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Background: Colorectal cancer (CRC) is a deadly but largely preventable disease. Screening improves outcomes, but screening rates vary across healthcare coverage models. In the Veterans Health Administration (VA), screening rates are high; however, it is unknown how CRC screening rates compare for Veterans with other types of healthcare coverage.Aims: To determine whether Veterans with Veteran-status-related coverage (VA, military, TRICARE) have higher rates of CRC screening than Veterans with alternate sources of healthcare coverage.Methods: We conducted a cross-sectional analysis of Veterans 50-75 years from the 2014 Behavioral Risk Factor Surveillance System survey. We examined CRC screening rates and screening modalities. We performed multivariable logistic regression to identify the role of coverage type, demographics, and clinical factors on screening status.Results: The cohort included 22,138 Veterans. Of these, 76.7% reported up-to-date screening. Colonoscopy was the most common screening modality (83.7%). Screening rates were highest among Veterans with Veteran-status-related coverage (82.3%), as was stool-based screening (10.8%). The adjusted odds of up-to-date screening among Veterans with Veteran-status-related coverage were 83% higher than among Veterans with private coverage (adjusted OR = 1.83, 95% CI = 1.52-2.22). Additional predictors of screening included older age, black race, high income, access to medical care, frequent medical visits, and employed or married status.Conclusions: CRC screening rates were highest among Veterans with Veteran-status-related coverage. High CRC screening rates among US Veterans may be related to system-level characteristics of VA and military care. Insight to these system-level characteristics may inform mechanisms to improve CRC screening in non-VA settings. [ABSTRACT FROM AUTHOR]

Purpose: To characterize practice patterns, including temporal trends, in fractionation schedules among patients in the United States undergoing definitive radiation therapy for early-stage glottic cancer and to compare overall survival outcomes between fractionation schedules.Methods and Materials: We queried the National Cancer Database for patients with TisN0M0, T1N0M0, or T2N0M0 squamous cell carcinoma of the glottic larynx diagnosed between 2004 and 2012 and undergoing definitive radiation therapy. Dose per fraction was calculated to define cohorts undergoing conventional fractionation (CFxn) and hypofractionation (HFxn). Logistic regression was performed to identify predictors of receiving HFxn, and Cox regression was used to determine predictors of death. One-to-one propensity score matching was then used to compare survival between fractionation schedules.Results: The study included 10,539 patients, with 6576 undergoing CFxn and 3963 undergoing HFxn. Patients with T1 disease comprised a majority of each cohort. Use of HFxn increased significantly over the period studied (P<.001), but even in the final year, nearly one-half of patients continued to receive CFxn. Receipt of HFxn was also independently associated with higher income and facility types other than community cancer programs on logistic regression. On multivariate Cox regression, HFxn was associated with improved survival (hazard ratio [HR] for death, 0.90; 95% confidence interval [CI], 0.83-0.97; P=.008), a finding redemonstrated on univariate Cox regression among a well-matched cohort after propensity score matching (HR, 0.88; 95% CI, 0.80-0.96; P=.003). Subgroup Cox multivariate analysis demonstrated a significant survival advantage with HFxn among patients with T1 disease (HR, 0.90; 95% CI, 0.81-0.99; P=.042) but a nonsignificant benefit among those with Tis (HR, 0.86; 95% CI, 0.57-1.30; P=.472) or T2 (HR, 0.88; 95% CI, 0.76-1.02; P=.099) disease.Conclusions: Use of HFxn is increasing and is associated with improved survival over CFxn. Our findings support the broadened use of HFxn for patients with early-stage glottic cancer undergoing definitive radiation therapy. [ABSTRACT FROM AUTHOR]

The concept of fuzzy random variable has been applied in several papers to model the present value of life insurance liabilities. It allows the fuzzy uncertainty of the interest rate and the probabilistic behaviour of mortality to be used throughout the valuation process without any loss of information. Using this framework, and considering a triangular interest rate, this paper develops closed expressions for the expected present value and its defuzzified value, the variance and the distribution function of several well-known actuarial liabilities structures, namely life insurances, endowments and life annuities. [ABSTRACT FROM AUTHOR]

Background: Chronic myeloid leukemia (CML) can be treated effectively with tyrosine kinase inhibitor therapy directed at BCR-ABL, but access to care, medication cost, and adherence may be barriers to treatment. This study was designed to determine whether the insurance status at diagnosis influences CML patient outcomes.Methods: The Surveillance, Epidemiology, and End Results database was used to identify 5784 patients, aged 15 years or older, who were diagnosed with CML between 2007 and 2012 and whose insurance status was documented at diagnosis. The primary outcome was 5-year overall survival (OS). Covariates of interest included the age at diagnosis, race, ethnicity, sex, county-level socioeconomic status, and marital status. OS was evaluated with a log-rank test and Kaplan-Meier estimates.Results: Among patients aged 15 to 64 years, insurance status was associated with OS (P < .001): being uninsured or having Medicaid was associated with worse 5-year OS in comparison with being insured (uninsured patients, 72.7%; Medicaid patients, 73.1%; insured patients, 86.6%). For patients who were 65 years old or older, insurance had less of an impact on OS (P = .07), with similar 5-year OS rates for patients with Medicaid and those with other insurance (40.2% vs 43.4%). In a multivariate analysis of patients aged 15 to 64 years, both uninsured patients (hazard ratio [HR], 1.93; P < .001) and Medicaid patients (HR, 1.83; P < .001) had an increased hazard of death in comparison with insured patients; patients younger than 40 years, female patients, and married patients also had a lower hazard of death.Conclusion: These findings suggest that CML patients under the age of 65 years who are uninsured or have Medicaid have significantly worse survival than patients with other insurance coverage. Cancer 2017;123:2561-69. © 2017 American Cancer Society. [ABSTRACT FROM AUTHOR]

Objectives: To assess the reliability of codes relevant to critically ill patients in administrative data.Design: Retrospective cohort study linking data from Acute Physiology and Chronic Health Evaluation Outcomes, a clinical database of ICU patients with data from Medicare Provider Analysis and Review. We linked data based on matching for sex, date of birth, hospital, and date of admission to hospital.Setting: Forty-six hospitals in the United States participating in Acute Physiology and Chronic Health Evaluation Outcomes.Patients: All patients in Acute Physiology and Chronic Health Evaluation Outcomes greater than or equal to 65 years old who could be linked with hospitalization records in Medicare Provider Analysis and Review from January 1, 2009, through September 30, 2012.Measurements and Main Results: Of 62,451 patients in the Acute Physiology and Chronic Health Evaluation Outcomes dataset, 80.1% were matched with data in Medicare Provider Analysis and Review. All but 2.7% of Acute Physiology and Chronic Health Evaluation Outcomes ICU patients had either an ICU or coronary care unit charge in Medicare Provider Analysis and Review. In Acute Physiology and Chronic Health Evaluation Outcomes, 37.0% received mechanical ventilation during the ICU stay versus 24.1% in Medicare Provider Analysis and Review. The Medicare Provider Analysis and Review procedure codes for mechanical ventilation had high specificity (96.0%; 95% CI, 95.8-96.2), but only moderate sensitivity (58.4%; 95% CI, 57.7-59.1), with a positive predictive value of 89.6% (95% CI, 89.1-90.1) and negative predictive value of 79.7% (95% CI, 79.4-80.1). For patients with mechanical ventilation codes, Medicare Provider Analysis and Review overestimated the percentage with a duration greater than 96 hours (36.6% vs 27.3% in Acute Physiology and Chronic Health Evaluation Outcomes). There was discordance in the hospital discharge status (alive or dead) for only 0.47% of all linked records (κ = 1.00).Conclusions: Medicare Provider Analysis and Review data contain robust information on hospital mortality for patients admitted to the ICU but have limited ability to identify all patients who received mechanical ventilation during a critical illness. Estimates of use of mechanical ventilation in the United States should likely be revised upward. [ABSTRACT FROM AUTHOR]

