Economic Evaluation of Tympanostomy Tube Placement.

The dynamics of health care delivery for children and adolescents have greatly evolved over the last 5 years. The growth of managed care has been especially rapid, and has coincided with other fundamental changes—declines in private coverage, growth of Medicaid, welfare reform, and the creation of the state Child Health Insurance Program (CHIP).1 Over the past 10 years, the number of children covered through employer-sponsored plans and other private plans has dropped.2 During this same period, changes to Medicaid have begun to de-couple eligibility from welfare eligibility, theoretically enabling states to expand coverage. For children, this movement from private to public coverage has accelerated the movement to managed care systems. Between 1991 and 1997, Medicaid enrollment in managed care plans increased from 9.5% to 47.8% of total Medicaid enrollment.3 Recent estimates suggest that over half of these Medicaid managed care enrollees are children.4 However, little is known about the impact of these trends on children's access to and use of services, let alone the quality and outcomes of that care. This report is the first in what is anticipated to be an annual series of reports on access to and use of health care services by America's children and youth. The report capitalizes on the existence of 2 national datasets, the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP), which have not been widely used by the child health services research community. As background to these new sources of data, we have provided a detailed description of the datasets, and review some of the fundamental tabulations. In future years, as more data are accumulated, these reports will focus on delineation of key trends and analyses addressing policy issues. ### MEPS The MEPS is conducted to provide nationally representative estimates of health care use, …

Objective-Discontinuities in health insurance coverage may make it difficult for individuals early in psychosis to receive the services that are critical in determining long-term outcome.This study reports on the rates and continuity of insurance coverage among a cohort of early-psychosis patients enrolled in Specialized Treatment Early in Psychosis (STEP) at the Connecticut Mental Health Center.Methods-Insurance status at baseline, six months, and 12 months was collected from 82 participants from a combination of self-reports, clinical chart review, clinician reports, and a database maintained by the state Department of Social Services.Results-A total of 34 participants did not know whether they had health insurance or did not appear for follow-up assessments at six and 12 months.Among the remaining 48 participants, at baseline 18 had private insurance, 13 had public insurance, and 16 had no insurance.

This paper documents the changing picture of health insurance coverage for pregnant women in the four-year period following Medicaid expansion and assesses the extent to which the crowding-out phenomenon may have influenced the observed trends. The report documents the distribution of insurance coverage for pregnant women in the post-expansion period and describes demographic characteristics of women covered under Medicaid. It examines the rate at which Medicaid-eligible women enroll in the program and addresses the crowding-out issue by comparing the trend in employer-sponsored coverage among poor and near-poor pregnant women with those among nonpregnant women and men of similar ages and incomes.

Children without Health Insurance

ACA and Medicaid Expansion Increased Breast Pump Claims and Breastfeeding for Women with Public and Private Insurance.

BackgroundChina is reforming and restructuring its health insurance system to achieve the goal of universal coverage. This study aims to understand the determinants of public, private and multiple insurance coverage among people of retirement-age in China.MethodsWe used data from the China Health and Retirement Longitudinal Survey 2011 and 2013, a nationally representative survey of Chinese people aged 45 and over. Multinomial logit regression was performed to identify the determinants of public, private and multiple health insurance coverage. We also conducted logit regression to examine the association between public insurance coverage and demand for private insurance.ResultsIn 2013, 94.5% of this population had at least one type of public insurance, and 12.2% purchased private insurance. In general, we found that rural residents were less likely to be uninsured (Relative Risk Ratio (RRR) = 0.40, 95% Confidence Interval (CI): 0.34–0.47) and were less likely to buy private insurance (RRR = 0.22, 95% CI: 0.16–0.31). But rural-to-urban migrants were more likely to be uninsured (RRR = 1.39, 95% CI: 1.24–1.57). Public health insurance coverage may crowd out private insurance market (Odds Ratio = 0.55, 95% CI: 0.48–0.63), particularly among enrollees of Urban Resident Basic Medical Insurance. There exists a huge socioeconomic disparity in both public and private insurance coverage.ConclusionThe migrants, the poor and the vulnerable remained in the edge of the system. The growing private insurance market did not provide sufficient financial protection and did not cover the people with the greatest need. To achieve universal coverage and reduce socioeconomic disparity, China should integrate the urban and rural public insurance schemes across regions and remove the barriers for the middle-income and low-income to access private insurance.

