Association of State Insulin Out-of-Pocket Caps With Insulin Cost-Sharing and Use Among Commercially Insured Patients With Diabetes : A Pre-Post Study With a Control Group.

BACKGROUND: Twenty-five states have implemented insulin out-of-pocket (OOP) cost caps, but their effectiveness is uncertain. OBJECTIVE: To examine the effect of state insulin OOP caps on insulin use and OOP costs among commercially insured persons with diabetes. DESIGN: Pre-post study with control group. SETTING: Eight states implementing insulin OOP caps of $25 to $30, $50, or $100 in January 2021, and 17 control states. PARTICIPANTS: Commercially insured persons with diabetes and insulin users younger than 65 years. Subgroups of particular interest included members from states with insulin OOP caps of $25 to $30, enrollees with health savings accounts (HSAs) that require high insulin OOP payments, and lower-income members. MEASUREMENTS: Mean monthly 30-day insulin fills and OOP costs. RESULTS: State insulin caps were not associated with changes in insulin use in the overall population (relative change in fills per month, 1.8% [95% CI, -3.2% to 6.9%]). Insulin users in intervention states saw a 17.4% (CI, -23.9% to -10.9%) relative reduction in insulin OOP costs, largely driven by reductions among HSA enrollees; there was no difference in OOP costs among nonaccount plan members. More generous ($25 to $30) state insulin OOP caps were associated with insulin OOP cost reductions of 40.0% (CI, -62.5% to -17.6%), again primarily driven by a larger reduction in the subgroup with HSA plans. LIMITATIONS: Single national insurer; 9-month follow-up. CONCLUSION: Insulin OOP caps were associated with reduced insulin OOP costs but no overall increases in insulin use. A proposed national insulin cap of $35 for commercially insured persons might lead to meaningful insulin OOP savings but have a limited effect on insulin use. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases.

"The Water in Which We Swim:" A Unique, Post-Clerkship Multidisciplinary Course.

OBJECTIVE: To improve patient outcomes and promote health equity, medical students must be taught not only biomedicine, but also the social sciences to understand the larger contexts in which patients live and health care operates. Yet, most undergraduate medical education does not explicitly cover these topics in a required, longitudinal curriculum. METHODS: In January 2015 at Harvard Medical School, we created a two-part sequence (pre- and post-clerkship) of required, 4-week multidisciplinary courses-"Essentials of the Profession I and II"-to fill this gap. "Essentials of the Profession II (EOP2)" is an advanced social sciences course anchored in patient narratives and the lived experiences of students and includes clinical epidemiology and population health, healthcare delivery and leadership, health policy, medical ethics and professionalism, and social medicine that engages students to conduct structural analyses to be effective healers, advocates, and leaders. RESULTS: Per student course evaluations, the overall course rating was 1.7 (SD 0.9, 1 = excellent and 5 = poor); its overall rating has improved over time; and it has scored well even when run virtually. It was rated highly in application of critical thinking, integration of the disciplines, and relevance for clinical work. Qualitative analyses of student responses revealed the following key course strengths: breadth of topics, teaching faculty and guest speakers, and small group discussions. The weaknesses included workload, lack of diversity of opinions, repetition, and time spent in lectures. CONCLUSIONS: We argue that EOP2 is "essential" for post-clerkship medical education. It offers an opportunity to re-ignite and enhance humanism and activism; remind students why they chose the medical profession; equip them with frameworks and toolkits to help them to overcome challenges; and devise solutions to improve health care and patient outcomes that are applicable to their future training and ongoing practice of medicine.

Trends in High-Acuity Cardiovascular Events During the COVID-19 Pandemic.

This cohort study describes changes in myocardial infarction and stroke hospitalizations as well as congestive heart failure, angina, and transient ischemic attack incidents months before and after March 2020 among insured people in New England.

Vaccine Mandates and Influenza Vaccination During the Pandemic.

OBJECTIVES: To determine whether a state influenza vaccine mandate and elevated community coronavirus disease 2019 (COVID-19) severity affected a child's probability of receiving an influenza vaccine during the 2020-2021 influenza season, given the child's previous vaccination history. METHODS: Longitudinal cohort study using enrollment and claims data of 71 333 children aged 6 months to 18 years living in Massachusetts, New Hampshire, and Maine, from a regional insurer. Schoolchildren in Massachusetts were exposed to a new influenza vaccine mandate in the 2020-2021 season. Community COVID-19 severity was measured using county-level total cumulative confirmed case counts between March 2020 and August 2020 and linked by zip codes. The primary outcome of interest was a claim for any influenza vaccine in the 2020-2021 season. RESULTS: Children living in a state with a vaccine mandate during the 2020-2021 influenza season had a higher predicted probability of receiving an influenza vaccine than those living in states without a mandate (47.7%, confidence interval 46.4%-49.0%, vs 21.2%, confidence interval 18.8%-23.6%, respectively, for previous nonvaccinators, and 78.2%, confidence interval 77.4%-79.0%, vs 58.2%, confidence interval 54.7%-61.7%, for previous vaccinators); the difference was 6.5 percentage points greater among previous nonvaccinators (confidence interval 1.3%-11.7%). Previously vaccinated children had a lower predicted probability of receiving an influenza vaccine if they lived in a county with the highest COVID-19 severity compared with a county with low COVID-19 severity (72.1%, confidence interval 70.5%-73.7%, vs 77.3%, confidence interval 74.7%-79.9%). CONCLUSIONS: Strategies to improve uptake of influenza vaccination may have differential impact based on previous vaccination status and should account for community factors.

