Utilization of preventive services by women enrolled in the Affordable Care Act's Health Insurance Marketplace.

The Health Insurance Marketplace has offered access to private health insurance coverage for over 10 million Americans, including previously uninsured women. Per Affordable Care Act requirements, Marketplace plans must cover preventive services without patient cost-sharing in the same way as in employer-sponsored insurance (ESI). However, no study has evaluated whether the utilization of preventive services is similar between Marketplace enrollees and ESI enrollees. Using the Medical Expenditure Panel Survey data for 2014-2016, we identified working-age women with Marketplace plans (n = 792, N = 2,567,292) and ESI (n = 13,100, N = 52,557,779). We compared the two groups' receipt rates of five evidence-based preventive services: blood pressure screening, influenza vaccine, Pap test, mammogram, and colorectal cancer screening. Unadjusted results showed marketplace enrolled women had significantly lower odds of influenza vaccination, Pap test, and mammogram. However, after controlling for other factors, Marketplace insurance was not associated with lower receipt rates of preventive services, except for influenza vaccination (Adjusted OR = 0.64; 95% CI = 0.50-0.82). Regardless of an individual's private insurance type, higher educational attainment and having a usual source of medical care showed the strongest association with the receipt of all investigated preventive services. With the increased role of the Marketplace as a safety net in the COVID-19 pandemic, more research and outreach efforts should be made to facilitate access to preventive services for its enrollees.

Financial burden and medication adherence among near-poor older adults in a pharmaceutical assistance program.

BACKGROUND: With increasing drug prices in the past decade, affordability and medication adherence are a growing concern for near-poor older adults, especially for those who are not receiving Low-Income Subsidy in Medicare Part D. SeniorCare is a pharmaceutical assistance program in Wisconsin for near-poor older adults, providing comprehensive prescription coverage with flat copayments. OBJECTIVES: To evaluate five-year trends in financial hardship and medication adherence and to examine factors associated with these outcomes in SeniorCare members. METHODS: SeniorCare program enrollment and pharmacy claims data from 2014 to 2018 were used. The study population was near-poor older adults in SeniorCare with annual family income ≤200% of the federal poverty level. Financial burden was assessed using the proportion of total annual out-of-pocket costs to total annual income. Medication adherence was assessed by adapting the measures endorsed by the Pharmacy Quality Alliance and National Quality Forum. Descriptive statistics and independent t-tests were used to evaluate the trends, and multivariate logistic regressions were conducted to examine factors associated with financial burden and medication adherence. RESULTS: From 2014 to 2018, mean annual out-of-pocket costs per member declined by 3.7% (p < 0.001) for all drugs, while those for specialty drugs increased by 31.2% (p < 0.05). Around 3.3% spent more than 5% of their income for prescription drugs in 2014, which decreased to 2.4% in 2018 (p < 0.001). The proportions of adherent patients increased from 78.1% to 81.2% (p < 0.001) for diabetes medications (excluding insulins), from 77.3% to 79.5% (p < 0.001) for statins, and from 79.8% to 80.8% (p < 0.05) for RASA. Members subject to a $500 annual deductible were more likely to experience high financial burden (adjusted odds ratio (AOR) = 1.677, p < 0.001) and less likely to be adherent to diabetes medications (AOR = 0.484, p < 0.001). CONCLUSIONS: The near-poor older adults enrolled in Wisconsin SeniorCare program had low financial burden and good medication adherence within the program.

Lessons learned recruiting a diverse sample of rural study participants during the COVID-19 pandemic.

Residents of rural areas have been a hard-to-reach population for researchers. Geographical isolation and lower population density in rural areas can make it particularly challenging to identify eligible individuals and recruit them for research studies. If the study is about a stigmatizing topic, such as opioid overdose, recruitment can be even more difficult due to confidentiality concerns and distrust of outside researchers. This paper shares lessons learned, both successes and failures, for recruiting a diverse sample of rural participants for a multi-state research study about naloxone, an opioid overdose reversal agent. In addition, because our recruitment spanned the period before and after the COVID-19 pandemic in the U.S., we share lessons learned regarding the transition to all remote recruitment and data collection. We utilized various recruitment strategies including rural community pharmacy referrals, community outreach, participant referrals, mass emails, and social media with varying degrees of success. Among these modalities, pharmacist referrals and community outreach produced the highest number of participants. The trust and rapport that pharmacists have with rural community members eased their concerns about working with unknown researchers from outside their communities and facilitated study team members' ability to contact those individuals. Even with the limited in-person options during the pandemic, we reached our recruitment targets by employing multiple recruitment strategies with digital flyers and emails. We also report on the importance of establishing trust and maintaining honest communication with potential participants as well as how to account for regional characteristics to identify the most effective recruitment methods for a particular rural area. Our suggested strategies and recommendations may benefit researchers who plan to recruit underrepresented minority groups in rural communities and other historically hard-to-reach populations for future studies.

