Prior Insurance Research Articles

Analysing Health Insurance Customer Dataset to Determine Cross-Selling Potential

Health insurance cross-selling refers to the practice of offering additional or complementary insurance products to existing policyholders. Insurance providers leverage cross-selling, offering customers additional policies like dental or life insurance when they already have a basic health insurance plan. This study is conducted to focus on the application of machine learning techniques to predict health insurance cross-selling opportunities among South African customers. The aim of this study is to develop a cross-selling predictive machine learning model that can assist health insurance companies to identify potential customers for cross-selling probabilities. To achieve this goal, a quantitative research methodology is adopted, focusing on extracting a comprehensive dataset of health insurance consumer information and employing various machine learning algorithms using the Python programming language, including Random Forest, K-Nearest Neighbours, XGBoost classifier, and Logistic Regression algorithms to build the cross-selling predictive machine learning model. The experimental results obtained demonstrate the accuracy scores of four different machine learning algorithms trained using 1,000,000 customer dataset with 17 features, logistic regression is considered as the top-performing model. It achieved an accuracy score of 0.83 and an F1 score of 0.91. The analysis indicates that customers aged 30-60, with prior insurance, and longer service history are more likely to buy additional health insurance products. The findings of this research can help health insurers boost revenue by improving their customer targeting and retention strategies.

Impact of prior underinsurance on cervical cancer screening among Davidson County, Tennessee, women diagnosed with invasive cervical cancer, 2008\u20132018

IntroductionWe sought to investigate the association between insurance coverage history and cervical cancer screening among Davidson County, Tennessee, women diagnosed with incident cervical cancer.MethodsWe reviewed medical records of women diagnosed with invasive cervical cancer from 2008 through 2018 identified via the state's cancer registry and by active surveillance of diagnostic pathology reports for the HPV-IMPACT project. Per 2012 United States Preventive Services Task Force recommended cervical cancer screening guidelines, women were characterized into three screening history categories: “no screening”, “no follow-up” and “test/screening failure”. Multivariable logistic regression measured the association of prior inadequate insurance (underinsurance) and screening history (“no screening/no follow-up” compared to “test/screening failure”).ResultsOf 212 women, most (77%) had not undergone recommended cervical cancer screening or follow-up prior to cancer diagnosis. Overall, 28% of women had history of underinsurance in 5 years prior to diagnosis. In adjusted analyses, underinsured women were more likely to have a “no screening/no follow-up” prior to cancer diagnosis (aOR 4.26; 95% CI 1.15–15.80) compared to “test/screening failure” history. Non-white race (aOR 2.73; 95% CI 0.98–7.61), older age (aOR 1.03 per year; 95% CI 1.00–1.07), and history of smoking (aOR 4.07; 95% CI 1.54–10.74) were also associated with increased likelihood of “no screening/no follow-up”.ConclusionsPrevious underinsurance was independently associated with non-adherence to cervical cancer screening and follow-up guidelines among women with incident cervical cancer. Further study of factors contributing to inadequate cervical cancer screening and interventions to increase cervical cancer screening in high-risk populations is needed.

Crowd-Out and Emergency Department Utilization

When consumers gain Medicaid, their cost of healthcare changes. The direction of this change determines how utilization changes. The previously uninsured see a stark decrease in the price of primary care after gaining public insurance. Due to charity care, they may face an increase in the price of emergency department care. The previously insured see a reduction in emergency department prices and decreased access to primary care. We examine the impact of the prior insurance status of the newly publicly insured on substitution between healthcare. We base our identification on California’s LIHP and ACA Medicaid expansions. One challenge we face is estimating crowd-out. We use machine learning techniques to predict prior insurance status based on observable covariates in cross-sectional data. We find an increase in emergency department utilization caused entirely by those crowded-out whose access to primary care has decreased. We find the opposite utilization patterns for the previously uninsured.