Trends in high deductible health plan enrolment and spending among commercially insured members with and without chronic conditions: a Natural Experiment for Translation in Diabetes (NEXT-D2) Study.

OBJECTIVES: To examine trends in high deductible health plan (HDHP) enrolment among members with diabetes and cardiovascular disease (CVD) compared with healthy members and compare out-of-pocket (OOP) and total spending for members with chronic conditions in HDHPs versus low deductible plans. DESIGN: Descriptive study with time trends. SETTING: A large national commercial insurance database. PARTICIPANTS: 1.2 million members with diabetes, 4.5 million members with CVD (without diabetes) and 18 million healthy members (defined by a low comorbidity score) under the age of 65 years and insured between 2005 and 2013. OUTCOME MEASURES: Percentage of members in an HDHP (ie, annual deductible ≥$1000) by year, annual mean OOP and total spending, adjusted for member sociodemographic and employer characteristics. RESULTS: Enrolment in HDHPs among members in all disease categories increased by 5 percentage points a year and was over 50% by 2013. On average, over the study period, HDHP enrolment among members with diabetes and CVD was 2.84 (95% CI: 2.78 to 2.90) and 2.02 (95% CI: 1.98 to 2.05) percentage points lower, respectively, than among healthy members. HDHP members with diabetes, CVD and low morbidity had higher annual OOP costs ($636 (95% CI: 630 to 642), $539 (95% CI: 537 to 542) and $113 (95% CI: 112 to 113)) and lower total costs (-$529 (95% CI: -597 to -461), -$364 (95% CI: -385 to -342) and -$79 (95% CI: -81 to -76)), respectively, than corresponding low deductible members when averaged over the study period. Members with chronic diseases had yearly OOP expenditures that were five to seven times higher than healthier members. CONCLUSION: High HDHP enrolment coupled with the high OOP costs associated with HDHPs may be particularly detrimental to the financial well-being of people with diabetes and CVD, who have more healthcare needs than healthier populations.

Costs Are Higher For Marketplace Members Who Enroll During Special Enrollment Periods Compared With Open Enrollment.

More than 20 percent of Affordable Care Act (ACA) exchange market (Marketplace) members insured by a large national insurer in 2015 and 2016 enrolled during a special enrollment period (SEP), defined as any enrollment outside the annual open enrollment period. These members were younger and had approximately 34 percent higher average monthly total costs than members who enrolled during open enrollment. SEP members had 69-114 percent higher inpatient costs and 11-19 percent higher emergency department costs than open enrollment members. Higher costs, especially among a slightly younger population, may suggest potential adverse selection among SEP members, which could contribute to increased premiums and insurer exit from ACA Marketplaces. Although SEP members had a shorter average enrollment length per calendar year, they were more likely than open enrollment members to stay insured through the end of the calendar year and to renew in a Marketplace plan offered by the insurer in the following year. However, renewing SEP and open enrollment members were older, sicker, and costlier than nonrenewing members of both enrollee types, which suggests that healthier members are switching carriers or leaving the market over time. Additional research is urgently needed to inform evidence-based policy regarding Marketplace risk adjustment and SEP eligibility rules and to improve outreach to people who are eligible for SEP enrollment.

Will it Hurt? The Intrauterine Device Insertion Experience and Long-Term Acceptability Among Adolescents and Young Women.

