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Purpose Provisions of the Patient Protection and Affordable Care Act (ACA) of 2010 hold promise for improving access to and receipt of preventive services for adolescents and young adults (AYAs). The Title V Block Grant transformation also includes a focus on improving adolescent preventive care. This brief report describes and discusses an inquiry of promising strategies for improving access and preventive care delivery identified in selected high-performing states. Methods Two data sources were used to identify top-performing states in insurance enrollment and preventive care delivery: National Survey of Children's Health for adolescents (ages 12-17 years) and Behavioral Risk Factors Surveillance System for young adults (ages 18-25 years). Interviews were conducted with key stakeholders to identify promising strategies related to increasing AYAs' insurance enrollment and receipt of preventive services. Results Seven top-performing states were selected: California, Colorado, Illinois, Iowa, Oregon, Vermont, and Texas; 27 stakeholders completed interviews. Four strategies were identified regarding insurance enrollment: use of partnerships; special populations outreach; leveraging laws and resources; and youth engagement. Four strategies were identified regarding quality preventive care: expand provider capacity to serve AYAs; adopt medical home policies; establish quality improvement projects; and enhance consumer awareness of well-visit. States focused more on adolescents than young adults and on increasing health insurance enrollment than the provision of preventive services. Conclusions This commentary identifies strategies and recommends areas for future action, as Title V programs and their partners focus on improving healthcare for AYAs as ACA implementation and the Title V transformation continues.

BACKGROUND: Should health systems invest more in access to care by expanding insurance coverage or in health care services including improving the quality of care? Comparing these options experimentally would shed light on the impact and cost-effectiveness of these strategies. METHODS: The Quality Improvement Demonstration Study (QIDS) was a randomized policy experiment conducted across 30 districts in the Philippines. The study had a control group and two policy intervention groups intended to improve the health of young children. The demand-side intervention in QIDS was universal health insurance coverage (UHC) for children aged 5 years or younger, and a supply-side intervention, a pay-for-performance (P4P) bonus for all providers who met pre-determined quality levels. In this paper, we compare the impacts of these policies from the QIDS experiment on childhood wasting by calculating DALYs averted per US$spent. RESULTS: The direct per capita costs to implement UHC and P4P are US$4.08 and US$1.98 higher, respectively, compared to control. DALYs due to wasting were reduced by 334,862 in UHC and 1,073,185 in P4P. When adjustments are made for the efficiency of higher quality, the DALYS averted per US$ spent is similar in the two arms, 1.56 and 1.58 for UHC and P4P, respectively. Since the P4P quality improvements touches all patients seen by qualifying providers (32% in UHC versus 100% in P4P), there is a larger reduction in DALYs. With similar programmatic costs for either intervention, in this study, each US$spent under P4P yielded 1.52 DALYs averted compared to the standard program, while UHC yielded only a 0.50 DALY reduction. CONCLUSION: P4P had a greater impact and was more cost-effective compared to UHC as measured by DALYs averted. While expanded insurance benefit ceilings affected only those who are covered, P4P incentivizes practice quality improvement regardless of whether children are insured or uninsured.

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

To characterize sleep duration, timing and continuity measures in pregnancy and their association with key demographic variables. Multisite prospective cohort study. Women enrolled in the nuMoM2b study (nulliparous women with a singleton gestation) were recruited at the second study visit (16-21 weeks of gestation) to participate in the Sleep Duration and Continuity substudy. Women 9 hours. In multivariable models including age, race/ethnicity, body mass index, insurance status, and recent smoking history, sleep duration was significantly associated with race/ethnicity and insurance status, while time in bed was only associated with insurance status. Sleep continuity measures and sleep midpoint were significantly associated with all covariates in the model, with the exception of age for fragmentation index and smoking for wake after sleep onset. Our results demonstrate the relationship between sleep and important demographic characteristics during pregnancy.

The Personal Responsibility Work Opportunity and Reconciliation Act (PRWORA) of 1996 imposed time limits on the receipt of welfare cash benefits and mandated cash benefit sanctions for failure to meet work requirements. Many studies examining the health implications of PRWORA have found associated declines in health insurance coverage and healthcare utilization among single mothers but no impact of PRWORA on health outcomes. A limitation of this literature is that most studies cover a time period before time limits were implemented in all states and also before individuals began actually timing out. This work builds on previous studies by exploring this research question using data from the Survey of Income and Program Participation that covers a time period after all states have implemented time limits (1991-2009). We use a difference-in-differences study design that exploits variability in eligibility for cash welfare benefits by marital status and state-level variation in timing of PRWORA implementation to identify the effect of PRWORA. Using ordinary least square regression models, controlling for state-level and federal policies, individual-level demographics and state and year fixed-effects, we find that PRWORA leads to 7 and 5 percentage point increases in self-reported poor health and self-reported disability among white single mothers without a diploma, respectively.

ObjectivesTo examine rates of smoking and tobacco treatment utilization by insurance coverage status (Medicaid, commercial, exchange) among newly enrolled patients in the post Affordable Care Act (ACA) era.MethodsWe examined new members who enrolled in Kaiser Permanente Northern California through Medicaid, the California exchange, or nonexchange commercial plans (N=122,298) in the first 6 months of 2014 following ACA implementation. We compared these groups on smoking prevalence and tested whether smokers in each group differed on sociodemographic characteristics and in their utilization of tobacco treatment (pharmacotherapy and counseling) in 2014.ResultsSmoking prevalence was higher among Medicaid (22%) than exchange (13%) or commercial (12%) patients (P

PurposeCell-free DNA (cfDNA) prenatal screening tests have been rapidly adopted into clinical practice, due in part to positive insurance coverage. We evaluated the framework payers used in making coverage decisions to describe a process that should be informative for other sequencing tests.MethodsWe analyzed coverage policies from the 19 largest US private payers with publicly available policies through February 2016, building from the University of California San Francisco TRANSPERS Payer Coverage Policy Registry.ResultsAll payers studied cover cfDNA screening for detection of trisomies 21, 18, and 13 in high-risk, singleton pregnancies, based on robust clinical validity (CV) studies and modeled evidence of clinical utility (CU). Payers typically evaluated the evidence for each chromosomal abnormality separately, although results are offered as part of a panel. Starting in August 2015, 8 of the 19 payers also began covering cfDNA screening in average-risk pregnancies, citing recent CV studies and updated professional guidelines. Most payers attempted, but were unable, to independently assess analytic validity (AV).ConclusionPayers utilized the standard evidentiary framework (AV/CV/CU) when evaluating cfDNA screening but varied in their interpretation of the sufficiency of the evidence. Professional guidelines, large CV studies, and decision analytic models regarding health outcomes appeared highly influential in coverage decisions.Genet Med advance online publication 22 September 2016.

Changing the Medicaid program is a top priority for the Republican party. Common themes from GOP proposals include converting Medicaid from a jointly financed entitlement benefit to a form of capped federal financing. While proponents of this reform argue that it would provide greater flexibility and a more predictable budget for state governments, serious consequences would likely result for Medicaid enrollees and state governments. Under all three scenarios promoted by Republicans--block grants, capped allotments, and per capita caps—most states would face increased costs. For all three scenarios, the capped nature of the funding guarantees that the real value of funds would decrease in future years relative to what would be expected from growth under the current program. Although the federal government would undoubtedly realize savings from all three scenarios, the impact might lead states to reduce benefits and services, create waiting lists, impose cost-sharing on a traditionally low-income enrollee population, or impose other obstacles to coverage. Nationally, as many as 20.5 million Americans stand to lose coverage under the proposed Medicaid changes. In California, up to 6 million people could lose coverage if changes to the Medicaid program were coupled with the repeal of coverage for the expansion population.

