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Harris SJ, Golberstein E, Maclean JC, Stein BD, Ettner SL, Saloner B. How policymakers innovate around behavioral health: adoption of the New Mexico "No Behavioral Health Cost-Sharing" law. Health Aff Sch 2024; 2:qxad081. [PMID: 38756394 PMCID: PMC10986291 DOI: 10.1093/haschl/qxad081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/16/2023] [Accepted: 12/04/2023] [Indexed: 05/18/2024]
Abstract
State policymakers have long sought to improve access to mental health and substance use disorder (MH/SUD) treatment through insurance market reforms. Examining decisions made by innovative policymakers ("policy entrepreneurs") can inform the potential scope and limits of legislative reform. Beginning in 2022, New Mexico became the first state to eliminate cost-sharing for MH/SUD treatment in private insurance plans subject to state regulation. Based on key informant interviews (n = 30), this study recounts the law's passage and intended impact. Key facilitators to the law's passage included receptive leadership, legislative champions with medical and insurance backgrounds, the use of local research evidence, advocate testimony, support from health industry figures, the severity of MH/SUD, and increased attention to MH/SUD during the COVID-19 pandemic. Findings have important implications for states considering similar laws to improve access to MH/SUD treatment.
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Affiliation(s)
- Samantha J Harris
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Ezra Golberstein
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN 55455, United States
| | | | | | - Susan L Ettner
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA 90095, United States
- Department of Health Policy and Management, University of California Los Angeles, Los Angeles, CA 90095, United States
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, United States
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2
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Friedman SA, Xu H, Azocar F, Ettner SL. Quantifying Balance Billing for Out-of-Network Behavioral Health Care in Employer-Sponsored Insurance. Psychiatr Serv 2022; 73:1019-1026. [PMID: 35319917 PMCID: PMC9444804 DOI: 10.1176/appi.ps.202100157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The study estimated balance billing for out-of-network behavioral health claims and described subscriber characteristics associated with higher billing. METHODS Claims data (2011-2014) from a national managed behavioral health organization's employer-sponsored insurance (N=196,034 family-years with out-of-network behavioral health claims) were used to calculate inflation-adjusted annual balance billing-the submitted amount (charged by provider) minus the allowed amount (insurer agreed to pay plus patient cost-sharing) and any discounts offered by the provider. Among family-years with complete sociodemographic data (N=68,659), regressions modeled balance billing as a function of plan and provider supply, subscriber and family-year, and employer characteristics. A two-part model accounted for family-years without balance billing. RESULTS Among the 50% of family-years with balance billing, mean±SD balance billing was $861±$3,500 (median, $175; 90th percentile, $1,684). Adjusted analysis found balance billing was higher ($523 higher, 95% confidence interval [CI]=$340, $705) for carve-out versus carve-in plans and for health maintenance organization (HMO) enrollees versus non-HMO enrollees ($156, 95% CI=$75, $237); for subscribers with a bachelor's degree, compared with an associate's degree or with a high school diploma or lower (between $172 [95% CI=$228, $116] and $224 [95% CI=$284, $163] higher, respectively); and for subscribers ages 45-54, compared with those ages 35-44 and 18-24 (between $57 [95% CI=$103, $10] and $290 [95% CI=$398, $183] higher, respectively). Balance billing was lower in states with more in-network providers per capita (-$8, 95% CI=-$10, -$5). CONCLUSIONS Balance billing for out-of-network behavioral health claims may be burdensome. Expanded behavioral health networks may improve access.
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Affiliation(s)
- Sarah A Friedman
- School of Public Health, University of Nevada, Reno (Friedman); Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine (Xu, Ettner), and Department of Health Policy and Management, Fielding School of Public Health (Ettner), University of California, Los Angeles, Los Angeles; Optum, San Francisco (Azocar)
| | - Haiyong Xu
- School of Public Health, University of Nevada, Reno (Friedman); Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine (Xu, Ettner), and Department of Health Policy and Management, Fielding School of Public Health (Ettner), University of California, Los Angeles, Los Angeles; Optum, San Francisco (Azocar)
| | - Francisca Azocar
- School of Public Health, University of Nevada, Reno (Friedman); Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine (Xu, Ettner), and Department of Health Policy and Management, Fielding School of Public Health (Ettner), University of California, Los Angeles, Los Angeles; Optum, San Francisco (Azocar)
| | - Susan L Ettner
- School of Public Health, University of Nevada, Reno (Friedman); Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine (Xu, Ettner), and Department of Health Policy and Management, Fielding School of Public Health (Ettner), University of California, Los Angeles, Los Angeles; Optum, San Francisco (Azocar)
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3
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Huang CX, Turk N, Ettner SL, Mangione CM, Moin T, O’Shea D, Luchs R, Chan C, Duru OK. Does the diabetes health plan have a differential impact on medication adherence among beneficiaries with fewer financial resources? J Manag Care Spec Pharm 2022; 28:948-957. [PMID: 36001105 PMCID: PMC10372993 DOI: 10.18553/jmcp.2022.28.9.948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: The Diabetes Health Plan (DHP), a value-based insurance plan that reduces cost sharing, was previously shown to modestly increase employer-level medication adherence. It is unclear how the DHP might impact individuals with different incomes. OBJECTIVE: To examine the impact of the DHP on individual-level medication adherence, by income level. METHODS: This is a retrospective, quasiexperimental study. An employer-level propensity score match was done to identify suitable control employers, followed by individual-level propensity score weighing. These weights were applied to difference-in-difference models examining the effect of the DHP and the effect of income on changes in adherence to metformin, statins, and angiotensin-converting enzymes/angiotensin receptor blockers. The weights were then applied to a differences-in-differences-in-differences model to estimate the differential impact of DHP status on changes in adherence by income group. RESULTS: The study population included 2,065 beneficiaries with DHP and 17,704 matched controls. There were no significant differences in changes to adherence for any medications between beneficiaries enrolled in the DHP vs standard plans. However, adherence to all medications was higher among those with incomes greater than $75,000 (year 1: metformin: +7.3 percentage points; statin +4.3 percentage points; angiotensin-converting enzymes/angiotensin receptor blockers: +6.2 percentage points; P < 0.01) compared with those with incomes less than $50,000. The differences-in-differences-in-differences term examining the impact of income on the DHP effect was not significant for any comparisons. CONCLUSIONS: We did not find significant associations between the DHP and changes in individual-level medication adherence, even for low-income beneficiaries. New strategies to improve consumer engagement may be needed to translate value-based insurance designs into changes in patient behavior. DISCLOSURES: Drs Ettner and Moin received grants from the Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases (Principal Investigator: Carol Mangione). Mr Luchs received support for attending meetings and/or travel (minimal-mileage and hotel on 2 occasions). Mr Chan has an employee benefit to purchase stock for UnitedHealth Group.
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Affiliation(s)
- Cher X Huang
- Department of Internal Medicine, Massachusetts General Hospital, Boston
| | - Norman Turk
- Department of Medicine, University of California, Los Angeles
| | - Susan L Ettner
- Fielding School of Public Health, University of California, Los Angeles
| | - Carol M Mangione
- Department of Medicine, University of California, Los Angeles
- Fielding School of Public Health, University of California, Los Angeles
| | - Tannaz Moin
- Department of Medicine, University of California, Los Angeles
| | | | | | | | - O Kenrik Duru
- Department of Medicine, University of California, Los Angeles
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4
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Friedman SA, Xu H, Azocar F, Ettner SL. Comparing Gold-standard Copayment and Coinsurance Values From Claims Processing Engines to Values Derived From Behavioral Health Claims Databases. Med Care 2022; 60:279-286. [PMID: 35213427 PMCID: PMC8917070 DOI: 10.1097/mlr.0000000000001698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND While researchers use patient expenditures in claims data to estimate insurance benefit features, little evidence exists to indicate whether the resulting measures are accurate. OBJECTIVE To develop and test an algorithm for deriving copayment and coinsurance values from behavioral health claims data. SUBJECTS Employer-sponsored insurance plans from 2011 to 2013 for a national managed behavioral health organization (MBHO). MEASURES Twelve benefit features, distinguishing between carve-in and carve-out, in-network and out-of-network, inpatient and outpatient, and copayment and coinsurance, were created. Measures drew from claims (claims-derived measures), and benefit feature data from a claims processing engine database (true measures). STUDY DESIGN We calculate sensitivity and specificity of the claims-derived measures' ability to accurately determine if a benefit feature was required and for plan-years requiring the benefit feature, the accuracy of the claims-derived measures. Accuracy rates using the minimum, 25th, 50th, 75th, and maximum claims value for a plan-year were compared. PRINCIPAL FINDINGS Sensitivity (82% or higher for all but 3 benefit features) and specificity (95% or higher for all but 2 benefit features) were relatively high. Accuracy rates were highest using the 75th or maximum claims value, depending on the benefit feature, and ranged from 69% to 99% for all benefit features except for out-of-network inpatient coinsurance. CONCLUSIONS For most plan-years, claims-derived measures correctly identify required specialty mental health copayments and coinsurance, although the claims-derived measures' accuracy varies across benefit design features. This information should be considered when creating claims-derived benefit features to use for policy analysis.
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Affiliation(s)
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | | | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
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5
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Mukamel DB, Ladd H, Nuccio E, Zinn JS, Sorkin DH, Ettner SL. Home Health Care Quality, Its Costs and Implications for Home Health Value-Based Purchasing. Med Care Res Rev 2022; 79:90-101. [PMID: 33233999 PMCID: PMC8323610 DOI: 10.1177/1077558720974528] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The Home Health Value-based Purchasing (HHVBP) demonstration, incorporating a payment formula designed to incentivize both high-quality care and quality improvement, is expected to become a national program after 2022, when the demonstration ends. This study investigated the relationship between costs and several quality dimensions, to inform HHVBP policy. Using Medicare cost reports, OASIS and Home Health Compare data for 7,673 home health agencies nationally, we estimated cost functions with instrumental variables for quality. The estimated net marginal costs varied by composite quality measure, baseline quality, and agency size. For four of the five composite quality measures, the net marginal cost was negative for low-quality agencies, suggesting that quality improvement was cost saving for this agency type. As the magnitude of the net marginal cost is commensurate with the payment incentive planned for HHVBP, it should be considered when designing the incentives for HHVBP, to maximize their effectiveness.
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Affiliation(s)
- Dana B. Mukamel
- Department of Medicine, Division of General Internal Medicine; iTEQC Research Program; University of California, Irvine, CA
| | - Heather Ladd
- Department of Medicine, Division of General Internal Medicine; iTEQC Research Program; University of California, Irvine
| | - Eugene Nuccio
- School of Medicine; Division of Health Care Policy & Research; University of Colorado Anschutz Medical Campus
| | | | - Dara H. Sorkin
- Public Health, and Psychology and Social Behavior; Department of Medicine, Division of General Internal Medicine; University of California, Irvine
| | - Susan L. Ettner
- Department of Medicine; Division of General Internal Medicine and Health Services Research; University of California, Los Angeles
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6
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Yue D, Ponce NA, Needleman J, Ettner SL. The relationship between educational attainment and hospitalizations among middle-aged and older adults in the United States. SSM Popul Health 2021; 15:100918. [PMID: 34568538 PMCID: PMC8449049 DOI: 10.1016/j.ssmph.2021.100918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND There has been little research on the relationship between education and healthcare utilization, especially for racial/ethnic minorities. This study aimed to examine the association between education and hospitalizations, investigate the mechanisms, and disaggregate the relationship by gender, race/ethnicity, and age groups. METHODS A retrospective cohort analysis was conducted using data from the 1992-2016 US Health and Retirement Study. The analytic sample consists of 35,451 respondents with 215,724 person-year observations. We employed a linear probability model with standard errors clustered at the respondent level and accounted for attrition bias using an inverse probability weighting approach. RESULTS On average, compared to having an education less than high school, having a college degree or above was significantly associated with an 8.37 pp (95% CI, -9.79 pp to -7.95 pp) lower probability of being hospitalized, and having education of high school or some college was related to 3.35 pp (95% CI, -4.57 pp to -2.14 pp) lower probability. The association slightly attenuated after controlling for income but dramatically reduced once holding health conditions constant. Specifically, given the same health status and childhood environment conditions, compared to those with less than high school degree, college graduates saw a 1.79 pp (95% CI, -3.16 pp to -0.42 pp) lower chance of being hospitalized, but the association for high school graduates became indistinguishable from zero. Additionally, the association was larger for females, whites, and those younger than 78. The association was statistically significantly smaller for black college graduates than their white counterparts, even when health status is held constant. CONCLUSIONS Educational attainment is a strong predictor of hospitalizations for middle-aged and older US adults. Health mediates most of the education-hospitalization gradients. The heterogeneous results across age, gender, race, and ethnicity groups should inform further research on health disparities.