STUDY OBJECTIVE: To examine how the intrauterine device (IUD) insertion experience affects long-term IUD acceptability among adolescents. DESIGN: Text to Web survey study. SETTING: Boston Children's Hospital and Cambridge Health Alliance in Massachusetts. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Nulliparous adolescents aged 13-21 years who received an IUD or etonogestrel implant between January 2012 and May 2018. RESULTS: We received survey responses from 95 adolescents (n = 46 IUD; n = 49 implant; response rate = 95/1098 (9%)). Mean current age (20.8 years) and time since device insertion (2.4 years) were similar between groups. Although a large proportion of both groups (64%) experienced moderate to severe preprocedural anxiety, IUD users expected more insertional pain compared with implant users (55.6 vs 39.6; P = .01). Compared with implant users, more IUD users experienced moderate to severe insertional pain (80% vs 18%; P < .0001), recalled that the procedure hurt more than expected (52% vs 4%; P < .0001), and endorsed lower rates of pain management satisfaction (72.4 vs 85.6; P = .04). Most respondents would recommend their method to a friend (75%) or consider getting the same device in the future (63%). When explicitly asked, more IUD users reported that dislike of the insertion procedure might or would probably prevent them from getting the same device in the future (41% vs 14%; P = .005). CONCLUSION: Compared with implant users, IUD users reported more negative insertion experiences, although preprocedural anxiety was prevalent in both groups. Dislike of the insertion experience might negatively affect adolescents' willingness to continue using an IUD in the future. Findings should encourage multimodal interventions to holistically improve the IUD insertion experience.

Uptake and use of a diabetes management program with a mobile glucometer.

OBJECTIVE: Innovative mobile health technologies (mHealth) may facilitate self-management of blood glucose. This study evaluates uptake, use, and predictors of uptake and long-term use of a diabetes mHealth intervention, which comprises an FDA-approved mobile glucometer and nurse coaching, in a real-world setting. METHODS: n = 4438 commercially-insured adults with diabetes were recruited from 2014 to 2015 via an opt-in, phone-based process. In this post-only study, we obtained data on recruitment, glucometer use, demographics, and insurance and employer characteristics. We calculated percent uptake and reasons for unsuccessful recruitment. We used logistic regression to model predictors of uptake and survival analysis to examine duration of testing and predictors of discontinuation. RESULTS: Of the recruited members, 556 (12.5%) signed up for the mHealth program and 324 (7.3%) began testing. Of those who did not sign up, the majority (70.6%) were unable to be reached by phone. Male (OR = 1.60, 95% CI: 1.25, 2.03) and Spanish-speaking (OR = 8.34, 95% CI: 5.40, 12.88) members were more likely to start testing. Two-thirds (66.2%) of those who started testing had a first test value that indicated hyperglycemia; 97% tested more than once and the median time between first and last test was 407 days. Older age was the only significant predictor of long-term use. CONCLUSIONS: Although uptake of the mHealth program was low, most members who started testing had initial glucose values that indicated a need for better glucose management and the majority of patients engaged with the program for over a year. Male and Spanish-speaking members were more likely to initiate the program.

Provider Perspectives on Quality Payment Programs Targeting Diabetes in Primary Care Settings.

Public and private insurers increasingly use quality payment programs as a tool to improve quality of care in primary care settings. However, little is known about primary care providers' perspectives on whether and how quality payment programs improve diabetes quality of care. In this qualitative study, the authors conducted semi-structured interviews and focus groups with 23 providers from March to June 2015. Transcripts were analyzed to identify key themes using the immersion-crystallization method. Almost all of the providers believed that insurers play a meaningful role in improving quality of care for diabetes patients. Most thought that insurers' efforts are more effective when channeled through providers and delivery systems rather than directed at patients. Providers generally believed that quality payment programs have had a positive impact on quality of diabetes care, although provider views were not evidence based. Providers in practices in which quality payment programs were believed to have had a positive impact stated that the programs provided financial incentives and resources for improved population health management systems and additional staff. Conversely, most providers did not believe that quality payment programs have had any impact via direct financial incentives to individual physicians. A few providers were skeptical about the impact of quality payment programs and noted negative consequences that they had observed. Providers recommended strategies to improve quality payment programs (eg, refine quality measures, provide regular feedback on quality and costs) and additional strategies that insurers could consider to address provider- and patient-level barriers to high-quality diabetes care.

Quality Reporting by Payers: A Mixed-Methods Study of Provider Perspectives and Practices.

BACKGROUND: Providers need timely, clinically meaningful, and actionable information to improve quality of care. Payers may play an important role in providing such information in ambulatory care settings. We sought to learn about providers' use and perceptions of quality reports from insurers. METHODS: We employed a mixed-methods study design. We analyzed the performance of 118 provider groups on 21 HEDIS measures included in one New England insurer's quality reporting program and evaluated how a subset of provider groups (n = 55) accessed the reports. We also conducted 14 semistructured interviews with providers and administrators to assess their perspectives about quality reports from insurers in general. RESULTS: Performance on quality measures varied greatly across provider groups and by metric. Only 20% of provider groups accessed the quality reports during the study period. While providers reported that payer information on quality has the potential to be useful, respondents suggested important reasons why insurer quality reports were not widely accessed, including information overload, conflicts with other sources of information, and the significant provider effort required to make the reports actionable. CONCLUSIONS: Payer-provider collaborations are needed to improve the usefulness of payers' quality measurement reports, and coordination among payers is needed to streamline reported measures.