The Patient Protection and Affordable Care Act (ACA) expands access to health insurance in the United States, and, to date, an estimated 20 million previously uninsured individuals have gained coverage. Understanding the law's impact on coverage, access, utilization, and health outcomes, especially among low-income populations, is critical to informing ongoing debates about its effectiveness and implementation. Early findings indicate that there have been significant reductions in the rate of uninsurance among the poor and among those who live in Medicaid expansion states. In addition, the law has been associated with increased health care access, affordability, and use of preventive and outpatient services among low-income populations, though impacts on inpatient utilization and health outcomes have been less conclusive. Although these early findings are generally consistent with past coverage expansions, continued monitoring of these domains is essential to understand the long-term impact of the law for underserved populations.

Background: Hereditary cancer panels (HCPs), testing for multiple genes and syndromes, are rapidly transforming cancer risk assessment but are controversial and lack formal insurance coverage. We aimed to identify payers' perspectives on barriers to HCP coverage and opportunities to address them. Comprehensive cancer risk assessment is highly relevant to the Precision Medicine Initiative (PMI), and payers' considerations could inform PMI's efforts. We describe our findings and discuss them in the context of PMI priorities. Methods: We conducted semi-structured interviews with 11 major US payers, covering >160 million lives. We used the framework approach of qualitative research to design, conduct, and analyze interviews, and used simple frequencies to further describe findings. Results: Barriers to HCP coverage included poor fit with coverage frameworks (100%); insufficient evidence (100%); departure from pedigree/family history-based testing toward genetic screening (91%); lacking rigor in the HCP hybrid research/clinical setting (82%); and patient transparency and involvement concerns (82%). Addressing barriers requires refining HCP-indicated populations (82%); developing evidence of actionability (82%) and pathogenicity/penetrance (64%); creating infrastructure and standards for informing and recontacting patients (45%); separating research from clinical use in the hybrid clinical-research setting (44%); and adjusting coverage frameworks (18%). Conclusions: Leveraging opportunities suggested by payers to address HCP coverage barriers is essential to ensure patients' access to evolving HCPs. Our findings inform 3 areas of the PMI: addressing insurance coverage to secure access to future PMI discoveries; incorporating payers' evidentiary requirements into PMI's research agenda; and leveraging payers' recommendations and experience to keep patients informed and involved.

ObjectiveTo evaluate the effects of state insurance mandates requiring insurance plans to cover Pap tests, the standard screening for cervical cancer that is recommended for nearly all adult women.Data sourcesIndividual-level data on 600,000 women age 19-64 from the CDC's Behavioral Risk Factor Surveillance System.Study designTwenty-four states adopted state mandates requiring private insurers in the state to cover Pap tests from 1988 to 2000. We performed a difference-in-differences analysis comparing within-state changes in Pap test rates before and after adoption of a mandate, controlling for the associated changes in other states that did not adopt a mandate.Principal findingsDifference-in-differences estimates indicated that the Pap test mandates significantly increased past 2-year cervical cancer screenings by 1.3 percentage points, with larger effects for Hispanic and non-Hispanic white women. These effects are plausibly concentrated among insured women.ConclusionsMandating more generous insurance coverage for even inexpensive, routine services with already high utilization rates such as Pap tests can significantly further increase utilization.

Medicaid can serve as a bridge to Medicare coverage for the long-term disabled with sufficient covered work experience. We perform multinomial logistic regression on 2007-2010 Medicare and Medicaid claims data to examine transitions to Medicare for people living with HIV/AIDS (PLWHA) in California who had Medicaid coverage in 2007. We find only 16% had obtained Medicare coverage by 2010. African-Americans, women, individuals with schizophrenia diagnoses, alcohol or substance abuse disorders, and any physical comorbidity were significantly less likely than others to obtain Medicare (p < 0.001). This study contributes new information on the impact of eligibility requirements for Medicare long-term disability insurance for PLWHA. About one-third of PLWHA under age 65 are covered by Medicaid. Many PLWHA get stuck in Medicaid because their disability prevents them from obtaining the additional employment experience needed to qualify for Medicare.

ImportanceOffice-based opiate agonist therapy has dramatically expanded access to medication-assisted treatment over the past decade but has also led to increased buprenorphine diversion.ObjectiveOur study sought to characterize physicians who participate in office-based therapy (OBT) to assess patient access to OBT in Ohio 10 years after its introduction.Design/setting/participantsCross-sectional telephone survey of Drug Addiction Treatment Act-waivered physicians in Ohio listed by the Center for Substance Abuse Treatment (CSAT).Main outcomesThis study sought to determine what proportion of eligible physicians are actively prescribing buprenorphine, whether they accept insurance for OBT, and whether they accept insurance for non-OBT services. In addition, we evaluated what physician characteristics predicted those primary outcomes. We hypothesized that a significant minority of eligible physicians are not active prescribers of buprenorphine. In addition, we expected that a significant minority of OBT prescribers do not accept insurance, further restricting patient access. We further hypothesized that a large subset of OBT prescribers accept insurance in their regular practices but do not take insurance for OBT.ResultsOf the 466 listed physicians, 327 (70.2%) practice representatives were reached for interview. Thirty-three physicians were excluded, with a true response rate of 75.5%. In total, 80.7% of providers reached were active OBT prescribers. Of these, 52.7% accepted insurance for OBT, 20.8% accepted insurance for non-OBT services but not for OBT, and 26.5% did not accept insurance for any services. Practices who did not accept insurance were more likely among dedicated addiction clinics located outside of Ohio's 6 major cities. Practices who normally accepted insurance but did not for OBT services were more likely in urban locations and were not associated with dedicated addiction practices. Neither business practice was associated with physician specialty.Conclusions and relevanceAccess to OBT in Ohio is far lower than what the 466 listed physicians suggests. Nearly 1 in 5 of those physicians are not active OBT prescribers, and 1 in 2 active prescribers do not accept insurance for OBT. Further research is needed to determine whether practices who do not accept insurance provide care consistent with CSAT guidelines and whether such practice patterns contribute to buprenorphine diversion.

OBJECTIVES:The aim of this study was to examine the evidence payers cited in their coverage policies for multi-gene panels and sequencing tests (panels), and to compare these findings with the evidence payers cited in their coverage policies for other types of medical interventions. METHODS:We used the University of California at San Francisco TRANSPERS Payer Coverage Registry to identify coverage policies for panels issued by five of the largest US private payers. We reviewed each policy and categorized the evidence cited within as: clinical studies, systematic reviews, technology assessments, cost-effectiveness analyses (CEAs), budget impact studies, and clinical guidelines. We compared the evidence cited in these coverage policies for panels with the evidence cited in policies for other intervention types (pharmaceuticals, medical devices, diagnostic tests and imaging, and surgical interventions) as reported in a previous study. RESULTS:Fifty-five coverage policies for panels were included. On average, payers cited clinical guidelines in 84 percent of their coverage policies (range, 73-100 percent), clinical studies in 69 percent (50-87 percent), technology assessments 47 percent (33-86 percent), systematic reviews or meta-analyses 31 percent (7-71 percent), and CEAs 5 percent (0-7 percent). No payers cited budget impact studies in their policies. Payers less often cited clinical studies, systematic reviews, technology assessments, and CEAs in their coverage policies for panels than in their policies for other intervention types. Payers cited clinical guidelines in a comparable proportion of policies for panels and other technology types. CONCLUSIONS:Payers in our sample less often cited clinical studies and other evidence types in their coverage policies for panels than they did in their coverage policies for other types of medical interventions.

Study objectiveAmong children requiring hospital admission or transfer, we seek to determine whether insurance is associated with the decision to either admit locally or transfer to another hospital.MethodsThis cross-sectional study used Healthcare Cost and Utilization Project 2012 Nationwide Emergency Department Sample. Pediatric patients receiving care in emergency departments (EDs) who were either admitted or transferred were included. Clinical Classifications Software was used to categorize patients into noninjury diagnostic cohorts. Multivariable logistic regression models adjusting for potential confounders, including severity of illness and comorbidities, and incorporating nationally representative weights were used to determine the association between insurance and the odds of transfer relative to admission.ResultsA total of 240,620 noninjury pediatric ED events met inclusion criteria. Patient and hospital characteristics, including older age and nonteaching hospitals, were associated with greater odds of transfer relative to admission. Patients who were uninsured or had self-pay had higher odds of transfer (odds ratio [OR] 3.84; 95% confidence interval [CI] 2.08 to 7.09) relative to admission compared with those with private insurance. Uninsured and self-pay patients also had higher odds of transfer across all 13 diagnostic categories, with ORs ranging from 2.96 to 12.00. Patients with Medicaid (OR 1.05; 95% CI 0.90 to 1.22) and other insurances (OR 1.14; 95% CI 0.87 to 1.48) had similar odds of transfer compared with patients with private insurance.ConclusionChildren without insurance and those considered as having self-pay are more likely to be transferred to another hospital than to be admitted for inpatient care within the same receiving hospital compared with children with private insurance. This study reinforces ongoing concerns about disparities in the provision of pediatric ED and inpatient care.