Delayed Motor Development and Infant Obesity as Risk Factors for Severe Deformational Plagiocephaly: A Matched Case-Control Study.

The prevalence of deformational plagiocephaly (DP) has increased since the recommendation of positioning infants to their back during sleeping and is affected by various biological and environmental factors. This study aimed to investigate associations between DP and perinatal or infant characteristics, including obesity. This case-control study included 135 infants (81 males) aged 2-12 months who were diagnosed with DP using calculated cranial vault asymmetric index and cranial index and 135 age- and sex-matched controls. Motor development was evaluated using the Alberta Infant Motor Scale, and obesity was defined by body mass index. Univariate and multivariate logistic regression models were used to assess potential risk factors for DP and its severity. One hundred thirty-five infants with DP were divided into the following three subgroups according to severity indicated by the cranial vault asymmetry index: mild to moderate group (n = 87, 64.4%), severe group (n = 48, 35.6%), and a combined plagiocephaly and brachycephaly group (n = 79, 58.5%). Independent risk factors significantly associated with development of DP were bottle-only feeding (adjusted odds ratio (aOR) = 4.65; 95% CI: 2.70-8.00), little tummy time when awake (aOR = 3.51, 95% CI: 1.71-7.21), delay of motor development (aOR = 2.85, 95% CI: 1.08-7.49), and obesity at diagnosis (aOR = 2.45, 95% CI: 1.02-5.90). Among these risk factors, delay of motor development (aOR = 4.91, 95% CI: 1.46-16.51) and obesity at diagnosis (aOR = 4.10, 95% CI: 1.42-11.90) were particularly related to severe DP. In conclusion, this study confirms that DP risk is positively associated with bottle-only feeding, infrequent tummy time, and delayed development of motor milestones. Notably, this study demonstrates infant obesity as a new risk factor for DP. Our findings suggest that obesity should be identified early and managed comprehensively in infants with DP.

Implementing parity for mental health and substance use treatment in Medicaid.

OBJECTIVE: To estimate the association between the implementation of parity in coverage for mental health and substance use disorder (MHSUD) services within the Medicaid program and MHSUD service use. DATA SOURCES/STUDY SETTING: Wisconsin Medicaid enrollment and claims data from 2013 to 2015. In April 2014, Wisconsin Medicaid transitioned childless adult beneficiaries from coverage with limited MHSUD services to parity-consistent coverage. Preparity, they only had Medicaid coverage for MHSUD visits to psychiatrists and the emergency department, while parent beneficiaries had parity-consistent coverage. STUDY DESIGN: The study uses a difference-in-differences design to compare outcome changes for childless adult and parent beneficiaries. DATA COLLECTION/EXTRACTION METHODS: We identified 76, 569 childless adult and parent beneficiaries aged 18-64 who were continuously enrolled for the 2-year study period. PRINCIPAL FINDINGS: Introducing parity-consistent coverage within Medicaid was associated with increased utilization of Medicaid-reimbursed MHSUD services: outpatient, prescription medication, ED, and inpatient. Increased MHSUD outpatient visits were driven by increased visits to nonpsychiatrists. CONCLUSIONS: Parity's effects on MHSUD service use have been studied in the context of private insurance, but its impact among Medicaid beneficiaries has not. Our findings suggest that parity implementation in Medicaid could increase access to effective MHSUD services in a high-need population.

Trends in a State Pharmaceutical Assistance Program for Low-income Older Adults in Wisconsin.

