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This paper investigates how the design of health insurance plans influences individuals' treatment decisions. We derive several hypotheses how the framing of incentives in a plan affects behavior and test these hypotheses in a laboratory experiment. Our results show that rebates are more effective in containing costs, as individuals request significantly less inefficient low-value care under rebates than under cost-sharing. We elicit individuals' degree of loss aversion but find no evidence that loss aversion influences utilization rates. Instead, our results suggest that relative thinking and the difficulty of understanding the dynamic incentive structure drive the design effect.JELI13, I18, D02, D91

The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population.Cross-sectional study.Health claims database from a third-party payer.Data were reviewed for children up to 18 years of age who underwent tonsillectomy or arm fracture repair (nonelective control) from 2016 to 2019. Incidence of surgery by health plan deductible (high, low, or government insured) and met or unmet status of deductibles were compared.A total of 10,047 tonsillectomy claims and 9903 arm fracture repair claims met inclusion and exclusion criteria. The incidence of tonsillectomy was significantly different across deductible plan types. Patients with met deductibles were more likely to undergo tonsillectomy. In patients with deductibles ≥$4000, a 1.75-fold increase in tonsillectomy was observed in those who had met their deductible as compared with those who had not. These findings were not observed in controls (nonelective arm fracture). For those with met deductibles, those with high deductibles were much more likely to undergo tonsillectomy than those with low, moderate, and government deductibles. Unmet high deductibles were least likely to undergo tonsillectomy.Health insurance plan type influences the incidence of pediatric elective surgery such as tonsillectomy but not procedures such as nonelective repair of arm fracture. High deductibles may discourage elective surgery for those deductibles that are unmet, risking inappropriate care of vulnerable pediatric patients. However, meeting the deductible may increase incidence, raising the question of overutilization.

This paper develops a model of insurance choice and derives the implications for insurance plan selection when consumers are loss averse. Previous work has shown that health insurance plan switching costs can increase welfare by reducing adverse selection. Loss aversion provides a natural mechanism for modeling non-pecuniary switching costs and thus gives a basis for modeling insurance choice in environments where explicit switching costs might be minimal. I also derive a test for the presence of both adverse selection and switching costs based on differential spending of switchers and non-switchers. I test this model using data from a benefits firm providing employment-based health insurance. Employees choose between low and high coverage plans from the same insurer during the annual open enrollment period, and explicit switching costs are likely to be low. I assume employees take their current plan as the reference point for choosing the next year’s plan. I find evidence of adverse selection and significant switching costs.

BeneFIT was a demonstration project that worked with a Medicaid/Medicare health plan to implement a mailed fecal immunochemical test (FIT) program. The goal was to reach age-eligible enrollees who were due for colorectal cancer (CRC) screening and prompt them to complete a FIT. One health insurance plan collaborated with six federally qualified health centers (FQHCs) in Oregon. Reach was defined as the percent of eligible individuals overdue for CRC screening who were mailed a FIT in 2016. We examined patient-level factors associated with reach, using multivariable log binomial regression and FIT completion rates at 6 months. The health plan identified 3386 age-eligible members overdue for CRC screening. Of these, 2615 (77.2%) were reached (mailed FIT kits) and 771 (22.8%) were not; 478 (14.1%) because they were not considered to be clinic patients and 290 (8.6%) because of mailing issues. Patient-level factors associated with not being reached were: being male, being Medicaid-insured (vs. Medicare), and having no primary care visits (vs. 4+ visits) in the last year. Among all enrollees identified as overdue for CRC screening, FIT completion rates at 6 months were 14.8% overall and 18.5% in the subgroup reached. In a mailed FIT program, a health insurance plan attempted to reach as many enrollees overdue for CRC screening as possible, however 22.8% were not mailed a FIT. Additional efforts are needed to ensure that the hardest to reach enrollees can participate in CRC screening.

In the health policy literature, scholars and practitioners distinguish broadly between health care and public health interventions. Both types of policies are indispensable to deal with pressing health problems. Nevertheless, we know very little about how individuals support the principle logic behind these two approaches to health policy. In this paper, we analyze empirically whether individuals prefer either a health care-oriented or a public health-oriented approach to health policy. In addition, we explore political and socio-demographic factors explaining individuals’ choices. To conduct this analysis, we use multivariate regression analysis based on data ( N = 5 442 ) from the 2018 wave of the Swiss Household Panel Survey. The survey contains high-quality data from a representative sample of the population living in Switzerland. Our results demonstrate that a majority of citizens prefers public health policies rather than policies ensuring access to health care. Especially, individuals with higher out-of-pocket payments in their health insurance plan support a public health over health care policy approach. Furthermore, those who prefer environmental protection over economic growth support public health over health care policy.