Barriers and Facilitators of Advanced Practice Registered Nurse Participation in Medication Treatment for Opioid Use Disorder: A Mixed Methods Study

<h3>Background</h3> The misuse of opioids is a health crisis in the United States. Medication treatment for opioid use disorder reduces negative health outcomes, but there are widespread shortages of appropriately trained and credentialed providers. Advanced practice registered nurses (APRNs) have recently become eligible for Drug Enforcement Administration (DEA) waivers that allow them to prescribe the most common medication, buprenorphine, but many factors might constrain their full participation in opioid use disorder treatment. <h3>Purpose</h3> This study aimed to describe practice and regulatory barriers and facilitators to APRNs offering buprenorphine treatment. <h3>Methods</h3> This mixed methods study integrated quantitative data on whether states' APRN scope-of-practice regulations were correlated with obtaining DEA waivers and qualitative data from site visits to four states with high numbers of opioid overdose deaths. <h3>Results</h3> Quantitative analysis found that a higher percentage of APRNs were waivered in states in which APRNs could prescribe without physician oversight compared with states that require physician oversight. The average percentage of APRNs with a waiver was significantly greater in rural counties than in urban counties in states that do not require physician oversight of NPs (<i>p</i> = .006), as was the number of waivered APRNs per 100,000 population (<i>p</i> = .005). In contrast, the number of waivered APRNs per 100,000 population was lower in rural counties versus urban counties in states that required physician oversight (<i>p</i> = .005). Qualitative findings indicated that state regulations requiring physician supervision of APRNs, federal waiver restrictions on the number of patients treated, prior insurance authorization requirements for buprenorphine, insurance requirements of counseling services, and nurse attitudes toward addiction were barriers to buprenorphine prescribing. <h3>Conclusion</h3> Qualitative findings indicate that waivered APRNs may not use the waiver due to practice and regulatory barriers. Requirements that physicians oversee APRN prescribing of buprenorphine may have slowed the growth of the opioid treatment workforce. Other regulations, organizational culture, and community support of buprenorphine treatment also affect APRN engagement in offering buprenorphine treatment.

Insurance instability and use of emergency and office-based care after gaining coverage: An observational cohort study.

The Affordable Care Act led to improvements in reporting a usual source of care, but it is unclear whether patients are changing their usual source of care in response to coverage gains. We assess whether prior insurance instability is associated with changes in use of emergency and office-based care after the Marketplace and Medicaid expansion were introduced. Our study draws from the 2013-14 Medical Expenditure Panel Survey, identifying a cohort of non-elderly adults with full-year health insurance coverage in 2014. We use linear and multinomial logistic regression to assess the relationship between insurance instability prior to 2014 (uninsured for 1-11 months, ≥12 months) and person-level changes in use of health care after gaining coverage (change in ED and office visits from 2013 to 2014) with continuously insured individuals serving as a comparison group. Being uninsured for at least one year prior to gaining full-year coverage in 2014 was associated with a 33% increase in ED visits (0.06 visits, p<0.01) and a 47% increase in office visits (1.10 visits, p<0.01), driven by those gaining public coverage. We found no evidence of substitution across settings in the short term, often a stated goal of expansion. The long-term uninsured may have substantial health needs and pent-up demand for health care, seeing more physicians across multiple settings in the year after gaining coverage as they seek to get unmanaged conditions under control. Closing the gap in primary care use between the previously uninsured and those with health insurance coverage may help improve long-term health outcomes.

Barriers to the Treatment of Hepatitis C among Predominantly African American Patients Seeking Care in an Urban Teaching Hospital in Washington, D.C.