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Affiliation(s)
- Dahai Yue
- Department of Health Policy and Management, University of Maryland School of Public Health, 4200 Valley Drive, College Park, MD, 20742, USA
| | - Ninez A. Ponce
- Department of Health Policy and Management, University of California, Los Angeles, USA
| | - Jack Needleman
- Department of Health Policy and Management, University of California, Los Angeles, USA
| | - Susan L. Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, USA
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7
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Sacks GD, Dawes AJ, Tsugawa Y, Brook RH, Russell MM, Ko CY, Maggard-Gibbons M, Ettner SL. The Association Between Risk Aversion of Surgeons and Their Clinical Decision-Making. J Surg Res 2021; 268:232-243. [PMID: 34371282 DOI: 10.1016/j.jss.2021.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The extent to which a surgeon's risk aversion influences their clinical decisions remains unknown. We assessed whether a surgeon's attitude toward risk ("risk aversion") influences their surgical decisions and whether the relationship can be explained by differences in surgeons' perception of treatment risks and benefits. MATERIALS AND METHODS We presented a series of detailed clinical vignettes to a national sample of surgeons (n = 1,769; 13.4% adjusted response rate) and asked them to complete an instrument that measured how risk averse they are within their clinical practice (scale 6-36; higher number indicates greater risk aversion). For each vignette, participants rated their likelihood of recommending an operation and judged the likelihood of complications or full recovery. We examined whether differences in perceived likelihood of complications versus recovery could explain why risk-averse surgeons may be less likely to recommend an operation. RESULTS Surgeons varied in their self-reported risk aversion score (median = 25, interquartile range[22,28]). Scores did not differ by level of surgeon experience or gender. Risk-averse surgeons were significantly less likely to recommend an operation for patients with exactly the same condition (65.5% for surgeons in highest quartile of risk aversion versus 62.3% for lowest quartile; P = 0.02). However, after controlling for surgeons' perception of the likelihood of complications versus recovery, there was no longer a significant association between surgeons' risk aversion and the decision to recommend an operation (64.7% versus 64.8%; P = 0.96). CONCLUSIONS Surgeons vary widely in their self-reported risk aversion. Risk-averse surgeons were significantly less likely to recommend an operation, a finding that was explained by a higher perceived probability of post-operative complications than their colleagues.
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Affiliation(s)
- Greg D Sacks
- Department of Surgery, NYU Langone Health, New York, New York.
| | - Aaron J Dawes
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford, California
| | - Yusuke Tsugawa
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Robert H Brook
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; RAND Corporation, Los Angeles, California
| | - Marcia M Russell
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Clifford Y Ko
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Melinda Maggard-Gibbons
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Susan L Ettner
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
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8
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Grzenda A, Xu H, Miranda J, Ettner SL. Impact of the 2016 Election on the Quality of Life of Sexual and Gender Minority Adults: A Difference-in-Differences Analysis. LGBT Health 2021; 8:386-394. [PMID: 34242086 DOI: 10.1089/lgbt.2020.0334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: The 2016 U.S. election significantly changed the political landscape for sexual and gender minority (SGM) individuals. The current study assessed the consequences of the election and transition to a new overtly discriminatory administration on the health-related quality of life of SGM adults compared with their cisgender and heterosexual counterparts. Methods: The study used repeated cross-sectional data from the 17 states that administered the sexual orientation and gender identity module in the 2015 and 2018 Behavioral Risk Factor Surveillance System surveys. The sample included 268,851 adult respondents: 12,006 SGM adults (5.35%) and 256,845 cisgender and heterosexual adults (94.65%). Outcomes were frequent (≥14 days in the last month) physical distress, mental distress, limited activity, and/or fair/poor general health. Difference-in-differences estimates were calculated from logistic regression models, controlling for sociodemographic, health care coverage, and chronic medical condition confounders. Results: Compared with the cisgender and heterosexual population, frequent mental distress among SGM adults increased by 5% points, corresponding to a relative increase of 32.5% (p < 0.001) from 2015. Rates of frequent physical distress, limited activity, and fair/poor general health were not significantly altered between the two populations. Gender minority adults were most negatively affected with a relative increase in frequent mental distress of 117.5% (p < 0.001). Conclusions: The 2016 U.S. election and administration changeover were associated with a substantial increase in the proportion of SGM adults reporting frequent mental distress. These data provide empirical evidence as to the psychological effects of an abrupt political realignment on SGM mental health.
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Affiliation(s)
- Adrienne Grzenda
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California, USA.,Olive View-UCLA Medical Center, Sylmar, California, USA
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Jeanne Miranda
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California, USA.,Department of Health Policy and Management, Fielding School of Public Health, University of California-Los Angeles, Los Angeles, California, USA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA.,Department of Health Policy and Management, Fielding School of Public Health, University of California-Los Angeles, Los Angeles, California, USA
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9
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Childers CP, Ettner SL, Hays RD, Kominski G, Maggard-Gibbons M, Alban RF. Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures. Ann Surg 2021; 274:107-113. [PMID: 31460881 PMCID: PMC7035992 DOI: 10.1097/sla.0000000000003571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures. SUMMARY BACKGROUND DATA Reducing surgical costs is paramount to the viability of hospitals. METHODS Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons. RESULTS The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy. CONCLUSIONS Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.
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Affiliation(s)
| | - Susan L. Ettner
- Division of General Internal Medicine and Health Services
Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los
Angeles, CA
- Department of Health Policy & Management, UCLA
Fielding School of Public Health, Los Angeles, CA
| | - Ron D. Hays
- Division of General Internal Medicine and Health Services
Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los
Angeles, CA
- Department of Health Policy & Management, UCLA
Fielding School of Public Health, Los Angeles, CA
| | - Gerald Kominski
- Department of Health Policy & Management, UCLA
Fielding School of Public Health, Los Angeles, CA
- UCLA Center for Health Policy Research, Fielding School of
Public Health, Los Angeles, California
| | | | - Rodrigo F. Alban
- Department of Surgery, Cedars Sinai Medical Center, Los
Angeles, CA
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10
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Zinn JS, Ladd H, Nuccio E, Ettner SL, Sorkin DH, Mukamel DB. Identifying Associations between Quality Initiatives and Quality Measures among Home Health Agencies: Findings from a National Study. Health Serv Insights 2021; 14:1178632921992092. [PMID: 33613028 PMCID: PMC7868452 DOI: 10.1177/1178632921992092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/13/2021] [Indexed: 11/19/2022] Open
Abstract
Home health performance gained visibility with the publication of Home Health Compare and the Home Health Value-Based Payment demonstration. Both provide incentives for home health agencies (HHA) to invest in quality improvements. The objective of this study is to identify the association between quality initiatives adopted by HHAs and improved performance. A 2018 national survey of 7459 HHAs, yielding a sample of 1192 eligible HHAs, provided information about 23 quality initiatives, which was linked to 5 composite Super Quality Measures (SQMs): ADL/pain, self-treatment, timely care, hospitalizations, and patient experience. Exclusions for missing data and outliers yielded a final analytical sample of 903 HHAs. Regression models estimated associations between quality initiatives and SQMs. The relationships between sixteen of the SQM/quality initiative pairs were positively associated with improvement and 7 were negatively associated. Web-based technologies for staff and care-givers improved performance but deteriorated patient experience. Web support-groups for staff and review of HHC rankings reduced hospitalization rates. While this study offers insights for quality improvement, a limitation may be a lack of sensitivity to the nuances of quality improvement implementation. Therefore, this study should be viewed as hypothesis-generating concerning initiatives likely to have the greatest potential meriting further investigation.
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Affiliation(s)
| | - Heather Ladd
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, USA
| | - Eugene Nuccio
- School of Medicine, Division of Health Care Policy & Research, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Susan L Ettner
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, USA
| | - Dara H Sorkin
- Public Health, and Psychology and Social Behavior, Department of Medicine, Division of General Internal Medicine, University of California, Irvine, USA
| | - Dana B Mukamel
- Public Health and Nursing, Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, USA
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11
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Admon LK, Dalton VK, Kolenic GE, Ettner SL, Tilea A, Haffajee RL, Brownlee RM, Zochowski MK, Tabb KM, Muzik M, Zivin K. Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017. JAMA Psychiatry 2021; 78:171-176. [PMID: 33206140 PMCID: PMC7675215 DOI: 10.1001/jamapsychiatry.2020.3550] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Suicide deaths are a leading cause of maternal mortality in the US, yet the prevalence and trends in suicidality (suicidal ideation and/or intentional self-harm) among childbearing individuals remain poorly described. OBJECTIVE To characterize trends in suicidality among childbearing individuals. DESIGN, SETTING, AND PARTICIPANTS This serial cross-sectional study analyzed data from a medical claims database for a large commercially insured population in the US from January 2006 to December 2017. There were 2714 diagnoses of suicidality 1 year before or after 698 239 deliveries among 595 237 individuals aged 15 to 44 years who were continuously enrolled in a single commercial health insurance plan. Data were analyzed from October 2019 to September 2020. MAIN OUTCOMES AND MEASURES The primary outcome was diagnosis of suicidality in childbearing individuals 1 year before or after birth based on the identification of relevant International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes during at least 1 inpatient or 2 outpatient visits. RESULTS Of 595 237 included childbearing individuals, the mean (SD) age at delivery was 31.9 (6.4) years. A total of 40 568 individuals (6.8%) were Asian, 52 613 (8.6%) were Black, 73 172 (12.1%) were Hispanic, 369 501 (63.1%) were White, and 59 383 (9.5%) had unknown or missing race/ethnicity data. A total of 2683 individuals were diagnosed with suicidality 1 year before or after giving birth for a total of 2714 diagnoses. The prevalence of suicidal ideation increased from 0.1% per 100 individuals in 2006 to 0.5% per 100 individuals in 2017 (difference, 0.4%; SE, 0.03; P < .001). Intentional self-harm prevalence increased from 0.1% per 100 individuals in 2006 to 0.2% per 100 individuals in 2017 (difference, 0.1%; SE, 0.02; P < .001). Suicidality prevalence increased from 0.2% per 100 individuals in 2006 to 0.6% per 100 individuals in 2017 (difference, 0.4%; SE, 0.04; P < .001). Diagnoses of suicidality with comorbid depression or anxiety increased from 1.2% per 100 individuals in 2006 to 2.6% per 100 individuals in 2017 (difference, 1.4%; SE, 0.2; P < .001). Diagnoses of suicidality with comorbid bipolar or psychotic disorders increased from 6.9% per 100 individuals in 2006 to 16.9% per 100 individuals in 2017 (difference, 10.1%; SE, 0.2; P < .001). Non-Hispanic Black individuals, individuals with lower income, and younger individuals experienced larger increases in suicidality over the study period. CONCLUSIONS AND RELEVANCE In this cross-sectional study of US childbearing individuals, the prevalence of suicidal ideation and intentional self-harm occurring in the year preceding or following birth increased substantially over a 12-year period. Policy makers, health plans, and clinicians should ensure access to universal suicidality screening and appropriate treatment for pregnant and postpartum individuals and seek health system and policy avenues to mitigate this growing public health crisis, particularly for high-risk groups.
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Affiliation(s)
- Lindsay K. Admon
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Vanessa K. Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Giselle E. Kolenic
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - Susan L. Ettner
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, University of California, Los Angeles ,Department of Health Policy and Management, Fielding UCLA School of Public Health, University of California, Los Angeles
| | - Anca Tilea
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - Rebecca L. Haffajee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor,RAND Corporation, Boston, Massachusetts
| | | | | | - Karen M. Tabb
- University of Illinois at Urbana-Champaign School of Social Work, Urbana
| | - Maria Muzik
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Kara Zivin
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor,Department of Psychiatry, University of Michigan, Ann Arbor,VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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12
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Moin T, Steers N, Ettner SL, Duru K, Turk N, Chan C, Keckhafer AM, Luchs RH, Ho S, Mangione CM. Association of the Diabetes Health Plan with emergency room and inpatient hospital utilization: a Natural Experiment for Translation in Diabetes (NEXT-D) Study. BMJ Open Diabetes Res Care 2021; 9:9/1/e001802. [PMID: 33431601 PMCID: PMC7802657 DOI: 10.1136/bmjdrc-2020-001802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/16/2020] [Accepted: 12/14/2020] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION To examine the association of a novel disease-specific health plan, known as the Diabetes Health Plan (DHP), with emergency room (ER) and hospital utilization among patients with diabetes and pre-diabetes. RESEARCH DESIGN AND METHODS Quasi-experimental design, with employer group as the unit of analysis, comparing changes in any ER and inpatient hospital utilization over a 3-year period. Inverse probability weighting was used to control for differences between employers purchasing DHP versus standard plans. Estimated differences in utilization are calculated as average treatment effects on the treated. We used employees and dependents from employer groups contracting with a large, national private insurer between 2009 and 2012. Eligibility and claims data from continuously covered employees and dependents with diabetes and pre-diabetes (n=74 058) were aggregated to the employer level. The analysis included 9 DHP employers (n=7004) and 183 control employers (n=67 054). RESULTS DHP purchase was associated with 2.4 and 1.8 percentage points absolute reduction in mean rates of any ER utilization, representing 13% and 10% relative reductions at 1 and 2 years post-DHP (p=0.012 and p=0.046, respectively). There was no significant association between DHP purchase and hospital utilization. CONCLUSION Employers purchasing diabetes-specific health benefit designs may experience lower rates of resource-intensive services such as ER utilization.
