Commercial Insurance Research Articles

Real-world treatment patterns of patients with major depressive disorder treated with Auvelity in the United States

Aims Major depressive disorder (MDD) is a prevalent, chronic disorder. Auvelity (dextromethorphan-bupropion) is a novel, oral N-methyl-D-aspartate (NMDA) receptor antagonist and sigma-1 receptor agonist approved (August 2022) by the FDA for treating MDD in adults. This is the first analysis on real-world Auvelity usage in the United States. Methods Adult patients initiating Auvelity in the Symphony IDV databases by September 2023 were identified (index date: the first Auvelity claim). Patients had continuous eligibility over the 12-month pre-index period and ≥1 MDD diagnosis (ICD-10-CM codes: F32.*, F33.*) over the 5-year pre-index period. Demographic and clinical characteristics, comorbidities, prior MDD-related medications, and Auvelity initiation status were assessed. Results This analysis included 22,288 patients with MDD treated with Auvelity (mean age 45.1 years; 68.1% women); 40.0% lived in the South and 58.5% had commercial insurance. Comorbidities included mental health disorders (53.5%; 47.6% had anxiety disorders). Overall, 83.7% of the patients had received treatment with selective serotonin reuptake inhibitors (SSRIs; 54.9%), the norepinephrine-dopamine reuptake inhibitor (NDRI [bupropion]; 40.4%), and/or serotonin-norepinephrine reuptake inhibitors (SNRIs; 35.9%) over the 12-month pre-index period. The last MDD-related treatment prior to Auvelity comprised SSRI (22.4%), SNRI (13.2%), and NDRI (12.8%) monotherapies; 294 (1.3%) patients received esketamine. In total, 6,418 (28.8%) patients initiated Auvelity as monotherapy vs 15,870 (71.2%) as an add-on; Auvelity was most frequently added to an SSRI alone (10.7%) or SNRI alone (6.5%). A total of 2,254 (10.1%) patients initiated Auvelity without prior treatment in the 12-month pre-index period. Limitations Incomplete data due to reporting; diagnoses captured subject to coding error; and limited generalizability to other populations. Conclusions Using a large demographically distributed claims database, 22,288 patients with MDD initiated Auvelity within a year of its approval; 10.1% were treatment-naïve and 28.8% initiated Auvelity as monotherapy. Most patients had mental health-related comorbidities and attempted various MDD-related treatments prior to Auvelity.

High-Dose Opioid Prescribing in Individuals with Acute Pain: Assessing the Effects of US State Opioid Policies.

How state opioid policy environments with multiple concurrent policies affect opioid prescribing to individuals with acute pain is unknown. To examine how prescription drug monitoring programs (PDMPs), pain management clinic regulations, initial prescription duration limits, and mandatory continued medical education affected total and high-dose prescribing. A county-level multiple-policy difference-in-difference event study framework. A total of 2,425,643 individuals in a large national commercial insurance deidentified claims database (aged 12-64 years) with acute pain diagnoses and opioid prescriptions from 2007 to 2019. The total number of acute pain opioid treatment episodes and number of episodes containing high-dose (> 90 morphine equivalent daily dosage (MEDD)) prescriptions. Approximately 7.5% of acute pain episodes were categorized as high-dose episodes. Prescription duration limits were associated with increases in the number of total episodes; no other policy was found to have a significant impact. Beginning five quarters after implementation, counties in states with pain management clinic regulations experienced a sustained 50% relative decline in the number of episodes containing > 90 MEDD prescriptions (95 CIs: (Q5: - 0.506, - 0.144; Q12: - 1.000, - 0.290)). Mandated continuing medical education regarding the treatment of pain was associated with a 50-75% relative increase in number of high-dose episodes following the first year-and-a-half of enactment (95 CIs: (Q7: 0.351, 0.869; Q12: 0.413, 1.107)). Initial prescription duration limits were associated with an initial relative reduction of 25% in high-dose prescribing, with the effect increasing over time (95 CI: (Q12: - 0.967, - 0.335). There was no evidence that PDMPs affected high-dose opioids dispensed to individuals with acute pain. Other high-risk prescribing indicators were explored as well; no consistent policy impacts were found. State opioid policies may have differential effects on high-dose opioid dispensing in individuals with acute pain. Policymakers should consider effectiveness of individual policies in the presence of other opioid policies to address the ongoing opioid crisis.