This paper explores the existence of ex-ante moral hazard in private health insurance in Brazil. Before the advent of illness, insured individuals have no incentives to seek preventive care if it is not previously contractible. The data set comprises longitudinal administrative records of health care utilization from a Brazilian employer-sponsored health insurance plan. The empirical strategy is based on an exogenous and anticipated shock in health insurance coverage not associated with health conditions. The results show an increase of up to 17% on medical visits and 22% on diagnostic tests due to the loss of health insurance. Medical visits start to increase five months before the individual leaves the health insurance pool, reaching its peak at two months prior to exit. For diagnostic tests, the increase was observed only in the last two months before the loss of health insurance coverage. Resumo Este artigo explora a existência de risco moral ex-ante no setor de saúde suplementar no Brasil. Antes do evento da doença, indivíduos com plano/seguro saúde não têm incentivos para procurar cuidado preventivo se esse não for contratado previamente. O conjunto de dados utilizado inclui registros administrativos longitudinais da utilização de cuidados de saúde de um plano de saúde brasileiro patrocinado pelo empregador. A estratégia empírica é baseada em uma mudança exógena e antecipada na cobertura de seguro de saúde não associada à condição de saúde. Os resultados mostram um aumento de até 17% nas consultas médicas e 22% nos exames diagnósticos. As consultas médicas começam a aumentar a partir do quinto mês antes do indivíduo deixar a carteira com um pico em dois meses. Para testes diagnósticos, o maior aumento foi observado em um e dois meses antes da perda da cobertura do plano de saúde.

Objective To describe the characteristics, health service utilization, and clinical outcomes of Ontario residents who are not covered by the Ontario Health Insurance Plan and receive services from Ontario midwives. Design Retrospective cohort study. Setting Ontario, Canada. Participants All midwifery courses of care resulting in births between April 1, 2012 to March 31, 2015 and captured in the BORN perinatal registry. Within this cohort we compared midwifery clients without publicly funded health insurance to those covered by the Ontario Health Insurance Plan (OHIP). Measurements and findings Of 55, 634 midwifery clients assessed in Ontario, 92.8% were insured by OHIP and 7.2% were not insured. Among uninsured clients, 66.3% attended a prenatal visit during the first trimester compared to 92.8% of insured women, with uninsured clients presenting with fewer pre-existing conditions. A higher proportion of uninsured clients (33.9%) planned to birth at home and 28.7% of clients’ actual place birth was in the home, compared to 19.6% and 16.6% of insured clients respectively. Rates of both spontaneous labour and spontaneous vaginal birth were higher among uninsured clients (82.1% and 81.1%, respectively), compared to insured clients (77.3% and 78.1%, respectively). Clinical outcomes were generally similar, with postpartum hemorrhage (3.4%), preterm birth (5%), and small-for-gestational age (2.1%) slightly more common among uninsured clients compared to insured clients (2.9%, 4.4%, and 1.7%, respectively). Rates of most complications were lower for uninsured clients. Key conclusions Overall, uninsured clients used less services compared to insured clients and had good clinical outcomes under midwifery care in Ontario. Findings of this study support the policy decision in Ontario to fund midwifery care for uninsured clients and suggest that uninsured clients are well suited for midwifery care. Implications for practice Funding midwives to serve uninsured clients is appropriate and may improve uninsured clients access to care.