This paper proposes non parametric adaptive refined descriptive sampling algorithm (NARDS) to estimate the survival function in lifetime models using Kaplan–Meier and Fleming–Harrington estimators. Simulations were performed using real data to generate inputs. The obtained results prove that NARDS works well on non parametric data. [ABSTRACT FROM AUTHOR]

Purpose: Individuals who have sustained an injury from a road traffic crash (RTC) are at increased risk for long lasting health problems and non-return to work (NRTW). Determining the predictors of NRTW is necessary to develop screening tools to identify at-risk individuals and to provide early targeted intervention for successful return to work (RTW). The aim of this study was to identify factors that can predict which individuals will not RTW following minor or moderate injuries sustained from a RTC.Method: Participants were 194 claimants (63.4% female) within a common-law "fault-based" system from the UQ SuPPORT cohort who were working prior to their RTC. Participants were assessed at 6 months on a variety of physical and mental health measures and RTW status was determined at 2 years post-RTC. RTW rate was 78.4%.Results: Univariate predictors of NRTW included being the driver or passenger, having a prior psychiatric diagnosis, high disability level, low mental or physical quality of life, predicted non-recovery, high pain, low function, high expectations of pain persistency, low expectations about RTW, having a psychiatric diagnosis, elevated depression or anxiety. The final multivariable logistic regression model included only two variables: disability level and expectations about RTW. Seventy-five percent of individuals who will not RTW by 2 years can be identified accurately at an early stage, using only these two predictors.Conclusion: The results are promising, because they suggest that having information about two factors, which are easily obtainable, can predict with accuracy those who will require additional support to facilitate RTW. [ABSTRACT FROM AUTHOR]

Objective: To evaluate differences in hospital readmission risk across all payers in South Carolina (SC).Data Sources/study Setting: South Carolina Revenue and Fiscal Affairs Office (SCRFA) statewide all payer claims database including 2,476,431 hospitalizations in SC acute care hospitals between 2008 and 2014.Study Design: We compared the odds of unplanned all-cause 30-day readmission for private insurance, Medicare, Medicaid, uninsured, and other payers and examined interaction effects between payer and index admission characteristics using generalized estimating equations.Data Collection: SCRFA receives claims and administrative health care data from all SC health care facilities in accordance with SC state law.Principal Findings: Odds of readmission were lower for females compared to males in private, Medicare, and Medicaid payers. African Americans had higher odds of readmission compared to whites across private insurance, Medicare, and Medicaid, but they had lower odds among the uninsured. Longer length of stay had the strongest association with readmission for private and other payers, whereas an increased number of comorbidities related to the highest readmission odds within Medicaid.Conclusions: Associations between index admission characteristics and readmission likelihood varied significantly with payer. Findings should guide the development of payer-specific quality improvement programs. [ABSTRACT FROM AUTHOR]

Introduction: Colorectal cancer (CRC) is the second leading cause of cancer mortality in the U.S.; however, if the population aged 50 years or older received routine screening, approximately 60% of these deaths could be eliminated. This study investigates whether adults, aged 50-75 years, with one of three disabilities (blind/low vision [BLV], intellectual disability [ID], spinal cord injury [SCI]) receive CRC screening at rates equivalent to adults without the three disabilities, by accounting for combinations of recommended CRC screenings during a 10-year period (colonoscopy, sigmoidoscopy, fecal occult blood test).Methods: South Carolina Medicaid and Medicare, State Health Plan, and hospital discharge data (2000-2009) were analyzed (2013-2015) to estimate the proportion of adherence to and adjusted odds of CRC screening over time among adults with one of the three disabilities, BLV, ID, or SCI, versus adults without these conditions.Results: The estimated proportion of adults who adhere to changing recommendations over time was lower for adults with ID (34.32%) or SCI (44.14%) compared with those without these disabilities (48.48%). All three case groups had significantly lower AORs of adherence versus those without (BLV: AOR=0.88, 95% CI=0.80, 0.96; ID: AOR=0.55, 95% CI=0.52, 0.59; SCI: AOR=0.88, 95% CI=0.82, 0.95).Conclusions: In this study, adults with BLV, ID, or SCI were less likely to receive and adhere to CRC screening recommendations than those without these disabilities. This method provides a thorough evaluation of adherence to CRC screening by considering levels of adherence during each month of Medicaid or Medicare coverage. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether minority race or ethnicity is associated with mortality and mediated by health insurance coverage among older (≥ 65 yr old) survivors of critical illness.Design: A retrospective cohort study.Setting: Two New York City academic medical centers.Patients: A total of 1,947 consecutive white (1,107), black (361), and Hispanic (479) older adults who had their first medical-ICU admission from 2006 through 2009 and survived to hospital discharge.Interventions: None.Measurements and Main Results: We obtained demographic, insurance, and clinical data from electronic health records, determined each patient's neighborhood-level socioeconomic data from 2010 U.S. Census tract data, and determined death dates using the Social Security Death Index. Subjects had a mean (SD) age of 79 years (8.6 yr) and median (interquartile range) follow-up time of 1.6 years (0.4-3.0 yr). Blacks and Hispanics had similar mortality rates compared with whites (adjusted hazard ratio, 0.92; 95% CI, 0.76-1.11 and adjusted hazard ratio, 0.92; 95% CI, 0.76-1.12, respectively). Compared to those with commercial insurance and Medicare, higher mortality rates were observed for those with Medicare only (adjusted hazard ratio, 1.43; 95% CI, 1.03-1.98) and Medicaid (adjusted hazard ratio, 1.30; 95% CI, 1.10-1.52). Medicaid recipients who were the oldest ICU survivors (> 82 yr), survivors of mechanical ventilation, and discharged to skilled-care facilities had the highest mortality rates (p-for-interaction: 0.08, 0.03, and 0.17, respectively).Conclusions: Mortality after critical illness among older adults varies by insurance coverage but not by race or ethnicity. Those with federal or state insurance coverage only had higher mortality rates than those with additional commercial insurance. [ABSTRACT FROM AUTHOR]

Background: Few studies have investigated the risk of injuries associated with adults with attention-deficit hyperactivity disorder (ADHD), even though several studies have suggested a higher risk of injury in children and adolescents with ADHD.Aims: To investigate the risk of injury in adults with ADHD.Methods and Procedures: We included 665 adults with ADHD from January 1, to December 31, 2000, and 1995 sex-, age- and index day-matched controls without ADHD from the Longitudinal Health Insurance Database (LHID) subset of the National Health Insurance Research Database in Taiwan. The Cox proportional hazard models were used to analyze the associations between the relevant demographics, and the psychiatric comorbidities and the risk of injury.Outcomes and Results: The patients with ADHD had a 143% increased risk of overall injuries than the controls after considering all the confounding factors. In addition, the use of methylphenidate was associated with a 22.6% decrease in the risk of injuries in the patients with ADHD.Conclusions and Implications: Our findings strongly support that adults with ADHD are at an increased risk of injury, and imply that methylphenidate therapy may attenuate this risk. [ABSTRACT FROM AUTHOR]