BackgroundAntiretroviral therapy has increased longevity for people living with HIV (PLWH). As a result, PLWH increasingly experience the common diseases of aging and the resources needed to manage these comorbidities are increasing. This paper characterizes the number and types of comorbidities diagnosed among PLWH covered by Medicare and examines how non-HIV comorbidities relate to outpatient, inpatient, and pharmaceutical expenditures.MethodsThe study examined Medicare expenditures for 9767 HIV-positive Californians enrolled in Medicare in 2010 (7208 persons dually covered by Medicare and Medicaid and 2559 with Medicare only). Costs included both out of pocket costs and those paid by Medicare and Medicaid. Comorbidities were determined by examining diagnosis codes.FindingsMedicare expenditures for Californians with HIV averaged $47,036 in 2010, with drugs accounting for about 2/3 of the total and outpatient costs 19% of the total. Inpatient costs accounted for 18% of the total. About 64% of the sample had at least one comorbidity in addition to HIV. Cross-validation showed that adding information on comorbidities to the quantile regression improved the accuracy of predicted individual expenditures. Non-HIV comorbidities relating to health habits-diabetes, hypertension, liver disease (hepatitis C), renal insufficiency-are common among PLWH. Cancer was relatively rare, but added significantly to cost. Comorbidities had little effect on pharmaceutical costs, which were dominated by the cost of antiretroviral therapy, but had a major effect on hospital admission.ConclusionsComorbidities are prevalent among PLWH and add substantially to treatment costs for PLWH. Many of these comorbidities relate to health habits that could be addressed with additional prevention in ambulatory care, thereby improving health outcomes and ultimately reducing costs.

Abstract Background Orthodontics prevent and treat facial, dental, and occlusal anomalies. Untreated orthodontic problems can lead to significant dental public health issues, making it important to understand expenditures for orthodontic treatment. This study examined orthodontic expenditures and trends in the United States over 2 decades. Methods This study used data collected by the Medical Expenditure Panel Survey to examine orthodontic expenditures in the United States from 1996 to 2016. Descriptive statistics for orthodontic expenditures were computed and graphed across various groups. Trends in orthodontic expenditures were adjusted to the 2016 United States dollar to account for inflation and deflation over time. Sampling weights were applied in estimating per capita and total expenditures to account for non-responses in population groups. Results Total orthodontic expenditures in the United States almost doubled from $11.5 billion in 1996 to $19.9 billion in 2016 with the average orthodontic expenditure per person increasing from $42.69 in 1996 to $61.52 in 2016. Black individuals had the lowest per capita orthodontic visit expenditure at $30.35. Out-of-pocket expenses represented the highest total expenditure and although the amount of out-of-pocket expenses increased over the years, they decreased as a percentage of total expenditures. Public insurance increased the most over the study period but still accounted for the smallest percentage of expenditures. Over the course of the study, several annual decreases were interspersed with years of increased spending Conclusion While government insurance expenditure increased over the study period, out of pocket expenditures remained the largest contributor. Annual decreases in expenditure associated with economic downturns and result from the reliance on out-of-pocket payments for orthodontic care. Differences in spending among groups suggest disparities in orthodontic care among the US population.

Purpose: To determine the utilization of planned oocyte cryopreservation (OC) in the year immediately prior to, and the year of, insurance coverage commencement for employees at our institution. Methods: Patient demographics and cycle outcomes were retrospectively compared between the first OC cycles occurring in 2017 vs. 2018 according to insurance coverage and type, age, and the number of oocytes retrieved and cryopreserved. Continuous demographic variables including age, BMI, day 3 FSH and E2, AMH, gravidity, and parity were compared using student T-tests. Cycle outcomes, including the number of oocytes retrieved and cryopreserved were compared using linear regression models, adjusting for potential confounders including age, BMI, and ovarian reserve parameters. Results: Between January 2017 and December 2018, 123 patients underwent planned OC at our institution. Patient age ranged from 23 to 44 years and did not significantly differ from 2017 to 2018 (mean 34.9 vs. 35.2). There was a 12% increase in planned OC utilization from 2017 (N = 58) to 2018 (N = 65). Significantly, more patients had any insurance coverage in 2018 vs. 2017 (71.9% vs. 40.4%, p = 0.001), a 78% increase. From 2017 to 2018, the number of patients with hospital-based insurance coverage undergoing planned OC increased by a factor of 8 (5 to 41.5%, p < 0.001), while the number of self-pay patients significantly decreased (p = 0.001). No differences were found regarding cycle outcomes. Conclusion: A greater proportion of women at our institution had insurance coverage for planned OC in 2018 vs. 2017. Employer-based insurance coverage for planned OC was associated with a significant increase in utilization by hospital employees. [ABSTRACT FROM AUTHOR]

Objective: To assess and address through policy change the health‐care needs of immigrant populations in Colorado. Data Sources: Primary data were collected in two Colorado communities from June 2019 through December 2020. Study Design: This work utilized a mixed‐method, community power building approach to determine and meet health‐care needs of immigrants, a marginalized population of mixed documentation status. Findings were then used to inform Emergency Medicaid (EM) expansion in Colorado. Data Collection: In‐depth interviews were conducted in Spanish, English, and Somali with 47 immigrants in rural Morgan County in June–September 2019; findings were presented to the community for feedback in January–February 2020. In March–December 2020, 330 interviews were conducted in Spanish and English with 208 unique individuals in Morgan and Pueblo Counties by local community grassroots leaders via four rounds of a novel phone tree outreach method. Interviewees were identified through snowball sampling and direct outreach among individuals seeking immediate relief (i.e., food assistance). Principal Findings: Interviewees reported numerous barriers to health‐care access, including discrimination and limited service hours and transportation options. Data also revealed a clear health insurance coverage gap among undocumented immigrants. These data were then presented to Colorado's Department of Health‐Care Policy and Financing, ultimately contributing to securing EM expansion to this population to include COVID treatment, including respiratory therapies and outpatient follow‐up appointments. Data‐informed continued implementation advocacy to ensure the effectiveness of EM program expansion. Conclusions: Immigrants are particularly marginalized by the health‐care system. Rapid data collection grounded in a community power‐building approach produced data that directly informed state policy and an increased power base. This approach enables direct connection to immediate "downstream" needs in communities while simultaneously building collective systemic "upstream" analysis and capacity of community members and laying pathways to translation and implementation of research into policy. [ABSTRACT FROM AUTHOR]

The paper deals with the problem of possible ruin when providing insurance coverage for an epidemic. The model studied is an SIS type epidemic which generalizes the well-known logistic model. Contractually, the premiums are paid by susceptible people while the care costs are reimbursed to infected people via an annuity or a lump-sum benefit. Our goal is to determine the distribution of the main statistics of the ruin when it occurs during the epidemic. The case where the reserve alternates between normal and epidemic episodes is also discussed using a Brownian modeling of the reserve. Finally, some of the results are illustrated for two particular SIS epidemic models. [ABSTRACT FROM AUTHOR]