Purpose: The positive predictive value (PPV) of endovascular and open thoracoabdominal aortic aneurysm (TAAA) repair coding was assessed in Ontario health administrative databases. Methods: Between 1 January 2006 and 31 March 2016, a random sample of 192 patients was identified using Canadian Classification of Health Intervention (CCI) procedure codes and Ontario Health Insurance Plan (OHIP) billing codes from administrative data. Blinded chart reviews were conducted at two cardiovascular centers to assess the level of agreement between the administrative records and the corresponding patients’ hospital charts. The PPV was calculated with 95% confidence intervals using hospital charts as the gold standard. Results: The PPV for the single endovascular TAAA repair code, 1ID80GQNRN, was 0.90 (0.78, 0.97). A combination of all nine CCI open TAAA repair codes was performed, with a PPV of 0.62 (0.47, 0.76). The combination of any one of the nine CCI codes AND the single OHIP code for open TAAA repair (R803) rendered a PPV of 0.98 (0.90, 1.00). Conclusions: Endovascular TAAA repair may be identified using a single CCI code (1ID80GQNRN). Open TAAA repair may be identified using a combination of CCI and OHIP codes. Researchers may therefore use administrative data to conduct population-based studies of endovascular and open repair of TAAA.

We assessed online health insurance plan indication of coverage and accessibility of information for recommended services for transgender youth (TY). Content analysis was performed for plans used at a pediatric Gender Clinic by reviewing information about coverage of puberty blockers, hormones, masculinizing chest surgery, and counseling. Transgender-specific exclusions and the time required for the research assistant to review each plan's online information were noted. No plan (0%; n=36) indicated coverage of all four categories of recommended services online. Forty-nine percent indicated ≥1 transgender-specific exclusion. The median time required for a research assistant to review online coverage information for each insurance plan was 50 min. Efforts are needed to ensure that online insurance information is accessible and updated in accordance with policy and coverage recommendations for TY.

Choosing a health insurance plan is difficult for many people, and patient-centered decision support may help consumers make these choices. We tested whether providing a patient-centered decision-support tool-with or without machine-based, personalized expert recommendations-influenced decision outcomes for Medicare Part D enrollees. We found that providing an online patient-centered decision-support tool increased older adults' satisfaction with the process of choosing a prescription drug plan and the amount of time they spent choosing a plan. Providing personalized expert recommendations as well increased rates of plan switching. Many people who could have accessed the tool chose not to, and the characteristics of people who used the tool differed from those who did not. We conclude that a patient-centered decision-support tool providing personalized expert recommendations can help people choose a plan, but different approaches may be necessary to encourage more people to periodically reevaluate their options.

Objetivo : analisar as readmissoes hospitalares em instituicoes publicas e privadas de um municipio de grande porte populacional. Metodo : Estudo observacional analitico das readmissoes ocorridas em Ribeirao Preto, em 2011, em hospitais publicos e privados. Resultados : Identificou-se 16.123 readmissoes hospitalares em 11 hospitais, com taxa media de readmissao de 14,2%. As readmissoes mais frequentes ocorreram em pacientes em idade adulta, com no minimo uma comorbidade associada. Predominaram as readmissoes pelo Sistema Unico de Saude, em hospitais com mais de 100 leitos e elevada complexidade assistencial. A readmissao precoce esta associada ao sexo, tipo de convenio e tempo de permanencia na internacao inicial. Conclusoes : Os resultados sugerem que as readmissoes estejam relacionadas a dinâmica da rede de servicos e a complexidade assistencial dos casos atendidos; seu monitoramento auxilia no processo de planejamento, programacao e avaliacao das acoes em saude; entretanto, a utilizacao desse indicador de desempenho deve acontecer em conjunto com outros indicadores, analisados de acordo com a realidade institucional e dos fatores intervenientes. Palavras-chave: Readmissao do Paciente; Indicadores de Qualidade em Assistencia a Saude; Acesso aos Servicos de Saude. Occurrence of hospital readmissions in a large population municipality ABSTRACT Objective : to analyze hospital readmissions in public and private institutions in a large population size municipality. Method : Observational analytical study of readmissions in Ribeirao Preto in 2011, in public and private hospitals. Results : 16,123 hospital readmissions were identified in 11 hospitals, with a mean readmission rate of 14.2%. The most frequent readmissions occurred in adult patients, with at least one associated comorbidity. Readmissions were predominant in the Unified Health System, in hospitals with more than 100 beds and high complexity of care. Early readmission is associated with gender, type of health insurance plan and length of stay in the initial hospitalization. Conclusions : The results suggest that readmissions are related to the dynamics of the service network and to the complexity of care of the cases seen; its monitoring assists in the process of planning, programming and evaluating health actions; however, the use of this performance indicator should occur in conjunction with other indicators, analyzed according to the institutional reality and intervening factors. Keywords: Patient Readmission; Quality Indicators, Health Care; Health Services Accessibility.