Burden of illness and mortality in men with Adrenomyeloneuropathy: a retrospective cohort study

BackgroundAdrenomyeloneuropathy (AMN) is a neurodegenerative disease phenotype of X-linked adrenoleukodystrophy (ALD), resulting in progressive myeloneuropathy causing spastic paraparesis, sensory ataxia, and bowel/bladder symptoms. We conducted a retrospective cohort study using two large administrative databases to characterize mortality and the burden of illness in adult men with AMN in the US.ResultsHealthcare resource use was assessed using a national commercial insurance claims database (2006–2021). Males with AMN ages 18–64 years and no evidence of cerebral ALD or other peroxisomal disorders were included and 1:4 matched on demographic characteristics to individuals without AMN. All study participants were followed for as long as observable. Patients with AMN were also identified in the Medicare Limited Dataset (2017–2022); mortality and age at death were compared with all Medicare enrollees. We identified 303 commercially insured men with AMN. Compared with non-AMN, individuals with AMN had significantly more inpatient hospital admissions (0.44 vs. 0.04 admissions/patient/year), outpatient clinic (8.88 vs. 4.1 visits/patient/year), outpatient hospital (5.33 vs. 0.99 visits/patient/year), and home healthcare visits (4.66 vs. 0.2 visits/patient/year), durable medical equipment claims (0.7 vs. 0.1 claims/patient/year), and prescription medication fills (18.1 vs. 5.4 fills/patient/year) (all p < 0.001). Average length-of-stay per hospitalization was also longer in AMN (8.88 vs. 4.3 days; p < 0.001). Rates of comorbidities were significantly more common in AMN compared to controls, including peripheral vascular disease (4.6% vs. 0.99%), chronic pulmonary disease (6.3% vs. 2.6%), and liver disease (5.6% vs. 0.88%), all p < 0.001. Among individuals age < 65 with Medicare disability coverage, mortality rates were 5.3x higher for adult AMN males (39.3% vs. 7.4%) and the age at death significantly younger (47.0 ± 11.3 vs. 56.5 ± 7.8 years), both p < 0.001. Among Medicare beneficiaries ages ≥ 65 mortality rates were 2.2x higher for men with AMN vs. those without AMN (48.6% vs. 22.4%), p < 0.001.ConclusionAMN imposes a substantial and underrecognized health burden on men, with higher healthcare utilization, greater medical comorbidity, higher mortality rates, and younger age at death.

Early Implementation and Outcomes Among People with HIV Who Accessed Long-Acting Injectable Cabotegravir/Rilpivirine at Two Ryan White Clinics in the U.S. South.

The use of long-acting injectable cabotegravir/rilpivirine (LAI-CAB/RPV) as maintenance therapy for persons with HIV (PWH), which may improve treatment access and outcomes, though real-world data on uptake are limited, was studied at two Ryan White clinics in Atlanta, Georgia. Among PWH referred from 4/1/2021 to 9/15/2022 to switch to LAI-CAB/RPV, characteristics were ascertained at time of referral; and disposition (initiated; ineligible; uninterested; pending) was recorded as of 9/15/2022. Among patients initiated on CAB/RPV, we assessed the drug procurement process and clinical outcomes through 6/1/2023. Among 149 PWH referred, 74/149 (50%) initiated CAB/RPV as of 9/15/2022, of whom, characteristics were median age 47 (Q1-Q3 36-55) years, 16% cisgender female, 72% Black race, median HIV duration 15 (Q1-Q3 9-19) years, and 64% had commercial health insurance. Of the 75 PWH not initiated, 35 were ineligible owing to a clinical concern (n = 16) or insurance issue (n = 19); 15 patients changed their mind about switching; and 25 were pending eligibility review or therapy initiation. Median time from CAB/RPV prescription to initiation was 46 (Q1-Q3 29-78) days. Of 731 total injections administered (median 11 injections/patient), 95% were given within 7 days of the target treatment date. Nearly all patients were virally suppressed upon referral and remained suppressed through follow-up. At two clinics in the U.S. South, half of the patients referred for LAI-CAB/RPV successfully accessed therapy nearly 2 years after U.S. drug approval. We identified barriers to uptake at the patient and structural levels, highlighting key areas to invest resource and personnel support to sustain and scale long-acting antiretroviral therapy programming.