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Affiliation(s)
- Tannaz Moin
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Neil Steers
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Susan L Ettner
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Kenrik Duru
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Norman Turk
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Charles Chan
- United Healthcare Services, Minneapolis, Minnesota, USA
| | | | | | - Sam Ho
- United Healthcare Services, Minneapolis, Minnesota, USA
| | - Carol M Mangione
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
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13
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Block EP, Xu H, Azocar F, Ettner SL. The Mental Health Parity and Addiction Equity Act evaluation study: Child and adolescent behavioral health service expenditures and utilization. Health Econ 2020; 29:1533-1548. [PMID: 32813304 DOI: 10.1002/hec.4153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 07/24/2020] [Accepted: 08/06/2020] [Indexed: 06/11/2023]
Abstract
This study explores possible associations of the Mental Health Parity and Addiction Equity Act (MHPAEA) with child access to behavioral health (BH) services (preimplementation = 2008-2009, transition = 2010, and post = 2011-2013). The study sample included children aged 4-17 years in self-insured "carve-in" plans from large employers. In "carve-ins," BH and medical care are covered through the same insurance plan. The unit of analysis is the person-month (N = 61,823,533). This study employs an interrupted time series model allowing for intercept and slope changes for the transition and postparity periods. Outcomes included total, plan and patient out-of-pocket (OOP) expenditures, and several categories of service utilization. Generalized estimating equations were used to account for clustering. There were significant increases in total and plan expenditures postparity. To illustrate, in July 2012, mean per-member-per-month total expenditures were predicted to be $5.65 without parity but $8.72 with parity. Patient OOP costs did not change significantly. Significant overall increases were seen for utilization of most outpatient services but not intermediate or inpatient services. Our findings suggest that the introduction of MHPAEA was associated with an increase in specialty BH service access for children without a commensurate increase in financial burden for families.
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Affiliation(s)
- Eryn Piper Block
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Susan L Ettner
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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14
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Barnett ML, Dopp AR, Klein C, Ettner SL, Powell BJ, Saldana L. Collaborating with health economists to advance implementation science: a qualitative study. Implement Sci Commun 2020; 1:82. [PMID: 33005901 PMCID: PMC7523377 DOI: 10.1186/s43058-020-00074-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/14/2020] [Indexed: 01/13/2023] Open
Abstract
Background Implementation research infrequently addresses economic factors, despite the importance of understanding the costs of implementing evidence-based practices (EBPs). Though partnerships with health economists have the potential to increase attention to economic factors within implementation science, barriers to forming these collaborations have been noted. This study investigated the experiences of health economists and implementation researchers who have partnered across disciplines to inform strategies to increase such collaborations. Methods A purposeful sampling approach was used to identify eight health economists and eight implementation researchers with experience participating in cross-disciplinary research. We used semi-structured interviews to gather information about participants' experiences with collaborative research. Thematic analysis was conducted to identify core themes related to facilitators and barriers to collaborations. Results Health economists and implementation researchers voiced different perspectives on collaborative research, highlighting the importance of increasing cross-disciplinary understanding. Implementation researchers described a need to measure costs in implementation studies, whereas many health economists described that they seek to collaborate on projects that extend beyond conducting cost analyses. Researchers in both disciplines articulated motivations for collaborative research and identified strategies that promote successful collaboration, with varying degrees of convergence across these themes. Shared motivations included improving methodological rigor of research and making a real-world impact. Strategies to improve collaboration included starting partnerships early in the study design period, having a shared interest, and including health economists in the larger scope of the research. Conclusions Health economists and implementation researchers both conduct research with significant policy implications and have the potential to inform one another's work in ways that might more rapidly advance the uptake of EBPs. Collaborative research between health economists and implementation science has the potential to advance the field; however, researchers will need to work to bridge disciplinary differences. By beginning to develop strong working relationships; increasing their understanding of one another's disciplinary culture, methodology, and language; and increasing the role economists have within research design and execution, both implementation researchers and health economists can support successful collaborations and robust and informative research.
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Affiliation(s)
- Miya L Barnett
- Department of Counseling, Clinical, & School Psychology, University of California, Santa Barbara, Santa Barbara, California, 93106-9490 USA
| | - Alex R Dopp
- Department of Behavioral and Policy Sciences, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401 USA
| | - Corinna Klein
- Department of Counseling, Clinical, & School Psychology, University of California, Santa Barbara, Santa Barbara, California, 93106-9490 USA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095 USA.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095 USA
| | - Byron J Powell
- Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130 USA
| | - Lisa Saldana
- Oregon Social Learning Center, 10 Shelton McMurphey Blvd, Eugene, OR 97401 USA
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15
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Abstract
OBJECTIVES To examine changes in carve-out financial requirements (copayments, coinsurance, use of deductibles, and out-of-pocket maxima) following the Mental Health Parity and Addiction Equity Act (MHPAEA). DATA SOURCE/STUDY SETTING Specialty mental health benefit design information for employer-sponsored carve-out plans from a national managed behavioral health organization's claims processing engine (2008-2013). STUDY DESIGN This pre-post study reports linear and logistic regression as the main analysis. DATA COLLECTION/EXTRACTION METHODS NA. PRINCIPAL FINDINGS Copayments for in-network emergency room (-$44.9, 95% CI: -78.3, -11.5; preparity mean: $56.2), outpatient services (eg, individual psychotherapy: -$7.4, 95% CI: -10.5, -4.2; preparity mean: $17.8), and out-of-network coinsurance for emergency room (-11 percentage points, 95% CI: -16.7, -5.4; preparity mean: 38.8 percent) and outpatient (eg, individual psychotherapy: -5.8 percentage points, 95% CI: -10.0, -1.6; preparity mean 41.0 percent) decreased. Probability of family OOP maxima use (29 percentage points, 95% CI: 19.3, 38.6; preparity mean: 36 percent) increased. In-network outpatient coinsurance increased (eg, individual psychotherapy: 4.5 percentage points, 95% CI: 1.1, 7.9; preparity mean: 2.7 percent), as did probability of use of family deductibles (15 percentage points, 95% CI: 6.1, 23.3; preparity mean: 38 percent). CONCLUSIONS MHPAEA was associated with increased generosity in most financial requirements observed here. However, increased use of deductibles may have reduced generosity for some patients.
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Affiliation(s)
- Sarah Friedman
- School of Community Health Sciences, University of Nevada, Reno, Nevada
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | | | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
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16
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Keller MS, Xu H, Azocar F, Ettner SL. The Role of Behavioral Health Diagnoses in Adverse Selection. Psychiatr Serv 2020; 71:920-927. [PMID: 32438887 PMCID: PMC7682743 DOI: 10.1176/appi.ps.201900354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Adverse selection in medical insurance is well documented; however, little is known about the role of behavioral health. This study's objective was to examine the probability of being enrolled in the lowest-deductible plan among commercially insured patients, according to psychiatric diagnosis. METHODS This cross-sectional study used 2012-2013 benefit design and plan choice data linked to 2011-2012 behavioral health claims for a national sample of individuals (N=116,975) and different family types (couple with at least one dependent, N=59,237; single subscriber with at least one dependent, N=19,066; couple with no dependents, N=40,917) with Optum, UnitedHealth Group "carve-in" plans. Analyses included multiple logistic regressions examining whether the individual (or family) was enrolled in the plan with the lowest deductible as functions of whether individuals (or family members) had any psychiatric diagnosis, the number of psychiatric diagnoses they had, and whether they had individual major psychiatric diagnoses. RESULTS For individuals, having any psychiatric diagnosis was associated with an increase of about 10% in the probability of being enrolled in the lowest-deductible plan compared with having no psychiatric diagnosis (44.9% vs. 40.7%, p=0.04). Each additional psychiatric diagnosis increased this probability by three percentage points (p=0.02). A diagnosis of depression was associated with the largest increase. CONCLUSIONS When individuals were offered the choice of a health insurance plan, having a prior psychiatric diagnosis (specifically depression) was associated with being enrolled in the lowest-deductible plans. Individuals with depression may anticipate future expenditures and select plans accordingly.
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Affiliation(s)
- Michelle S Keller
- Department of Health Policy and Management, Fielding School of Public Health (Keller, Ettner), and Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine (Xu, Ettner), both at the University of California, Los Angeles (UCLA); Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles (Keller); Optum, UnitedHealth Group, San Francisco (Azocar)
| | - Haiyong Xu
- Department of Health Policy and Management, Fielding School of Public Health (Keller, Ettner), and Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine (Xu, Ettner), both at the University of California, Los Angeles (UCLA); Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles (Keller); Optum, UnitedHealth Group, San Francisco (Azocar)
| | - Francisca Azocar
- Department of Health Policy and Management, Fielding School of Public Health (Keller, Ettner), and Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine (Xu, Ettner), both at the University of California, Los Angeles (UCLA); Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles (Keller); Optum, UnitedHealth Group, San Francisco (Azocar)
| | - Susan L Ettner
- Department of Health Policy and Management, Fielding School of Public Health (Keller, Ettner), and Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine (Xu, Ettner), both at the University of California, Los Angeles (UCLA); Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles (Keller); Optum, UnitedHealth Group, San Francisco (Azocar)
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17
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Zhao B, Childers CP, Hays RD, Ettner SL, Alban RF, Maggard-Gibbons M, Clary BM. Surgeon Awareness of the Relative Costs of Common Surgical Instruments. JAMA Surg 2020; 154:877-878. [PMID: 31241725 DOI: 10.1001/jamasurg.2019.1746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Beiqun Zhao
- Department of Surgery, University of California, San Diego, La Jolla
| | | | - Ron D Hays
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
| | - Rodrigo F Alban
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | | | - Bryan M Clary
- Department of Surgery, University of California, San Diego, La Jolla
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18
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Moin T, Li J, Duru K, Ettner SL, Turk N, Chan C, Keckhafer AM, Luchs RH, Ho S, Mangione CM. Results from NEXT-D: the association of a pre-diabetes-specific health plan and rates of incident diabetes among a national sample of working-age adults. BMJ Open Diabetes Res Care 2020; 8:8/1/e001093. [PMID: 32312720 PMCID: PMC7199143 DOI: 10.1136/bmjdrc-2019-001093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/20/2020] [Accepted: 03/21/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pre-diabetes affects one-third of adults in the USA and a subset will progress to type 2 diabetes. Our objective was to determine whether a disease-specific health plan, known as the Diabetes Health Plan (DHP), designed to improve care for persons with pre-diabetes and diabetes also led to lower rates of incident diabetes among adults with pre-diabetes. METHODS We examined eligibility and claims data from a large payer who offered the DHP to a national sample of employers. We included adult employees and dependents who were continuously covered by the DHP over a 4-year study window. The primary outcome was incident diabetes. We conducted propensity score matching at the employer level to find comparable control employer groups offering standard plans. Using an adjusted logistic regression model at the individual level, we tested the association between DHP employer group status and incident diabetes diagnosis during the 3 years of postbaseline follow-up. FINDINGS Our analysis included data from 11 965 continuously enrolled adults with pre-diabetes (n=1538 from nine employers offering DHP; n=10 427 from 105 control employers offering standard plans). DHP employees and covered dependents with pre-diabetes had an 8% lower absolute predicted probability of incident diabetes compared with individuals from employer groups offering standard benefit plans (29% predicted probability of incident diabetes for DHP vs 37% for controls, p<0.001). CONCLUSIONS A pre-diabetes-specific health benefit design was associated with lower rates of incident diabetes and represents an area of needed future study.
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Affiliation(s)
- Tannaz Moin
- Department of Medicine, University of California, Los Angeles, California, USA
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Jinnan Li
- Department of Medicine, University of California, Los Angeles, California, USA
| | - Kenrik Duru
- Department of Medicine, University of California, Los Angeles, California, USA
| | - Susan L Ettner
- Department of Medicine, University of California, Los Angeles, California, USA
- Fielding School of Public Health, UCLA, Los Angeles, California, USA
| | - Norman Turk
- Department of Medicine, University of California, Los Angeles, California, USA
| | - Charles Chan
- United HealthCare Services, Minneapolis, Minnesota, USA
| | | | | | - Sam Ho
- United HealthCare Services, Minneapolis, Minnesota, USA
| | - Carol M Mangione
- Department of Medicine, University of California, Los Angeles, California, USA
- Fielding School of Public Health, UCLA, Los Angeles, California, USA
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19
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Ettner SL, Zinn JS, Xu H, Ladd H, Nuccio E, Sorkin DH, Mukamel DB. Certificate of need and the cost of competition in home healthcare markets. Home Health Care Serv Q 2020; 39:51-64. [PMID: 32058854 DOI: 10.1080/01621424.2020.1728464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We used 2010-16 Medicare Cost Reports for 10,737 freestanding home health agencies (HHAs) to examine the impact of home health (HH) and nursing home (NH) certificate-of-need (CON) laws on HHA caseload, total and per-patient variable costs. After adjusting for other HHA characteristics, total costs were higher in states with only HH CON laws ($2,975,698), only NH CON laws ($1,768,097), and both types of laws ($3,511,277), compared with no CON laws ($1,538,536). Higher costs were driven by caseloads, as CON reduced per-patient costs. Additional research is needed to distinguish whether this is due to skimping on quality vs. economies of scale.