The disparity in access to and delivery of health care among children has become increasingly apparent. The purpose of our study was to analyze demographic information, including health insurance status, of children with extremity injuries seen at a University Hospital emergency department (UH ED) after visiting another ED for the same complaint. A database of pediatric orthopaedic consults requested for extremity injuries at UH ED was reviewed. Information regarding patients' age, ethnicity, orthopaedic diagnosis, type of health insurance, time from injury to presentation at the first ED and at UH ED, mode of transportation to UH ED, and orthopaedic treatment rendered was analyzed. All patients with Medicaid, health maintenance organization-Medicaid, no insurance, or charity care were classified as having public insurance, whereas those with commercial insurance, including health maintenance organization and preferred provider organization plans, were placed in the private insurance category. Over a 30-month period, 125 children, of whom 18% had private health insurance, were noted to have recently visited another ED seeking treatment for an extremity injury. A closed fracture was diagnosed in 117 patients, 94% of whom were discharged from UH ED after cast application. There was no difference with regard to patients' age, sex, ethnicity, diagnosis, and time to presentation at the initial ED between private and public insurance groups. However, 52% of children with private insurance received orthopaedic care within 24 hours compared with 22% with public insurance (P = 0.013). Children with public insurance were more likely to have visited another health facility besides the initial ED before presenting to UH ED (P = 0.004). Moreover, 74% of privately insured patients presenting to UH ED arrived via ambulance compared with 34% with public insurance (P < 0.001). Most children with an extremity injury who received orthopaedic consultation at a tertiary-level ED after visiting another ED had an isolated fracture requiring cast treatment only. There was a trend for delay in receiving definitive orthopaedic care for patients with public health insurance compared with those with private insurance.

Background:Pediatric and adolescent patients who undergo shoulder stabilization surgery have higher rates of failure than their adult counterparts. The impact of insurance status on intra-operative findings and outcomes is largely unknown.Hypothesis/Purpose:We hypothesized that patients with public insurance who undergo shoulder stabilization surgery would have greater degrees of bony pathology; leading to poor outcomes after stabilization.Methods:This was a retrospective cohort study of pediatric and adolescent patients with public and private insurance who were treated for recurrent shoulder instability from 2011-2017. Patients were treated at a tertiary care children’s hospital by a single orthopaedic surgeon. Patients 10 to 18 years of age were included in the study if they presented with recurrent shoulder instability and underwent surgical intervention for their injury. Time from injury to clinical consultation, imaging, and surgical intervention; incidences of labral pathology and secondary bony injury; and rates of repeat dislocation and repeat surgery were compared between the public and private insurance cohortsResults:Thirty-seven patients had public insurance while 18 patients had private insurance. Privately insured patients were evaluated by clinicians nearly five times faster than were publicly insured patients (p < 0.001), and they obtained MRIs over four times faster than did public insurance patients (p < 0.001). Publicly insured patients were twice as likely to have secondary bony injuries (p=0.043). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced re-dislocation versus the complete absence of re-dislocation in the privately insured patients (p=0.022).Conclusion:Public insurance status impacts access to care and correlates with both the development of secondary bony injury and an increased rate of clinical failure manifested as repeat post-operative dislocations.Table 1.Data SummaryAll (n=55)Public Insurance (n=37)Private Insurance (n=18)Days from Injury to Clinic298.71402.3885.61Days from Injury to MRI323.04431.9799.11Days from Injury to Surgery451.76561.38226.44*Days from Clinic to MRI24.3329.5913.50*Days from MRI to Surgery128.73129.41127.33Number of prior dislocationsNone = 3Single = 2Multiple = 32None = 6Single = 0Multiple = 12Incidence of anterior only vs. complex labral pathologyAnterior only = 81.8% (45/55)Complex = 18.2% (10/55)Anterior only = 83.8% (31/37)Complex = 16.2% (6/37)Anterior only = 77.8% (14/18)Complex = 22.2% (4/18)Incidence of bony involvement (Y/N)56.4% (31/55)67.6% (25/37)33% (6/18)Incidence of repeat dislocations16.4% (9/55)24.3% (9/37)0.00% (0/18)*Incidence of repeat surgery5.5% (3/55)8% (3/37)0.00% (0/18)Table 1 shows the summary of results for public and private insurance cohorts for days from injury to clinic, injury to MRI, injury to surgery, clinic to MRI, MRI to surgery as well as number of prior dislocations, incidence of anterior only vs. complex labral pathology, incidence of bony involvement, incidence of repeat dislocations, and incidence of repeat surgery. * denotes that the difference between the two insurance cohorts was not statistically significant.