Background: A current appraisal of access to orthopaedic care for the adult patient receiving Medicaid is important, since Medicaid expansion was written into law by the Patient Protection and Affordable Care Act (PPACA).Questions/purposes: (1) Do orthopaedic practices provide varying access to orthopaedic care for simulated patients with Medicaid insurance versus private insurance in a blinded survey? (2) What are the surveyed state-by-state Medicaid acceptance rates for adult orthopaedic practices in the current era of Medicaid expansion set forth by the PPACA? (3) Do surveyed rates of access to orthopaedic care in the adult patient population vary across practice setting (private vs academic) or vary with different Medicaid physician reimbursement rates? (4) Are there differences in the surveyed Medicaid acceptance rates for adult orthopaedic practices in states that have expanded Medicaid coverage versus states that have foregone expansion?Methods: Simulated Patient Survey: We performed a telephone survey study of orthopaedic offices in four states with Medicaid expansion. In the survey, the caller assumed a fictitious identity as a 38-year-old male who experienced an ankle fracture 1 day before calling, and attempted to secure an appointment within 2 weeks. During initial contact, the fictitious patient reported Medicaid insurance status. One month later, the fictitious patient contacted the same orthopaedic practice and reported private insurance coverage status. National Orthopaedic Survey: Private and academic orthopaedic practices operating in each state in the United States were called and asked to complete a survey assessing their practice model of Medicaid insurance acceptance. State reimbursement rates for three different Current Procedural Terminology (CPT®) codes were collected from state Medicaid agencies. Results Simulated Patient Survey: Offices were less likely to accept Medicaid than commercial insurance (30 of 64 [47%] versus 62 of 64 [97%]; odds ratio [OR], 0.0145; 95% CI, 0.00088-0.23639; p < 0.001), and patients with Medicaid were less likely to be offered an appointment within 2 weeks (23 of 64 [36%] versus 59 of 64 [89%]; OR, 0.0154; 95% CI, 0.00094- 0.251; p < 0.001). The Medicaid acceptance rates observed across states sampled in the simulated patient survey were 67% (Pennsylvania), 21% (New Jersey), 58% (Delaware), and 50% (Maryland) (p = 0.04). National Orthopaedic Survey: Adult patients with Medicaid insurance had limited access to care in 109 of 342 (32%) orthopaedic practices: 37% of private and 13% of academic practices (p < 0.001). Practices that accepted Medicaid received higher reimbursement for each CPT® code relative to those that did not and acceptance of Medicaid became increasingly more likely as reimbursement rates increased (99243: OR, 1.03, 95% CI, 1.02-1.04 per dollar, p < 0.001; 99213: OR, 1.05; 95% CI, 1.03-1.07 per dollar, p < 0.001; 28876: OR, 1.01, 95% CI, 1.00-1.01 per dollar, p < 0.001). For a given reimbursement rate, private practices were less likely to take an adult patient with Medicaid relative to an academic practice (99243: OR, 0.11, 95% CI, 0.04-0.33, p < 0.001; 99213: OR, 0.11, 95% CI, 0.04-0.32, p < 0.001; 27786: OR, 0.12, 95% CI, 0.04-0.35, p < 0.001). No difference was observed when comparing Medicaid acceptance rates for all practice types between states that have expanded their Medicaid program versus those that have not (OR, 1.02; 95% CI 0.62-1.70; p = 0.934).Conclusions: In this two-part survey study, we found that a simulated patient with commercial insurance was more likely to have their insurance accepted and to gain timely access to orthopaedic care than a patient with Medicaid. Academic practice setting and increased Medicaid reimbursement rates were associated with increased access to care for the patient with Medicaid. Inequality in access to orthopaedic care based on health insurance status likely exists for the adult patient with Medicaid. Furthermore, Medicaid expansion has likely realized minimal gains in access to care for the adult orthopaedic patient. Further research is needed in delineating the patient-payer selection criteria used by orthopaedic practices to aid policymakers in reforming the Medicaid program and comprehensibly addressing this access to care disparity.Level Of Evidence: Level II, prognostic study. [ABSTRACT FROM AUTHOR]

Objective: Many adults who have mental or substance use disorders or both experience insurance-related barriers to care, contributing to low treatment utilization. Expanded insurance under the Affordable Care Act (ACA) could improve coverage and access. The study identified changes in coverage and treatment use following 2014 ACA insurance expansions.Methods: Data from the National Survey on Drug Use and Health were used to identify individuals ages 18-64 screening positive for any mental disorder (N=29,962) or substance use disorder (N=19,243) for two periods: 2011-2013 and 2014. Regression-adjusted means were calculated for insurance rates and treatment used in each period overall and among individuals with household incomes ≤200% of the federal poverty level (FPL).Results: Compared with 2011-2013, in 2014 significant reductions were seen in the uninsured rate for individuals with mental disorders (-5.4 percentage points, p<.01) and substance use disorders (-5.1 percentage points, p<.01). Increases in insurance coverage occurred mostly through Medicaid. Insurance gains were larger for adults with incomes ≤200% of FPL compared with the overall sample. Use of mental health treatment increased by 2.1 percentage points (p=.04), but use of substance use disorder treatment did not change. No significant changes were noted in treatment settings for mental and substance use disorder treatments. Payment by Medicaid for substance use disorder treatment increased by 7.4 percentage points (p=.05).Conclusions: Sizable increases in coverage for adults with mental disorders and adults with substance use disorders were identified in the year following the 2014 ACA expansions; however, low treatment rates among this population remain a concern. Initiatives to engage the newly insured in treatment are needed. [ABSTRACT FROM AUTHOR]

Even with the increasing importance being placed on research into immigrant elders' healthcare use as countries change their policies to reflect their increasing immigrant and aging populations, little research has examined changes in healthcare use disparities between immigrant and native elders in relation to these policy changes. To fill this gap in the literature, this study examined healthcare disparities in relation to the welfare reform that the US implemented in 1996 and then compared significant indicators of immigrants' healthcare use during the pre- and post-reform periods. The difference-in-difference (DD) analyses and post hoc probing of the DD analyses were used in multivariate logistic regression of the National Health Information Survey data that were pooled for the pre- and post-reform periods. The results revealed that while inequalities in healthcare existed before the reform, they significantly increased after the reform. A further test showed that the changes in the inequalities were significant among relatively long-stay immigrants, but not significant among immigrants who entered the US before the reform and thus were exempted from the reform restrictions. During the pre-reform period, insurance, employment, sex, and race/ethnicity were related to healthcare use; however, the enabling factors (i.e., insurance, income, and education) and social structural factors (i.e., marital status, family structure, length of US residency, race/ethnicity, and geographical region) explained the post-reform immigrants' healthcare use, while controlling for healthcare needs factors. These findings suggest that welfare reform may be the driving force of inequalities in healthcare. [ABSTRACT FROM AUTHOR]