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Affiliation(s)
- Susan L Ettner
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, California, USA
| | - Jacqueline S Zinn
- Fox School of Business, Temple University, Philadelphia, Philadelphia, USA
| | - Haiyong Xu
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, California, USA
| | - Heather Ladd
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, California, USA
| | - Eugene Nuccio
- School of Medicine, Division of Health Care Policy & Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Dara H Sorkin
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, California, USA
| | - Dana B Mukamel
- Public Health and Nursing, Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, California, USA
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20
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Takada S, Ettner SL, Harawa NT, Garland WH, Shoptaw SJ, Cunningham WE. Life Chaos is Associated with Reduced HIV Testing, Engagement in Care, and ART Adherence Among Cisgender Men and Transgender Women upon Entry into Jail. AIDS Behav 2020; 24:491-505. [PMID: 31396766 PMCID: PMC6994355 DOI: 10.1007/s10461-019-02570-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Life chaos, the perceived inability to plan for and anticipate the future, may be a barrier to the HIV care continuum for people living with HIV who experience incarceration. Between December 2012 and June 2015, we interviewed 356 adult cisgender men and transgender women living with HIV in Los Angeles County Jail. We assessed life chaos using the Confusion, Hubbub, and Order Scale (CHAOS) and conducted regression analyses to estimate the association between life chaos and care continuum. Forty-eight percent were diagnosed with HIV while incarcerated, 14% were engaged in care 12 months prior to incarceration, mean antiretroviral adherence was 65%, and 68% were virologically suppressed. Adjusting for sociodemographics, HIV-related stigma, and social support, higher life chaos was associated with greater likelihood of diagnosis while incarcerated, lower likelihood of engagement in care, and lower adherence. There was no statistically significant association between life chaos and virologic suppression. Identifying life chaos in criminal-justice involved populations and intervening on it may improve continuum outcomes.
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Affiliation(s)
- Sae Takada
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Veterans Affairs Health Services Research and Development Service, Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA.
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Nina T Harawa
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- College of Medicine, Charles R. Drew University, Los Angeles, CA, USA
| | - Wendy H Garland
- Los Angeles County Department of Public Health, Division of HIV and STD Programs, Los Angeles, CA, USA
| | - Steve J Shoptaw
- Department of Family Medicine, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - William E Cunningham
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
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21
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Ettner SL, Xu H, Azocar F. What Happens When Employers Switch from a "Carve-Out" to a "Carve-In" Model of Managed Behavioral Health? J Ment Health Policy Econ 2019; 22:85-94. [PMID: 31811752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 07/24/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Since the introduction and soaring popularity of the managed behavioral healthcare (BH) "carve-out" model in the 1980s, policymakers have been concerned with their impact on access. In carve-outs, BH and medical benefits are administered separately. Earlier literature found they reduced intensity of service use while maintaining penetration rates. Recently it has become more common for employers to drop existing carve-out contracts, partly due to the Mental Health Parity and Addiction Equity Act (MHPAEA), which placed a greater administrative burden on carve-outs for parity compliance. Although prior studies focused exclusively on the impact of moving from carve-in to carve-out models, it is now more policy-relevant to understand the effects of the move from carve-out to carve-in, which may not be symmetric. Moreover, the natural experiment resulting from MHPAEA implementation may attenuate concerns about selection bias. STUDY AIMS This study examines how specialty BH care patterns change when employees and dependents are moved from a "carve-out" plan to a "carve-in" plan. METHODS Linked insurance claims, eligibility, plan and employer data from 2008-14 were obtained for three Optum( employers who dropped their carve-out contracts but retained their carve-in plans. A longitudinal "difference-in-differences" study design was used to compare changes in BH services use over time among individuals who were: (i) moved to carve-in plans when the employer dropped its carve-out contract (N=177,653); and (ii) enrolled in carve-in plans before and after the transition (N=58,658). Outcomes included total and inpatient expenditures, broken down by plan, patient, and total; outpatient visits for assessment, individual psychotherapy, family psychotherapy, and medication management; and days of structured outpatient care, day treatment, residential care, and acute inpatient care. We pooled person-year observations and estimated regressions including individual fixed effects, year dummies and interactions between indicators for post-transition period and whether transitioned from carve-out to carve-in. RESULTS Relative to individuals continuously in carve-in plans, those who were transitioned experienced significant increases in inpatient utilization (beta =.02; p=.05) and patient inpatient costs (beta =2.35; p=.01) and decreases in day treatment (beta =-0.01; p=.02). Our conclusions proved robust against potential biases due to differing secular time trends and differential changes in benefits resulting from MHPAEA. DISCUSSION The increased inpatient utilization associated with switching from carve-out to carve-in plans is consistent with previous literature. Carve-outs may use day treatment to reduce inpatient care so that increased inpatient utilization post-transition reduced demand for day treatment. Limitations include possible selection bias at the employer level; lack of data on medication and generalist use, quality, clinical endpoints and quality of life; and potential lack of generalizability. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE The reduction in the use of carve-out contracts by private employers associated with MHPAEA implementation likely did not have a net negative impact and may have actually increased access to care among former carve-out enrollees in need of inpatient services. IMPLICATIONS FOR HEALTH POLICIES Policymakers should consider and evaluate possible unintended consequences of legislation designed to improve access to care. IMPLICATIONS FOR FURTHER RESEARCH Future work should replicate these analyses with a more representative sample.
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Affiliation(s)
- Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Dept. of Medicine, David Geffen School of Medicine, University of California Los Angeles. Address: 1100 Glendon Ave., Suite 850 - Room 879, Los Angeles, CA 90024, USA,
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Friedman SA, Ettner SL, Chuang E, Azocar F, Harwood JM, Xu H, Ong MK. The Effects of Three Kinds of Insurance Benefit Design Features on Specialty Mental Health Care Use in Managed Care. J Ment Health Policy Econ 2019; 22:43-59. [PMID: 31319375 PMCID: PMC10027396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/31/2019] [Indexed: 03/09/2023]
Abstract
BACKGROUND Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level. METHODS A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted. RESULTS For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.
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Affiliation(s)
- Sarah A Friedman
- School of Community Health Sciences University of Nevada, Reno, 1664 North Virginia St, Reno, Nevada, 89557, USA,
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Narain K, Xu H, Azocar F, Ettner SL. Racial/ethnic disparities in specialty behavioral health care treatment patterns and expenditures among commercially insured patients in managed behavioral health care plans. Health Serv Res 2019; 54:575-585. [PMID: 30734279 PMCID: PMC6505415 DOI: 10.1111/1475-6773.13121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To document differences among racial/ethnic/gender groups in specialty behavioral health care (BH) utilization/expenditures; examine whether these differences are driven by probability vs intensity of treatment; and identify whether differences are explained by socioeconomic status (SES). DATA SOURCE The cohort consists of adults continuously enrolled in Optum plans with BH benefits during 2013. STUDY DESIGN We modeled each outcome using linear regressions among the entire sample stratified by race/ethnicity, language and gender. Then, we estimated logistic regressions of the probability that an enrollee had any spending/use in a given service category (service penetration) and linear regressions of spending/use among the user subpopulation (treatment intensity). Lastly, all analyses were rerun with SES controls. DATA COLLECTION This study links administrative data from a managed BH organization to a commercial marketing database. PRINCIPAL FINDINGS We found that in many cases, racial/ethnic minorities had lower specialty BH expenditures/utilization, relative to whites, primarily driven by differences in service penetration. Among women, relative to whites, Asian non-English speakers, Asian English speakers, Hispanic non-English speakers, Hispanic English speakers, and blacks had $106, $95, $90, $48, and $61 less in total expenditures. SES explained racial/ethnic differences in treatment intensity but not service penetration. CONCLUSIONS In this population, SES was not a major driver of racial/ethnic differences in specialty BH utilization. Future studies should explore the role of other factors not studied here, such as stigma, cultural competence, and geography.
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Affiliation(s)
- Kimberly Narain
- Division of General Internal Medicine and Health Services ResearchDepartment of MedicineDavid Geffen School of MedicineUniversity of California, Los AngelesLos AngelesCalifornia
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services ResearchDepartment of MedicineDavid Geffen School of MedicineUniversity of California, Los AngelesLos AngelesCalifornia
| | | | - Susan L. Ettner
- Division of General Internal Medicine and Health Services ResearchDepartment of MedicineDavid Geffen School of MedicineUniversity of California, Los AngelesLos AngelesCalifornia
- Department of Health Policy and ManagementFielding School of Public HealthUniversity of California, Los AngelesLos AngelesCalifornia
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Chukmaitov AS, Kaidarova DR, Talaeyva ST, Sheppard VB, Xu H, Siangphoe U, Ettner SL. Analysis of Delays in Breast Cancer Treatment and Late-Stage Diagnosis in Kazakhstan. Asian Pac J Cancer Prev 2018; 19:2519-2525. [PMID: 30256046 PMCID: PMC6249466 DOI: 10.22034/apjcp.2018.19.9.2519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objective: Although Kazakhstan has made significant investments to improve health and life expectancy of its population, high cancer rates persist, with breast cancer being the most prevalent type. Factors contributing to delays in treatment and late staging for breast cancer patients were assessed. Methods: A retrospective follow-up study with registry data identified 4,248 breast cancer patients in sixteen regions of Kazakhstan in 2014. We used logistic regressions to estimate (i) associations of treatment delays with patient demographics and cancer center regions; and (ii) associations of late-stage (III and IV) cancer diagnosis with patient demographics and cancer center regions, with and without controlling for treatment delays. Results: Breast cancer patients treated in regions located further away from Almaty City had higher risks of treatment delays. However, the risks of late-stage cancer diagnosis were greater for patients treated in Almaty City and those with treatment delays. Conclusion: The main driver of delayed treatment is cancer center region. Residents of Almaty City, a major urban area of Kazakhstan, may have a better access to a tertiary cancer center, resulting in less treatment delays. Referrals of sicker patients from neighboring regions to Almaty City for cancer treatment is likely to increase risks of late-stage diagnosis. New or upgraded cancer centers may reduce treatment delays, but their case-mix is likely to increase.
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Affiliation(s)
- Askar S Chukmaitov
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, VCU Massey Cancer Center, USA.
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25
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Chung B, Ong M, Ettner SL, Jones F, Gilmore J, McCreary M, Ngo VK, Sherbourne C, Tang L, Dixon E, Koegel P, Miranda J, Wells KB. 12-Month Cost Outcomes of Community Engagement Versus Technical Assistance for Depression Quality Improvement: A Partnered, Cluster Randomized, Comparative-Effectiveness Trial. Ethn Dis 2018; 28:349-356. [PMID: 30202187 DOI: 10.18865/ed.28.s2.349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To compare community engagement and planning (CEP) for coalition support to implement depression quality improvement (QI) to resources for services (RS) effects on service-use costs over a 12-month period. Design Matched health and community programs (N=93) were cluster-randomized within communities to CEP or RS. Setting Two Los Angeles communities. Participants Adults (N=1,013) with depressive symptoms (Patient Health Questionnaire (PHQ-8) ≥10); 85% African American and Latino. Interventions CEP and RS to support programs in depression QI. Main Outcome Measures Intervention training and service-use costs over 12 months. Results CEP planning and training costs were almost 3 times higher than RS, largely due to greater CEP provider training participation vs RS, with no significant differences in 12-month service-use costs. Conclusions Compared with RS, CEP had higher planning and training costs with similar service-use costs.
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Affiliation(s)
- Bowen Chung
- Department of Psychiatry, Harbor-UCLA Medical Center/Los Angeles Biomedical Research Institute, Los Angeles, CA.,Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Bio-behavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA.,RAND Corporation, Los Angeles, CA
| | - Michael Ong
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Greater Los Angeles VA Health care System, Los Angeles, CA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Felica Jones
- Healthy African American Families II, Los Angeles, CA
| | | | - Michael McCreary
- Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Bio-behavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | | | - Lingqi Tang
- Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Bio-behavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | | | - Jeanne Miranda
- Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Bio-behavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Kenneth B Wells
- Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Bio-behavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA.,RAND Corporation, Los Angeles, CA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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26
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Friedman SA, Azocar F, Xu H, Ettner SL. The Mental Health Parity and Addiction Equity Act (MHPAEA) evaluation study: Did parity differentially affect substance use disorder and mental health benefits offered by behavioral healthcare carve-out and carve-in plans? Drug Alcohol Depend 2018; 190:151-158. [PMID: 30032052 PMCID: PMC6197987 DOI: 10.1016/j.drugalcdep.2018.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 05/11/2018] [Accepted: 06/03/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND To assess whether implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) was associated with: 1. Reduced differences in financial requirements (i.e., copayments and coinsurance) for substance use disorder (SUD) versus specialty mental health (MH) care and 2. Reductions in the level of cost-sharing for SUD-specific services. METHODS MH and SUD copayments and coinsurance, 2008-2013, were obtained from benefits databases for carve-in and carve-out plans from Optum®. Linear regression was used to estimate the association of MHPAEA with differences between MH and SUD care financial requirements among carve-in and carve-out plans. A two-part regression model investigated whether MHPAEA was associated with changes in the use or level of financial requirements for SUD-specific services among carve-out plans. RESULTS MHPAEA was not associated with significant changes in the difference between SUD and MH copayments or coinsurance levels among either carve-in or carve-out plans. MHPAEA was associated with decreases in the levels of inpatient (in-network: -$51.17; out-of-network: -$34.39) and outpatient (in-network: -$10.26) detox copayments, but increases in the levels of in-network outpatient detox coinsurance (6 percentage points) among all carve-out plans. CONCLUSION Even if SUD benefits had been historically less generous than MH benefits, SUD financial requirements were already at parity with MH financial requirements by the time MHPAEA was passed, among Optum® plans. MHPAEA's SUD parity mandate reduced cost-sharing for detox services via copayments, but, for outpatient detox, the law simultaneously increased cost-sharing via coinsurance.