BackgroundIn the United States, it is estimated that 2.4 million people are currently infected with the hepatitis C virus (HCV). In order to address HCV infection management in the U.S., several government entities collaborated to develop and release a multistep plan for the prevention, care, and treatment of viral hepatitis. Optimal health outcomes from the plan are contingent upon addressing each of the several steps in the HCV care cascade. Among the critical challenging steps is linkage to care and access to treatment. Of the nearly three million people in the U.S. infected with HCV, only 43% have been linked to care, 16% have received treatment, and 9% have had their infection resolved. ObjectiveThis retrospective study aims to identify predictors within the HCV treatment cascade that contribute to failures in care of HCV-infected patients in an urban hospital setting located in the District of Columbia. SettingThe outpatient clinics of a tertiary-care urban teaching hospital. MethodsA retrospective study was conducted using electronic medical records of persons 18 years and older who were HCV antibody positive and had at least one visit at any of the outpatient clinics from August 1, 2015 to August 1, 2016. Descriptive analysis of HCV positive persons was conducted, and predictors of HCV treatment were assessed. ResultsA total of 252 patients were included in the study. Overall, patients were predominantly male (63.1%), African American (97.6%), under the age of 65 (71.4%), covered by public insurance (89.3%), and were diagnosed with HCV after the year 2001 (53.2%). Additionally, majority of patients had not been treated for their HCV infection (58%). Multiple barriers resulted in HCV infected patients not obtaining access to treatment. Fibrosis stage (p < 0.001) and prior insurance denial (p < 0.05) were significant predictors of HCV treatment. Age, gender, insurance type, substance abuse, alcohol abuse, and year of HCV diagnosis were not associated with limited access of HCV treatment. ConclusionHCV infections remain a major public health concern among patients in the District of Columbia. This study identified fibrosis stage and prior insurance denial as primary barriers to access of HCV treatment. While there are many points in the hepatitis cascade of care in which patients can lose access to or fail treatment completion, the primary point of intervention in our patient population appears to be during the initiation of treatment and insurance prior authorization process.

Insurance Purchase for Low-Probability Losses

It is widely accepted that individuals tend to underinsure against low-probability, high-loss events relative to high-probability, low-loss events. This conventional wisdom is based largely on field studies, as there is very little experimental evidence. We reexamine this issue with an experiment that accounts for possible confounds in prior insurance experiments. Our results are counter to the prior experimental evidence, as we observe subjects buying more insurance for low-probability events than the higher-probability events, given a constant expected loss and load factor. Our results suggest that, to the extent underinsurance for catastrophic risk is observed in the field, it can be attributed to factors other than the relative probability of the loss events.

Characteristics of Hemophilia A Patients Treated with Emicizumab: an Early View using Claims Database Analysis