Association of Gaps in Medical Insurance Coverage with Vision Care Benefits Among US Adults

ABSTRACT Background In the US, routine vision care and medical services are often covered by separate insurance plans. Unmet needs for vision care are more common among adults with gaps in medical coverage, but it is unclear how gaps in medical coverage correlate with lack of vision benefits among currently insured adults. We hypothesized that gaps in medical coverage in the past 12 months would be associated with lack of coverage for vision care among US adults currently covered by commercial medical insurance. Methods We included adults age 18–65 with private insurance who participated in the 2019–2022 National Health Interview Survey. The primary outcome was any coverage for vision care services, and the secondary outcome was a source of vision coverage (primary health insurance policy as compared to single-service plans only). Results Based on a sample of 50,000 participants, we estimated 4% of commercially insured adults recently experienced coverage gaps, and 75% had coverage for vision care services. On multivariable analysis, commercially insured adults with recent gaps in medical coverage were more likely to lack coverage for vision care at the time of the survey, compared to adults with continuous medical coverage (odds ratio [OR], 0.77; 95% CI: 0.68, 0.86). However, medical coverage gaps were not associated with source of vision care coverage. Conclusions Gaps in medical insurance coverage were associated with lower likelihood of vision care coverage compared to continuous medical coverage. Protecting continuity of health insurance may support access to vision benefits and reduce gaps in routine vision care.

Determinants of the Profitability of Commercial and Islamic Insurance Companies in Iraq: An Applied Study (Workers in Iraqi and National Insurance Companies)

Determinants of the Profitability of Commercial and Islamic Insurance Companies in Iraq: An Applied Study (Workers in Iraqi and National Insurance Companies)

Lifestyle Medicine as a Public Health Solution for Treatment–Resistant Depression (TRD)

Treatment–⁠resistant depression (TRD) is defined as failing to fully remit after 2 antidepressant treatments of adequate dose and duration. A study that analyzed commercial insurance claims, Medicaid, and the Veterans Administration populations showed TRD to be a very costly healthcare disorder thereby making TRD a major public health concern for policymakers. Studies were analyzed and the results of the cost–⁠effective lifestyle medicine practices in treating TRD are shared. Recommendations include further funding and resources and more advanced research in using lifestyle medicine to treat TRD and other mental health problems.

Trends in heart failure costs for commercially insured patients in the United States (2006–2021)

BackgroundAlthough prior research has estimated the overarching cost burden of heart failure (HF), a thorough analysis examining medical expense differences and trends, specifically among commercially insured patients with heart failure, is still lacking. Thus, the study aims to examine historical trends and differences in medical costs for commercially insured heart failure patients in the United States from 2006 to 2021.MethodsA population-based, cross-sectional analysis of medical and pharmacy claims data (IQVIA PharMetrics® Plus for Academic) from 2006 to 2021 was conducted. The cohort included adult patients (age > = 18) who were enrolled in commercial insurance plans and had healthcare encounters with a primary diagnosis of HF. The primary outcome measures were the average total annual payment per patient and per cost categories encompassing hospitalization, surgery, emergency department (ED) visits, outpatient care, post-discharge care, and medications. The sub-group measures included systolic, diastolic, and systolic combined with diastolic, age, gender, comorbidity, regions, states, insurance payment, and self-payment.ResultsThe study included 422,289 commercially insured heart failure (HF) patients in the U.S. evaluated from 2006 to 2021. The average total annual cost per patient decreased overall from $9,636.99 to $8,201.89, with an average annual percentage change (AAPC) of -1.11% (95% CI: -2% to -0.26%). Hospitalization and medication costs decreased with an AAPC of -1.99% (95% CI: -3.25% to -0.8%) and − 3.1% (95% CI: -6.86–0.69%). On the other hand, post-discharge, outpatient, ED visit, and surgery costs increased by an AAPC of 0.84% (95% CI: 0.12–1.49%), 4.31% (95% CI: 1.03–7.63%), 7.21% (95% CI: 6.44–8.12%), and 9.36% (95% CI: 8.61–10.19%).ConclusionsThe study’s findings reveal a rising trend in average total annual payments per patient from 2006 to 2015, followed by a subsequent decrease from 2016 to 2021. This decrease was attributed to the decline in average patient costs within the Medicare Cost insurance category after 2016, coinciding with the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Additionally, expenses related to surgical procedures, emergency department (ED) visits, and outpatient care have shown substantial growth over time. Moreover, significant differences across various variables have been identified.