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Affiliation(s)
- Sarah A. Friedman
- Department of Health Policy and Management, Fielding School of Public Health, Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 911 S. Broxton Avenue, Los Angeles, CA 90095, United States, , Phone: 775-784-1816
| | - Francisca Azocar
- Optum, United Health Group, 245 Market Street, San Francisco, 94105, United States, , Phone: 415-547-6148
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 911 S. Broxton Avenue, Los Angeles, CA 90095, United States,
| | - Susan L. Ettner
- Department of Health Policy and Management, Fielding School of Public Health, and Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 911 S. Broxton Avenue, Los Angeles, CA 90095, United States, , Phone: 310-794-2289
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Thalmayer AG, Harwood JM, Friedman S, Azocar F, Watson LA, Xu H, Ettner SL. The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Nonquantitative Treatment Limits for Specialty Behavioral Health Care. Health Serv Res 2018; 53:4584-4608. [PMID: 29740807 DOI: 10.1111/1475-6773.12871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To assess frequency, type, and extent of behavioral health (BH) nonquantitative treatment limits (NQTLs) before and after implementation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). DATA SOURCES Secondary administrative data for Optum carve-out and carve-in plans. STUDY DESIGN Cross-tabulations and "two-part" regression models were estimated to assess associations of parity period with NQTLs. DATA COLLECTION/EXTRACTION METHODS Optum provided four proprietary BH databases, including 2008-2013 data for 40 carve-out and 385 carve-in employers from Optum's claims processing databases and 2010 data from interviews conducted by Optum's parity compliance team with 49 carve-out employers. PRINCIPAL FINDINGS Preparity, carve-out plans required preauthorization for in-network inpatient/intermediate care; otherwise coverage was denied. Postparity, 73 percent would review later by request and half charged no penalty for late authorization. Outpatient visit authorization requirements virtually disappeared. For carve-out out-of-network inpatient/intermediate care, and for carve-ins, plans changed penalties to match medical service policies, but this did not necessarily lead to fewer requirements or lower penalties. CONCLUSION After 2011, MHPAEA was associated with the transformation of BH care management, including much less restrictive preauthorization requirements, especially for in-network care provided by carve-out plans.
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Affiliation(s)
| | - Jessica M Harwood
- Division of General Internal Medicine and Health Services Research, UCLA Department of Medicine, Los Angeles, CA
| | - Sarah Friedman
- Health Administration and Policy, School of Community Health Sciences, University of Nevada, Reno, NV
| | | | | | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Tran LD, Xu H, Azocar F, Ettner SL. Behavioral Health Treatment Patterns Among Employer-Insured Adults in Same- and Different-Gender Marriages and Domestic Partnerships. Psychiatr Serv 2018; 69:572-579. [PMID: 29385953 PMCID: PMC5930123 DOI: 10.1176/appi.ps.201700331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study examined specialty behavioral health treatment patterns among employer-insured adults in same- and different-gender domestic partnerships and marriages. METHODS The study used behavioral health service claims (2008-2013) from Optum to estimate gender-stratified penetration rates of behavioral health service use by couple type and partnership status among partnered adults ages 18-64 (N=12,727,292 person-years) and levels of use among those with any use (conditional analyses). Least-squares, logistic, and zero-truncated negative binomial regression analyses adjusted for age, employer and plan characteristics, and provider supply and for sociodemographic factors in sensitivity analyses. Generalized estimating equations were used to address within-group correlation of adults clustered in employer groups. RESULTS Both women and men in same-gender marriages or domestic partnerships had higher rates of behavioral health service use, particularly diagnostic evaluation, individual psychotherapy, and medication management, and those in treatment had, on average, more psychotherapy visits than those in different-gender marriages. Behavioral health treatment patterns were similar between women in same-gender domestic partnerships and same-gender marriages, but they diverged between men in same-gender domestic partnerships and same-gender marriages. Moderation analysis results indicated that adults with same-gender partners living in states with fewer legal protections for lesbian, gay, bisexual, and transgender persons were less likely than adults with same-gender partners in LGBT-friendly states to receive behavioral health treatment. Sensitivity analyses did not affect findings. CONCLUSIONS Behavioral health treatment patterns varied by couple type, partnership status, and gender. Results highlight the importance of increasing service acceptability and delivering inclusive, culturally relevant behavioral health treatment for lesbian, gay, and bisexual persons.
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Affiliation(s)
- Linda Diem Tran
- Ms. Tran is with the Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, and Dr. Xu and Dr. Ettner are with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, all at the University of California, Los Angeles. Dr. Azocar is with OptumHealth Behavioral Solutions, San Francisco
| | - Haiyong Xu
- Ms. Tran is with the Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, and Dr. Xu and Dr. Ettner are with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, all at the University of California, Los Angeles. Dr. Azocar is with OptumHealth Behavioral Solutions, San Francisco
| | - Francisca Azocar
- Ms. Tran is with the Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, and Dr. Xu and Dr. Ettner are with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, all at the University of California, Los Angeles. Dr. Azocar is with OptumHealth Behavioral Solutions, San Francisco
| | - Susan L Ettner
- Ms. Tran is with the Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, and Dr. Xu and Dr. Ettner are with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, all at the University of California, Los Angeles. Dr. Azocar is with OptumHealth Behavioral Solutions, San Francisco
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Cunningham WE, Weiss RE, Nakazono T, Malek MA, Shoptaw SJ, Ettner SL, Harawa NT. Effectiveness of a Peer Navigation Intervention to Sustain Viral Suppression Among HIV-Positive Men and Transgender Women Released From Jail: The LINK LA Randomized Clinical Trial. JAMA Intern Med 2018; 178. [PMID: 29532059 PMCID: PMC5885257 DOI: 10.1001/jamainternmed.2018.0150] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Diagnosis of human immunodeficiency virus (HIV) infection, linkage and retention in care, and adherence to antiretroviral therapy are steps in the care continuum enabling consistent viral suppression for people living with HIV, extending longevity and preventing further transmission. While incarcerated, people living with HIV receive antiretroviral therapy and achieve viral suppression more consistently than after they are released. No interventions have shown sustained viral suppression after jail release. OBJECTIVE To test the effect on viral suppression in released inmates of the manualized LINK LA (Linking Inmates to Care in Los Angeles) peer navigation intervention compared with standard transitional case management controls. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted from December 2012 through October 2016 with people living with HIV being released from Los Angeles (LA) County Jail. All participants were (1) 18 years or older; (2) either men or transgender women diagnosed with HIV; (3) English speaking; (4) selected for the transitional case management program prior to enrollment; (5) residing in LA County; and (6) eligible for antiretroviral therapy. MAIN OUTCOMES AND MEASURES Change in HIV viral suppression (<75 copies/mL) over a 12-month period. INTERVENTIONS During the 12-session, 24-week LINK LA Peer Navigation intervention, trained peer navigators counseled participants on goal setting and problem solving around barriers to HIV care and adherence, starting while the participants were still in jail. After their release, they continued counseling while they accompanied participants to 2 HIV care visits, then facilitated communication with clinicians during visits. RESULTS Of 356 participants randomized, 151 (42%) were black; 110 (31%) were Latino; 303 (85%) were men; 53 (15%) were transgender women; and the mean (SD) age was 39.5 (10.4) years. At 12 months, viral suppression was achieved by 62 (49.6%) of 125 participants in the peer navigation (intervention) arm compared with 45 (36.0%) of 125 in the transitional case management (control) arm, for an unadjusted treatment difference of 13.6% (95% CI, 1.34%-25.9%; P = .03). In the repeated measures, random effects, logistic model the adjusted probability of viral suppression declined from 52% at baseline to 30% among controls, while those in the peer navigation arm maintained viral suppression at 49% from baseline to 12 months, for a difference-in-difference of 22% (95% CI, 0.03-0.41; P = .02). CONCLUSIONS AND RELEVANCE The LINK LA peer navigation intervention was successful at preventing declines in viral suppression, typically seen after release from incarceration, compared with standard transitional case management. Future research should examine ways to strengthen the intervention to increase viral suppression above baseline levels. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01406626.
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Affiliation(s)
- William E Cunningham
- Department of Medicine, Division of General Internal Medicine and Health Services Research, Geffen School of Medicine, University of California, Los Angeles.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
| | - Robert E Weiss
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles
| | - Terry Nakazono
- Department of Medicine, Division of General Internal Medicine and Health Services Research, Geffen School of Medicine, University of California, Los Angeles
| | - Mark A Malek
- Los Angeles County Sheriff's, Los Angeles, California.,Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Steve J Shoptaw
- Department of Family Medicine, Geffen School of Medicine, University of California, Los Angeles
| | - Susan L Ettner
- Department of Medicine, Division of General Internal Medicine and Health Services Research, Geffen School of Medicine, University of California, Los Angeles.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
| | - Nina T Harawa
- Department of Medicine, Division of General Internal Medicine and Health Services Research, Geffen School of Medicine, University of California, Los Angeles.,Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles.,Charles R. Drew University College of Medicine, Los Angeles, California
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Friedman SA, Thalmayer AG, Azocar F, Xu H, Harwood JM, Ong MK, Johnson LL, Ettner SL. The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Mental Health Financial Requirements among Commercial "Carve-In" Plans. Health Serv Res 2018; 53:366-388. [PMID: 27943277 PMCID: PMC5785319 DOI: 10.1111/1475-6773.12614] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Did mental health cost-sharing decrease following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA)? DATA SOURCE Specialty mental health copayments, coinsurance, and deductibles, 2008-2013, were obtained from benefits databases for "carve-in" plans from a national commercial managed behavioral health organization. STUDY DESIGN Bivariate and regression-adjusted analyses compare the probability of use and (conditional) level of cost-sharing pre- and postparity. An interaction term is added to compare differential levels of pre- and postparity cost-sharing changes for plans that were and were not already at parity pre-MHPAEA. FINDINGS Controlling for employer/plan characteristics, MHPAEA is associated with higher intermediate care copayments ($15.9) but lower outpatient ($2.6) copayments among in-network-only plans. Among plans with in- and out-of-network benefits, MHPAEA is associated with lower inpatient ($23.2) and outpatient ($2.5) copayments, but increases in inpatient and intermediate in-network and out-of-network coinsurance (about 1 percentage point). Among the few plans not at parity pre-MHPAEA, changes in use and level of cost-sharing associated with MHPAEA were more dramatic. CONCLUSION Mixed evidence that MHPAEA led to more generous mental health benefits may stem from the finding that many plans were already at parity pre-MHPAEA. Future policy focus in mental health may shift to slowing growth in cost-sharing for all health services.
