center patients. [ABSTRACT FROM AUTHOR]

Since 2006 numerous insurers have stopped serving the low-income segment of the Medicare Part D program, forcing millions of beneficiaries to change prescription drug plans. Using data from participating plans, we found that Medicare payments do not sufficiently reimburse insurers for the relatively high medication use among this population, creating perverse incentives for plans to avoid this part of the Part D market. Plans can accomplish this by increasing their premiums for all beneficiaries to an amount above regional benchmarks. We demonstrate that improving the accuracy of Medicare's risk and subsidy adjustments could mitigate these perverse incentives. [ABSTRACT FROM AUTHOR]

Introduction: Sexual orientation and gender identity data collection is necessary to address health inequities. This study examines sexual orientation and gender identity data reporting among community health centers.Methods: Using the 2016-2019 Uniform Data System for 1,381 community health centers, trends in reporting of sexual orientation and gender identity data were examined. Multivariable logistic regression was used to assess associations between community health center characteristics and whether sexual orientation and gender identity data were available for ≥75% of a community health center's patients in 2019. Data were analyzed in 2021.Results: In 2016-2019, the percentage of community health centers with sexual orientation and gender identity data for ≥75% of patients increased from 14.9% to 53.0%. In 2019, community health centers were more likely to have this data for ≥75% of patients if they were in nonmetro counties (OR=1.48, 95% CI=1.04, 2.10 versus metro), were in the South (OR=2.27, 95% CI=1.57, 3.31) or West (OR=1.91, 95% CI=1.27, 2.88 versus the Northeast), and had more patients aged between 18 and 39 years (OR=1.04, 95% CI=1.02, 1.07), between 40 and 64 years (OR=1.04, 95% CI=1.02, 1.06 vs <18 years), or veterans (OR=1.10, 95% CI=1.01, 1.20). This was less likely among community health centers serving 10,000-20,000 patients (OR=0.70, 95% CI=0.52, 0.95) and >20,000 patients (OR=0.44, 95% CI=0.32, 0.61 vs <10,000) and community health centers with more patients of American Indian/Alaskan Native (OR=0.98, 95% CI=0.97, 0.99) or unknown race (OR=0.92, 95% CI=0.86, 0.97 versus White).Conclusions: Collection of sexual orientation and gender identity data by community health centers has increased substantially since 2016, although gaps remain. [ABSTRACT FROM AUTHOR]

Consumer-directed health plans are plans with high deductibles that typically require patients to bear no out-of-pocket costs for preventive care, such as annual physicals or screening tests, in order to ease financial barriers and encourage patients to seek such care. We surveyed people in California who had a consumer-directed health plan and found that fewer than one in five understood that their plan exempted preventive office visits, medical tests, and screenings from their deductible, meaning that this care was free or had a modest copayment. Roughly one in five said that they had delayed or avoided a preventive office visit, test, or screening because of cost. Those who were confused about the exemption were significantly more likely to report avoiding preventive visits because of cost concerns. Special efforts to educate consumers about preventive care cost-sharing exemptions may be necessary as more health plans, including Medicare, adopt this model. [ABSTRACT FROM AUTHOR]

Purpose: In 2009, the US Food and Drug Administration (FDA) mandated a label change for leukotriene inhibitors (LTIs) to include neuropsychiatric adverse events (eg, depression and suicidality) as a precaution. This study investigated how this label change affected the use of LTIs and other asthma controller medications, mental health visits, and suicide attempts. Methods: We analyzed data (2005-2010) from 5 large health plans in the US Population-Based Effectiveness in Asthma and Lung Diseases (PEAL) Network. The study cohort included children and adolescents (n = 30,000), young adults (n = 20,0), and adults (n = 90,000) with asthma. We used interrupted time series to examine changes in rates of LTI dispensings, non-LTI dispensings, mental health visits, and suicide attempts (using a validated algorithm based on a combination of diagnoses of injury or poisoning and psychiatric conditions). Findings: The label change was associated with abrupt reductions in LTI use among all age groups (relative reductions of 8.3%, 15.1%, and 6.0% among adolescents, young adults, and adults, respectively, compared with expected rates at 1 year after the warnings). Although we detected immediate offset increases in non-LTI asthma medication use, these increases were not sustained among adolescents and young adults. There were small increases in mental health visits among LTI users. Implications: The FDA label change for LTIs communicated possible risk of neuropsychiatric events. Communication and enhanced awareness may have increased reporting of mental health symptoms among young adults and adults. It is important to assess intended and unintended consequences of FDA warnings and label changes. [ABSTRACT FROM AUTHOR]