Financial literacy and the household participation in commercial insurance: Evidence from China

Utilizing China Household Finance Survey (CHFS) data in 2017, this study examines the influence of financial literacy on household commercial insurance engagement. Empirical findings reveal that higher financial literacy correlates with increased likelihood and expenditure on commercial insurance. Education level and trust in commercial insurance also significantly enhance market participation. The study also discovers that financial literacy interacts with entrepreneurship, positively affecting family insurance purchasing behaviors. Particularly, financial literacy more significantly promotes insurance purchases in less educated families and communities with lower purchasing rates. In conclusion, our research not only contributes to enriching the study on the real effects of financial literacy, but also provides policy guidelines for governments on enhancing household participation in commercial insurance markets.

Insurance Instability for Patients With Opioid Use Disorder in the Year After Diagnosis

Transitions in insurance coverage may be associated with worse health care outcomes. Little is known about insurance stability for individuals with opioid use disorder (OUD). To examine insurance transitions among adults with newly diagnosed OUD in the 12 months after diagnosis. Longitudinal cohort study using data from the Massachusetts Public Health Data Warehouse. The cohort includes adults aged 18 to 63 years diagnosed with incident OUD between July 1, 2014, and December 31, 2014, who were enrolled in commercial insurance or Medicaid at diagnosis; individuals diagnosed after 2014 were excluded from the main analyses due to changes in the reporting of insurance claims. Data were analyzed from November 10, 2022, to May 6, 2024. Insurance type at time of diagnosis (commercial and Medicaid). The primary outcome was the cumulative incidence of insurance transitions in the 12 months after diagnosis. Logistic regression models were used to generate estimated probabilities of insurance transitions by insurance type and diagnosis for several characteristics including age, race and ethnicity, and whether an individual started medication for OUD (MOUD) within 30 days after diagnosis. There were 20 768 individuals with newly diagnosed OUD between July 1, 2014, and December 31, 2014. Most individuals with newly diagnosed OUD were covered by Medicaid (75.4%). Those with newly diagnosed OUD were primarily male (67% in commercial insurance, 61.8% in Medicaid). In the 12 months following OUD diagnosis, 30.4% of individuals experienced an insurance transition, with adjusted models demonstrating higher transition rates among those starting with Medicaid (31.3%; 95% CI, 30.5%-32.0%) compared with commercial insurance (27.9%; 95% CI, 26.6%-29.1%). The probability of insurance transitions was generally higher for younger individuals than older individuals irrespective of insurance type, although there were notable differences by race and ethnicity. This study found that nearly 1 in 3 individuals experience insurance transitions in the 12 months after OUD diagnosis. Insurance transitions may represent an important yet underrecognized factor in OUD treatment outcomes.

Interhospital Transfer of Patients With Acute Respiratory Failure in the United States: A Scoping Review.

Interhospital transfer of patients with acute respiratory failure (ARF) is relevant in the current landscape of critical care delivery. However, current transfer practices for patients with ARF are highly variable, poorly formalized, and lack evidence. We aim to synthesize the existing evidence, identify knowledge gaps, and highlight persisting questions related to interhospital transfer of patients with ARF. Ovid Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, CINAHL Plus, and American Psychological Association. We included studies that evaluated or described hospital transfers of adult (age > 18) patients with ARF between January 2020 and 2024 conducted in the United States. Using predetermined search terms and strategies, a total of 3369 articles were found across all databases. After deduplication, 1748 abstracts were screened by authors with 45 articles that advanced to full-text review. This yielded 16 studies that fit our inclusion criteria. The studies were reviewed in accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews by three authors. Included studies were mostly retrospective analyses of heterogeneous patients with various etiologies and severity of ARF. Overall, transferred patients were younger, had high severity of illness, and were more likely to have commercial insurance compared with nontransferred cohorts. There is a paucity of data examining why patients get transferred. Studies that retrospectively evaluated outcomes between transferred and nontransferred cohorts found no differences in mortality, although transferred patients have a longer length of stay. There is limited evidence to suggest that patients transferred early in their course have improved outcomes. Our scoping review highlights the sparse evidence and the urgent need for further research into understanding the complexity behind ARF transfers. Future studies should focus on defining best practices to inform clinical decision-making and improve downstream outcomes.

