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Although cigarette smoking is a leading cause of premature morbidity and mortality in the United States, insurance coverage for smoking-cessation services is uncommon. 1 Lack of information about the effect of insurance coverage on the demand for and use of effective smoking-cessation services has prevented widescale adoption of coverage for such services. 2 The cost effectiveness of smoking-cessation interventions as compared with other medical services is well documented. 3 – 5 The few studies of the effects of out-of-pocket cost on the use of nicotine-replacement therapy have focused on nicotine gum, and the results suggest that offering it at a reduced cost or at . . .

Background Patients with gaps in health insurance coverage often defer or forgo cancer prevention services. These delays in cancer detection and diagnoses lead to higher rates of morbidity and mortality and increased costs. Recent advances in health information technology (HIT) create new opportunities to enhance insurance support services that reduce coverage gaps through automated processes applied in healthcare settings. This study will assess the implementation of insurance support HIT tools and their effectiveness at improving patients’ insurance coverage continuity and cancer screening rates. Methods/design This study uses a hybrid cluster-randomized design—a combined effectiveness and implementation trial—in community health centers (CHCs) in the USA. Eligible CHC clinic sites will be randomly assigned to one of two groups in the trial’s implementation component: tools + basic training (Arm I) and tools + enhanced training + facilitation (Arm II). A propensity score-matched control group of clinics will be selected to assess the tools’ effectiveness. Quantitative analyses of the tools’ impact will use electronic health record and Medicaid data to assess effectiveness. Qualitative data will be collected to evaluate the implementation process, understand how the HIT tools are being used, and identify facilitators and barriers to their implementation and use. Discussion This study will test the effectiveness of HIT tools to enhance insurance support in CHCs and will compare strategies for facilitating their implementation in “real-world” practice settings. Findings will inform further development and, if indicated, more widespread implementation of insurance support HIT tools. Trial registration Clinical trial NTC02355262

BackgroundBariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies.MethodsWe surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation.ResultsSixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%).ConclusionsA majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.

Selection (adverse or advantageous) is the central problem that inhibits the smooth, efficient functioning of competitive health insurance markets. Even—and perhaps especially—when consumers are well-informed decision makers and insurance markets are highly competitive and offer choice, such markets may function inefficiently due to risk selection. Selection can cause markets to unravel with skyrocketing premiums and can cause consumers to be under- or overinsured. In its simplest form, adverse selection arises due to the tendency of those who expect to incur high health care costs in the future to be the most motivated purchasers. The costlier enrollees are more likely to become insured rather than to remain uninsured, and conditional on having health insurance, the costlier enrollees sort themselves to the more generous plans in the choice set. These dual problems represent the primary concerns for policymakers designing regulations for health insurance markets. In this essay, we review the theory and evidence concerning selection in competitive health insurance markets and discuss the common policy tools used to address the problems it creates. We emphasize the two markets that seem especially likely to be targets of reform in the short and medium term: Medicare Advantage (the private plan option available under Medicare) and the state-level individual insurance markets.

At the beginning of the Covid pandemic, legislation ensured that Medicaid beneficiaries would remain enrolled until the public health emergency ended. What will happen now that the Biden administration has announced that it will end in May?

Undocumented migrant workers are generally ineligible for state social security schemes, and either forego needed health services or pay out of pocket. In 2001, the Thai Ministry of Public Health introduced a policy on migrant health. Migrant health insurance is a voluntary scheme, funded by an annual premium paid by workers. It enables access to health care at public facilities and reduces catastrophic health expenditures for undocumented migrants and their dependants. A range of migrant-friendly services, including trained community health volunteers, was introduced in the community and workplace. In 2014, the government introduced a multisectoral policy on migrants, coordinated across the interior, labour, public health and immigration ministries. In 2011, around 0.3 million workers, less than 9% of the estimated migrant labour force of 3.5 million, were covered by Thailand's social security scheme. A review of the latest data showed that from April to July 2016, 1 146 979 people (33.7% of the total estimated migrant labourers of 3 400 787) applied, were screened and were enrolled in the migrant health insurance scheme. Health volunteers, recruited from migrant communities and workplaces are appreciated by local communities and are effective in promoting health and increasing uptake of health services by migrants. The capacity of the health ministry to innovate and manage migrant health insurance was a crucial factor enabling expanded health insurance coverage for undocumented migrants. Continued policy support will be needed to increase recruitment to the insurance scheme and to scale-up migrant-friendly services.