Introduction Hemophilia A is a genetic bleeding disorder characterized by bleeding episodes due to deficiency of factor VIII (FVIII). Emicizumab (EMI) is a recombinant, humanized, bispecific factor IXa- and factor X-directed monoclonal antibody, indicated for routine prophylaxis in all persons with hemophilia A (PwHA) with or without FVIII inhibitors. This study aimed to provide an early view of the characteristics of PwHA who are treated with emicizumab. Methods This was a retrospective cohort study using US commercial insurance claims data from MarketScan Commercial Research Database and PharMetrics Plus Database from 11/16/17 to 12/30/18 (MarketScan data available until 9/30/18 at the time of analysis). The study cohort included PwHA with ≥1 emicizumab claim during the study period. Emicizumab claims were identified using NDC or HCPCS codes (Q9995). The index date was defined as the date of first emicizumab claim. However, this index date was adjusted to an earlier date during the study period, if an appropriate miscellaneous/unclassified drug or biologic HCPCS J-code claim was identified indicating emicizumab use prior to the specific NDC or Q-code claim. The study sample was required to have ≥12 months of continuous insurance enrollment prior to the index date i.e. prior to starting emicizumab (pre-EMI period). Demographics, all-cause health care resource utilization and clinical characteristics including major bleeds, arthropathy, and any pain diagnosis were examined in the pre-EMI period. Major bleeds were identified using a previously developed algorithm (Shrestha et al. 2017) while arthropathy and pain were identified using International Classification of Diseases, 9th Revision, Clinical Modification or ICD-9-CM/ICD-10-CM diagnosis codes. FVIII and bypassing agents (BPAs) were identified using NDC or HCPCS codes. Results We identified a total of 47 PwHA taking emicizumab with ≥12 months of prior continuous insurance enrollment. The mean age of these individuals was 20.4 years (standard deviation [SD]=16.7, range=1-61y); 19.1% (n=9) were under 5 years of age and 36.2% (n=17) ages 6-17 years. All individuals were male (100%), and the majority were in the Southern region of the US (44.7%, n=21) and covered with Preferred Provider Organization insurance plans (78.7%, n=37). In the pre-EMI period, 25.5% (n=12) of the cohort had evidence of inhibitors (i.e. claim for a BPA); 27.7% (n=13) had evidence of a major bleed, with an average of 2.8 bleeds (SD=2.3; range=1-8) among those with ≥1 major bleed-related claim; 21.3% (n=10) had diagnosis of any arthropathy; and 19.1% (n=9) had diagnosis of any pain. A total of 76.6% (n=36) and 25.5% (n=12) of PwHA had evidence of FVIII or BPA use in the pre-EMI year, with an average of 12.8 (SD=15.1) and 11.5 (SD=8.6) prescriptions/ administrations among those with ≥1 FVIII or BPA claim, respectively. Overall, 36.2% (n=17) of the cohort had ≥1 emergency room visit (mean=0.8, SD = 1.6); 17.0% (n=8) had ≥1 inpatient hospital stay (mean=0.2, SD=0.6), with a mean length of stay of 1.3 days (SD=3.3); 80.9% (n=38) had ≥1 outpatient hospital visit (mean=5.4, SD=14.2); and 83.0% (n=39) had ≥1 office visit (mean=7.3, SD=9.3) in the pre-EMI period. Conclusions This is the first study to provide an understanding of the disease and treatment characteristics of PwHA who are initiating treatment with emicizumab using insurance claims data. Based on these findings, emicizumab is being used across all age groups and in patients with different clinical characteristics. Availability of more longitudinal data following treatment initiation with emicizumab will allow for an assessment and comparison of real-world treatment outcomes in PwHA. Disclosures Mahajerin: Spark: Speakers Bureau; Alexion: Speakers Bureau; Kedrion: Membership on an entity's Board of Directors or advisory committees; Genentech: Consultancy, Speakers Bureau. Yang:Genentech: Employment, Equity Ownership. Patel:Genentech: Employment; Roche/Genentech: Equity Ownership.

Association Between Prior Insurance and Health Service Utilization Among the Long-Term Uninsured in South Carolina.

Purpose: Strong evidence supports the relationship between health coverage and improved health status. Little is known about the lasting impact of prior health insurance on the prior insured's use of health services. We aimed to examine the association between prior insurance status and health service utilization (HSU) among the long-term uninsured (LTU) in South Carolina.Methods: The current study used data from in-person interviews of the LTU collected in a 2014 cross-sectional South Carolina survey. Men and women between 18–64 years of age who reported not having health insurance for at least 24 months at the time of data collection were included. Propensity score analysis was used to examine the associations between prior insurance status and three outcome variables: (1) having a usual source of care, (2) HSU, and (3) delaying health care needs.Results: Prior health insurance significantly predicted a greater likelihood of having a usual source of care (effect size: 9.2%, p=0.004) and having had at least one preventive visit during the past 2 years (effect size: 6.4%, p=0.035). Prior insurance coverage was positively associated with delayed health care utilization, but the result was not statistically significant (p=0.703).Conclusions: Among the LTU, ever having insurance coverage was positively associated with having a usual source of care and HSU. The lasting impact of insurance coverage on HSU behavior extends beyond the period of insurance coverage, which provides a more comprehensive and deeper understanding of the long-term implications of national and local efforts in expanding insurance coverage.