Collaborative Care Cost-Sharing and Referral Rates in Colorado.

Collaborative care integrates mental health treatment into primary care and has been shown effective. Yet even in states where its use has been encouraged, take-up remains low and there are potential financial barriers to care. Describe patient out-of-pocket costs and variations in referral patterns for collaborative care in Colorado. Retrospective observational study using administrative medical claims data to identify outpatient visits with collaborative care. For individuals with ≥1 visit, we measure spending and visits at the month level. Among physicians with billings for collaborative care, we measure prevalence of eligible patients with collaborative care utilization. Patients with Medicare, Medicare Advantage, or commercial health insurance in Colorado, 2018-2019. Out-of-pocket costs (enrollee payments to clinicians), total spending (insurer+enrollee payments to clinicians), percent of patients billed collaborative care. Median total spending (insurer+patient cost) was $48.32 (IQR: $41-$53). Median out-of-pocket cost per month in collaborative care was $8.35 per visit (IQR: $0-$10). Patients with commercial insurance paid the most per month (median: $15); patients with Medicare Advantage paid the least (median: $0). Among clinicians billing for collaborative care (n=193), a mean of 12 percent of eligible patients utilized collaborative care; family practice and advanced practice clinicians' patients utilized it most often. Collaborative care remains underused with fewer than 1 in 6 potentially eligible patients receiving care in this setting. Out-of-pocket costs varied, though were generally low; uncertainty about costs may contribute to low uptake.

Patient accessibility and utilization of behavioral sleep medicine referrals in an academic center.

Behavioral sleep medicine (BSM) is a subspecialty that combines behavioral psychology and sleep medicine specialties. The objective of this study was to analyze referral patterns to a BSM clinic. The three specific aims were: (1) describe factors that predict referral acceptance, (2) identify barriers to attending initial appointment, and (3) describe variables associated with the number of visits attended. Retrospective chart reviews were conducted as part of a quality improvement project by this study team's clinical setting. Adults over 21 years of age who were referred to a behavioral sleep medicine clinic in an urban Midwestern academic healthcare system between 2014-2019 were included in this study. Sleep medicine was the main referral source for BSM patients (74.2%), followed by internal medicine (9.3%) and neurology/psychiatry (7.3%). Thirty-eight percent of patients did not schedule an appointment after a referral for BSM was initiated. Younger age, longer distance from clinic, commercial insurance and out of network insurance were all significantly greater for non-schedulers. Eighty-three percent of patients did attend the initial intake session with BSM providers. Older age was associated with lower likelihood of not attending scheduled BSM appointments. Patient characteristics of older age, closer distance from clinic, and in network insurance coverage were found to significantly increase the likelihood of BSM scheduling, while younger age, Black race and not getting a primary sleep disorder diagnosis (versus a diagnosis of Insomnia Disorder) and shorter days from referral to appointment were associated with an increased likelihood of not attending the scheduled BSM treatment engagement.

Estimates of the excess cost burden of Ehlers-Danlos syndromes: a United States MarketScan® claims database analysis.