The first randomized trial to assess the potential benefits of screening mammography was conducted by the Health Insurance Plan of New York between 1963 and 1970. The initial results from two randomized screening trials begun in 1977 in Sweden have demonstrated a 40% reduction in deaths from breast cancer in women aged 50 to 74 years, although there was an insufficient number of women aged 40–49 with breast cancer to unequivocally prove screening benefit of mammography in that age group. Given the current knowledge of radiation risk, as well as the remarkable decrease in radiation dose, controversy over the risk/benefit ratio of screening mammography that raged in the 1970s should no longer be an issue in women of screening age. Mammography has its limitations, particularly in women with dense breasts. Multiple attempts have been made to find a nonionizing imaging technique as good as, or superior to, mammography for breast cancer screening and diagnosis.

OBJECTIVE: Comprehensive Score for Financial Toxicity (COST) is a validated instrument measuring the economic burden experienced by cancer patients. We evaluated the frequency of financial toxicity at different COST levels and stratified risk factors and associations with cost-coping strategies by financial toxicity severity. METHODS: We analyzed previously collected survey data of gynecologic oncology patients from two tertiary-care institutions. Both surveys included the COST tool and questions assessing economic and behavioral cost-coping strategies. We adapted a proposed grading scale to define three groups: no/mild, moderate, and severe financial toxicity. We used Chi-square, Fisher’s exact test, and Wilcoxon rank sum test to compare groups. We used Poisson regression to calculate crude and adjusted risk ratios for cost-coping strategies comparing patients with moderate or severe to no/mild financial toxicity. RESULTS: Among 308 patients, 14.9% had severe, 32.1% had moderate and 52.9% had no/mild financial toxicity. Younger age, non-white race, lower education, unemployment, lower income, use of systemic therapy, and shorter time since diagnosis were associated with worse financial toxicity (all p

Background and Aims We aimed to evaluate trends in Ontario, Canada, 2002 to 2016, in uptake of colorectal evaluative procedures, colorectal cancer (CRC) incidence and incidence-based mortality in the colorectal screening-age population. Methods We defined the screening age-eligible population as persons 51 to 74 years of age with ≥1 year eligibility for the Ontario Health Insurance Plan, excluding those with a diagnosis of CRC in the Ontario Cancer Registry (OCR) prior to age 50 or January 1, 2002. We computed annual up-to-date status with colorectal evaluative procedures from billing claims, and CRC incidence from the OCR. In order to compute incidence-based CRC mortality, we included persons with a first diagnosis of CRC between the ages of 51 and 74, diagnosed between January 1, 1992 and December 31, 2001, still alive and Results Persons up to date with colorectal evaluative procedures increased from 628,214/2,782,061 (22.6%) in 2002 to 2,584,570/4,179,789 (62.2%) in 2016. CRC incidence fell from 129.3/100,000 in 2002 to 94.54/100,000 in 2016, and incidence-based CRC mortality fell from 40.8/100,000 to 24.1/100,000. Decreasing trends in overall and stratified incidence and mortality were all significant, except among persons 51 to 54 years old. Conclusions There was continued increase in persons up-to-date with colorectal evaluative procedures, and significant decrease in CRC incidence and incidence-based CRC mortality from 2002 through 2016.

To examine sex differences in Ontario Health Insurance Plan (OHIP) payments from 1992 to 2018.Population-based observational study.Ophthalmologists submitting claims to OHIP from 1992 to 2018.Physician billing data over 27 years (1992-2018) were analyzed for yearly number of ophthalmologists, OHIP payments, distinct patients, and patient visits.Yearly median OHIP payments to female ophthalmologists were less than to male ophthalmologists with a gap ratio of 0.55 in 1992 to 0.73 in 2018. Stratifying by full-time equivalent (FTE), there was little difference in median payments between males and females for 1 FTE. Median female-to-male payments ratio varied from 0.80 to 1.16 for1 FTE and 1.14 to 0.84 for1 FTE from 1992 to 2018. Among female ophthalmologists, 72.7% and 52.9% were1 FTE and 11.4% and 19.2% were1 FTE in 1992 and 2018, respectively. In comparison, for male ophthalmologists, 35.7% and 45.6% were1 FTE and 43.4% and 45.6% were1 FTE in 1992 and 2018, respectively. Overall, male ophthalmologists had more patients and patient visits than female ophthalmologists, but there was little difference between male and female ophthalmologists for 1 and1 FTE. The results for1 FTE varied by year.Overall, female ophthalmologists have lower OHIP payments compared with males, but there was little difference for those stratified to 1 FTE. This overall payments difference by sex is largely explained by the higher proportion of1 FTE females, lower proportion of1 FTE females, and higher payments for1 FTE males.