Introduction: Acupuncture is a potential treatment option for pain, nausea, vomiting, anxiety, and agitation in the perioperative period. Patient preference for participating in acupuncture in the perioperative period is not well understood. The aim of this study was to quantify patient interest in perioperative acupuncture, explore the relationship between acupuncture interest, insurance coverage and patient cost, and identify clinical factors associated with patient interest in acupuncture. Materials and Methods: Adult patients evaluated in the Preoperative Evaluation Clinic at the Mayo Clinic in Phoenix, AZ, between June 2019 and July 2019, received a voluntary survey to assess their attitudes toward receiving acupuncture in the perioperative period. Patient interest in acupuncture to help treat pain, anxiety, and postoperative nausea and vomiting, as well as their willingness to pay for such services, were assessed. Demographic data, American Society of Anesthesiologists (ASA) physical class, scheduled procedure, and insurance coverage were extracted from the medical record. Univariate analysis was performed to estimate interest in acupuncture. Results: Three hundred and seven respondents were included in this study with a response rate of 60.4%. A total of 68.4% of study participants were interested in receiving perioperative acupuncture. Of those interested in acupuncture, 86.7% were interested if acupuncture was offered at no cost (either free or fully covered by insurance). A total of 47.1% of those patients interested in acupuncture would be interested if the cost of acupuncture was between 20 and 50 U.S. dollars. A total of 8.6% would be interested in acupuncture if patients were expected to pay the full cost of treatment (estimated 175 U.S. dollars). Age, sex, ASA status, type of surgery, risk of procedure, and Medicare/Medicaid coverage were not statistically associated with interest in acupuncture. Conclusions: When there is little to no direct cost to the patient, the majority of patients are interested in acupuncture in the perioperative period. [ABSTRACT FROM AUTHOR]

Objective: To study the racial and socioeconomic characteristics of women seeking fertility care in a state with mandated insurance coverage for fertility testing and treatment. Design: Cross-sectional, self-administered survey. Setting: Academic fertility center in Illinois. Patient(s): Of 5,000 consecutive fertility care patients, 1,460 completed the survey and were included in the study sample. Intervention(s): None. Main Outcome Measure(s): Details about demographic characteristics and health care access on the basis of patient race/ethnicity and socioeconomic status. Result(s): The mean age of participants was 36.1 years; 75.5% were White, 10.2% Asian, 7.3% Black, 5.7% Latinx, and 1.3% Other. Most women had a bachelor’s (35.5%) or master’s degree (40.5%) and an annual household income of >$100,000 (81.5%). Black and Hispanic women traveled twice as far (median 10 miles) as White and Asian women (median 5 miles for both) for treatment. Black women (14.7%) were more likely to report that their race was a barrier to getting fertility treatment compared with White (0.0%), Hispanic (5.1%), and Asian (5.4%) women. Black and Hispanic women were approximately twice as likely to report income level (26.5% and 20.3%, respectively) and weight (7.8% and 8.9%, respectively) as barriers compared with White and Asian respondents. Conclusion(s): Significant racial and socioeconomic disparities exist among fertility patients accessing care. Beyond providing all Americans with health insurance that covers fertility treatment, further research in the general population is needed to understand the complex social, cultural, racial, and economic factors that prohibit many individuals from accessing needed fertility care.

Diagnostic testing and treatment for infertility should be available to everyone in need of these services. The disparities in rates of infertility and the barriers to accessing assisted reproductive technology services should be understood through and addressed within a reproductive justice framework. Obstetrician-gynecologists and other health care professionals should identify specific populations at risk and their accompanying barriers to access to help improve infertility care across populations. Health care professionals should ask appropriate questions about social and structural drivers of health that may influence a patient's health and use of the health care system to better understand their patients' needs and lived experiences. Obstetrician-gynecologists and other health care professionals should advocate for insurance coverage for infertility services, including assisted reproductive technology; policy changes that promote comprehensive reproductive health; and evidence-based, lower cost treatment options., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Age is one of the most relevant observable risk attributes in determining the value of health insurance premiums. Empirical evidence indicates that the cost of health insurance is the leading cause of contract switching, which can compromise access to healthcare services and potentially result in treatment discontinuities. Using data from a Health Maintenance Organization in the Southern region of Brazil, we examined the effect of health plan price readjustment resulting from changes in the beneficiary's age group on disenrollment or switches to a more limited coverage plan. The estimates were obtained using the method of regression discontinuity. The main findings indicate that for age group transitions at 59 years old, the price readjustment effect led to an increase in contract cancellations and switching to cheaper plans. These findings highlight that an important consequence of the difference in premium sensitivity among age groups is that the exit of individuals from the health insurance sector is selective in age. The results of this paper can support policymaking to improve access to health insurance., (© 2024 John Wiley & Sons Ltd.)