There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC. To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance. This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018. The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes. Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8% (95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5% (95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5% (95% CI, 28.3%-42.7%) among the public insurance group (P < .001). The cumulative incidence of LT within 2 years of baseline was 67.3% (95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5% (95% CI, 40.4%-56.1%) among the public insurance group (P < .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10). Waiting list dropout was also significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P < .001), Model for End-Stage Liver Disease score at baseline (HR per point, 1.06 [95% CI, 1.03-1.09]; P < .001), and 3 or more lesions at baseline (HR vs 1 lesion of 2- to 3-cm diameter, 2.07 [95% CI, 1.27-3.37]; P = .004). In this large cohort of patients with HCC on an LT waiting list, patients with public insurance were associated with worse wait-list outcomes compared with patients with Kaiser Permanente insurance or other private insurance, despite similar tumor-related characteristics at baseline. Improved health care coordination and delivery may be options to reduce these disparities.

SY15-02: Health insurance and outcome disparities in adolescents and young adults with cancer

Although psychological trauma affects millions of Americans, few studies have examined treatment of posttraumatic stress disorder (PTSD) in real-world service environments. This study explored pharmacological treatment of PTSD among privately insured individuals. Data were from the MarketScan database, which compiles claims from private health insurance plans nationwide. Descriptive statistics and multivariate logistic regression were used to identify predictors of any use of a psychotropic medication and use of three medication classes: antidepressants, anxiolytics or sedative-hypnotics, and antipsychotics. Of 860,090 adult mental health care users in 2005, only 10,636 (1.2%) had a diagnosis of PTSD. Sixty percent of PTSD patients received any psychotropic medication: 74.3% of those received antidepressants, 73.7% received anxiolytics or sedative-hypnotics, and 21.3% received antipsychotics. Greater likelihood of any medication use was associated with greater use of mental health services and with several comorbid psychiatric disorders. Having a comorbid diagnosis of an indicated disorder was the most robust predictor of use of each of the three medication classes: major depressive disorder and dysthymia were most strongly associated with antidepressant use, schizophrenia and bipolar disorder were associated with antipsychotic use, and anxiety disorders were associated with use of anxiolytics or sedative-hypnotics. Psychotropic medications were frequently used in the treatment of PTSD among privately insured clients. Although use targeted specifically to PTSD and to comorbid disorders was common, substantial use appeared to be unrelated to diagnosis and may be targeted at specific symptoms rather than diagnosed illnesses. Further research is needed to determine symptom-specific responses to medications across diagnoses.

BackgroundUniversal health coverage (UHC) is a goal of the member states of the United Nations. The negative impact of the COVID-19 pandemic on mental health, inequalities in access to care, and financing gaps set a problematic scenario for universal mental health coverage. In Latin America, depression and anxiety disorders have increased by more than 30%. Chile implemented a reform for UHC in 2005 generating a mandatory guaranteed plan for health insurance (GES) that covers schizophrenia, depression, bipolar disorders, and Alzheimer's disease. We assume that the pandemic increased cases of mental illness in GES of public and private insurance.ObjectivesThis study aimed to explore the effects of the pandemic on the use of the GES mental health plan of public and private insurance.MethodsA descriptive analysis of secondary data from public and private insurance on the use and expenditure of the GES plan in mental illness between 2005 and 2020 was carried out. An aggregate analysis of the use of psychiatric consultations without a guaranteed plan and sick leave was performed.ResultsBetween 2005 and 2020, 18.5% of GES cases corresponded to four mental health illnesses (1,682,021 cases). Public insurance covered 80% of cases. In the pandemic, cases of mental illness fell by 10.5% in public insurance and 28.7% in private ones, reducing spending by 33 and 6.2%, respectively. Psychiatric consultations without using the GES plan doubled in 2020 in private insurance, and medical discharges due to mental illness also increased. Leave due to mental illness increased by 20% in both types of insurance.ConclusionThe results suggest that the demand for mental healthcare increased during the pandemic, but public and private health insurance reduced admissions to the GES universal plan for schizophrenia, depression, and bipolar disorder. A universal guaranteed plan in an individual contribution system can have essential weaknesses for people when the principles of social security are not complied with, especially concerning the solidarity of the health insurance system.