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Affiliation(s)
- Sarah A. Friedman
- Department of Health Policy and ManagementFielding School of Public HealthUniversity of CaliforniaLos AngelesCA
- Division of General Internal Medicine and Health Services ResearchDepartment of MedicineDavid Geffen School of MedicineUCLALos AngelesCA
| | | | | | - Haiyong Xu
- Division of General Internal Medicine and Health Services ResearchDepartment of MedicineDavid Geffen School of MedicineUCLALos AngelesCA
| | - Jessica M. Harwood
- Division of General Internal Medicine and Health Services ResearchDepartment of MedicineDavid Geffen School of MedicineUCLALos AngelesCA
| | - Michael K. Ong
- Division of General Internal Medicine and Health Services ResearchDepartment of MedicineDavid Geffen School of MedicineUCLALos AngelesCA
- Veterans Affairs Greater Los Angeles Healthcare SystemLos AngelesCA
| | | | - Susan L. Ettner
- Department of Health Policy and ManagementFielding School of Public HealthUniversity of CaliforniaLos AngelesCA
- Division of General Internal Medicine and Health Services ResearchDepartment of MedicineDavid Geffen School of MedicineUCLALos AngelesCA
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Friedman S, Xu H, Harwood JM, Azocar F, Hurley B, Ettner SL. The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders. J Subst Abuse Treat 2017; 80:67-78. [PMID: 28755776 DOI: 10.1016/j.jsat.2017.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 04/27/2017] [Accepted: 06/23/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between behavioral health and medical health insurance benefits among the commercially insured. This study determines whether MHPAEA was associated with increased BH expenditures and utilization among a population with substance use disorder (SUD) diagnoses. METHODS Claims and eligibility data from 5,987,776 enrollees, 2008-2013, were obtained from a national, commercial, managed behavioral health organization. An interrupted time series study design with segmented regression analysis estimated time trends of per-member-per-month (PMPM) spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance. The study sample contained individuals with drug or alcohol use disorder diagnosis during study period (N=2,716,473 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits; medication management; individual, group and family psychotherapy, and structured outpatient care); intermediate care utilization (day treatment; recovery home and residential); and inpatient utilization. RESULTS Starting at the beginning of the post-parity period, MHPAEA was associated with increased levels of PMPM total and plan spending ($25.80 [p=0.01]; $28.33 [p=0.00], respectively), as well as the number of PMPM assessment/evaluation, individual psychotherapy, and group psychotherapy visits, and inpatient days (0.01 visits [p=0.01]; 0.02 visits [p=0.01]; 0.01 visits [p=0.03]; 0.01days [p=0.01], respectively). Following these initial level changes, MHPAEA was also associated with monthly increases in PMPM total, plan, and patent out-of-pocket spending ($2.56/month [p=0.00]; $2.25/month [p=0.00]; $0.27 [p=0.03], respectively), as well as structured outpatient visits and inpatient days (0.0012 visits/month [p=0.01]; 0.0012days/month [p=0.00]). CONCLUSION MHPAEA was associated with modest increases in total, plan, and patient out-of-pocket spending and outpatient and inpatient utilization. These increases, while modest in magnitude, are larger in magnitude than increases detected among a sample of all enrollees (i.e. not only those with SUD diagnoses).
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Affiliation(s)
- Sarah Friedman
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 911 Broxton Avenue, Los Angeles, CA 90024, United States; Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, 911 Broxton Avenue, Los Angeles, CA 90024, United States; School of Community Health Sciences, Division of Health Sciences, University of Nevada, 1664 N. Virginia Street, Reno, NV 89557, United States.
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, 911 Broxton Avenue, Los Angeles, CA 90024, United States.
| | - Jessica M Harwood
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, 10940 Wilshire Boulevard, Suite 700, Los Angeles, CA 90024, United States.
| | - Francisca Azocar
- Optum®, United Health Group, 425 Market Street, 14th Floor, San Francisco, CA 94105, United States.
| | - Brian Hurley
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, 50-078 Center for Health Sciences, Box 951683, Los Angeles, CA 90095, United States.
| | - Susan L Ettner
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 911 Broxton Avenue, Los Angeles, CA 90024, United States; Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, 911 Broxton Avenue, Los Angeles, CA 90024, United States.
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Thalmayer AG, Friedman SA, Azocar F, Harwood JM, Ettner SL. The Mental Health Parity and Addiction Equity Act (MHPAEA) Evaluation Study: Impact on Quantitative Treatment Limits. Psychiatr Serv 2017; 68:435-442. [PMID: 27974003 PMCID: PMC5411313 DOI: 10.1176/appi.ps.201600110] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The Mental Health Parity and Addiction Equity Act (MHPAEA) significantly changed regulations governing behavioral health benefits for large, commercially insured employers. Pre-MHPAEA, many plans covered only a specific number of behavioral health treatment days or visits; post-MHPAEA, such quantitative treatment limits (QTLs) were allowed only if they were "at parity" with medical-surgical limits. This study assessed MHPAEA's effect on the prevalence of behavioral health QTLs. METHODS Analyses used 2008-2013 specialty behavioral health benefit design data for Optum large-group plans, both carve-outs (N=2,257 plan-years, corresponding to 1,527 plans and 40 employers) and carve-ins (N=11,644 plan-years, 3,569 plans, and 340 employers). Descriptive statistics were calculated for limits existing at parity implementation, distinguished by accumulation period (annual or lifetime), level of care (inpatient, intermediate, or outpatient), unit (days, visits, or courses), condition, and network level. Proportions of plans using specific limits during the preparity (2008-2009), transition (2010), and postparity (2011-2013) periods were compared with Fisher's exact tests. RESULTS Preparity, the most common QTLs were annual visit or day limits. Accounting for overlap in limit types, 89% of regular carve-out plans, 90% of in-network-only carve-outs, and 77% of carve-in plans limited outpatient visits; 66% of regular carve-out plans, 74% of in-network-only carve-outs, and 73% of carve-ins limited inpatient or intermediate days. Postparity, QTLs almost entirely disappeared (p<.001). CONCLUSIONS Before MHPAEA, QTLs were common. Postimplementation, virtually all plans dropped such limits, suggesting that MHPAEA was effective at eliminating QTLs. However, increasing access to behavioral health care will mean going beyond such QTL changes and looking at other areas of benefit management.
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Affiliation(s)
- Amber Gayle Thalmayer
- When this work was done, Dr. Thalmayer was with Optum, United Health Group, Eden Prairie, Minnesota, where Dr. Azocar is affiliated. Dr. Thalmayer is now with the Institute of Psychology, University of Lausanne, Lausanne, Switzerland (e-mail: ). Ms. Friedman and Dr. Ettner are with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and with the Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles (UCLA). Ms. Harwood is with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA
| | - Sarah A Friedman
- When this work was done, Dr. Thalmayer was with Optum, United Health Group, Eden Prairie, Minnesota, where Dr. Azocar is affiliated. Dr. Thalmayer is now with the Institute of Psychology, University of Lausanne, Lausanne, Switzerland (e-mail: ). Ms. Friedman and Dr. Ettner are with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and with the Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles (UCLA). Ms. Harwood is with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA
| | - Francisca Azocar
- When this work was done, Dr. Thalmayer was with Optum, United Health Group, Eden Prairie, Minnesota, where Dr. Azocar is affiliated. Dr. Thalmayer is now with the Institute of Psychology, University of Lausanne, Lausanne, Switzerland (e-mail: ). Ms. Friedman and Dr. Ettner are with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and with the Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles (UCLA). Ms. Harwood is with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA
| | - Jessica M Harwood
- When this work was done, Dr. Thalmayer was with Optum, United Health Group, Eden Prairie, Minnesota, where Dr. Azocar is affiliated. Dr. Thalmayer is now with the Institute of Psychology, University of Lausanne, Lausanne, Switzerland (e-mail: ). Ms. Friedman and Dr. Ettner are with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and with the Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles (UCLA). Ms. Harwood is with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA
| | - Susan L Ettner
- When this work was done, Dr. Thalmayer was with Optum, United Health Group, Eden Prairie, Minnesota, where Dr. Azocar is affiliated. Dr. Thalmayer is now with the Institute of Psychology, University of Lausanne, Lausanne, Switzerland (e-mail: ). Ms. Friedman and Dr. Ettner are with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and with the Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles (UCLA). Ms. Harwood is with the Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA
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Chukmaitov AS, Sianghpoe U, Kaidarova DR, Talaeva ST, Sheppard VB, Ettner SL. Analysis of Delays in Breast Cancer Treatment and Late-Stage Diagnosis in Kazakhstan By Using Electronic Cancer Registry Data. J Glob Oncol 2017. [DOI: 10.1200/jgo.2017.009795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract 27 Background: Although Kazakhstan (KZ) has made significant investments to improve population health, high cancer rates persist, with breast cancer as the most prevalent. We assessed factors that contribute to delays in treatment and late staging for patients with breast cancer. Methods: A retrospective follow-up study design was used. By using 2014 registry data, we identified 4,248 patients with breast cancer who were treated at cancer centers in the 16 KZ regions. Patients with delays in treatment as a result of medical errors and other reasons were identified. We used logistic regression to estimate associations of delays with patient demographics, occupation, and cancer center region; and associations of late-stage (III and IV) cancer diagnosis with delays in treatment while controlling for patient demographics, occupation, and cancer center region. Results: Approximately 9% (n = 378) of patients experienced delayed treatment. Older and Russian patients as well as those treated in regions further away from Almaty City had significantly higher adjusted risk of delayed treatment. However, risk of late-stage diagnosis was greater for patients who were treated in Almaty City and for those who were Russian, unemployed, or who had delayed treatment. Conclusion: The main driver of delayed treatment was cancer center region. Patients who were treated in Almaty City, where the national cancer research and treatment center is located, had fewer delays in treatment but a higher likelihood of late-stage diagnosis, likely as a result of referrals of sicker patients from neighboring regions. These findings suggest that referrals to new tertiary care centers being developed in KZ may reduce treatment delays but affect facility case mix. Future research will examine the role played by distance to cancer centers in access to specialty care and whether tertiary care is associated with improved outcomes conditional on case mix. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST No COIs from the authors.
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Affiliation(s)
- Askar S. Chukmaitov
- Askar S. Chukmaitov and Vanessa B. Sheppard, Virginia Commonwealth University School of Medicine; Vanessa B. Sheppard, Massey Cancer Center, Richmond, VA; Umaporn Sianghpoe, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD; Susan L. Ettner, Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA; and Dilyara R. Kaidarova and Snnar T. Talaeva, Kazakh National Research Institute of Oncology and Radiology,
| | - Umaporn Sianghpoe
- Askar S. Chukmaitov and Vanessa B. Sheppard, Virginia Commonwealth University School of Medicine; Vanessa B. Sheppard, Massey Cancer Center, Richmond, VA; Umaporn Sianghpoe, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD; Susan L. Ettner, Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA; and Dilyara R. Kaidarova and Snnar T. Talaeva, Kazakh National Research Institute of Oncology and Radiology,
| | - Dilyara R. Kaidarova
- Askar S. Chukmaitov and Vanessa B. Sheppard, Virginia Commonwealth University School of Medicine; Vanessa B. Sheppard, Massey Cancer Center, Richmond, VA; Umaporn Sianghpoe, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD; Susan L. Ettner, Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA; and Dilyara R. Kaidarova and Snnar T. Talaeva, Kazakh National Research Institute of Oncology and Radiology,
| | - Snnar T. Talaeva
- Askar S. Chukmaitov and Vanessa B. Sheppard, Virginia Commonwealth University School of Medicine; Vanessa B. Sheppard, Massey Cancer Center, Richmond, VA; Umaporn Sianghpoe, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD; Susan L. Ettner, Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA; and Dilyara R. Kaidarova and Snnar T. Talaeva, Kazakh National Research Institute of Oncology and Radiology,
| | - Vanessa B. Sheppard
- Askar S. Chukmaitov and Vanessa B. Sheppard, Virginia Commonwealth University School of Medicine; Vanessa B. Sheppard, Massey Cancer Center, Richmond, VA; Umaporn Sianghpoe, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD; Susan L. Ettner, Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA; and Dilyara R. Kaidarova and Snnar T. Talaeva, Kazakh National Research Institute of Oncology and Radiology,
| | - Susan L. Ettner
- Askar S. Chukmaitov and Vanessa B. Sheppard, Virginia Commonwealth University School of Medicine; Vanessa B. Sheppard, Massey Cancer Center, Richmond, VA; Umaporn Sianghpoe, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD; Susan L. Ettner, Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA; and Dilyara R. Kaidarova and Snnar T. Talaeva, Kazakh National Research Institute of Oncology and Radiology,
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Abstract
BACKGROUND Falls and fall-related injuries (FRI) are common and costly occurrences among older adults living in the community, with increased risk for those with physical and cognitive limitations. Caregivers provide support for older adults with physical functioning limitations, which are associated with fall risk. DESIGN Using the 2004-2012 waves of the Health and Retirement Study, we examined whether receipt of low (0-13 weekly hours) and high levels (≥14 weekly hours) of informal care or any formal care is associated with lower risk of falls and FRIs among community-dwelling older adults. We additionally tested whether serious physical functioning (≥3 activities of daily living) or cognitive limitations moderated this relationship. RESULTS Caregiving receipt categories were jointly significant in predicting noninjurious falls (P=0.03) but not FRIs (P=0.30). High levels of informal care category (P=0.001) and formal care (P<0.001) had stronger associations with reduced fall risk relative to low levels of informal care. Among individuals with ≥3 activities of daily living, fall risks were reduced by 21% for those receiving high levels of informal care; additionally, FRIs were reduced by 42% and 58% for those receiving high levels of informal care and any formal care. High levels of informal care receipt were also associated with a 54% FRI risk reduction among the cognitively impaired. CONCLUSIONS Fall risk reductions among older adults occurred predominantly among those with significant physical and cognitive limitations. Accordingly, policy efforts involving fall prevention should target populations with increased physical functioning and cognitive limitations. They should also reduce financial barriers to informal and formal caregiving.