Little is known about the impact of drug abuse/dependence on health insurance coverage, especially by race groups and income levels. In this study, we examine the disparities in health insurance predictors and investigate the impact of drug use (alcohol abuse/dependence, nicotine dependence, and illicit drug abuse/dependence) on lack of insurance across different race and income groups. To perform the analysis, we used insurance data (8057 uninsured and 28,590 insured individual adults) from the National Surveys on Drug Use and Health (NSDUH 2011). To analyze the likelihood of being uninsured we performed weighted binomial logistic regression analyses. The results show that the overall prevalence of lacking insurance was 19.6 %. However, race differences in lack of insurance exist, especially for Hispanics who observe the highest probability of being uninsured (38.5 %). Furthermore, we observe that the lowest income level bracket (annual income <$20,000) is associated with the highest likelihood of being uninsured (37.3 %). As the result of this investigation, we observed the following relationship between drug use and lack of insurance: alcohol abuse/dependence and nicotine dependence tend to increase the risk of lack of insurance for African Americans and whites, respectively; illicit drug use increases such risk for whites; alcohol abuse/dependence increases the likelihood of lack of insurance for the group with incomes $20,000-$49,999, whereas nicotine dependence is associated with higher probability of lack of insurance for most income groups. These findings provide some useful insights for policy makers in making decisions regarding unmet health insurance coverage. [ABSTRACT FROM AUTHOR]

Background: Income-based deductibles are present in several provincial public drug plans in Canada and have been the subject of extensive debate. We studied the impact of such deductibles in British Columbia's Fair PharmaCare plan on drug and health care utilization among older adults.Methods: We used a quasi-experimental regression discontinuity design to compare the impact of deductibles in BC's PharmaCare plan between older community-dwelling adults registered for the plan who were born in 1928 through 1939 (no deductible) and those born in 1940 through 1951 (deductible equivalent to 2% of household income). We used 1.2 million person-years of data between 2003 and 2015 to study public drug plan expenditures, overall drug use, and physician and hospital resource utilization in these 2 groups.Results: The income-based deductible led to a 28.6% decrease in person-years in which public drug plan benefits were received (95% confidence interval [CI] -29.7% to -27.5%) and to a reduction in the per capita extent of annual benefits by $205.59 (95% CI -$247.81 to -$163.37). Despite this difference in public subsidy, we found no difference in the number of drugs received or in total drug spending once privately paid amounts were accounted for (p = 0.4 and 0.8, respectively). Further, we found only small or nonexistent changes in health care resource utilization at the 1939 threshold.Interpretation: A modest income-based deductible had a considerable impact on the extent of public subsidy for prescription drugs. However, it had only a trivial impact on overall access to medicines and use of other health services. Unlike copayments, modest income-based deductibles may safely reduce public spending on drugs for some population groups. [ABSTRACT FROM AUTHOR]

Among 10,068 incident cases of invasive melanoma, we examined the effects of patient characteristics and access-to-care on the risk of advanced melanoma. Access-to-care was defined in terms of census tract-level sociodemographics, health insurance, cost of dermatological services and appointment wait-times, clinic density and travel distance. Public health insurance and education level were the strongest predictors of advanced melanomas but were modified by race/ethnicity and poverty: Hispanic whites and high-poverty neighborhoods were worse off than non-Hispanic whites and low-poverty neighborhoods. Targeting high-risk, underserved Hispanics and high-poverty neighborhoods (easily identified from existing data) for early melanoma detection may be a cost-efficient strategy to reduce melanoma mortality. [ABSTRACT FROM AUTHOR]

The behavior of noncoresident family members motivates much of the literature on consumption smoothing, risk-sharing, and informal networks, yet little is known empirically on the topic due to a lack of data simultaneously observing multiple households in an extended family. This study utilizes genealogically linked longitudinal data to examine how extended family networks insure against financial risks from severely limiting health conditions. We find that nonhealth consumption of unmarried households declines in response to worsening health, whereas married households smooth expenditures in a way that is consistent with full insurance. Families mitigate losses by reallocating home production, drawing down home equity, holding formal health insurance, collecting social security, and receiving transfers from noncoresident relatives. We illustrate that the costs of health shocks are transmitted throughout family networks, and that noncoresident children draw down their assets and consumption when responding to a parent's health decline. [ABSTRACT FROM AUTHOR]

A primary purpose of health insurance is to protect families from medical expenditure risk. Despite this goal and despite the fact that research has found that Medicaid can crowd out private coverage, little is known about the effect of Medicaid on families' spending patterns. This paper implements a simulated instrumental variables strategy with data from the Consumer Expenditure Survey to estimate the effect of an additional family member becoming eligible for Medicaid on family-level health insurance coverage and spending. The results indicate that an additional family member becoming eligible for Medicaid increases the number of people in the family with Medicaid coverage by about 0.135-0.142 and decreases the likelihood that a family has any medical spending in a quarter by 2.7 percentage points. As previous research often finds with different data sets, I find evidence that Medicaid expansions crowd out some private coverage. Unlike most other data sets, the Consumer Expenditure Survey allows for considering the financial implications of crowd-out. The results indicate that families that transition from private coverage to Medicaid are able to spend significantly less on health insurance expenses, meaning Medicaid expansions can be welfare improving for families even when crowd-out occurs. [ABSTRACT FROM AUTHOR]

Purpose: We characterized factors related to nondefinitive management (NDM) of patients with high-risk prostate cancer and assessed impact from race, insurance status, and facility-level volume of technologically advanced prostate cancer treatments (i.e., intensity-modulated radiation therapy, robotic-assisted laparoscopic radical prostatectomy) on this outcome.Methods: We identified men with high-risk localized prostate cancer (based on D׳Amico criteria) in the National Cancer Database (2010-2012). Primary outcome was NDM (i.e., delayed/no treatment with prostatectomy/radiation therapy or androgen-deprivation monotherapy). Treating facilities were classified by quartiles of proportions of patients treated with advanced technology. Multivariable regression estimated odds of primary outcome based on race, insurance status, and facility-level technology use, and evaluated for interactions between these covariates.Results: Among 60,300 patients, 9,265 (15.4%) received NDM. This was more common among non-White men (P<0.001), Medicaid/uninsured patients (P<0.001), and those managed at facilities in the lowest quartile of technology use (25.1% vs. 11.0% highest, P<0.001). Though NDM was common among non-White men with Medicaid/no insurance treated at low-technology centers (43% vs. 10% White, private/Medicare, high-tech facility; adjusted odds ratios = 7.18, P<0.001), this was less likely if this group was managed at a high-tech hospital (22% vs. 43% low-tech, P<0.001).Conclusions: Technology use at a facility correlates with high-quality prostate cancer care and is associated with diminished disparities based on insurance status and patient race. More research is required to characterize other facility-level factors explaining these findings. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective analysis of patients undergoing elective lumbar fusion operations, comparing rates of repeat spine surgery based on method of ascertainment.Objective: We report the accuracy of a claims-based approach for reporting repeat surgery compared with medical records abstraction as the "gold standard."Summary Of Background Data: Previous studies have reported the validity of a claims-based algorithm for grouping patients by surgical indication and classifying operative features, but their accuracy in measuring surgical quality indicators has not been widely examined.Methods: We identified a subset of patients undergoing elective lumbar fusion operations at a single institution from 1996 to 2011, excluding those with spinal fracture, spinal cord injury, or cancer. From the medical record we abstracted the incidence of repeat spine operation or rehospitalization at 1 year. We cross-classified each event record with its corresponding value derived from claims. The sensitivity and specificity of the claims-based approach were calculated for reoperation within 30, 90, and 365 days, and all-cause hospital readmission within 30 days.Results: Medical records linked to claims data were obtained for 520 patients undergoing elective lumbar fusion. Reoperation rates based on chart review were 1.0%, 1.3%, 3.6%, compared with 0.8%, 1.7%, and 3.8% based on the final claims methods at 30, 90, and 365 days, respectively. The claims-based algorithm had sensitivities of 80.0%, 100%, and 94.1% and specificities of 100%, 99.6%, 99.2% for repeat surgery within 30, 90, and 365 days, respectively. The sensitivity for all-cause readmission was 50%.Conclusion: Health care quality improvement efforts often rely on administrative data to report surgical safety. We found that claims-based ascertainment of safety at a single institution was very accurate. However, accuracy depended on careful attention to the timing of outcomes, as well as the definitions and coding of repeat surgery, including how orthopedic device removal codes are classified.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Objective: The 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.Methods: Analyses 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.Results: Preparity, 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<.001).Conclusions: Before MHPAEA, QTLs were common. Postimplementation, virtually all plans dropped such limits, suggesting that MHPAEA was effective at eliminating QTLs. However, increasing access to behavioral health care will mean going beyond such QTL changes and looking at other areas of benefit management. [ABSTRACT FROM AUTHOR]