Patients with Ehlers-Danlos syndromes (EDS) and hypermobility spectrum disorders (HSD) have significant health challenges that are well-documented, however their impact in terms of cost is not known. Our research objective was to examine the cost burden of EDS and HSD in the United States. We focused this analysis on those with commercial insurance plans. We queried the MarketScan® database for year 2021 for claims that contained an ICD-10 diagnosis code for EDS or hypermobility. Excess costs for patients in the EDS and HSD cohorts were determined by matching each patient to one patient in the database that did not have a claim for EDS or HSD and comparing total costs for the calendar year. We determined whether patients had claims for selected comorbid conditions likely to impact costs during the calendar year. Sample sizes were 5,113 for adult (age ≥ 18) patients with EDS, 4,880 for adult patients with HSD, 1,059 for child (age 5-17) patients with EDS, and 2,427 for child patients with HSD. The mean excess costs were $21,100 for adult EDS patients, $11,600 for adult HSD patients, $17,000 for child EDS patients, and $11,000 for child HSD patients. EDS and HSD cohorts, both adults and children, with any of the comorbidities had greater healthcare costs. The largest difference was found in the EDS cohort with gastrointestinal comorbid conditions, with more than double the costs for adults. We found that patients in the MarketScan database, adults and children, who had EDS or HSD had substantially higher associated excess healthcare costs than patients without EDS or HSD when considering age, sex, geographic location, and comorbidities. These disproportionate healthcare costs in this population have health policy and economic implications, including the need for rapid diagnosis, access to treatment, and accelerated research to advance treatments.

Analyzing Racial Disparities in Pediatric Atopic Comorbidity Emergency Department Visitation Using Electronic Health Records

BackgroundAlthough atopic diseases and associated co-morbidities are prevalent in children, little is known about racial differences in emergency department (ED) visitation. ObjectiveWe sought to examine racial differences in ED visitation among children with allergic comorbidities. MethodsWe conducted a retrospective study of patients (<21 years) who visited the ED at a large pediatric hospital for atopic dermatitis (AD), food allergy (FA), asthma, allergic rhinitis (AR), and eosinophilic esophagitis (EoE) from 2015 to 2019. We determined the probability of ED encounter-free using hazard ratios (HR) and time to recurrence (TTR) of ED encounter for patients identified as Black/African American (AA) and White/European American (EA). We assessed potentially underlying allergic, demographic, and place-based factors, and potential interactions between factors. ResultsA total of 30,894 patients (38% AA, 62% EA) had 83,078 ED encounters (38,378 first ED encounters, and 44,700 recurrent ED encounters) during the study period. Asthma and AR showed the highest rate of comorbidity in ED encounters in both AA and EA children. AA children exhibited higher HR for encounter following index AD and asthma encounters. We found an interaction between the type of insurance and race in ED encounters for AD, FA, AR, and EoE. In AA children, those insured by Medicaid demonstrated a higher HR for any encounter compared to those with commercial insurance. Conversely, in EA children, those with Medicaid insurance showed a lower HR compared to their commercially insured peers. Regardless of race, allergic comorbidity increased the HR of ED encounter (1.12-1.62) for all allergic diseases. At 5-years follow up, mean differences in TTR were shorter in AA children compared to EA children in AD, FA, and asthma. ConclusionIdentification of disease-specific racial disparities in ED visitation related to atopic diseases is a necessary first step toward the design and implementation of interventions capable of equitably reducing emergency care in atopic comorbid children.

Changes in payer mix of new and established trauma centers: the new trauma center money grab?

BackgroundAlthough timely access to trauma center (TC) care for injured patients is essential, the proliferation of new TCs does not always improve outcomes. Hospitals may seek TC accreditation for financial...

Poster 286: The Literature that Commercial Payers Use to Substantiate Coverage Policy Are of Low Level of Evidence