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Affiliation(s)
- Geoffrey J Hoffman
- *Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI †UCLA Division of General Internal Medicine and Health Services Research ‡Department of Community Health Sciences §Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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Green JB, Shapiro MF, Ettner SL, Malin J, Ang A, Wong MD. Physician variation in lung cancer treatment at the end of life. Am J Manag Care 2017; 23:216-223. [PMID: 28554208 PMCID: PMC5762116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To determine whether a treating oncologist's characteristics are associated with variation in use of chemotherapy for patients with advanced non-small cell lung cancer (aNSCLC) at the end of life. STUDY DESIGN Retrospective cohort. METHODS Using the 2009 Surveillance, Epidemiology, and End Results-Medicare database, we studied chemotherapy receipt within 30 days of death among Medicare enrollees who were diagnosed with aNSCLC between 1999 and 2006, received chemotherapy, and died within 3 years of diagnosis. A multilevel model was constructed to assess the contribution of patient and physician characteristics and geography to receiving chemotherapy within 30 days of death. RESULTS Among 21,894 patients meeting eligibility criteria, 43.1% received chemotherapy within 30 days of death. In unadjusted bivariate analyses, female sex, Asian or black race, older age, and a greater number of comorbid diagnoses predicted lower likelihood of receiving chemotherapy at the end of life (P ≤.038 for all comparisons). Adjusting for patient and physician characteristics, physicians in small independent practices were substantially more likely than those employed in other practice models, particularly academic practices or nongovernment hospitals, to order chemotherapy for a patient in the last 30 days of life (P <.001 for all comparisons); female physicians were less likely than males to prescribe such treatment (P = .04). CONCLUSIONS Patients receiving care for aNSCLC in small independent oncology practices are more likely to receive chemotherapy in the last 30 days of life.
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Affiliation(s)
- Jonas B Green
- Cedars-Sinai Medical Care Foundation, Los Angeles, CA. E-mail:
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Hoffman GJ, Hays RD, Wallace SP, Shapiro MF, Ettner SL. Depressive symptomatology and fall risk among community-dwelling older adults. Soc Sci Med 2017; 178:206-213. [PMID: 28279573 PMCID: PMC5411980 DOI: 10.1016/j.socscimed.2017.02.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 02/03/2017] [Accepted: 02/12/2017] [Indexed: 12/15/2022]
Abstract
RATIONALE Falls are common among older adults and may be related to depressive symptoms (DS). With advancing age, there is an onset of chronic conditions, sensory impairments, and activity limitations that are associated with falls and with depressive disorders. Prior cross-sectional studies have observed significant associations between DS and subsequent falls as well as between fractures and subsequent clinical depression and DS. OBJECTIVE The directionality of these observed relationship between falls and DS is in need of elaboration given that cross-sectional study designs can yield biased estimates of the DS-falls relationship. METHODS Using 2006-2010 Health and Retirement Study data, cross-lagged panel structural equation models were used to evaluate associations between falls and DS among 7233 community-dwelling adults ages ≥65. Structural coefficients between falls and DS (in 2006→2008, 2008→2010) were estimated. RESULTS A good-fitting model was found: Controlling for baseline (2006) physical functioning, vision, chronic conditions, and social support and neighborhood social cohesion, falls were not associated with subsequent DS, but a 0.5 standard deviation increase in 2006 DS was associated with a 30% increase in fall risk two years later. This DS-falls relationship was no longer significant when use of psychiatric medications, which was positively associated with falls, was included in the model. CONCLUSION Using sophisticated methods and a large U.S. sample, we found larger magnitudes of effect in the DS-falls relationship than in prior studies-highlighting the risk of falls for older adults with DS. Medical providers might assess older individuals for DS as well as use of psychotropic medications as part of a broadened falls prevention approach. National guidelines for fall risk assessments as well as quality indicators for fall prevention should include assessment for clinical depression.
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Affiliation(s)
- Geoffrey J Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, 400 N. Ingalls Street, Room 4352, Ann Arbor, MI 48109, United States.
| | - Ron D Hays
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Department of Health Policy and Management, UCLA Fielding School of Public Health, United States
| | - Steven P Wallace
- Department of Community Health Sciences, UCLA Fielding School of Public Health, United States
| | - Martin F Shapiro
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Department of Health Policy and Management, UCLA Fielding School of Public Health, United States
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, United States
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Harwood JM, Azocar F, Thalmayer A, Xu H, Ong MK, Tseng CH, Wells KB, Friedman S, Ettner SL. The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Specialty Behavioral Health Care Utilization and Spending Among Carve-In Enrollees. Med Care 2017; 55:164-172. [PMID: 27632769 PMCID: PMC5233645 DOI: 10.1097/mlr.0000000000000635] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees. METHODS We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in self-insured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N=179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization. RESULTS MHPAEA was associated with increases in monthly per-member total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P=0.02); $0.88 (P=0.04); 0.00045 visits (P=0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P=0.00) and additional increases of 0.00017 visits/mo (P=0.03)]. CONCLUSIONS MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.
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Affiliation(s)
- Jessica M. Harwood
- Division of General Internal Medicine and Health Services Research,
Department of Medicine, David Geffen School of Medicine, University of California,
Los Angeles
| | | | | | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research,
Department of Medicine, David Geffen School of Medicine, University of California,
Los Angeles
| | - Michael K. Ong
- Division of General Internal Medicine and Health Services Research,
Department of Medicine, David Geffen School of Medicine, University of California,
Los Angeles
- Veterans Affairs Greater Los Angeles Healthcare System
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research,
Department of Medicine, David Geffen School of Medicine, University of California,
Los Angeles
| | | | - Sarah Friedman
- Department of Health Policy and Management, Fielding School of
Public Health, UCLA
| | - Susan L. Ettner
- Division of General Internal Medicine and Health Services Research,
Department of Medicine, David Geffen School of Medicine, University of California,
Los Angeles
- Department of Health Policy and Management, Fielding School of
Public Health, UCLA
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Ettner SL, M Harwood J, Thalmayer A, Ong MK, Xu H, Bresolin MJ, Wells KB, Tseng CH, Azocar F. The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral health utilization and expenditures among "carve-out" enrollees. J Health Econ 2016; 50:131-143. [PMID: 27736705 PMCID: PMC5127782 DOI: 10.1016/j.jhealeco.2016.09.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 09/26/2016] [Accepted: 09/26/2016] [Indexed: 06/06/2023]
Abstract
Interrupted time series with and without controls was used to evaluate whether the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and its Interim Final Rule increased the probability of specialty behavioral health treatment and levels of utilization and expenditures among patients receiving treatment. Linked insurance claims, eligibility, plan and employer data from 2008 to 2013 were used to estimate segmented regression analyses, allowing for level and slope changes during the transition (2010) and post-MHPAEA (2011-2013) periods. The sample included 1,812,541 individuals ages 27-64 (49,968,367 person-months) in 10,010 Optum "carve-out" plans. Two-part regression models with Generalized Estimating Equations were used to estimate expenditures by payer and outpatient, intermediate and inpatient service use. We found little evidence that MHPAEA increased utilization significantly, but somewhat more robust evidence that costs shifted from patients to plans. Thus the primary impact of MHPAEA among carve-out enrollees may have been a reduction in patient financial burden.
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Affiliation(s)
- Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA.
| | - Jessica M Harwood
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | - Michael K Ong
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | - Kenneth B Wells
- Department of Psychiatry, Neuropsychiatric Institute, University of California Los Angeles, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Walling AM, Tisnado D, Ettner SL, Asch SM, Dy SM, Pantoja P, Lee M, Ahluwalia SC, Schreibeis-Baum H, Malin JL, Lorenz KA. Palliative Care Specialist Consultation Is Associated With Supportive Care Quality in Advanced Cancer. J Pain Symptom Manage 2016; 52:507-514. [PMID: 27401515 PMCID: PMC5173291 DOI: 10.1016/j.jpainsymman.2016.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 03/02/2016] [Accepted: 04/29/2016] [Indexed: 12/25/2022]
Abstract
CONTEXT Although recent randomized controlled trials support early palliative care for patients with advanced cancer, the specific processes of care associated with these findings and whether these improvements can be replicated in the broader health care system are uncertain. OBJECTIVES The aim of this study was to evaluate the occurrence of palliative care consultation and its association with specific processes of supportive care in a national cohort of Veterans using the Cancer Quality ASSIST (Assessing Symptoms Side Effects and Indicators of Supportive Treatment) measures. METHODS We abstracted data from 719 patients' medical records diagnosed with advanced lung, colorectal, or pancreatic cancer in 2008 over a period of three years or until death who received care in the Veterans Affairs Health System to evaluate the association of palliative care specialty consultation with the quality of supportive care overall and by domain using a multivariate regression model. RESULTS All but 54 of 719 patients died within three years and 293 received at least one palliative care consult. Patients evaluated by a palliative care specialist at diagnosis scored seven percentage points higher overall (P < 0.001) and 11 percentage points higher (P < 0.001) within the information and care planning domain compared with those without a consult. CONCLUSION Early palliative care specialist consultation is associated with better quality of supportive care in three advanced cancers, predominantly driven by improvements in information and care planning. This study supports the effectiveness of early palliative care consultation in three common advanced cancers within the Veterans Affairs Health System and provides a greater understanding of what care processes palliative care teams influence.
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Affiliation(s)
- Anne M Walling
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA; RAND Health, Santa Monica, California, USA.
| | - Diana Tisnado
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA; Department of Health Science, California State University, Fullerton, California, USA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA; Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Steven M Asch
- VA Palo Alto Healthcare System, Palo Alto, California, USA; Stanford School of Medicine, Stanford, California, USA
| | - Sydney M Dy
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | | | - Martin Lee
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA
| | - Sangeeta C Ahluwalia
- RAND Health, Santa Monica, California, USA; Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | | | - Jennifer L Malin
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA
| | - Karl A Lorenz
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA; VA Palo Alto Healthcare System, Palo Alto, California, USA; Stanford School of Medicine, Stanford, California, USA
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40
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Hoffman GJ, Hays RD, Shapiro MF, Wallace SP, Ettner SL. The Costs of Fall-Related Injuries among Older Adults: Annual Per-Faller, Service Component, and Patient Out-of-Pocket Costs. Health Serv Res 2016; 52:1794-1816. [PMID: 27581952 DOI: 10.1111/1475-6773.12554] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To estimate expenditures for fall-related injuries (FRIs) among older Medicare beneficiaries. DATA SOURCES The 2007-2009 Medicare claims and 2008 Health and Retirement Study (HRS) data for 5,497 (228 FRI and 5,269 non-FRI) beneficiaries. STUDY DESIGN FRIs were indicated by inpatient/outpatient ICD-9 diagnostic codes for fractures, trauma, dislocations, and by e-codes. A pre-post comparison group design was used to estimate the differential change in pre-post expenditures for the FRI relative to the non-FRI cohort (FRI expenditures). Out-of-pocket (OOP) costs, service category total annual FRI-related Medicare expenditures, expenditures related to the type of initial FRI treatment (inpatient, ED, outpatient), and the risk of persistently high expenditures (4th quartile for each post-FRI quarter) were estimated. PRINCIPAL FINDINGS Estimated FRI expenditures were $9,389 (95 percent CI: $5,969-$12,808). Inpatient, physician/outpatient, skilled nursing facility, and home health comprised 31, 18, 39, and 12 percent of the total. OOP costs were $1,363.0 (95 percent CI: $889-$1,837). Expenditures for FRIs initially treated in inpatient/ED/outpatient settings were $21,424/$6,142/$8,622. The FRI cohort had a 64 percent increased risk of persistently high expenditures. Total Medicare expenditures were $13 billion (95 percent CI: $9-$18 billion). CONCLUSIONS FRIs are associated with substantial, persistent Medicare expenditures. Cost-effectiveness of multifactorial falls prevention programs should be assessed using these expenditure estimates.
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Affiliation(s)
- Geoffrey J Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI
| | - Ron D Hays
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, CA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Martin F Shapiro
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, CA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Steven P Wallace
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, CA
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Abstract
Background. Although the problem of adverse selection into more generous health insurance plans has been the focus of previous work, risk adjustment systems have only recently begun to be implemented to blunt its effect. Objectives. This study examines the ability of the leading risk adjustment systems to predict health care expenditures for people with chronic conditions, using claims and enrollment data from 2 large employers. Research design. Predictive errors and total financial losses/gains are compared for different risk adjustment approaches (primarily hierarchical condition categories [HCCs] and adjusted clinical groups) for several chronic conditions. Results. One of the best performing risk adjusteent systems was a regression-based HCC method, which had an average under-prediction error rate of 9% or 6%, depending on the employer. In comparison, more typical actuarial risk adjustments based on just age, gender, and prevailing area wages lead to a prediction error of at least 50%. We did not find evidence that payments for particular chronic conditions would be consistently and significantly under- or overestimated. Conclusion. The leading risk adjustment approaches substantially reduce the incentives for adverse se-lection but do not eliminate them.