Last Insurer Standing: Accounting for Policyholder Settlements in an “All Sums” World

In 2016, New York became the latest state to interpret insurance policies with prior insurance or non-cumulation of liability clauses as permitting a policyholder to recover damages under “all sums” for long-tail liabilities, including environmental liabilities. But two major questions were left unanswered in New York, as in many other states, when a policyholder seeks all sums recovery from a non-settled insurer after the policyholder settles with other insurers: first, how to account for a policyholder’s prior settlements—through set-off, contribution, or both. Second, how to calculate any set-off or contribution—should it be pro tanto, pro rata, or something else. This article examines the arguments on both sides of these issues and looks ahead to how courts may resolve these questions going forward.

Outcomes of Angiotensin Receptor-Neprilysin Inhibitor Prescriptions for Patients with Heart Failure and Reduced Ejection Fraction in Real World Clinical Practice

Introduction While guidelines now recommend the use of Angiotensin Receptor-Neprilysin Inhibitors (ARNI) in place of ACE inhibitors and angiotensin receptor blockers for select patients with heart failure and reduced ejection fraction, the utilization of ARNI among eligible patients in clinical practice remains low. Access, cost, and tolerability are perceived barriers to use. Hypothesis We hypothesized that financial barriers to prescriptions are an important factor contributing to underutilization of ARNI among eligible patients in clinical practice. Methods We conducted a single-center, retrospective analysis of all new ARNI prescriptions at our center written from June 2015 to May 2017. For all prescriptions, we tracked the subsequent success with prior insurance authorization (PA), patient initiation of medication, dose titration, as well as adaptations to concomitant heart failure medications. Results Of 167 prescriptions written, 139 reflected new starts of sacubitril/valsartan, 26 reflected continuations, and 2 had insufficient data for analysis. Of the new prescriptions, PAs were requested in 81 (58% of new starts), and granted in 75 patients (92.6% of requests). Prescriptions were successfully filled in 123 (88.5% of new starts), and subsequently discontinued in 17 patients (13.8%). Of subjects filling prescriptions, 33.3% of patients were titrated to the high dose (97/103 mg sacubitril/valsartan twice daily), 34.2% were titrated to the middle dose (49/51 mg twice daily) and 18.7% were titrated to the low dose (24/26 mg twice daily) [Figure 1] . Limiting factors to titration and continuation of therapy included hypotension (37%) and renal function (5.7%). During titration, dose reductions in beta-blockers and loop diuretics were made in 6.5% and 14% of patients respectively. Minimal changes were noted in dosing of aldosterone antagonists or other vasodilators. Conclusions Most patients prescribed ARNI therapy are successfully initiated in practice without significant cost or insurance barriers. As in the trials which led to approval, dose titration of ARNI was frequently limited by hypotension and renal dysfunction, and often facilitated reduction in loop diuretics. These ‘real-world’ data suggest that financial/insurance factors do not account for most underutilization of ARNI

Effect of Medicare (CMS) Insulin Pump Policies in T1D

CMS has numerous requirements for insulin pump coverage and obtaining disposable supplies. T1D Exchange surveyed 241 adult T1D patients who had been on a pump with CMS coverage for at least 6 mo on their experience. Median age 67, 64% women, 93% white, 16% on disability, median T1D duration 42 y, median pump use 15 y, mean A1c 7.0%, 82% on pump before starting CMS, 95% current pump users. Of those starting a pump while on CMS, 50% reported challenges, most commonly cost of the supplies (29%) or the pump (24%). Issues with obtaining supplies reported in 57.5%, the most common problems being delays releasing supplies (29%), difficulty getting paperwork completed (23.5%), and seeing an HCP face to face every 90 days (18%). When asked if they had changed pump behaviors because of possible or actual supply delays, 39% answered yes. Most common responses: leaving site in place &amp;gt;3 days (64%), explicitly to reduce cost (33%), reused pump supplies (34%), used injections to supplement pump (23%), or temporarily stopped pump (17%). Responses to a question about any adverse effects of these actions are shown in Table. On their experience with CMS compared to prior insurance, a minority thought it was somewhat (4%) or much (6%) better; 31% about the same; 28% found it somewhat worse, and 31% found it much worse. Conclusion: current CMS pump policies cause increased adverse pump behaviors and outcomes in T1D, and CMS is perceived negatively compared to prior insurers by 59% of respondents.Adverse outcomes from changes in pump related actions, n=88QuestionfrequencypercentQuestionfrequencypercentNone2122.8Hospitalization66.5Higher blood sugar3740.2More hypoglycemia1516.3Infection at site1314.1Increased anxiety or frustration3942.4Pain or irritation3032.6Required emergency pump supply shipment1718.5More scarring2527.2Needed emergency supplies from local source1314.1More erratic blood sugar4245.7Other11.1Diabetic Ketoacidosis88.7No change needed22.2 Disclosure N.B. Argento: Speaker's Bureau; Self; Dexcom, Inc., Novo Nordisk Inc.. Advisory Panel; Self; Eli Lilly and Company. Speaker's Bureau; Self; Eli Lilly and Company. Advisory Panel; Self; Unomedical a/s, T1D Exchange. Speaker's Bureau; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc.. Advisory Panel; Self; Senseonics. Consultant; Self; Intuity Medical. J. Liu: None. A. Hickey: None. E. Gautschi: None. A.H. McAuliffe-Fogarty: Advisory Panel; Self; Novo Nordisk Inc..