Objective: To determine the degree of transparency of health insurance policies regarding coverage of male sexual health conditions, we examined the publicly available policy coverage documents of the largest U.S. medical insurance plans.Methods: We selected 2 index patients across the male sexual health spectrum: (1) a phosphodiesterase type 5 refractory erectile dysfunction (ED) patient requiring intracavernosal injection therapy or penile prosthesis and (2) a 50-year-old male patient with laboratory-confirmed, symptomatic hypogonadism requiring testosterone replacement therapy as defined by endocrine society criteria. We researched the policy documents regarding coverage for standard therapies. We used breast reconstruction after mastectomy as a control.Results: We queried the publicly available policy statements for 84 of the largest health-care plans in the United States. Whereas breast reconstruction policies are publicly available for 94% of the plans examined, policies of only 39% of the plans for advanced ED treatment options and 62% for hypogonadism are publicly available. Of the plans that had publicly accessible data for ED coverage, 85% viewed penile prosthesis and intracavernosal injection as medically necessary, whereas 91% viewed androgen replacement as medically necessary for our index patient.Conclusion: There is a lack of transparency among medical insurers regarding coverage of ED and hypogonadism in stark contrast to reconstructive breast surgery. [ABSTRACT FROM AUTHOR]

The Affordable Care Act (ACA) expanded insurance benefits and coverage for substance use disorder (SUD) treatment and encouraged delivery and payment reforms. Massachusetts passed a similar reform in 2006. This study aims to assess Massachusetts SUD treatment organizations' responses to the ACA. Organizational interviews addressing challenges of and responses to the ACA were conducted in person June-December 2014 with 31 leaders at 12 treatment organizations across Massachusetts. Many organizations were affiliated with medical or social services and offered a range of SUD services. Sampling was based on services offered (detoxification only, detoxification and outpatient, outpatient only). Framework analysis was used. Challenges identified were considered similar to ongoing challenges, not unique to the ACA. Organizations experienced insurance expansions in 2006 and faced new challenges, including insurance coverage, payment arrangements, expansion of services, and system design. System design efforts included care coordination/integration, workforce development, and health information technology. Differences in responses related to connections with medical and social service organizations. Many organizations engaged in efforts to respond to changing policies by expanding capacity and services. Offering a range of SUD treatment (e.g., detoxification and outpatient) and affiliating with a medical organization could enable organizations to respond to new insurance, delivery, and payment reforms. [ABSTRACT FROM AUTHOR]

Opioid use disorders (OUDs) are receiving significant attention in the U.S. as a public health crisis. Access to treatment for OUDs is essential and was expected to improve following implementation of the federal parity law and the Affordable Care Act. This study examines changes in coverage and management of treatments for OUDs (opioid treatment programs (OTPs) as a covered service benefit, buprenorphine as a pharmacy benefit) before, during, and after parity and ACA implementation. Data are from three rounds of a nationally representative survey conducted with commercial health plans regarding behavioral health services in benefit years 2003, 2010, and 2014. Data were weighted to be representative of health plans' commercial products in the continental United States (2003 weighted N = 7,469, 83% response rate; 2010 N = 8,431, 89% response rate; and 2014 N = 6,974, 80% response rate). Results showed treatment for OUDs was covered by nearly all health plan products in each year of the survey, but the types and patterns varied by year. Prior authorization requirements for OTPs have decreased over time. Despite the promise of expanded access to OUD treatment suggested by parity and the ACA, improved health plan coverage for treatment of OUDs, while essential, is not sufficient to address the opioid crisis. [ABSTRACT FROM AUTHOR]

The launch of the Affordable Care Act was accompanied by major insurance information campaigns by government, nonprofit, political, news media, and private-sector organizations, but it is not clear to what extent these efforts were associated with insurance gains. Using county-level data from the Census Bureau's American Community Survey and broadcast television airings data from the Wesleyan Media Project, we examined the relationship between insurance advertisements and county-level health insurance changes between 2013 and 2014, adjusting for other media and county- and state-level characteristics. We found that counties exposed to higher volumes of local insurance advertisements during the first open enrollment period experienced larger reductions in their uninsurance rates than other counties. State-sponsored advertisements had the strongest relationship with declines in uninsurance, and this relationship was driven by increases in Medicaid enrollment. These results support the importance of strategic investment in advertising to increase uptake of health insurance but suggest that not all types of advertisements will have the same effect on the public. [ABSTRACT FROM AUTHOR]

Purpose: Surgical repair of groin hernia should be carried out with minimal complication rates, and it is important to have regular quality control and accurate means of assessment. The Swedish healthcare system has a mutual insurance company (LÖF) that receives claims from patients who have suffered healthcare-related damage or malpractice. The Swedish Hernia Register (SHR) currently covers around 98% of all Swedish groin hernia operations. The aim of this study was to analyse damage claims following groin hernia repair surgery and link these with entries in the SHR, in order to identify risk factors and causes of injuries and malpractice associated with hernia repair.Methods: Data on all 48,574 groin hernia operations registered in the SHR between 2008 and 2010 were compared and linked with data on claims made to the Swedish National Patient Injury Insurance (LÖF).Results: Of the 130 damage claims received by LÖF, 26 dealt with bleeding, 20 with testicular injury and 7 with intestinal lesions. Eighty (62%) of the complications were considered malpractice according to the Swedish Patient Injury Act. Acute and recurrent surgery, sutured repair and general anaesthesia were associated with a significantly increased risk for a damage claim independently the patients were compensated or not. Females filed claims in greater proportion than males. There was no significant difference in background factors between claims accepted by LÖF and compensated and those who were rejected compensation.Conclusion: Risk factors for filing a damage claim included acute surgery, operation for recurrence, sutured repair and general anaesthesia, whereas local anaesthesia reduced the risk. [ABSTRACT FROM AUTHOR]