Objectives: Injury to hyaline cartilage is problematic for both patients and physicians due to a limited potential for cartilage to heal. In the case of large chondral lesions, osteochondral allograft transplantation (OCA) is a popular and effective treatment modality with well-reported outcomes. However, given the costs of surgical operations in the United States, most patients require reimbursements through private insurance payers. It has previously been reported that the literature that substantiates the private commercial payers’ policies regarding certain orthopaedic procedures is based on low level of evidence studies. However, to the best of our knowledge, this information is not available regarding policies on OCA. Therefore, the purpose of this study is to determine the level of evidence of the referenced cited in the policies regarding OCA for the leading commercial payers in the United States and to determine whether these references investigated the criteria that has been established by the payers. Methods: Ten national commercial private health insurance payers were identified. These payers included Centene Corporation, United Healthcare, Humana, Health Care Service Corporation, Cigna, Kaiser Permanente, WellCare Health Plans, The UPMC Health Plan, Anthem, and Aetna. Each payer was contacted either via phone or email to obtain their coverage policies regarding OCA. For each policy, all references related to OCA were collected for a standardized review completed by reviewers. The information collected included the criteria set by each policy, level of evidence of each reference, and whether the cited reference investigated the commercial payers’ eligibility criteria for OCA. Results: Six main private health insurance companies had publicly available and current medical policies on osteochondral allograft transplants, including Centene Corporation, United Healthcare, Humana, Health Care Service Corporation, Cigna, and Aetna. A total of 110 references were found amongst these six medical healthcare providers of which 65 (59%) are primary journal articles, 29 (26%) are reviews or expert opinion articles, 5 (4.5%) are government reports, 6 (5.5%) are society guidelines, 3 (2.7%) are websites, 1 (1%) are rated as miscellaneous and 1 (1%) could not be found/accessed. Of the 102 references that were accessible, 1 reference showed a level of evidence (LOE) I (1%), 12 with LOE II (12%), 7 with LOE III (7%), 57 with LOE IV(57%), and 18 with LOE V(18%). The remaining 6 references had either a variable LOE or where an LOE rating was deemed unapplicable. Of the six main private health insurance medical policies attained, five (excluding United Healthcare) had corresponding publicly accessible medical necessity guidelines outlining criteria for procedural approval. From these five private health insurance companies, 22 of the 91 references directly tested for any of the listed medical necessity criteria. Amongst references directly testing the medical necessity criteria, 19 (86%) had a LOE IV, 1 (4.5%) with LOE I, 1 (4.5%) with LOE II, and 1 (4.5%) with a variable LOE. Conclusions: Analyzing commercial payers’ policies highlights that the majority of cited references that substantiate these policies are of low level of evidence. Furthermore, less than a quarter (24.2%) of references directly investigate the policy’s medical necessity. This perhaps illustrates a combination of a lack of high-quality studies investigating OCA and selective reporting of literature by these commercial payers. Patients and surgeons will benefit from future studies aimed at increasing awareness of the quality of evidence that helps establish commercial payers’ policies.

Outpatient Factors Implicated in Timing of Delayed Elective Inguinal Hernia Repair in Premature Neonates: Single Center Analysis Brings Up a Touchy Issue and Balancing Metric

IntroductionAmong premature infants, the incidence of inguinal hernias (IH) has been reported to be as high as 10–30%. We performed this study to characterize the association between individual and systemic variables that may affect diagnosis to definitive operative repair of the premature neonatal IH in the outpatient setting. MethodsA single center cohort retrospective review analyzing IH repair in the premature neonatal (<37 GA) population was performed. Data was collected between 2013 and 2022. The cohort was defined as patients who underwent repair before the age of 1 and excluded patients with major medical comorbidities or underwent simultaneous major abdominal surgeries. ResultsOf the 836 premature neonates who underwent IH repair, the majority (73%) were repaired electively. Patients were characterized into risk cohorts a-priori. High-risk patients (HR, n = 43) were more likely to have Government insurance (67%). There was a significant difference in HR patient time to surgery between Government versus Commercial insurance, 10.6 versus 4.7 days, respectively (95% CI -11.09 to −0.4396, p = 0.0345). HR patients were also seen more frequently (clinic or emergency department) prior to operative repair (2.51 vs 1.72 95% CI –1.296% to −0.289%, p = 0.0021). A multivariate linear regression model demonstrated that risk class (p = 0.0244), touches (p < 0.0001), GA (p < 0.001), and prior authorization (p < 0.0001) were significantly associated with time to hernia repair. ConclusionsSystemic variables such as insurance type may increase average wait time for elective outpatient IH repair. This increase in wait time is associated with an increased number of healthcare visits. Therefore, timely access to surgical care prevents potential harm and may decrease health system burden. Type of StudyRetrospective comparative study/cohort study. Level of EvidenceIII.