Oregon Medicaid Expenditures After the 2014 Affordable Care Act Medicaid Expansion: Over-time Differences Among New, Returning, and Continuously Insured Enrollees.

There is interest in assessing health care utilization and expenditures among new Medicaid enrollees after the 2014 Medicaid expansion. Recent studies have not differentiated between newly enrolled individuals and those returning after coverage gaps. To assess health care expenditures among Medicaid enrollees in the 24 months after Oregon's 2014 Medicaid expansions and examine whether expenditure patterns were different among the newly, returning, and continuously insured (CI). Retrospective cohort study using inverse-propensity weights to adjust for differences between groups. Oregon adult Medicaid beneficiaries insured continuously from 2014 to 2015 who were either newly, returning, or CI. Monthly expenditures for inpatient care, prescription drugs, total outpatient care, and subdivisions of outpatient care: emergency department, dental, mental and behavioral health, primary care, and specialist care. After initial increases, newly and returning insured (RI) outpatient expenditures dropped below CI. Expenditures for emergency department and dental services among the RI remained higher than among the newly insured. Newly insured mental and behavioral health, primary care, and specialist expenditures plateaued higher than RI. Prescription drug expenditures increased over time for all groups, with CI highest and RI lowest. All groups had similar inpatient expenditures over 24 months post-Medicaid expansion. Our findings reveal that outpatient expenditures for new nonpregnant, non-dual-eligible Oregon Medicaid recipients stabilized over time after meeting pent-up demand, and prior insurance history affected the mix of services that individuals received. Policy evaluations should consider expenditures over at least 24 months and should account for enrollees' prior insurance histories.

Busting the Myth of the Unavailability of Insurance Rule's Application to Loss Allocation for Pollution Liability Claims Since 1986

ABSTRACTTens of millions of dollars in pollution liability losses have been mistakenly allocated to general liability insurers under the “Unavailability of Insurance” rule in jurisdictions that employ it. Under this rule, a policyholder is not allocated losses for years when they claim that pollution liability was unavailable – mainly after the advent of the 1986 “absolute” pollution exclusion. Recent research has been compiled to include thousands of pages of evidence that by 1986 and to this date there was and has been a viable pollution liability insurance market that would not only underwrite a current year's risks, but also erase any prior pollution insurance coverage gaps by insuring decades of prior acts. This article looks at this rule and the enormous impact it could have on insurers' pollution liability reserves if it continues to be misapplied.

Prevalence and Predictors of Postdischarge Antibiotic Use Following Mastectomy.