An Ontario Medical Association (OMA) analysis has found a 15.6% unexplained pay gap between female and male physicians. The analysis, based on billings from doctors to the Ontario Health Insurance Plan, accounted for years in practice, specialty, days worked, and other factors to make an “apples

We explore the challenges faced by a large employer designing a health insurance plan menu for its employees. Using detailed administrative data from Harvard University, we estimate a model of plan choice and utilization, and evaluate the benefits of cost sharing and plan variety. For a single plan with a generous out-of-pocket maximum, we find that a modest coinsurance rate of approximately 30% with a zero deductible maximizes average employee surplus. Gains from offering choice are limited if based solely on financial dimensions, but can be economically significant if paired with other features that appeal to sicker households.

BeneFIT is a 4-year observational study of a mailed fecal immunochemical test (FIT) program in 2 Medicaid/Medicare health plans in Oregon and Washington. In Health Plan Oregon's (HPO) collaborative model, HPO mails FITs that enrollees return to their clinics for processing. In Health Plan Washington's (HPW) centralized model, FITs are mailed directly to enrollees who return them to a centralized laboratory. This paper examines model-specific Year 1 development and implementation costs and estimates costs per screened enrollee. Staff completed activity-based costing spreadsheets. Non-labor costs were from study and external data. Data matched each plan's 2016 development and implementation dates. HPO development costs were $23.0K, primarily administration (eg, clinic recruitment). HPW development costs were $37.3K, 38.8% for FIT selection and mailing/tracking protocols. Year 1 implementation costs were $51.6K for HPO and $139.7K for HPW, reflecting HPW's greater outreach. Labor was 50.4% ($26.0K) of HPO's implementation costs, primarily enrollee eligibility and processing returned FITs, and was shared by HPO ($17.0K) and 6 participating clinics ($9.0K). Labor was 10.5% of HPW's implementation costs, primarily administration and enrollee eligibility. HPO's implementation costs per enrollee were 12.3% higher ($18.36) than for HPW ($16.34). Similar proportions of completed FITs among screening-eligibles produced a 15% lower cost per completed FIT in HPW ($89.75) vs. HPO ($105.79). Implementation costs for HPO only (without clinic costs) were $15.16/mailed introductory letter, $16.09/mailed FIT, and $87.35/completed FIT, comparable to HPW. Results highlight cost implications of different approaches to implementing a mailed FIT program in 2 Medicaid/Medicare health plans.

We investigate the impact of losing health insurance coverage at age 26 due to aging out of the Affordable Care Act's dependent coverage on health insurance coverage rates and various indicators of inpatient medical care. We find that the probability of being covered under any type of health insurance plan decreases by 2.5-6.2 percentage points at age 26. However, the effects of this discrete change in health insurance coverage on inpatient medical care and related costs are insignificant.

International audience; BACKGROUND:Given the public health problem generated by posture and gait disorders, a preventive approach is essential.OBJECTIVE:We investigated the impact of an ambulatory physical activity program (APAP) on the motor skills of retirees.METHOD:Retirees ≥ 60 years were recruited in this prospective study. The APAP was supported by a French regional health insurance plan. Between inclusion (T0) and 12 weeks (T1), subjects participated in an APAP (1 hour/week) that included strengthening muscular exercises, balance work, joint flexibility exercises, one-leg-balance test (OLB), stimulation of the foot arch, and rise-from-the-floor (RFF). Timed-up-and-go test (TUG) duration, gait speed (GS), OLB duration and RFF success were compared between T1 and T0.RESULTS:Two hundred subjects (86% women) were enrolled; mean age was 73.8 years (45.5% ≥ 75 years). TUG durations (s) were lower at T1 than at T0 (8.98 and 9.64; P < .0001). The GS (m/s) and OLB durations (s) were higher at T1 than at T0 (1.26 vs 1.12 for GS, 16.16 vs 13.02 for OLB; P < .0001). The rate of participants who successfully completed RFF was higher at T1 (94%) than at T0 (76%) (P < .0001). After the APAP, TUG duration was reduced in 64.5% of cases, the GS improved in 73% of cases, OLB duration increased in 50% of cases, and RFF became possible in 18.5% of cases (all P < .0001).CONCLUSION:Physical activity programs are effective for improving motor performance, even in older adults. Retirees must be encouraged to do regular physical activity to prevent or slow the functional decline associated with aging, and to improve their overall quality of life.