Objective: To explore the changing disparities in access to health care insurance in the United States using time-varying coefficient models.Data: Secondary data from the Behavioral Risk Factor Surveillance System (BRFSS) from 1993 to 2009 was used.Study Design: A time-varying coefficient model was constructed using a binary outcome of no enrollment in health insurance plan versus enrolled. The independent variables included age, sex, education, income, work status, race, and number of health conditions. Smooth functions of odds ratios and time were used to produce odds ratio plots.Results: Significant time-varying coefficients were found for all the independent variables with the odds ratio plots showing changing trends except for a constant line for the categories of male, student, and having three health conditions. Some categories showed decreasing disparities, such as the income categories. However, some categories had increasing disparities in health insurance enrollment such as the education and race categories.Conclusions: As the Affordable Care Act is being gradually implemented, studies are needed to provide baseline information about disparities in access to health insurance, in order to gauge any changes in health insurance access. The use of time-varying coefficient models with BRFSS data can be useful in accomplishing this task. [ABSTRACT FROM AUTHOR]

We document the recent profile of health insurance and health care among mid-aged and older Chinese using data from the China Health and Retirement Longitudinal Study conducted in 2011. Overall health insurance coverage is about 93%. Multivariate regressions show that respondents with lower income as measured by per capita expenditure have a lower chance of being insured, as do the less-educated, older, and divorced/widowed women and rural-registered people. Premiums and reimbursement rates of health insurance vary significantly by schemes. Inpatient reimbursement rates for urban people increase with total cost to a plateau of 60%; rural people receive much less. Demographic characteristics such as age, education, marriage status, per capita expenditure, and self-reported health status are not significantly associated with share of out-of-pocket cost after controlling community effects. For health service use, we find large gaps that vary across health insurance plans, especially for inpatient service. People with access to urban health insurance plans are more likely to use health services. In general, Chinese people have easy access to median low-level medical facilities. It is also not difficult to access general hospitals or specialized hospitals, but there exists better access to healthcare facilities in urban areas. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Importance: Testosterone initiation increased substantially in the United States from 2000 to 2013, especially among men without clear indications. Direct-to-consumer advertising (DTCA) also increased during this time.Objective: To investigate associations between televised DTCA and testosterone testing and initiation in the United States.Design, Setting, and Population: Ecologic study conducted in designated market areas (DMAs) in the United States. Monthly testosterone advertising ratings were linked to DMA-level testosterone use data from 2009-2013 derived from commercial insurance claims. Associations between DTCA and testosterone testing, initiation, and initiation without recent baseline tests were estimated using Poisson generalized estimating equations.Exposures: Monthly Nielsen ratings for testosterone DTCA in the 75 largest DMAs.Main Outcomes and Measures: (1) Rates of new serum testosterone testing; (2) rates of testosterone initiation (in-office injection, surgical implant, or pharmacy dispensing) for all testosterone products combined and for specific brands; and (3) rates of testosterone initiation without recent serum testosterone testing.Results: Of 17 228 599 commercially insured men in the 75 DMAs, 1 007 990 (mean age, 49.6 [SD, 11.5] years) had new serum testosterone tests and 283 317 (mean age, 51.8 [SD, 11.3] years) initiated testosterone treatment. Advertising intensity varied by geographic region and time, with the highest intensity seen in the southeastern United States and with months ranging from no ad exposures to a mean of 13.6 exposures per household. Nonbranded advertisements were common prior to 2012, with branded advertisements becoming more common during and after 2012. Each household advertisement exposure was associated with a monthly increase in rates of new testosterone testing (rate ratio [RR], 1.006; 95% CI, 1.004-1.008), initiation (RR, 1.007; 95% CI, 1.004-1.010), and initiation without a recent test (RR, 1.008; 95% CI, 1.002-1.013). Mean absolute rate increases were 0.14 tests (95% CI, 0.09-0.19), 0.05 new initiations (95% CI, 0.03-0.08), and 0.02 initiations without a recent test (95% CI, 0.01-0.03) per 10 000 men for each monthly ad exposure over the entire period.Conclusions and Relevance: Among US men residing in the 75 designated market areas, regional exposure to televised direct-to-consumer advertising was associated with greater testosterone testing, new initiation, and initiation without recent testing. [ABSTRACT FROM AUTHOR]

The article focuses on the debate regarding the future of the Affordable Care Act (ACA). The campaign of U.S. President Donald Trump and large fractions of the Republican majority party in the House and Senate campaigned on an explicit pledge to repeal and replace the ACA is mentioned. The inability of some private insurance companies to succeed under the ACA is stated. An analysis on the market entries and exits in State Insurance Marketplaces from 2014-2017 is presented.

Purpose: The objective of this study is to identify the demographic and payer factors that are associated with lumbar fusion surgery.Methods: A case-control study was conducted utilizing a population of 38,092 patients from the 2010 Florida Agency for Health Care Administration (AHCA), USA hospital discharge data. The case population included 16,236 records with any of five ICD-9-CM principal procedure codes for initial lumbar fusion. The control group was comprised of 21,856 patients who were admitted for the same principal diagnoses as the cases, but who did not have initial fusion surgery. Logistic regression was used to analyze the association of age, gender, race and principal payer type with initial lumbar fusions. The interaction between age and payer was also examined, as payer type may moderate the association between age and lumbar fusion surgery.Results: Gender, race, principal payer and age were all found to be significantly associated with lumbar fusion surgery. The interaction of payer and age was also found to be significant. Being female was significantly associated with having a fusion (OR = 1.11, 95 % CI 1.07-1.16). The association between age and receiving surgery was greatest for the less than 20 age group (OR = 10.43, 95 % CI 8.74-12.45). Employees and dependents of Federal government agencies (Tricare, etc.) and patients with commercial insurance were significantly associated with surgery (OR = 1.48, 95 % CI 1.29-1.70 and OR = 1.12, 95 % CI 1.04-1.20, respectively). Patients insured through Medicaid (a social health care program for those with low incomes and limited resources), and the uninsured were negatively associated with surgery (OR = 0.53, 95 % CI 0.47-0.60 and OR = 0.52, 95 % CI 0.46-0.58, respectively).Conclusions: Lumbar fusion surgery is not recommended in clinical practice guidelines for the top four principal diagnoses in this study. Yet, patients covered by certain types of insurance were found to be significantly associated with fusion surgery. [ABSTRACT FROM AUTHOR]

Objectives: Medicare does not usually include a dental benefit. Adults who are unaware of this fact risk unanticipated expenses after retirement. This report will explore the sociodemographic and oral health literacy determinants of this knowledge.Methods: Data came from the Multi-Site Oral Health Literacy Research Study, a survey of patients presenting to two university dental clinics. Sociodemographic descriptors included age, sex, race/ethnicity, education level, and dental insurance status. Oral health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D).Results: Only 34 percent of respondents knew the correct answer to the Medicare question. Knowledge was significantly associated with age, race/ethnicity, education level (bivariate only), and REALM-D score.Conclusions: Policymakers and those assisting in Medicare enrollment should ensure information regarding dental coverage is communicated in ways that individuals of varying literacy, language, and culture understand what is necessary to make appropriate decisions. [ABSTRACT FROM AUTHOR]