Background: Severe cases of varicose veins can cause psychological distress as well as physical symptoms including skin discoloration, wounds, and burning sensations. One intervention, endovenous laser/radiofrequency ablation, is variably covered by insurance. Insurance coverage for this procedure was assessed for all indications of endovenous laser/radiofrequency ablation as medically necessity criteria., Methods: A cross-sectional analysis was conducted of 57 insurance policies for endovenous laser/radiofrequency ablation. The insurance companies were selected based on the greatest state enrollment and market share. A web-based search and telephone interviews were utilized to identify the policies. Medically necessary criteria were then extracted from the publicly available policies., Results: Fifty-seven (57) insurance policies were assessed, with 36 (63.2%) of these policies providing coverage for endovenous radiofrequency or laser ablation. Six indications existed for coverage, with the most common indication being the demonstration of valvular reflux (n = 29, 80.6%). Of the 29 companies that indicated coverage for valvular reflux, 19 (52.8%) specifically required saphenous reflux. Significantly more companies required saphenous reflux versus other specified types of valvular reflux (52.8% vs 8.3%, P < 0.001 for saphenous vs junctional reflux and 52.8% vs 16.7%, P < 0.003 for saphenous vs nonspecific). Prior to proceeding with endovenous laser or radiofrequency ablation, up to 33% of insurance companies required a trial of conservative management as medically necessary., Conclusions: There is a great discrepancy in insurance policy criteria for coverage of endovenous laser/radiofrequency ablation for the treatment of varicose veins, particularly regarding the requirements for valvular reflux and a trial of conservative therapy., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Acute limb ischemia (ALI) is a morbid and deadly diagnosis. However, existing epidemiologic studies describing ALI predate the introduction of the Affordable Care Act in 2010 and direct oral anticoagulants in 2011. Thus, we synergized the National Inpatient Sample (NIS) and United States Census to define contemporary trends in the incidence, treatment, and outcomes of ALI in the US., Methods: We included emergent admissions of adults with primary diagnosis of lower extremity ALI in survey-weighted NIS data (2005-2020). Mann-Kendal trend test evaluated ALI incidence (primary outcome), anticoagulation usage, insurance coverage, revascularization type, and in-hospital amputation/death. Multivariable logistic regression quantified covariate associations with in-hospital amputation/death., Results: Of the 582,322,862 estimated hospitalizations in the NIS, 227,440 met the inclusion criteria (mean age 68.80 years, 49.94% women, 76.66% White). ALI incidence peaked in 2006 (7.16/100,000 person-years) but has declined since 2015 to 4.16/100,000 person-years in 2020 (p trend  = 0.008). Endovascular revascularization, anticoagulation, and Medicaid coverage increased, while self-pay insurance decreased (p trend < 0.05). Amputation rates significantly decreased from 8.04 to 6.54% (p trend  = 0.01) while death rate remained at 5.59% (p trend  = 0.16) over the study period. Prehospitalization anticoagulation was associated with decreased amputation (adjusted odds ratio [aOR] = 0.74 (95% confidence interval [CI] 0.65-0.84)) and death (aOR = 0.50 (95% CI 0.43-0.57)). When controlling for covariates, women had a higher risk of death (aOR = 1.17 (95% CI 1.07-1.27), P < 0.0001), while Black patients had a higher risk of amputation (aOR = 1.24 (95% CI 1.10-1.41), P < 0.0001)., Conclusions: Our US population based epidemiological study demonstrates that ALI incidence and in-hospital amputation rates are decreasing, while mortality remains unchanged. We further highlight the ongoing need for ALI investigation specifically as it relates to access to care, antithrombotic therapy use, treatment strategy, and strategies to combat gender and racial disparities., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Photo by Engin Yapici on Unsplash ABSTRACT Medical tourism has excellent potential and downfalls, which this paper will extensively cover. While medical tourism has great economic benefits to the host country and calls for the increase of professionalism and skill of physicians, it also influences doctors locating to private hospitals and skewing healthcare costs and access for locals. Given the many weights and balances to consider, the discussion of expanding this type of healthcare into Turkey is ethically needed. INTRODUCTION I watched from the hotel lobby as a group of men with surgically wrapped heads strolled in line behind a young woman; she was speaking to them in English with a heavy Turkish accent. Across the room was another group like this one, but the women had bandages on their noses. As a Turk, this sight was not new to me: over the years, I witnessed the number of foreigners coming to Turkey for medical procedures increase by tenfold. And, I began to see how savvy Turkish tourist companies became over time, creating enticing packages for people to tour the beautiful city of Istanbul while receiving a hair transplant procedure or rhinoplasty. While I understood why individuals would come to Turkey for their procedure ― lower prices, expert physicians, and a lovely tourist destination ― I began to question whether profiting from the health care of others was ethical. This paper examines whether it is ethical for Turkey to invest in a growing medical tourism field, which has the potential for significant economic benefits yet could threaten health inequalities between locals and foreigners. Further, it will outline why tourists choose Turkey as a medical tourism destination, the reasons to favor medical tourism, and the reasons to oppose it. Finally, the paper will conclude that Turkey should cultivate and invest in medical tourism, with suggestions for expanding the field into a thriving market. ANALYSIS By definition, a medical tourist is an individual who travels to a foreign country to experience both cultural tourism and medical treatment.[1] Global medical tourism is a $55billion industry, and the industry in Turkey is experiencing an annual growth rate of 22.6 percent.[2] In 2017, more than one million individuals traveled to Turkey for medical tourism, putting approximately ten billion dollars of foreign currency into the economy.[3] Medical tourists who traveled to Turkey received, on average, more than one procedure during their stay.[4] Due to the increasing demand for medical tourism, the Ministry of Health in Turkey emphasized the expansion of medical tourism in its strategic plan, implementing initiatives to grow the industry.[5] These initiatives include improving the quality of Turkish hospitals and receiving Joint Commission International (JCI) accreditation, which is an internationally recognized quality healthcare index.[6] There are multiple reasons why individuals choose Turkey as their destination for medical tourism. First, it is easy to travel to: individuals need only an E-visa, which they can easily receive through an online application.[7] In addition, Turkey has lower prices compared to the Western hemisphere.[8] The Turkish government incentivizes medical tourism through lucrative advertising specials. For example, Turkish Airlines offers discounted airline ticket prices of 50 percent for patients who demonstrate a patient admission document from a Turkish-certified health institution.[9] Private hospitals have opened advertising offices in the Ataturk airport as well.[10] Lastly, hotels and hotel chains collaborate with hospitals to offer lucrative tourist packages for patients.[11] While these perks and incentives draw people to Turkey, the lack of insurance coverage, high cost of treatment, and long wait times in their home countries are the most significant reasons that tourists choose Turkey as their medical destination.[12] Arab tourists previously traveled to the United States and the United Kingdom for medical treatment, but due to the implementation of strict travel sanctions after the September 11 attacks, they have had to look elsewhere.[13] For Arab tourists, the similarity of culture and religion in Turkey, a predominantly Muslim country, is also an enticing factor.[14] And, while Thailand and Singapore offer lower health care costs than Turkey, the shorter distance from the home country plays an important role in choosing Turkey as a medical destination.[15] European tourists choose Turkey for different reasons. For example, some surgeries conducted in Turkey are not available in Europe.[16] Patients from the Balkans and Central Asia prefer Turkey because of Turkey’s highly trained physicians and brand new, well-equipped hospitals compared to those in their home countries.[17] Interestingly, the low costs rank lower in importance than cultural similarity among those seeking care in Turkey.[18] The most important factor for choosing Turkey was quality: most tourists came from countries with a healthcare system marred by a lack of expertise or technological advancement.[19] One Turkish physician stated, “[Turkey] really ha[s] practices, doctors, services, hospitals and treatments that are above world standards in terms of health care.”[20] l. Ethical Permissibility of Medical Tourism in Turkey Health tourism has the potential to make a significant impact on the economic and social life of countries.[21] As a developing country, Turkey cannot afford to overlook this economic possibility.[22] The expansion of medical tourism in Turkey has allowed the country to reform its healthcare system into one that competes with health care quality in the Western hemisphere. Since 2010, there has been a significant increase in patients traveling to Turkey for health care.[23] The AK Party in Turkey pledged to promote health tourism in its campaign in 2011.[24] This inspired health care reform in 2013, with Turkey instituting a publicly funded and organized healthcare system.[25] In 2013, the Turkish government created publicly funded city hospitals. These hospitals were formed for medical tourism, meeting quality levels never-before-seen in the country.[26] In 2014, the Ministry of Health began granting accreditation to medical providers for medical tourism services and supporting translation services, patient transportation, and marketing.[27] Additionally, strategic initiatives were implemented to increase the number of Turkish medical school graduates.[28] The number of private medical schools increased from five before 2013 to 24 by the end of 2015.[29] A 50 percent tax reduction was granted to healthcare institutions that provided health care to foreigners.[30] Finally, Turkey began reforming hospital systems to obtain JCI accreditation. The growth of medical tourism in Turkey has resulted in positive reform of Turkey’s healthcare system. Turkey has over ten city hospitals in Istanbul, with qualified professionals proficient in English and other languages.[31] These hospitals are public and thus open and available for use by the general Turkish community, offering excellent quality health care to the country’s citizens. However, private hospitals have also flourished and, in some cases, have drained some of the doctors from public hospitals. With the increase in quality measures and regulatory healthcare committees, such as the Health Tourism Coordination Council (SATURK), Turkey’s healthcare system rivals the West's with highly trained professionals, competitive medical schools, and modern medical facilities.[32] Turkey has even reached the forefront of medical advancement: the World Eye Hospital is renowned for its cutting-edge ophthalmology services.