INTRODUCTION: Self-perceived health reported by older adults is a tool of great importance for the health care system as it provides an indicator representing physical, cognitive, and emotional aspects of health. OBJECTIVE: To report how a group of older adults covered by a health insurance plan evaluate their self-perceived health and which variables influence their perception. METHODS: This quantitative cross-sectional study included 148 older adults living in the city of São Paulo, Brazil, in 2017. The study variables were sex, age, marital status, performance in basic activities of daily living and instrumental activities of daily living, sleep quality, leisure activity, number of diseases, and use of continuous medication. Statistical analysis was performed using Student’s t-test, χ2 test, or Fisher’s exact test, and logistic regression was used. RESULTS: Significant relationships were observed between poor self-perceived health and the following variables: being female, polypharmacy, number of diseases, sleep quality, and performance in instrumental activities of daily living. Dependence on the instrumental activities of daily living made these older adults 5.33 times more likely to have poor self-perceived health. Each comorbidity added to the health status of this group increased the chance of poor self-perceived health by 1.39 times. CONCLUSION: Self-perceived health in this group of older adults is influenced by several variables; however, degree of dependence and number of diseases were those with the greatest impact.

Given the widespread lack of access to dental care for many vulnerable Americans, there is a growing realization that integrating dental and primary care may provide comprehensive care. We sought to model the financial impact of integrating dental care provision into a primary care practice. A microsimulation model was used to estimate changes in net revenue per practice by simulating patient visits to a primary dental practice within primary care practices, utilizing national survey and un-identified claims data from a nationwide health insurance plan. The impact of potential changes in utilization rates and payer distributions and hiring additional staff was also evaluated. When dental care services were provided in the primary care setting, annual net revenue changes per practice were &minus, $92,053 (95% CI: &minus, 93,054, &minus, 91,052) in the first year and $104,626 (95% CI: 103,315, 105,316) in subsequent years. Net revenue per annum after the first year of integration remained positive as long as the overall utilization rates decreased by less than 25%. In settings with a high proportion of publicly insured patients, the net revenue change decreased but was still positive. Integrating primary dental and primary care providers would be financially viable, but this viability depends on demands of dental utilization and payer distributions.

BACKGROUND: Psychotherapy is recommended as a first-line treatment for the management of common psychiatric disorders. The objective of this study was to evaluate the availability of publicly funded psychotherapy provided by physicians in Ontario by describing primary care physicians (PCPs) and psychiatrists whose practices focus on psychotherapy and comparing them to PCPs and psychiatrists whose practices do not. METHODS: This was a population-based retrospective cohort study. We included all PCPs and psychiatrists in Ontario who submitted at least 1 billing claim to the Ontario Health Insurance Plan between Apr. 1, 2015, and Mar. 31, 2016, and categorized them as psychotherapists if at least 50% of their outpatient billings were related to the provision of psychotherapy. We measured practice characteristics such as total number of patients and new patients, and average visit frequency for 4 physician categories: PCP nonpsychotherapists, PCP psychotherapists, psychiatrist nonpsychotherapists and psychiatrist psychotherapists. We also measured access to care for people with urgent need for mental health services. RESULTS: Of 12 772 PCPs, 404 (3.2%) were PCP psychotherapists; of 2150 psychiatrists, 586 (27.3%) were psychotherapists. Primary care physician nonpsychotherapists had the highest number of patients and number of new patients, followed by psychiatrist nonpsychotherapists, PCP psychotherapists and psychiatrist psychotherapists. Primary care physician nonpsychotherapists had the lowest average annual number of visits per patient, whereas both types of psychotherapists had a much greater number of visits per patient. Primary care physician and psychiatrist nonpsychotherapists saw about 25% of patients with urgent needs for mental health services, whereas PCP and psychiatrist psychotherapists saw 1%–3% of these patients. INTERPRETATION: Physicians who provide publicly funded psychotherapy in Ontario see a small number of patients, and they see few of those with urgent need for mental health services. Our findings suggest that improving access to psychotherapy will require the development of alternative strategies.