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Affiliation(s)
- Tami L Mark
- The MEDSTAT Group, Inc., Washington, DC, USA
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42
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Abstract
IMPORTANCE Patients treated outside of their Medicare Shared Savings Program (MSSP) accountable care organization (ACO) likely benefit less from the ACO's integration of care. Consequently, the MSSP's open-network design may preclude ACOs from improving value in care. OBJECTIVES Quantify out-of-ACO care in a single urban ACO and examine associations between patient-level predictors and out-of-ACO expenditures. RESEARCH DESIGN Secondary data analysis using Centers for Medicare and Medicaid ACO Program Claim and Claim Line Feed dataset (dates of service January 1, 2013-December 31, 2013). Two-part modeling was used to examine associations between patient-level predictors and likelihood and level of out-of-ACO expenditures. SUBJECTS Patients were included if they were prospectively assigned to the MSSP in 2013. Patients were excluded if they declined to share data with the ACO, were not retrospectively confirmed to be in the ACO, or had missing data on covariates. Analytic sample included 11,922 patients. MEASURES Total out-of-ACO expenditures and out-of-ACO expenditures by place of service. RESULTS Of total expenditures, 32.9% were paid to out-of-ACO providers, and 89.8% of beneficiaries had out-of-ACO expenditures. The presence of almost all medical comorbidities increased out-of-ACO expenditures ($800-$3000 per comorbidity) across the study population. Racial/ethnic minority groups spent between $1076 and $1422 less outside of the ACO than white patients, which was driven by less out-of-ACO outpatient office expenditures ($417-$517 less for each racial/ethnic minority group). CONCLUSIONS Out-of-ACO expenditures represented a significant portion of expenditures for the study population. Medically complex patients spent more outside of the ACO and represent an important population to study further.
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Affiliation(s)
- Maria A. Han
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA
- Robert Wood Johnson Clinical Scholars Program, University of California-Los Angeles, Los Angeles, CA
| | - Robin Clarke
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA
- UCLA Faculty Practice Group, Los Angeles, CA
| | - Susan L. Ettner
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA
- Department of Health Policy and Management, Fielding School of Public Health, University of California-Los Angeles, Los Angeles, CA
| | - William Neil Steers
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA
- Robert Wood Johnson Clinical Scholars Program, University of California-Los Angeles, Los Angeles, CA
| | - Mei Leng
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA
| | - Carol M. Mangione
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA
- Robert Wood Johnson Clinical Scholars Program, University of California-Los Angeles, Los Angeles, CA
- Department of Health Policy and Management, Fielding School of Public Health, University of California-Los Angeles, Los Angeles, CA
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Doyle BJ, Ettner SL, Nuckols TK. Supplemental insurance reduces out-of-pocket costs in medicare observation services. J Hosp Med 2016; 11:502-4. [PMID: 27373701 DOI: 10.1002/jhm.2588] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 02/04/2016] [Accepted: 02/09/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Brian J Doyle
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California and Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Teryl K Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedar-Sinai Medical Center, Los Angeles, California, and the RAND Corporation, Santa Monica, California
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44
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Grinshteyn EG, Eisenman DP, Cunningham WE, Andersen R, Ettner SL. Individual- and Neighborhood-Level Determinants of Fear of Violent Crime Among Adolescents. Fam Community Health 2016; 39:103-112. [PMID: 26882413 DOI: 10.1097/fch.0000000000000095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Fear of violent crime is common among adolescents in urban settings; however, little is known about individual- and neighborhood-level determinants of fear. A generalized ordered logit model was used to analyze individual- and neighborhood-level variables among 2474 adolescents. Seeing violence significantly reduced the probability of feeling unafraid, as did higher levels of social disorder. The more block faces where police were visible, the higher the probability of feeling unafraid and lower the probability of feeling very afraid. Reducing fear could affect more people than just reducing crime. Fear-reduction strategies should target those most at risk of becoming fearful.
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Affiliation(s)
- Erin G Grinshteyn
- School of Community Health Sciences, University of Nevada, Reno (Dr Grinshteyn); Divisions of General Internal Medicine (Dr Eisenman) and General Internal Medicine and Health Services Research (Drs Cunningham and Ettner), David Geffen School of Medicine at University of California, Los Angeles (UCLA); Department of Community Health Sciences, UCLA Center for Public Health and Disasters (Dr Eisenman), and Department of Health Policy and Management (Drs Cunningham, Ettner, and Andersen), UCLA Fielding School of Public Health, Los Angeles, California
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45
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Moin T, Steers WN, Ettner SL, Duru OK, Turk N, Neugebauer R, Chan C, Luchs RH, Ho S, Mangione CM. The association of a diabetes-specific health plan with ER and inpatient hospital utilization: a natural experiment for translation in diabetes (NEXT-D). Implement Sci 2015. [PMCID: PMC4933984 DOI: 10.1186/1748-5908-10-s1-a4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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46
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Gilmer TP, Stefancic A, Henwood BF, Ettner SL. Fidelity to the Housing First Model and Variation in Health Service Use Within Permanent Supportive Housing. Psychiatr Serv 2015; 66:1283-9. [PMID: 26325459 DOI: 10.1176/appi.ps.201400564] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Permanent supportive housing (PSH) programs are being implemented throughout the United States. This study examined the relationship between fidelity to the Housing First model and health service use among clients in PSH programs in California. METHODS Data from a survey of PSH program practices were merged with administrative data on service utilization to examine the association between fidelity to a benchmark program, the Housing First model, and health service use among 5,067 clients in 77 PSH programs. Regression analyses were used to compare inpatient, crisis and residential, and outpatient mental health service use between high-, mid-, and low-fidelity programs in a pre-post design. RESULTS During the preenrollment period, clients in mid- and high-fidelity PSH programs, compared with low-fidelity programs, used inpatient and crisis and residential services more but used outpatient mental health services less. Postenrollment, patients in high-fidelity programs showed the largest increase in the number of outpatient visits, followed by clients in mid- and low-fidelity programs: 71.6 versus 48.2 and 29.0, respectively. CONCLUSIONS Clients in housing programs with higher fidelity to the Housing First model had greater increases in outpatient visits. Compared with lower-fidelity programs, higher-fidelity programs also enrolled clients who used fewer mental health outpatient services in the year before enrollment. Higher-fidelity programs may be more effective than lower-fidelity programs in increasing outpatient service utilization and in their outreach to and engagement of clients who are not appropriately served by the public mental health system.
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Affiliation(s)
- Todd P Gilmer
- Dr. Gilmer is with the Department of Family Medicine and Public Health, University of California, San Diego (e-mail: ). Dr. Stefancic is with the Department of Psychiatry, Columbia University, and Pathways to Housing, Inc., New York City. Dr. Henwood is with the School of Social Work, University of Southern California, Los Angeles. Dr. Ettner is with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and with the Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
| | - Ana Stefancic
- Dr. Gilmer is with the Department of Family Medicine and Public Health, University of California, San Diego (e-mail: ). Dr. Stefancic is with the Department of Psychiatry, Columbia University, and Pathways to Housing, Inc., New York City. Dr. Henwood is with the School of Social Work, University of Southern California, Los Angeles. Dr. Ettner is with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and with the Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
| | - Benjamin F Henwood
- Dr. Gilmer is with the Department of Family Medicine and Public Health, University of California, San Diego (e-mail: ). Dr. Stefancic is with the Department of Psychiatry, Columbia University, and Pathways to Housing, Inc., New York City. Dr. Henwood is with the School of Social Work, University of Southern California, Los Angeles. Dr. Ettner is with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and with the Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
| | - Susan L Ettner
- Dr. Gilmer is with the Department of Family Medicine and Public Health, University of California, San Diego (e-mail: ). Dr. Stefancic is with the Department of Psychiatry, Columbia University, and Pathways to Housing, Inc., New York City. Dr. Henwood is with the School of Social Work, University of Southern California, Los Angeles. Dr. Ettner is with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and with the Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
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Duru OK, Turk N, Ettner SL, Neugebauer R, Moin T, Li J, Kimbro L, Chan C, Luchs RH, Keckhafer AM, Kirvan A, Ho S, Mangione CM. Adherence to Metformin, Statins, and ACE/ARBs Within the Diabetes Health Plan (DHP). J Gen Intern Med 2015; 30:1645-50. [PMID: 25944019 PMCID: PMC4617948 DOI: 10.1007/s11606-015-3284-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 02/24/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Reducing patient cost-sharing and engaging patients in disease management activities have been shown to increase uptake of evidence-based care. OBJECTIVE To evaluate the effect of employer purchase of a disease-specific plan with reduced cost-sharing and disease management (the Diabetes Health Plan/DHP) on medication adherence among eligible employees and dependents. DESIGN Employer-level "intent to treat" cohort study, including data from eligible employees and their dependents with diabetes, regardless of whether they were enrolled in the DHP. SETTING Employers that contracted with a large national health plan administrator in 2009, 2010, and/or 2011. PARTICIPANTS Ten employers that purchased the DHP and 191 employers that did not (controls). Inverse probability weighting (IPW) estimation was used to adjust for inter-group differences. INTERVENTION The DHP includes free or low-cost medications and physician visits. Enrollment strategies and specific benefit designs are determined by the employer and vary in practice. DHP participants are notified up front that they must engage in their own health care (e.g., receiving diabetes-related screening) in order to remain enrolled. MAIN OUTCOME MEASURE Mean employee adherence to metformin, statins, and ACE/ARBs at the employer level at one year post-DHP implementation, as measured by the proportion of days covered (PDC). RESULTS Baseline adherence to the three medications was similar across DHP and control employers, ranging from 64 to 69 %. In the first year after DHP implementation, predicted employer-level adherence for metformin (+4.9 percentage points, p = 0.017), statins (+4.8, p = 0.019), and ACE/ARBs (+4.4, p = 0.02) was higher with DHP purchase. LIMITATIONS Non-randomized, observational study. CONCLUSIONS The Diabetes Health Plan, an innovative health plan that combines reduced cost-sharing and disease management with an up-front requirement of enrollee participation in his or her own health care, is associated with a modest improvement in medication adherence at 12 months.
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Affiliation(s)
- O Kenrik Duru
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA.
| | - Norman Turk
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Susan L Ettner
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
- Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Tannaz Moin
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jinnan Li
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Lindsay Kimbro
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | | | | | | | | | - Sam Ho
- UnitedHealthcare, Minnetonka, MN, USA
| | - Carol M Mangione
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
- Fielding School of Public Health, University of California, Los Angeles, CA, USA
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Sacks GD, Dawes AJ, Russell MM, Brook RH, Ettner SL, Fox CR, Ko CY, Gibbons MM. Does Use of the American College of Surgeons NSQIP Calculator Change a Surgeon’s Decision to Operate? A Randomized Trial. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sacks GD, Dawes AJ, Gibbons MM, Brook RH, Ettner SL, Fox CR, Ko CY, Russell MM. Do Surgeons’ Perceptions of Treatment Risks and Benefits Influence Their Decision to Operate? J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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50
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Ahluwalia SC, Tisnado DM, Walling AM, Dy SM, Asch SM, Ettner SL, Kim B, Pantoja P, Schreibeis-Baum HC, Lorenz KA. Association of Early Patient-Physician Care Planning Discussions and End-of-Life Care Intensity in Advanced Cancer. J Palliat Med 2015; 18:834-41. [PMID: 26186553 DOI: 10.1089/jpm.2014.0431] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Early patient-physician care planning discussions may influence the intensity of end-of-life (EOL) care received by veterans with advanced cancer. OBJECTIVE The study objective was to evaluate the association between medical record documentation of patient-physician care planning discussions and intensity of EOL care among veterans with advanced cancer. METHODS This was a retrospective cohort study. Subjects were 665 veteran decedents diagnosed with stage IV colorectal, lung, or pancreatic cancer in 2008, and followed till death or the end of the study period in 2011. We estimated the effect of patient-physician care planning discussions documented within one month of metastatic diagnosis on the intensity of EOL care measured by receipt of acute care, intensive interventions, chemotherapy, and hospice care, using multivariate logistic regression models. RESULTS Veterans in our study were predominantly male (97.1%), white (74.7%), with an average age at diagnosis of 66.4 years. Approximately 31% received some acute care, 9.3% received some intensive intervention, and 6.5% had a new chemotherapy regimen initiated in the last month of life. Approximately 41% of decedents received no hospice or were admitted within three days of death. Almost half (46.8%) had documentation of a care planning discussion within the first month after diagnosis and those who did were significantly less likely to receive acute care at EOL (OR: 0.67; p=0.025). Documented discussions were not significantly associated with intensive interventions, chemotherapy, or hospice care. CONCLUSION Early care planning discussions are associated with lower rates of acute care use at the EOL in a system with already low rates of intensive EOL care.
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Affiliation(s)
| | - Diana M Tisnado
- 9 Department of Health Science, California State University , Fullerton, Fullerton, California
| | - Anne M Walling
- 2 VA Greater Los Angeles Medical Center , Los Angeles, California.,3 UCLA School of Medicine , Los Angeles, California
| | - Sydney M Dy
- 4 Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University , Baltimore, Maryland
| | - Steven M Asch
- 5 VA Palo Alto Healthcare System , Palo Alto, California.,6 Stanford University School of Medicine , Palo Alto, California
| | - Susan L Ettner
- 7 UCLA Fielding School of Public Health , Los Angeles, California
| | - Benjamin Kim
- 8 University of California , San Francisco, California
| | - Philip Pantoja
- 2 VA Greater Los Angeles Medical Center , Los Angeles, California
| | | | - Karl A Lorenz
- 2 VA Greater Los Angeles Medical Center , Los Angeles, California.,3 UCLA School of Medicine , Los Angeles, California
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