[33] The investment in medical tourism has allowed Turkey to invest more in its private sector as well: the total expenditure on health as a proportion of the GDP rose from 2.4 percent in 1980 to 6.1 percent in 2008,[34] with an almost $2 billion national income from medical tourism in 2010. ll. Arguments Against the Ethical Permissibility of Medical Tourism in Turkey While public city hospitals were opened with the potential to support the Turkish medical tourism industry, private hospitals support 83 percent of the medical tourism market, and the gap between private and public hospitals has been growing yearly.[35] Private hospitals have mostly opened in urban areas, such as Istanbul, Ankara, and Antalya.[36] As a result, there has been a “brain drain,” in which members of the health workforce have left rural areas and have moved to urban cities where they can make larger profits from the medical tourism industry.[37] In addition, the use of public city hospitals has been met with concern regarding whether inequalities in health care between foreigners and Turkish citizens will arise. The Ministry of Health pays rent for the city hospitals in US dollars, exacerbating inflation in the Turkish lira currency and increasing reliance on high-paying medical tourists to support the public hospital system.[38] Due to this pressure, the prices for medical services are not consistently kept at affordable levels for Turkish citizens.[39] The head of The Private Hospitals and Health Institutions Association, Resat Bahat, stated, “Turkish citizens must receive priority for public resources. You cannot treat a Libyan or a Dutch when your own citizen is shaking at home with pneumonia. You [the public sector] can perhaps engage in medical tourism if you have excess bed capacity. But it is hard to do this [medical tourism] with the public sector.”[40] Rapid growth has also compromised patient safety and health care quality. While clinics must receive medical tourism certificates to provide treatment, fraud has risen.[41] In 2016, six out of ten hair transplant clinics were operating illegally.[42] These clinics offered hair transplants for as low as $800 when the treatment costs approximately $2000 in a Ministry of Health authorized clinic.[43] International patients have complained of inadequate human resources, such as the inability to communicate appropriately and insensitivity to tourists’ cultural features and habits, as well as a lack of facilitators in hospital systems.[44] The most common complaint has been that medical tourism companies fail to direct patients well and follow up after procedures.[45] Furthermore, multiple Turkish physicians have cited cases of malpractice with foreign patients.[46] One Turkish physician highlighted the ethical dilemma of turning health care into a commodity: “It is important that healthcare should be provided in such a way that institutions can continue their business without turning into a commercial commodity, ignoring the health and the aspect of the event. All people should have access to health equally.”[47] A Turkish pulmonologist also supported the idea of the separation between health and tourism, claiming that health care is a subject that requires unique methods to meet its needs, which should be addressed separately from the tourism industry.[48] lll. The Case for Continuing Medical Tourism While the above arguments demonstrate the difficulties with medical tourism, I argue that it is ethically permissible to invest in and expand Turkish health tourism. From a utilitarian perspective, the benefits of medical tourism to Turkish citizens outweigh the costs of expansion. Since investing in medical tourism, the quality of Turkish health care on both public and private levels has increased drastically. Turkey has also moved towards implementing more regulations surrounding the quality of health care.[49] International standards for health care have been adopted as well allowing Turkish citizens to reap the benefits of the medical tourism industry through access to advanced and high-quality health care.[50] While access and affordability for local patients must improve, the very existence of high-quality care and care standards that are better regulated exemplify improvements. Investments in medical education have also allowed Turkish citizens to gain greater access to higher education throughout the country with more medical seats and the opening of multiple private medical schools.[51] In addition, the expansion of the health industry has increased the professional opportunities available in healthcare for Turkish citizens. There is no doubt that medical tourism has greatly benefited the Turkish economy. Turkey aims to be the leading country in medical tourism by 2023, opening economic opportunities within and beyond medicine. The financial benefit is not reserved for the hospital systems and could provide high-paying jobs in hospitality, food service, etc.[52] People coming to Turkey spend money sightseeing and enjoying hotels, nature, and cities. While concerns about fraud exist, the medical tourism industry in Turkey is still relatively new, dating back to 2013. Thus, fraud is not widespread, considering the rate at which the industry has grown and its remarkable milestones in quality and patient services. There is no doubt that Turkey will continue to reform to meet the demands of various patient populations without compromising the safety and quality of its healthcare commodities. The government has been adept at tracking the industry and can adopt new regulations and enforcement to discourage and punish fraud. In addition to the existing policy guiding the expansion of Turkey’s medical tourism industry, more can be done to expand the industry. Some argue that barriers to medical tourism growth include inadequate human resources, negative corporate images and perceptions of Turkey globally, lack of facilitators, and unsatisfactory quality of care for medical tourists.[53] While Arab tourists are more at ease in choosing Turkey as a health destination because of the shared religion and understanding of Islamic accommodations, marketing to European and Asian tourists should address the possibility that they may feel uneasy about cultural differences or even that their cultural needs will not be respected or met. Therefore, more effort must be directed toward training medical personnel to exercise cultural competency and make hospitals culturally welcoming. This may include offering diverse food choices and ensuring that translators are available during all aspects of the medical tourist experience, starting at the airport. County-specific environmental factors should also be considered before a private hospital can enter the medical tourism market.[54] For example, hospitals should offer tour vouchers to capitalize on the historical sites in Cappadoccia. In addition, hospitals in Gaziantep should be sure to have signs in Arabic, and Arab-speaking health personnel, to meet the needs of the large Arab population in the area. Turkey must also do more to control costs to prevent the exacerbation of inequalities between foreigners’ and citizens’ access to health care. For example, some clinics have been able to circumvent cost regulations by the Ministry of Health.[55] By appointing region-specific regulatory overseers, they can ensure that costs are not prohibiting the local population from seeking necessary health care. CONCLUSION Turkey has seen enormous expansion in its medical tourism industry in recent years. Through government support and collaboration between the tourism and healthcare sectors, the Turkish economy has amassed billions of dollars in revenue annually from medical tourism alone. The investment into the medical tourism industry has placed Turkey at the forefront of quality and cutting-edge health care. While medical tourism has contributed enormous benefits to communities and the economy, there is more to do to ensure that health care inequalities between foreigners and Turkish citizens do not rise. The medical tourism industry in Turkey is not yet perfect; however, the potential is enormous. All things considered, medical tourism stands to help Turkey’s economy both through hospital systems and the increased tourism that coincides with travel for medical care. Due to expanded demand for services, medical tourism has led Turkey to develop its healthcare system and expand the number of people who can become physicians. Yet, more must be done to prevent fraud, ensure fair prices that Turkish locals can afford, and help public hospitals maintain some of the tourism market shares. Overall, medical tourism stands to benefit the people of Turkey and is an ethical way to expand the economy. - [1] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [2] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031; Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [3] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [4] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [5] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [6] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79; Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475; Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [7] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [8] Ibid. [9] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [10] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [11] Ibid. [12] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [13] Ibid. [14] Ibid. [15] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [16] Ibid. [17] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [18] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [19] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [20] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [21] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [22] Ibid. [23] Akgün, S. (2015). Medical tourism in Turkey: past, present, and future. Seval Akgün. European Journal of Public Health, 25(suppl_3). [24] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [25] Ibid. [26] Ibid. [27] Ibid. [28] Ibid. [29] Ibid. [30] Ibid. [31] Ibid. [32] Ibid. [33] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [34] Ibid; Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [35] Akgün, S. (2015). Medical tourism in Turkey: past, present, and future. Seval Akgün. European Journal of Public Health, 25(suppl_3); Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [36] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [37] Ibid. [38] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [39] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [40] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [41] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [42] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [43] Ibid. [44] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [45] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [46] Ibid. [47] Ibid. [48] Ibid. [49] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism; Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [50] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: Case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [51] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [52] Akgün, S. (2015). Medical tourism in Turkey: past, present, and future. Seval Akgün. European Journal of Public Health, 25(suppl_3). [53] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [54] Ulaş, D., & Anadol, Y. (2016). A case study for medical tourism: investigating a private hospital venture in Turkey. Anatolia: An International Journal of Tourism & Hospitality Research, 27(3), 327–338. https://doi-org.ezproxy.cul.columbia.edu/10.1080/13032917.2016.1191763 [55] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318.