Introduction: Asthma is one of the most common chronic diseases in Germany. Substantial economic evaluation of asthma cost requires knowledge of asthma severity, which is in general not part of claims data. Algorithms need to be defined to use this data source.Aims and Objectives: The aim of this study was to systematically review the international literature to identify algorithms for the stratification of asthma patients according to disease severity based on available information in claims data.Methods: A systematic literature review was conducted in September 2015 using the DIMDI SmartSearch, a meta search engine including several databases with a national and international scope, e.g. BIOSIS, MEDLINE, and EMBASE. Claims data based studies that categorize asthma patients according to their disease severity were identified.Results: The systematic research yielded 54 publications assessing asthma severity based on claims data. Thirty-nine studies used a standardized algorithm such as HEDIS, Leidy, the GINA based approach or CACQ. Sixteen publications applied a variety of different criteria for the severity categorisation such as asthma diagnoses, asthma-related drug prescriptions, emergency department visits, and hospitalisations.Conclusion: There is no best practice method for the categorisation of asthma severity with claims data. Rather, a combination of algorithms seems to be a pragmatic approach. A transfer to the German context is not entirely possible without considering particular conditions associated with German claims data. [ABSTRACT FROM AUTHOR]

Background: Ambulatory geriatric rehabilitation (AGR) is a community based outpatient intervention which aims to improve physical function, maintain independent living of geriatric patients, avoiding hospitalisation and institutionalisation. It should therefore reduce health care costs. The objective of our study is to evaluate the effectiveness of AGR for frail elderly patients insured by the statutory health insurance AOK Nordost compared to care as usual. Outcome variables are progression to higher nursing care levels, admission to nursing home, incident fractures, hospital admission, ambulatory care sensitive hospital admissions, days spent in hospital, and health care costs.Methods: This matched cohort study aims to estimate average treatment effects of AGR. For this purpose we will compare patients receiving AGR with matched patients receiving care as usual. Patients in the intervention group were treated between the years 2009 and 2013 from three centres in Mecklenburg-Vorpommern, Germany. Matching will be conducted using propensity score techniques. Claims data will be provided by the statutory health insurance AOK Nordost. The primary outcomes are the progression of nursing care levels, incident fractures, and admission to nursing home. Secondary outcomes are total and ambulatory care sensitive hospital admissions, and health care costs from the statutory health insurance perspective. Data will be analysed using appropriate regression models.Discussion: This study aims to quantify the effectiveness of AGR. Results will be important for providers of AGR, policy makers and stakeholders to make informed decisions on whether to continue, modify or extend AGR.Trial Registration: German Clinical Trials Register (DRKS) S00008926 , registered 29.07.2015. [ABSTRACT FROM AUTHOR]

Background: Injury is a major contributor to morbidity and mortality in the United States. Accordingly, expanding access to trauma care is a Healthy People priority. The extent to which disparities in access to trauma care exist in the US is unknown. Our objective was to describe geographic, demographic, and socioeconomic disparities in access to trauma care in the United States.Methods: Cross-sectional study of the US population in 2010 using small units of geographic analysis and validated estimates of population access to a Level I or II trauma center within 60minutes via ambulance or helicopter. We examined the association between geographic, demographic, and socioeconomic factors and trauma center access, with subgroup analyses of urban-rural disparities.Results: Of the 309 million people in the US in 2010, 29.7 million lacked access to trauma care. Across the country, areas with higher income were significantly more likely to have access (OR 1.30, 95% CI 1.12-1.50), as were major cities (OR 2.13, 95% CI 1.25-3.62) and suburbs (OR 1.27, 95% CI 1.02-1.57). Areas with higher rates of uninsured (OR 0.09, 95% CI 0.07-0.11) and Medicaid or Medicare eligible patients (OR 0.69, 95% CI 0.59-0.82) were less likely to have access. Areas with higher proportions of blacks and non-whites were more likely to have access (OR 1.37, 95% CI 1.19-1.58), as were areas with higher proportions of Hispanics and foreign-born persons (OR 1.51, 95% CI 1.13-2.01). Overall, rurality was associated with significantly lower access to trauma care (OR 0.20, 95% CI 0.18-0.23).Conclusion: While the majority of the United States has access to trauma care within an hour, almost 30 million US residents do not. Significant disparities in access were evident for vulnerable populations defined by insurance status, income, and rurality. [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]

Study Design: Retrospective cohort study.Objective: The aim of the study was to assess factors potentially impacting the operative approach chosen for cervical spondylotic myelopathy (CSM) patients on a nationwide level.Summary Of Background Data: CSM is one of the most common spinal disorders treated by spine surgeons, with operative management consisting of three approaches: anterior-only, posterior-only, or combined anterior-posterior. It is unknown whether the operative approach used differs based on patient demographics and/or insurance status.Methods: The nationwide inpatient sample from 2001 to 2010 was used for analysis. Admissions having a diagnosis code of 721.1 and a primary procedure code of 81.02/81.03, 81.32/81.33, 81.02/81.03, or 81.32/81.33 (combined anterior and posterior fusion/refusion at C2 or below), and 3.09 (decompression of the spinal canal including laminoplasty) were included. Analysis was adjusted for several variables including patient age, race, sex, primary payer for care, and admission source/type.Results: Multivariate analyses revealed that non-white race (black [odds ratio, OR = 1.39; 95% confidence interval, CI = 1.32-1.47; P < 0.0001], Hispanic [OR = 1.51; 95% CI = 1.38-1.66; P < 0.0001], Asian/Pacific Islander [OR = 1.40; 95% CI = 1.15-1.70; P = 0.0007], Native American [OR = 1.33; 95% CI = 1.02-1.73; P = 0.037]) and increasing age (OR = 1.03; P < 0.0001) were predictive of receiving posterior-only approaches. Female sex (OR = 1.39; 95% CI = 1.34-1.43; P < 0.0001), private insurance (OR = 1.19; 95% CI = 1.14-1.25; P < 0.0001), and nontrauma center admission type (OR = 1.29-1.39; 95% CI = 1.16-1.56; P < 0.0001) were independently predictive of increased likelihood of receiving an anterior-only approach. Hispanic race (OR = 1.35; 95% CI = 1.14-1.59; P = 0.0004) and admission source (another hospital [OR = 1.65; 95% CI = 1.20-2.27; P = 0.0023], other health facility [OR = 1.68; 95% CI = 1.13-2.51; P = 0.011]) were the only variables predictive of increased combined anterior-posterior approaches; Native American race (OR = 0.32; 95% CI = 0.13-0.78; P = 0.013) decreased the likelihood of a combined anterior-posterior approach.Conclusion: Private insurance status, female sex, and white race independently predict receipt of anterior-only CSM approaches, whereasd non-white race (black, hispanic, Asian/Pacific Islander, Native American) and nonprivate insurance predict receiving posterior-only CSM approaches. Given recent literature demonstrating posterior-only approaches as predictive of increased mortality in CSM (Kaye et al, 2015), our findings indicate that for CSM patients, non-white race may significantly increase mortality risk, whereas private insurance status may significantly decrease the risk of mortality. Further prospective study will be needed to more definitively address these issues.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