OBJECTIVE Survey results suggest that prolonged administration of prophylactic antibiotics is common after mastectomy with reconstruction. We determined utilization, predictors, and outcomes of postdischarge prophylactic antibiotics after mastectomy with or without immediate breast reconstruction. DESIGN Retrospective cohort. PATIENTS Commercially insured women aged 18-64 years coded for mastectomy from January 2004 to December 2011 were included in the study. Women with a preexisting wound complication or septicemia were excluded. METHODS Predictors of prophylactic antibiotics within 5 days after discharge were identified in women with 1 year of prior insurance enrollment; relative risks (RR) were calculated using generalized estimating equations. RESULTS Overall, 12,501 mastectomy procedures were identified; immediate reconstruction was performed in 7,912 of these procedures (63.3%). Postdischarge prophylactic antibiotics were used in 4,439 procedures (56.1%) with immediate reconstruction and 1,053 procedures (22.9%) without immediate reconstruction (P.05). CONCLUSIONS Prophylactic postdischarge antibiotics are commonly prescribed after mastectomy; immediate reconstruction is the strongest predictor. Stewardship efforts in this population to limit continuation of prophylactic antibiotics after discharge are needed to limit antimicrobial resistance. Infect Control Hosp Epidemiol 2017;38:1048-1054.

Effect of a new cancer diagnosis on labor force participation (LFP): Has there been a change over time?

e18004 Background: Health shocks, such as a new cancer diagnosis, have been shown to reduce LFP in working adults. Over the past decade, there have economic swings, retirement age has increased, while newer cancer treatments may be less toxic or disabling. We update prior estimates of LFP responses, and assess whether patterns changed over time. Methods: Adults from the 1998-2014 waves of the Health and Retirement Study (HRS) who were aged 51+ yrs and working in 1998 or at HRS cohort entry in 2004 or 2010, were followed until their LFP decreased. Decreased LFP was defined as a switch from fulltime work, or a 10 hour or 25% decrease in hours worked. We created time varying indicators for health conditions (cancer, heart condition, lung disease, stroke) newly reported or worsened since the prior wave, condition history, demographics, net worth, and insurance coverage. We estimated discrete Cox proportional hazard survival models for the full sample, and with person-wave observations stratified pre/post 2008. Results: Among 13,918 working adults, mean age was 56 years, 45% women; health history included 5.3% cancer, 9.5% heart condition, 4.1% lung disease, 1.5% stroke; new health conditions included 2.9% cancer, 4.7% heart, 2.3% lung, and 1.3% stroke. Newly reported or worsened cancer, heart and lung disease were associated with similar risk of LFP decrease (see table). Prior history of lung disease, diabetes, arthritis and psychiatric disorders were associated with LFP decreases, but cancer was not. There was no difference in the effect of a new condition on LFP pre/post 2008. Conclusions: Many working adults reported preexisting health conditions. New diagnoses or worsening of cancer and other serious health conditions were associated with LFP reductions, although a longer term history of cancer was not associated with LFP changes. [Table: see text]

Health Care Utilization Rates After Oregon's 2008 Medicaid Expansion: Within-Group and Between-Group Differences Over Time Among New, Returning, and Continuously Insured Enrollees.

Although past research demonstrated that Medicaid expansions were associated with increased emergency department (ED) and primary care (PC) utilization, little is known about how long this increased utilization persists or whether postcoverage utilization is affected by prior insurance status. (1) To assess changes in ED, PC, mental and behavioral health care, and specialist care visit rates among individuals gaining Medicaid over 24 months postinsurance gain; and (2) to evaluate the association of previous insurance with utilization. Using claims data, we conducted a retrospective cohort analysis of adults insured for 24 months following Oregon's 2008 Medicaid expansion. Utilization rates among 1124 new and 1587 returning enrollees were compared with those among 5126 enrollees with continuous Medicaid coverage (≥1 y preexpansion). Visit rates were adjusted for propensity score classes and geographic region. PC visit rates in both newly and returning insured individuals significantly exceeded those in the continuously insured in months 4 through 12, but were not significantly elevated in the second year. In contrast, ED utilization rates were significantly higher in returning insured compared with newly or continuously insured individuals and remained elevated over time. New visits to PC and specialist care were higher among those who gained Medicaid compared with the continuously insured throughout the study period. Predicting the effect of insurance expansion on health care utilization should account for the prior coverage history of new enrollees. In addition, utilization of outpatient services changes with time after insurance, so expansion evaluations should allow for rate stabilization.