The population of children living in poverty and lacking healthcare insurance has increased in the United States of America in the last decade. Several factors have been responsible for this trend including illegal immigration, socioeconomic deprivation, young age, racial segregation, environmental degradation, and discriminatory housing policies. These systemic barriers have contributed to the exclusion of families from essential healthcare services. They are also contributory to the development of chronic illnesses (such as dialysis-dependent kidney disease) that are debilitating and frequently require considerable therapeutic resources. This unfortunate scenario creates a never-ending vicious cycle of poverty and diseases in a segment of society. For pediatric nephrologists, the challenges of caring for uninsured children with chronic kidney disease are all too familiar. Federally funded healthcare programs do not cover this patient population, leaving them the option of seeking care in emergency healthcare settings. Presentation with a critical illness often necessitates urgent placement of vascular catheters and the choice of acute hemodialysis. Adverse social environment influences the need for protracted chronic hemodialysis and a delay in kidney transplantation. Consequently, there is greater comorbidity, recurrent hospitalization, and a higher mortality rate. New policies should address the deficit in health insurance coverage while promoting social programs that will remove structural barriers to health care resources for undocumented children and young adults.

This study investigates whether sociodemographic factors are associated with utilization of intervention services for children with autism spectrum disorder (ASD) enrolled in the Childhood Autism Risks from Genetics and the Environment Study. Maternal ethnicity, insurance status, and education for 696 families of children with ASD were available. Children of Black mothers entered intervention earlier compared to White mothers (2 vs. 2.6 years; p = 0.001). Having public insurance was associated with receiving

BackgroundInsurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government-sponsored insurance had worse quality of care or in-hospital outcomes in acute ischemic stroke.Methods and resultsMultivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in-hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines-Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED, or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (

Previous research has demonstrated that Latino young adults are uninsured at higher rates relative to other ethnoracial groups. Recent implementation of the 2010 Affordable Care Act (ACA) has increased access to health insurance for young adults, in part by maintaining health coverage through their parents until age 26. This paper examines patterns of Latino young adults' insurance coverage during early ACA implementation by addressing three questions: 1) To what extent do Latino young adults remain uninsured relative to their peers of other ethnoracial groups? 2) How do young adults' family socioeconomic background, immigrant characteristics, college enrollment, and employment status mediate their coverage? And, 3) do patterns of insurance coverage differ for employer-provided coverage versus other sources of coverage (including parents' health insurance)? Using a 2011 representative sample of U.S.-born and 1.5-generation immigrant young adults in California, we find that Latinos are more likely than other ethnoracial groups to remain uninsured. While they are as likely as similar peers to obtain employer-provided health insurance, they are less likely to possess insurance through other sources (including their parents). This study contributes to our understanding of the limits of the ACA in reducing disparities in insurance coverage for Latinos by highlighting the importance of family socioeconomic background, immigrant characteristics, college enrollment, and employment in shaping coverage among this age group.

BACKGROUND: Chronic liver disease and cirrhosis are a leading cause of morbidity and mortality in the United States. Primary biliary cholangitis (PBC), previously known as primary biliary cirrhosis and which has been designated an orphan condition, is a chronic autoimmune disease resulting in the destruction of the small bile ducts in the liver. Without effective treatment, disease progression frequently leads to liver failure and death. Until May 2016, the only FDA-approved treatment for PBC was ursodiol (UDCA), an oral hydrophilic bile acid, which can slow progression of liver damage due to PBC. However, 1 out of 3 patients taking UDCA has an inadequate biochemical response, leading to increased risk of disease progression, liver transplantation, and mortality. Given this unmet clinical need, new therapies are in development for the treatment of PBC. To provide pharmacists with an overview of the latest research on the pathophysiology of PBC and potential new treatment options and to highlight medical and specialty pharmacy approaches to managing access to drugs to treat orphan diseases such as PBC, a 2-hour satellite symposium was presented in conjunction with the 2015 Academy of Managed Care Pharmacy (AMCP) Nexus meeting. Although obeticholic acid was approved by the FDA for the treatment of PBC in May 2016, this development occurred after the symposium presentation. The symposium was supported by an independent educational grant from Intercept Pharmaceuticals and was managed by Analysis Group. Robert Navarro, PharmD, moderated the CPE-accredited symposium titled Medical and Specialty Pharmacy Management Update on Primary Biliary Cirrhosis. Expert panelists included Christopher L. Bowlus, MD; James T. Kenney, RPh, MBA; and Gary Rice, RPh, MS, MBA, CSP. OBJECTIVE: To summarize the educational satellite symposium presentations and discussions. SUMMARY: Autoimmune liver diseases, including PBC, are responsible for 15% of all liver transplants performed and an equal percentage of deaths related to liver disease. UDCA is the only FDA-approved therapy for treatment of PBC and is considered the standard of care. Nevertheless, many patients do not respond to UDCA, creating the need for new therapeutic options to improve clinical outcomes for PBC patients with inadequate response to treatment. While several agents are being studied in combination with UDCA, monotherapy with the novel agent obeticholic acid, a farnesoid X receptor agonist, has also shown promising results. Health plans are anticipated to assign any newly introduced therapy for the treatment of PBC to specialty pharmacy given its orphan disease status. This assignment enables the health plan to receive disease education, which is particularly important when new drugs are indicated for orphan diseases, and assistance with designing appropriate prior authorization criteria. The clinical value of any new therapeutic options that will inform formulary decisions and prior authorization criteria will be assessed based on evidence of efficacy, safety, and tolerability, among other factors, such as the potential to reduce or delay medical resource utilization (e.g., liver transplant). Key considerations for prior authorization of a new therapy will be determining which PBC patients are appropriate candidates for the new therapy and developing criteria for that determination. These are likely to include clinical diagnostic criteria and degree of response to prior treatment with UDCA. Initially, any new therapy would likely be positioned as noncovered until appropriate prior authorization criteria are established. CONCLUSIONS: PBC is a chronic liver disease with significant morbidity and mortality, as well as a significant burden on the health care system if the disease progresses to the point at which a liver transplant is needed. Although UDCA, the current standard of care, has improved outcomes for many patients, others have an inadequate response to this treatment. This symposium discussed these issues and also addressed the overall treatment paradigm for orphan drug therapies, key implications for patient management, and the role of specialty pharmacy management and any associated needs both in general and specifically for new therapeutic options for PBC.

Federally Qualified Health Centers--commonly referred to as Community Health Centers (CHCs)--serve as a safety net for people who did not gain health insurance under the Affordable Care Act (ACA), including those immigrants not eligible for Medicaid or health insurance exchange coverage. ACA-driven changes in health insurance coverage, funding, and related policy have created new challenges for these safety net organizations. This policy brief reports the findings from analyses of the U.S. HRSA Uniform Data System and interviews conducted in 2014-16 with the leadership of 31 CHCs. The CHCs were located in communities with high concentrations of immigrants and uninsured residents, in states that either expanded Medicaid (California and New York) or that chose not to expand it (Georgia and Texas). The study found that most CHCs now see more patients, including significant numbers without insurance. The ACA has brought new resources to CHCs but has also reinforced challenges, including the need for stable revenue streams, sufficient staffing support, and assistance in leveraging new reimbursement mechanisms. Policy recommendations to address these challenges include continuing core federal funding, insuring the remaining uninsured, addressing workforce challenges, and preparing CHCs for alternative payment mechanisms.

ObjectiveTo compare physicians' self-reported willingness to provide new patient appointments with the experience of research assistants posing as either a Medicaid beneficiary or privately insured person seeking a new patient appointment.Data sources/study settingSurvey administered to California physicians and telephone calls placed to a subsample of respondents.Study designCross-sectional comparison.Data collection/extraction methodsAll physicians whose California licenses were due for renewal in June or July 2013 were mailed a survey, which included questions about acceptance of new Medicaid and new privately insured patients. Subsequently, research assistants using a script called the practices of a stratified random sample of 209 primary care physician respondents in an attempt to obtain a new patient appointment. By design, half of the physicians selected for the telephone validation reported on the survey that they accepted new Medicaid patients and half indicated that they did not.Principal findingsThe percentage of callers posing as Medicaid patients who could schedule new patient appointments was 18 percentage points lower than the percentage of physicians who self-reported on the survey that they accept new Medicaid patients. Callers were also less likely to obtain appointments when they posed as patients with private insurance.ConclusionsPhysicians overestimate the extent to which their practices are accepting new patients, regardless of insurance status.

Study objectiveThe 2010 provision of the Patient Protection and Affordable Care Act (ACA) extended eligibility for health insurance for young adults aged 19 to 25 years. It is unclear, however, how expanded coverage changes health care behavior and promotes efficient use of emergency department (ED) services. Our objective was to use population-level emergency department data to characterize any changes in diagnoses seen in ED among young adults since the implementation of the ACA dependent coverage expansion.MethodsWe performed a difference-in-differences analysis of 2009 to 2011 ED visits from California, Florida, and New York, using all-capture administrative data to determine how the use of ED services changed for clinical categories after the ACA provision among young adults aged 19 to 25 years compared with slightly older adults unaffected by the provision, aged 26 to 31 years.ResultsWe analyzed a total of 10,158,254 ED visits made by 4,734,409 patients. After the implementation of the 2010 ACA provision, young adults had a relative decrease of 0.5% ED visits per 1,000 people compared with the older group. For the majority of diagnostic categories, young adults' rates and risk of visit did not change relative to that of slightly older adults after the implementation of the ACA. However, although young adults' ED visits significantly increased for mental illnesses (2.6%) and diseases of the circulatory system (eg, nonspecific chest pain) (4.8%), visits decreased for pregnancy-related diagnoses and diseases of the skin (eg, cellulitis, abscess) compared with that of the older group (3.7% and 3.1%, respectively).ConclusionOur results indicate that increased coverage has kept young adults out of the ED for specific conditions that can be cared for through access to other channels. As EDs face capacity challenges, these results are encouraging and offer insight into what could be expected under further insurance expansions from health care reform.