INTRODUCTION: Many older adults face difficulty in affording their prescription drugs, despite having coverage available through Medicare Part D. SeniorCare is Wisconsin's pharmaceutical assistance program that provides comprehensive drug coverage for low-income older adults who are not eligible for full Medicaid benefits. METHODS: We analyzed SeniorCare enrollment and pharmacy claims data from 2014 to 2018. RESULTS: Total drug expenditures increased by 19.3%, with the proportion of expenditures paid by SeniorCare and members decreasing while the proportion paid by other payers increased. Specialty drugs accounted for a substantial and growing proportion of total expenditures (20.4% in 2018) despite accounting for <0.2% of all claims. CONCLUSIONS: Total drug expenditures in SeniorCare have steadily increased over time, primarily due to rising average expenditures per drug fill and increased use of specialty drugs. However, SeniorCare members have been largely protected from these increases and have paid a decreasing proportion of costs over time.

The Effect of Reduced Drug Copayments on Adherence to Oral Diabetes Medications Among Childless Adults in Wisconsin Medicaid.

BACKGROUND: Medication adherence is an indicator of the quality of drug use, which is associated with better health outcomes and reduced health care expenditures. Drug cost sharing can be a barrier to adherence, especially for low-income individuals with chronic conditions. Most of the existing studies in a Medicaid population have evaluated the effects of increasing drug copayments, but few studies have evaluated the effects of reducing drug copayments on medication adherence. Medicaid coverage for low-income childless adults in Wisconsin was expanded on April 1, 2014, which included reductions in drug copayments and monthly caps on out-of-pocket spending. OBJECTIVE: To evaluate changes in adherence to oral diabetes medications using proportion of days covered (PDC) among Medicaid childless adults with type 2 diabetes after the 2014 Medicaid drug copayment reduction. METHODS: A difference-in-differences design was used to compare the changes in medication adherence between childless adults (treatment group) and parents/caretakers (control group). Wisconsin Medicaid's administrative enrollment records, pharmacy claims, and medical claims data were analyzed. Medication adherence was evaluated for 4 commonly used oral diabetes drug classes (i.e., biguanides, sulfonylureas, dipeptidyl peptidase-IV inhibitors, and thiazolidinediones) by adapting the medication adherence quality measures endorsed by the Pharmacy Quality Alliance. The PDC for all diabetes drugs was calculated among patients who filled ≥ 2 prescriptions for any of the 4 drug classes. PDC for each drug class was also measured among patients who had ≥ 2 drug fills for each drug class. The proportion of adherent patients was evaluated using a threshold of PDC ≥ 0.80. RESULTS: Average PDC for all diabetes drugs was 0.87 in the childless adults at baseline and significantly increased by 0.02 (P = 0.025) relative to the parents/caretakers after the copayment reduction. The baseline proportion of adherent patients (PDC ≥ 0.80) among the childless adults was 76% and significantly increased by 6.2 percentage points (P = 0.003) relative to the control group. The odds of adherence to oral antidiabetic drugs increased by 47%, resulting in the proportion of adherent patients in the childless adults group reaching almost 80% after the coverage expansion. In the per class analyses, a significant effect was found for biguanides; the proportion of adherent patients increased by 5.5 percentage points in childless adults compared with the control group (P = 0.022). CONCLUSIONS: This program evaluation found that a reduction of drug copayments in Wisconsin Medicaid improved the quality of medication use by increasing adherence to oral antidiabetic drugs among childless adults. DISCLOSURES: This study was conducted as part of a larger study funded by the Wisconsin Department of Health Services. The authors are solely responsible for the content of this study. The authors report an evaluation contract with the Wisconsin Department of Health Services, unrelated to this study. An earlier version of this paper was presented at the AcademyHealth Annual Research Meeting; June 23-24, 2018; Seattle, WA.

Low-Income Childless Adults' Access To Antidiabetic Drugs In Wisconsin Medicaid After Coverage Expansion.

Medicaid coverage was expanded for childless adults in Wisconsin through an amended Section 1115 demonstration waiver on April 1, 2014. Coverage for prescription drugs was expanded via copayment reductions and a drug formulary expansion. We analyzed administrative drug claims data to evaluate changes in the use of and out-of-pocket spending on antidiabetic drugs among childless adults who experienced the drug coverage expansion. Compared to parents or caretakers, who were not affected by the expansion, childless adults experienced a significant increase of 4 percent in the use of antidiabetic drugs-driven mainly by an increase in the population using the drugs, rather than by more intense use. The expanded drug coverage also reduced the burden of out-of-pocket spending for childless adults by 70 percent. Our findings demonstrate that expanding prescription drug benefits led to increased access to antidiabetic drugs for childless adults in Wisconsin Medicaid.