The Microstructure of the US Property-Casualty Reinsurance Network: Performance Effects

Reinsurance is the primary source of interconnectedness in the insurance industry. As such, reinsurance connectivity provides a transmission mechanism for financial shocks and exposes insurers to contagion and potential systemic risk. In this paper, connectivity within the U.S. property-casualty (P/C) reinsurance market is modeled as a network. We extend the prior insurance network literature by modeling the network of all insurers in the market (primary insurers and reinsurers) not just primary insurers. We analyze all bilateral reinsurance counterparty relationships (domestic and foreign) of U.S. P/C insurers, and we model both intra- and inter-group transactions. Our analysis of contagion and insolvency risk reveals that even the failure of the top 10 in-degree or in-strength reinsurers with 100 percent loss given default would not lead to widespread insolvencies in the U.S. P/C insurance industry.

Specialty Practice and Cost Considerations in the Management of Uveitis Associated With Juvenile Idiopathic Arthritis.

To evaluate whether cost, prior insurance authorization concerns, and subspecialty practice influence therapeutic decisions in the treatment of uveitis associated with juvenile idiopathic arthritis. A total of 2,965 pediatric ophthalmologists, uveitis specialists, retina specialists, and rheumatologists across the United States were surveyed via e-mail regarding their choice in long-term therapy for a hypothetical patient with uveitis associated with juvenile idiopathic arthritis. Outcomes of interest were differences in therapy choice based on cost/prior authorization and specialty practice. There were significant differences in the use of methotrexate and biologics among specialists, both with and without consideration for cost and prior authorization. Physicians in four different specialties who treat uveitis associated with juvenile idiopathic arthritis agree on methotrexate as a first-line treatment choice and a biologic immunosuppressive medication as a second choice, but there are significant differences between the specialties in their use of these medications. Cost and insurance considerations did not affect therapy selection. [J Pediatr Ophthalmol Strabismus. 2016;53(4):246-251.].

Design, methods, and baseline characteristics of the Kids' Health Insurance by Educating Lots of Parents (Kids' HELP) trial: A randomized, controlled trial of the effectiveness of parent mentors in insuring uninsured minority children

Background & objectivesSix million US children have no health insurance, and substantial racial/ethnic disparities exist. The design, methods, and baseline characteristics are described for Kids' Health Insurance by Educating Lots of Parents (Kids' HELP), the first randomized, clinical trial of the effectiveness of Parent Mentors (PMs) in insuring uninsured minority children. Methods & research designLatino and African-American children eligible for but not enrolled in Medicaid/CHIP were randomized to PMs, or a control group receiving traditional Medicaid/CHIP outreach. PMs are experienced parents with ≥1 Medicaid/CHIP-covered children. PMs received two days of training, and provide intervention families with information on Medicaid/CHIP eligibility, assistance with application submission, and help maintaining coverage. Primary outcomes include obtaining health insurance, time interval to obtain coverage, and parental satisfaction. A blinded assessor contacts subjects monthly for one year to monitor outcomes. ResultsOf 49,361 candidates screened, 329 fulfilled eligibility criteria and were randomized. The mean age is seven years for children and 32years for caregivers; 2/3 are Latino, 1/3 are African-American, and the mean annual family income is $21,857. Half of caregivers were unaware that their uninsured child is Medicaid/CHIP eligible, and 95% of uninsured children had prior insurance. Fifteen PMs completed two-day training sessions. All PMs are female and minority, 60% are unemployed, and the mean annual family income is $20,913. Post-PM-training, overall knowledge/skills test scores significantly increased, and 100% reported being very satisfied/satisfied with the training. ConclusionsKids' HELP successfully reached target populations, met participant enrollment goals, and recruited and trained PMs.