BackgroundThe Patient Protection and Affordable Care Act (ACA) included provisions to extend dependent health care coverage up to the age of 26 years in 2010. The authors examined the early impact of the ACA (before the implementation of insurance exchanges in 2014) on insurance rates in young adults with cancer, a historically underinsured group.MethodsUsing National Cancer Institute Surveillance, Epidemiology, and End Results data for 18 cancer registries, the authors examined insurance rates before (pre) (January 2007-September 2010) versus after (post) (October 2010-December 2012) dependent insurance provisions among young adults aged 18 to 29 years when diagnosed with cancer during 2007 through 2012. Using multivariate generalized mixed effect models, the authors conducted difference-in-differences analysis to examine changes in overall and Medicaid insurance after the ACA among young adults who were eligible (those aged 18-25 years) and ineligible (those aged 26-29 years) for policy changes.ResultsAmong 39,632 young adult cancer survivors, the authors found an increase in overall insurance rates in those aged 18 to 25 years after the dependent provisions (83.5% for pre-ACA vs 85.4% for post-ACA; P

BackgroundAlmost one-half of women having an abortion in the United States have had a previous procedure, which highlights a failure to provide adequate preventive care. Provision of intrauterine devices and implants, which have high upfront costs, can be uniquely challenging in the abortion care setting.ObjectiveWe conducted a study of a clinic-wide training intervention on long-acting reversible contraception and examined the effect of the intervention, insurance coverage, and funding policies on the use of long-acting contraceptives after an abortion.Study designThis subanalysis of a cluster, randomized trial examines data from the 648 patients who had undergone an abortion who were recruited from 17 reproductive health centers across the United States. The trial followed participants 18-25 years old who did not desire pregnancy for a year. We measured the effect of the intervention, health insurance, and funding policies on contraceptive outcomes, which included intrauterine device and implant counseling and selection at the abortion visit, with the use of logistic regression with generalized estimating equations for clustering. We used survival analysis to model the actual initiation of these methods over 1 year.ResultsWomen who obtained abortion care at intervention sites were more likely to report intrauterine device and implant counseling (70% vs 41%; adjusted odds ratio, 3.83; 95% confidence interval, 2.37-6.19) and the selection of these methods (36% vs 21%; adjusted odds ratio, 2.11; 95% confidence interval, 1.39-3.21). However, the actual initiation of methods was similar between study arms (22/100 woman-years each; adjusted hazard ratio, 0.88; 95% confidence interval, 0.51-1.51). Health insurance and funding policies were important for the initiation of intrauterine devices and implants. Compared with uninsured women, those women with public health insurance had a far higher initiation rate (adjusted hazard ratio, 2.18; 95% confidence interval, 1.31-3.62). Women at sites that provide state Medicaid enrollees abortion coverage also had a higher initiation rate (adjusted hazard ratio, 1.73; 95% confidence interval, 1.04-2.88), as did those at sites with state mandates for private health insurance to cover contraception (adjusted hazard ratio, 1.80; 95% confidence interval, 1.06-3.07). Few of the women with private insurance used it to pay for the abortion (28%), but those who did initiated long-acting contraceptive methods at almost twice the rate as women who paid for it themselves or with donated funds (adjusted hazard ratio, 1.94; 95% confidence interval, 1.10-3.43).ConclusionsThe clinic-wide training increased long-acting reversible contraceptive counseling and selection but did not change initiation for abortion patients. Long-acting method use after abortion was associated strongly with funding. Restrictions on the coverage of abortion and contraceptives in abortion settings prevent the initiation of desired long-acting methods.

The United States Equal Employment Opportunity Commission has proposed rules allowing employers to penalize employees up to 30% of health insurance costs if they fail to meet 'health' criteria, such as reaching a specified body mass index (BMI). Our objective was to examine cardiometabolic health misclassifications given standard BMI categories. Participants (N=40 420) were individuals aged 18+ in the nationally representative 2005-2012 National Health and Nutrition Examination Survey. Using the blood pressure, triglyceride, cholesterol, glucose, insulin resistance and C-reactive protein data, population frequencies/percentages of metabolically healthy versus unhealthy individuals were stratified by BMI. Nearly half of overweight individuals, 29% of obese individuals and even 16% of obesity type 2/3 individuals were metabolically healthy. Moreover, over 30% of normal weight individuals were cardiometabolically unhealthy. There was no significant race-by-BMI interaction, but there was a significant gender-by-BMI interaction, F(4,64)=3.812, P=0.008. Using BMI categories as the main indicator of health, an estimated 74 936 678 US adults are misclassified as cardiometabolically unhealthy or cardiometabolically healthy. Policymakers should consider the unintended consequences of relying solely on BMI, and researchers should seek to improve diagnostic tools related to weight and cardiometabolic health.

BackgroundBecause value-based care is critical to the Affordable Care Act success, we forecasted inpatient costs and the potential impact of podiatric medical care on savings in the diabetic population through improved care quality and decreased resource use during implementation of the health reform initiatives in California.MethodsWe forecasted enrollment of diabetic adults into Medicaid and subsidized health benefit exchange programs using the California Simulation of Insurance Markets (CalSIM) base model. Amputations and admissions per 1,000 diabetic patients and inpatient costs were based on the California Office of Statewide Health Planning and Development 2009-2011 inpatient discharge files. We evaluated cost in three categories: uncomplicated admissions, amputations during admissions, and discharges to a skilled nursing facility. Total costs and projected savings were calculated by applying the metrics and cost to the projected enrollment.ResultsDiabetic patients accounted for 6.6% of those newly eligible for Medicaid or health benefit exchange subsidies, with a 60.8% take-up rate. We project costs to be $24.2 million in the diabetic take-up population from 2014 to 2019. Inpatient costs were 94.3% higher when amputations occurred during the admission and 46.7% higher when discharged to a skilled nursing facility. Meanwhile, 61.0% of costs were attributed to uncomplicated admissions. Podiatric medical services saved 4.1% with a 10% reduction in admissions and amputations and an additional 1% for every 10% improvement in access to podiatric medical care.ConclusionsWhen implementing the Affordable Care Act, inclusion of podiatric medical services on multidisciplinary teams and in chronic-care models featuring prevention helps shift care to ambulatory settings to realize the greatest cost savings.

BackgroundHomeless young adults are a vulnerable population with great healthcare needs. Under the Affordable Care Act, homeless young adults are eligible for Medicaid, in some states, including California. This study assesses homeless young adults' health insurance coverage and healthcare utilization prior to Medicaid expansion.MethodsAll homeless young adults accessing services at a drop-in center in Venice, CA, were invited to complete a self-administered questionnaire; 70% of eligible clients participated (n = 125).ResultsWithin this majority White, heterosexual, male sample, 70% of homeless young adults did not have health insurance in the prior year, and 39% reported their last healthcare visit was at an emergency room. Past year unmet healthcare needs were reported by 31%, and financial cost was the main reported barrier to receiving care. Multivariable logistic regression found that homeless young adults with health insurance were almost 11 times more likely to report past year healthcare utilization.ConclusionsHealth insurance coverage is the sole variable significantly associated with healthcare utilization among homeless young adults, underlining the importance of insurance coverage within this vulnerable population. Service providers can play an important role by assisting homeless young adults with insurance applications and facilitating connections with regular sources of health care.

ObjectiveTo examine racial and ethnic disparities in health care access and utilization after the Affordable Care Act (ACA) health insurance mandate was fully implemented in 2014.Research designUsing the 2011-2014 National Health Interview Survey, we examine changes in health care access and utilization for the nonelderly US adult population. Multivariate linear probability models are estimated to adjust for demographic and sociodemographic factors.ResultsThe implementation of the ACA (year indicator 2014) is associated with significant reductions in the probabilities of being uninsured (coef=-0.03, P