This study estimated the rates of health insurance coverage in the U.S. civilian noninstitutionalized population with schizophrenia and assessed whether basic access to health care varied across health insurance categories. Data from the Medical Expenditures Panel Survey collected between 2002 and 2006 were used. The sample contained 328 records representing 493,006 noninstitutionalized civilian persons with schizophrenia. Eighty-seven percent had Medicaid or Medicare, 8% received care through the Veterans Health Administration, and 15% had private insurance for at least one day during the year. About 7% were uninsured all of the year. The uninsured tended to be male (92%), nonwhite (54%), and unmarried (97%), and 30% of the uninsured had not had a medical checkup in more than five years. Almost all U.S. adults with schizophrenia were found to receive government health insurance, yet a measurable minority remained uninsured. These national estimates highlight opportunities for improving health service delivery for this vulnerable population.

PHS155 - Moral hazard and health insurance: examining the role of private vs. Public insurance in prostate cancer screening, prostate cancer diagonosis and patient satisfaction with prostate cancer care

Private vs. Public Insurance Delays in Gender Affirming Mastectomy Coverage Elise Hogan, BS, Kiersten Woodyard, BS, Ermina Lee, BS, Douglas Dembinski, MD, Ryan Gobble, MD, FACS Intro: Gender affirming care is recognized by every major medical association in the US as medically necessary for the treatment of gender dysphoria1. However, a 2015 national survey of transgender individuals found that 25% of respondents were denied coverage for hormones and 55% were denied coverage for surgical care within that year2. Access to gender affirming care has been associated with improved health outcomes in the transgender population, but there is a paucity of literature characterizing wait time from initial surgical consult to gender-affirming mastectomy. The purpose of this study was to investigate insurer coverage practices for transgender patients seeking gender-affirming mastectomy at the University of Cincinnati Medical Center to better inform surgical providers and their patients. Methods: A retrospective review of patients presenting to our institution interested in gender-affirming mastectomies from July 2014 to January 2022 was conducted. Patients were sub-stratified into those with public insurance and private insurance providers. Patient demographic data was collected, including insurance type, race, ethnicity, age, BMI, and smoking status, with additional information such as time on hormone replacement therapy (HRT) and prior psychiatric involvement. Categorical variables were analyzed with t-tests, and continuous variables were examined via linear regression. Results: 90 patients were interested in gender-affirming mastectomies that presented to our institution; 67 were insured by public providers and 23 by private insurers. 51 patients went on to have surgery (56.67%); 38 patients with public insurance (74.51% of surgical patients; 56.72% of publicly insured) and 12 patients with private insurance (23.53% of surgical patients; 52.17% of privately insured). 77 of the original 90 new patient consults (85.56%) had previously documented psychiatric involvement; 49 of 51 surgical patients (96.08%) had documented psychiatric involvement. Surgical patients with public insurance were on HRT for an average of 21 months compared to 30 months for private insurance. Average time from initial consultation to surgery was significantly longer for public insurers, with an average of 280 days, compared to private insurers, with an average of 186 days. For both public and private insurance, there was no association between months on HRT and time to surgery. Conclusion: There is a delay in time to surgery associated with patients who have public insurance when compared to private insurance that is unassociated with time on hormone replacement therapy. Awareness of a patient’s insurance status allows providers to provide realistic surgical timelines more accurately for patients interested in gender affirming mastectomy.