Evaluating inter-rater reliability of indicators to assess performance of medicines management in health facilities in Uganda.

BACKGROUND: To build capacity in medicines management, the Uganda Ministry of Health introduced a nationwide supervision, performance assessment and recognition strategy (SPARS) in 2012. Medicines management supervisors (MMS) assess performance using 25 indicators to identify problems, focus supervision, and monitor improvement in medicines stock and storage management, ordering and reporting, and prescribing and dispensing. Although the indicators are well-recognized and used internationally, little was known about the reliability of these indicators. An initial assessment of inter-rater reliability (IRR), which measures agreement among raters (i.e., MMS), showed poor IRR; subsequently, we implemented efforts to improve IRR. The aim of this study was to assess IRR for SPARS indicators at two subsequent time points to determine whether IRR increased following efforts to improve reproducibility. METHODS: IRR was assessed in 2011 and again after efforts to improve IRR in 2012 and 2013. Efforts included targeted training, providing detailed guidelines and job aids, and refining indicator definitions and response categories. In the assessments, teams of three MMS measured 24 SPARS indicators in 26 facilities. We calculated IRR as a team agreement score (i.e., percent of the MMS teams in which all three MMS had the same score). Two sample tests for proportions were used to compare IRR scores for each indicator, domain, and overall for the initial assessment and the following two assessments. We also compared the IRR scores for indicators classified as simple (binary) versus complex (multi-component). Logistic regression was used to identify supervisor group characteristics associated with domain-specific and overall IRR scores. RESULTS: Initially only five (21%) indicators had acceptable reproducibility, defined as an IRR score ≥ 75%. At the initial assessment, prescribing quality indicators had the lowest and stock management indicators had the highest IRR. By the third IRR assessment, 12 (50%) indicators had acceptable reproducibility, and the overall IRR score improved from 57% to 72%. The IRR of simple indicators was consistently higher than that of complex indicators in the three assessment periods. We found no correlation between IRR scores and MMS experience or professional background. CONCLUSIONS: Assessments of indicator reproducibility are needed to improve IRR. Using simple indicators is recommended.

Impact of Massachusetts Health Reform on Enrollment Length and Health Care Utilization in the Unsubsidized Individual Market.

OBJECTIVE: To evaluate the impact of the 2006 Massachusetts health reform, the model for the Affordable Care Act, on short-term enrollment and utilization in the unsubsidized individual health insurance market. DATA SOURCE: Seven years of administrative and claims data from Harvard Pilgrim Health Care. RESEARCH DESIGN: We employed pre-post survival analysis and an interrupted time series design to examine changes in enrollment length, utilization patterns, and use of elective procedures (discretionary inpatient surgeries and infertility treatment) among nonelderly adult enrollees before (n = 6,912) and after (n = 29,207) the MA reform. PRINCIPAL FINDINGS: The probability of short-term enrollment dropped immediately after the reform. Rates of inpatient encounters (HR = 0.83, 95 percent CI: 0.74, 0.93), emergency department encounters (HR = 0.85, 95 percent CI: 0.80, 0.91), and discretionary inpatient surgeries (HR = 0.66 95 percent CI: 0.45, 0.97) were lower in the postreform period, whereas the rate of ambulatory visits was somewhat higher (HR = 1.04, 95 percent CI: 1.00, 1.07). The rate of infertility treatment was higher after the reform (HR = 1.61, 95 percent CI: 1.33, 1.97), driven by women in individual (vs. family) plans. The reform was not associated with increased utilization among short-term enrollees. CONCLUSIONS: MA health reform was associated with a decrease in short-term enrollment and changes in utilization patterns indicative of reduced adverse selection in the unsubsidized individual market. Adverse selection may be a problem for specific, high-cost treatments.

Mobile Phone and Smartphone Technologies for Diabetes Care and Self-Management.

Mobile and smartphone (mHealth) technologies have the potential to improve diabetes care and self-management, but little is known about their effectiveness and how patients, providers, and payers currently interact with them. We conducted a systematic review and found only 20 peer-reviewed articles, published since 2010, with robust evidence about the effectiveness of mHealth interventions for diabetes. The majority of these interventions showed improvement on primary endpoints, such as HbA1c; mHealth technologies that interacted with both patients and providers were more likely to be effective. There was little evidence about persistent use by patients, use by a patient's health care provider, or long-term effectiveness. None of the studies discussed regulatory oversight of mHealth technologies or payer reimbursement for them. No robust studies evaluated the more than 1100 publicly available smartphone apps for diabetes. More research with valid study designs and longer follow-up is needed to evaluate the impact of mHealth technologies for diabetes care and self-management.