The COVID-19 pandemic caused substantial disruptions in the field operations of all 3 major components of the Medical Expenditure Panel Survey (MEPS). The MEPS is widely used to study how policy changes and major shocks, such as the COVID-19 pandemic, affect insurance coverage, access, and preventive and other health care utilization and how these relate to population health. We describe how the MEPS program successfully responded to these challenges by reengineering field operations, including survey modes, to complete data collection and maintain data release schedules. The impact of the pandemic on response rates varied considerably across the MEPS. Investigations to date show little effect on the quality of data collected. However, lower response rates may reduce the statistical precision of some estimates. We also describe several enhancements made to the MEPS that will allow researchers to better understand the impact of the pandemic on US residents, employers, and the US health care system. (Am J Public Health. 2021;111(12):2157–2166. https://doi.org/10.2105/AJPH.2021.306534 )

Context: The Affordable Care Act (ACA) has reduced the US uninsured rate to a historic low. But coverage is only one of many factors contributing to race-and income-based disparities in health care access, affordability, and quality. Methods: Using a novel 2015 national survey of more than 8,000 Americans, we examined disparities between low-income and high-income adults and between racial/ethnic minorities and whites. We conducted a series of regression analyses, starting with models that only took into account income or race, and then sequentially adjusted for health insurance, state of residence, demographics, and health status. We examined self-reported quality of care, cost-related delays in care, and emergency department (ED) use due to lack of available appointments. Then we used multivariate regression to assess respondents' views of whether quality and affordability had improved over the past 2 years and whether the ACA was helping them. Findings: Quality of care ratings were significantly worse among lower-income adults than higher-income adults. Only 10%-25% of this gap was explained by health insurance coverage. Cost-related delays in care and ED use due to lack of available appointments were nearly twice as common in the lowest-income group, and less than 40% of these disparities was explained by insurance. There were significant racial/ethnic gaps: reported quality of care was worse among blacks and Latinos than whites, with 16%-70% explained by insurance. In contrast to these disparities, lower-income and minority groups were generally more likely than whites or higher-income adults to say that the ACA was helping them and that the quality and/or affordability of care had improved in recent years. Conclusions: Our post–health reform survey shows ongoing stark income and racial disparities in the health care experiences of Americans. While the ACA has narrowed these gaps, insurance expansion alone will not be enough to achieve health care equity.

Despite decades of experience treating heroin or prescription opioid dependence with methadone or buprenorphine--two forms of opioid substitution therapy--gaps remain between current practices and evidence-based standards in both Canada and the United States. This is largely because of regulatory constraints and pervasive suboptimal clinical practices. Fewer than 10 percent of all people dependent on opioids in the United States are receiving substitution treatment, although the proportion may increase with expanded health insurance coverage as a result of the Affordable Care Act. In light of the accumulated evidence, we recommend eliminating restrictions on office-based methadone prescribing in the United States; reducing financial barriers to treatment, such as varying levels of copayment in Canada and the United States; reducing reliance on less effective and potentially unsafe opioid detoxification; and evaluating and creating mechanisms to integrate emerging treatments. Taking these steps can greatly reduce the harms of opioid dependence by maximizing the individual and public health benefits of treatment.Despite decades of experience treating heroin or prescription opioid dependence with methadone or buprenorphine--two forms of opioid substitution therapy--gaps remain between current practices and evidence-based standards in both Canada and the United States. This is largely because of regulatory constraints and pervasive suboptimal clinical practices. Fewer than 10 percent of all people dependent on opioids in the United States are receiving substitution treatment, although the proportion may increase with expanded health insurance coverage as a result of the Affordable Care Act. In light of the accumulated evidence, we recommend eliminating restrictions on office-based methadone prescribing in the United States; reducing financial barriers to treatment, such as varying levels of copayment in Canada and the United States; reducing reliance on less effective and potentially unsafe opioid detoxification; and evaluating and creating mechanisms to integrate emerging treatments. Taking these steps can greatly reduce the harms of opioid dependence by maximizing the individual and public health benefits of treatment.

Accountable care organizations (ACOs) have attracted interest from many policy makers and clinical leaders because of their potential to improve the quality of care and reduce costs. Federal ACO programs for Medicare beneficiaries are now up and running, but little information is available about the baseline characteristics of early entrants. In this descriptive study we present data on the structural and market characteristics of these early ACOs and compare ACOs' patient populations, costs, and quality with those of their non-ACO counterparts at baseline. We found that ACO patients were more likely than non-ACO patients to be older than age eighty and had higher incomes. ACO patients were less likely than non-ACO patients to be black, covered by Medicaid, or disabled. The cost of care for ACO patients was slightly lower than that for non-ACO patients. Slightly fewer than half of the ACOs had a participating hospital. Hospitals that were in ACOs were more likely than non-ACO hospitals to be large, teaching, and not-for-profit, although there was little difference in their performance on quality metrics. Our findings can be useful in interpreting the early results from the federal ACO programs and in establishing a baseline to assess the programs' development.Accountable care organizations (ACOs) have attracted interest from many policy makers and clinical leaders because of their potential to improve the quality of care and reduce costs. Federal ACO programs for Medicare beneficiaries are now up and running, but little information is available about the baseline characteristics of early entrants. In this descriptive study we present data on the structural and market characteristics of these early ACOs and compare ACOs' patient populations, costs, and quality with those of their non-ACO counterparts at baseline. We found that ACO patients were more likely than non-ACO patients to be older than age eighty and had higher incomes. ACO patients were less likely than non-ACO patients to be black, covered by Medicaid, or disabled. The cost of care for ACO patients was slightly lower than that for non-ACO patients. Slightly fewer than half of the ACOs had a participating hospital. Hospitals that were in ACOs were more likely than non-ACO hospitals to be large, teaching, and not-for-profit, although there was little difference in their performance on quality metrics. Our findings can be useful in interpreting the early results from the federal ACO programs and in establishing a baseline to assess the programs' development.