Building Bridges: Increasing Access to Care and Continuation of Medication for Opioid Use Disorder Through Community Partnerships

The opioid epidemic continues to pose a formidable challenge to public health, necessitating innovative approaches to enhance access to care and support continuity of treatment for individuals with opioid use disorder (OUD). Opioid overdose-related deaths in Detroit have increased over four-fold from 1999 to 2019, yet the rate of medication for opioid use disorder (MOUD) prescriptions in Detroit has been half the rate compared to Michigan as a whole. Limited access to care remains a major factor in continued opioid use, which is driven in part by an individual’s insurance coverage. As the largest payer of substance use disorder services in the United States, Medicaid plays a central role in efforts to address the opioid epidemic. Over half of the Detroit population is either enrolled in Medicaid or uninsured. Henry Ford Hospital (HFH) continues to treat hospitalized patients with OUD. Post-discharge follow-up appointments for continuation of MOUD have been shown to increase rates of prolonged abstinence, reduce rates of readmission, and decrease mortality rates. Despite HFH’s significant community impact, there have been limitations on which insurance carriers are accepted at our institution when patients try to establish outpatient primary care or specialty addiction medicine services for MOUD. This insurance-driven barrier has consequently limited our ability to provide best practices in supporting patients with OUD. To address this disparity, we aimed to investigate the impact of leveraging our partnership with Community Health and Social Services (CHASS) Clinic, a local Federally Qualified Health Center network, as an opportunity for underinsured and non-insured patients with OUD to have increased access to post-discharge follow-up appointments with qualified providers for continuation of MOUD. In collaboration with the HFH Addiction Medicine Consult team, HFH Primary Care Physicians, and CHASS MOUD providers, we designed a multifaceted intervention to improve the continuum of care for patients with OUD. We established a post-discharge referral pathway between HFH and CHASS, enhancing communication channels to facilitate care coordination. If a patient was admitted to HFH with a diagnosis of OUD and received an Addiction Medicine consult, the primary team was advised to arrange a post-discharge follow-up appointment for MOUD. The location of the appointment was determined by the patient’s insurance. Patients already established with HFH, or with commercial insurance, were scheduled with HFH providers for MOUD. Patients with Medicaid or no insurance were scheduled with CHASS MOUD providers. In the six months prior to implementation, only 3 of 60 (5%) of patients with a diagnosis of OUD that received an Addiction Medicine consult were scheduled to have a post-discharge follow-up for MOUD. In three months after implementation, 8 of 32 (25%) patients received post-discharge follow-up for MOUD. By utilizing the partnership between HFH and CHASS, our intervention was associated with a five-fold higher rate of follow-up appointments for continuation of MOUD. These findings underscore the effectiveness of community partnerships in addressing barriers to care and enhancing treatment for individuals with OUD.

Glycemic Control Impacts the Quality of Bowel Preparation in Patients Undergoing Elective Colonoscopy: A Multicenter Retrospective Cohort Study

Introduction: Diabetes Mellitus has been linked to poor quality of bowel preparation (BP) but the impact of various glycemic control levels remains unclear. The primary objective of this study was to investigate the relationship between the quality of BP and the glycemic control in patients with diabetes. Methods: Data was collected retrospectively to identify adults who underwent elective colonoscopy from March 2020-December 2022. The patient population was subdivided into two groups based on the quality of BP. Univariate and multivariate analyses were used to assess associations between glycemic control, medications, sociodemographic factors, and BP quality. Results: A total of 1458 patients who met the inclusion criteria were included in the final analysis. Of these, 6.3% of patients had suboptimal BP. Non-diabetics, prediabetics, and well-controlled diabetics had lower odds (0.28, 0.20, and 0.32;p&lt;0.001) of having suboptimal BP as compared to poorly controlled diabetics. Insulin users had higher odds (5.39;p&lt;0.01), non-smokers and former smokers had lower odds (0.54, 0.40;p&lt;0.04), and medicare and commercial insurance holders had lower odds (0.49, 0.28;p&lt;0.001) of suboptimal BP. Gender, body mass index, and the use of glucagon-like peptide-1 (GLP-1) agonists were not shown to impact the quality of BP. Conclusions: This study shows that poorly controlled and insulin-dependent diabetics have higher rates of suboptimal QBP, leading to missed lesions and increased colon cancer risk. Limited access to healthcare due to low socioeconomic status indirectly contributes to poorly controlled DM and higher rates of suboptimal QBP. Identifying poor preparation risks allows targeted interventions to enhance QBP in high-risk patients. By prioritizing bowel preparation optimization, we can enhance the overall quality of colonoscopy screening, leading to earlier detection of colorectal malignancies, improved patient outcomes, and a reduction in the burden of colorectal cancer.