At the end of 1998, China launched a government-run mandatory insurance program, the urban employee basic medical insurance (UEBMI), to replace the previous medical insurance system. Using the UEBMI reform in China as a natural experiment, this study identifies variations in patient cost sharing that were imposed by the UEBMI reform and examines their effects on the demand for healthcare services. Using data from the 1991-2006 waves of the China Health and Nutrition Survey, we find that increased cost sharing is associated with decreased outpatient medical care utilization and expenditures but not with decreased inpatient care utilization and expenditures. Patients from low-income and middle-income households or with less severe medical conditions are more sensitive to prices. We observe little impact on patient's health, as measured by self-reported health status. Copyright © 2015 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: A major concern by the health decision makers in Gulf Cooperative Council (GCC) countries is the burden of financing healthcare. While other GCC countries have been examining different options, Saudi Arabia has endeavoured to reform its private healthcare system and control expatriate access to government resources through the provision of Compulsory Employment-Based Health Insurance (CEBHI). The objective of this research was to investigate, in a natural setting, the characteristics of uninsured expatriates based on their personal and workplace characteristics.Methods: Using a cross-sectional survey, data were collected from a sample of 4,575 male expatriate employees using a multi-stage stratified cluster sampling technique. Descriptive statistics were used to summarize all variables, and the dependent variable was tabulated by access to health insurance and tested using Chi-square. Logistic analysis was performed, guided by the conceptual model.Results: Of survey respondents, 30% were either uninsured or not yet enrolled in a health insurance scheme, 79.4% of these uninsured expatriates did not have valid reasons for being uninsured, with Iqama renewal accounting for 20.6% of the uninsured. The study found both personal and workplace characteristics were important factors influencing health insurance status. Compared with single expatriates, married expatriates (accompanied by their families) are 30% less likely to be uninsured. Moreover, workers occupying technical jobs requiring high school level of education or above were two-thirds more likely to be insured compared to unskilled workers. With regard to firm size, respondents employed in large companies (more than 50 employees) are more likely to be insured compared to those employed in small companies (less than ten employees). In relation to business type, the study found that compared to workers from the agricultural sector, industrial/manufacturing, construction and trading sectors, workers were, respectively, 76%, 85%, and 60% less likely to be uninsured.Conclusion: Although the CEBHI is mandatory, this study found that the characteristics of uninsured expatriates, in respect of their personal and workplace characteristics have similarities with the uninsured from other private employment-sponsored health insurance schemes. Other factors influencing access to health insurance, besides employee and workplace characteristics, include the development and extent of the country's insurance industry. [ABSTRACT FROM AUTHOR]

Enacted 3 years ago, the Patient Protection and Affordable Care Act continues to be the subject of intense discussions and controversy. Herein, the progress in health care promulgated by implementation of the Patient Protection and Affordable Care Act is reviewed, persistent issues and unforeseen consequences discussed, and remedial solutions proposed. [ABSTRACT FROM AUTHOR]

Introduction: Text messaging may be an effective method for providing health care reminders to patients. We aimed to understand patient access to and preferences for receiving health-related reminders via text message among patients receiving care in safety-net hospitals.Materials and Methods: We conducted face-to-face surveys with 793 patients seeking care in three hospital emergency departments at a large safety-net institution and determined clinical and demographic predictors of preferences for text messaging for health care reminders.Results: 95% of respondents reported having daily access to text messaging. Text messaging was preferred over e-mail, phone, and letters for communication. 78% of respondents wanted to receive appointment reminders, 56% wanted expiring insurance reminders, and 36% wanted reminders to take their medications. We found no clinical predictors but did find some demographic predictors-including age, ethnicity, insurance status, and income-of wanting text message reminders.Discussion: In our convenience sample of safety-net patients, text messaging is an accessible, acceptable, and patient-preferred modality for receiving health care reminders. Text messaging may be a promising patient-centered approach for providing health care and insurance reminders to patients seeking care at safety-net institutions. [ABSTRACT FROM AUTHOR]

The article focuses on a study based on health insurance gains after the implementation of the Affordable Care Act's (ACA) in the U.S. It mentions about the Medicaid expansion's role in reducing disparities in health insurance coverage for U.S. people; and also mentions about examining the impact of the ACA for individuals with probation.

This study uses Medicare Part D prescription drug plan formulary files to characterize changes in coverage of buprenorphine and buprenorphine-naloxone for opioid use disorder in 2007, 2012, and 2018. [ABSTRACT FROM AUTHOR]

The authors argues on the need to build a national surveillance system for malpractice claims in the U.S. to improve patient safety and better understand the performance of the medical liability system. Topics covered include how underreporting of malpractice claims has undervalued malpractice claims, the value of malpractice claims data, and how to collect these data more systematically and use them effectively.

Objective: Determine if race or ethnicity is associated with missed or late transvaginal cervical length screening in a universal screening program.Methods: Retrospective cohort study of nulliparous women with singleton gestations and a fetal anatomical ultrasound from 16-24 weeks' gestation from January 2012 to November 2013. We classified women into mutually exclusive racial and ethnic groups: non-Hispanic black (black), Hispanic, Asian, non-Hispanic white (white), and other or unknown race. We used log-binomial regression to calculate the risk ratio (RR) and 95% confidence interval (CI) of missed or late (≥20 weeks' gestation) screening versus optimally timed screening between the different racial and ethnic groups.Results: Among the 2967 women in our study population, 971 (32.7%) had either missed or late cervical length screening. Compared to white women, black (RR: 1.3; 95% CI: 1.1-1.5) and Hispanic (RR:1.2; 95% CI: 1.01-1.5) women were more likely to have missed or late screening. Among women screened, black (versus white) women were more likely to be screened late (RR: 2.2; 95% CI: 1.6-3.1).Conclusions: Black and Hispanic women may be more likely to have missed or late cervical length screenings. [ABSTRACT FROM AUTHOR]

Objective: Treatment guidelines for rheumatoid arthritis (RA) recommend early, aggressive treatment with nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs) to minimize long-term disability. We aimed to assess differences in medical resource utilization, drug therapy, and health outcomes among RA patients by insurance type in the United States.Methods: Individuals with a self-reported diagnosis of RA were identified in the Medical Expenditure Panel Survey (MEPS) database, 2006-2009. Data regarding sociodemographic characteristics, insurance type and status, and outcomes (including health care resource utilization, prescription medication use, health status, and patient-reported barriers to health care) were extracted. Multivariable regression analyses were used to examine the impact of insurance type (private, Medicare, Medicaid, or uninsured) on outcome measures while controlling for age group, sex, and race/ethnicity.Results: A total of 693 individuals with a self-reported diagnosis of RA during the study period were identified; 423 were aged 18-64 years and 270 were aged ≥65 years. Among patients aged 18-64, those with Medicaid or who were uninsured were less likely than those with private insurance to visit a rheumatologist (adjusted odds ratio [aOR] 0.13 and 0.17, respectively; p < .001) and to receive biologic DMARDS (aOR 0.09 [p < .001] and 0.16 [p < .01], respectively); those with Medicaid were also less likely to receive nonbiologic DMARDS (aOR 0.26 [p < .01]). Those with Medicaid were more likely than those with private insurance to be unable/delayed in getting prescription drugs (aOR 2.9 [p < .05]), to experience cognitive, social, and physical limitations (aOR 8.7 [p < .001], 4.7 [p < .001], and 2.5 [p < .05], respectively); they also reported significantly lower general health and health-related quality of life. Patients aged ≥65 experienced greater equity in care and outcomes.Conclusions: Younger RA patients with Medicaid (including those who receive coverage under the Medicaid expansion component of the Affordable Care Act) may be at risk for inadequate treatment. [ABSTRACT FROM AUTHOR]