Purpose: To determine the positive predictive values (PPV) of Ontario administrative data codes for the identification of open (OSR) and endovascular (EVAR) repairs of elective (eAAA) and ruptured (rAAA) abdominal aortic aneurysms. Methods: We randomly identified 319 eAAA and rAAA repairs at two Toronto hospitals between April 2003 and March 2015, using administrative health data in Ontario, Canada. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes I71.3 and I71.4, were used to identify rAAA and eAAA patients, respectively. A blinded retrospective chart review was conducted and served as the gold standard comparator. Re-abstracted records were compared to Canadian Classification of Health Interventions (CCI) and Ontario Health Insurance Plan (OHIP) codes in the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) and OHIP databases. We calculated the PPV and 95% confidence intervals (95% CI) of individual and combined procedure and billing codes for elective and ruptured OSR and EVAR (eOSR, eEVAR, rOSR, and rEVAR). Results: Permutation of codes allowed identification of eOSR with 95% PPV (95% CI 88, 98), eEVAR with 96% PPV (95% CI 90, 99), rOSR with 87% PPV (95% CI 79, 93) and rEVAR with 91% PPV (95% CI 59, 100). Conclusions: Diagnostic, procedure and billing code combinations allow identification of eOSR, eEVAR, rOSR and rEVAR patients in Ontario administrative data with a high degree of certainty.

Background Tertiary referral centers provide specialty and critical care for patients presenting to hospitals that lack these resources. There is a notion among tertiary centers that outside hospitals are more likely to transfer uninsured or underinsured patients. We examined funding status of patients transferred to our tertiary pediatric hospital for surgical management of appendicitis, hypothesizing that transferred patients were more likely to have unfavorable coverage. Materials and methods The electronic medical record was queried for all cases of laparoscopic appendectomy at our hospital between 2011 and 2015. Insurance was grouped into three categories: commercial, Medicaid/Children's Health Insurance Plan, or none. Transferred patients were compared to patients who presented directly. Results A total of 5758 patients underwent laparoscopic appendectomy during the study period, of which 1683 (29.2%) were transfer patients. Transfer patients were more likely to be older, with a median age of 10.5 y versus 9.8 y in nontransferred patients (P ≤ 0.0001), and were more likely to be identified as non-Hispanic (50.0% versus 36.5%; P ≤ 0.0001). Insurance coverage was similar between groups. However, subgroup analysis of the hospitals that most frequently used our transfer services revealed a trend to transfer a higher proportion of Medicaid/Children's Health Insurance Plan patients. Conclusions Overall, pediatric patients transferred for laparoscopic appendectomy had similar insurance coverage to patients admitted directly, but subgroup analysis shows that not all centers follow this trend. Transfer patients were more frequently older and non-Hispanic. This builds upon the existing literature regarding the correlation of funding and transfer practices and highlights the need for additional research in this area.

We examined annual outpatient antibiotic dispensings within a health insurance plan covering ∼970,000 members per year during 2000–2016. The proportion of members with antibiotic dispensings decreased from 33.3% in 2000 to 25.9% in 2016. This trend was consistent in all stratifications of age, race/ethnicity, sex, and comorbidities.

Behavioural economic research has established that defaults, one form of nudge, powerfully influence choices. In most policy contexts, all individuals receive the same nudge. We present a model that analyses the optimal universal nudge for a situation in which individuals differ in their preferences and hence should make different choices and may incur a cost for resisting a nudge. Our empirical focus is onterminated choosers(TCs), individuals whose prior choices become no longer available. Specifically, we examine the power of defaults on individuals who had enrolled in Medicare Advantage plans with drug coverage and whose plans were then discontinued. Currently, if these TCs fail to actively choose another Medicare Advantage plan, they are defaulted into traditional fee-for-service Medicare (TM) without drug coverage. Overall, the rate of transition of TCs into TM is low, implying that original preferences and status quo bias overpower the default. Increasing numbers of Americans are choosing plans in health insurance exchange settings such as Medicare, the Affordable Care Act and private exchanges. Plan exits and large numbers of TCs are inevitable, along with other forms of turmoil. Any guidance and defaults provided for TCs should factor in their past revealed preferences.