The predictors for the non-compliance to follow-up among very low birth weight infants in the Korean neonatal network.

The critical need to emphasize preterm infant follow-up after neonatal intensive care unit (NICU) discharge assures early identification of and intervention for neurodevelopmental disability. The aims of this study were to observe the follow-up rates in high-risk follow-up clinics, and analyze factors associated with non-compliance to follow-up among very low birth weight (VLBW) infants. The data was prospectively collected for 3063 VLBW infants between January 2013 and December 2014 from 57 Korean neonatal network (KNN) centers at a corrected age of 18-24 months. Correlations among demographic data, clinical variables, and neonatal intensive care unit (NICU) volume (divided into 4 quartiles) with the occurrence of non-compliance were analyzed. The overall follow-up rate at the corrected age of 18-24 month was 65.4%. The follow-up rates were inversely related to birth weight and gestational age. Apgar score, hospital stay, maternal age, and maternal education were significantly different between the compliance and non-compliance groups. The follow-up rate was higher for mothers with chorioamnionitis, abnormal amniotic fluid, multiple pregnancy, and in vitro fertilization. Infants with respiratory distress syndrome, bronchopulmonary dysplasia, patent ductus arteriosus ligation, periventricular leukomalacia, and retinopathy of prematurity were more common in the compliance group. Follow-up rates showed significant differences according to NICU volume. Using multivariate logistic regression, high birth weight, low NICU volume, siblings, foreign maternal nationality and high 5 min APGAR scores were significant independent factors associated with the non-compliance of VLBW infants for follow-up at 18-24 months of age. This is the first nation-wide analysis of follow-up for VLBW infants in Korea. Understanding factors associated with failure of compliance could help improve the long-term follow-up rates and neurodevelopmental outcomes through early intervention.

Effects of the Affordable Care Act's contraceptive coverage requirement on the utilization and out-of-pocket costs of prescribed oral contraceptives.

BACKGROUND: The Affordable Care Act (ACA) mandated that private health insurance plans cover prescribed contraceptive services for women, including oral contraceptives (OCs), without charging a patient any cost-sharing beginning in August 2012. OBJECTIVE: To evaluate the effects of the ACA's contraceptive coverage requirement on the utilization and out-of-pocket costs of prescribed OCs after two years of implementation. METHODS: A retrospective, cross-sectional study was designed using data from the 2010 to 2014 waves of the Medical Expenditure Panel Survey. The sample consisted of reproductive-aged women who have either private health insurance or Medicaid. Utilization of OCs was evaluated using 1) the proportion of women who purchased any OCs and 2) the mean annual number of cycles prescribed per woman. Out-of-pocket costs for OCs were evaluated using 1) the proportion of women who had any OC purchase with $0 out-of-pocket costs, 2) the mean annual out-of-pocket costs per woman, and 3) the mean out-of-pocket costs per cycle. Descriptive analyses and a difference-in-difference linear regression approach were used. MAIN FINDINGS: No substantial changes were seen in the utilization of OCs after the ACA requirement became effective. The difference-in-difference regression showed that the proportion of women who had any OC purchase with $0 out-of-pocket costs increased significantly by 54.0 percentage points after the ACA requirement in the private insurance group relative to the Medicaid group. Mean annual out-of-pocket costs in the private insurance group dropped by 37% in the first year and an additional 52% decrease was found in the second year of the policy. Mean out-of-pocket costs per cycle also decreased substantially in the private insurance group by 39% in the first year and an additional decrease of 44% was seen in the second year. CONCLUSIONS: The ACA's contraceptive coverage requirement markedly reduced out-of-pocket costs of prescribed OCs for women with private health insurance.

Effects of the Affordable Care Act's Dependent Coverage Mandate on Private Health Insurance Coverage in Urban and Rural Areas.

PURPOSE: To evaluate the impact of the Affordable Care Act's (ACA) dependent coverage mandate on insurance coverage among young adults in metropolitan and nonmetropolitan areas. METHODS: A cross-sectional analysis was conducted using data from 2006-2009 and 2011 waves of the Medical Expenditure Panel Survey. A difference-in-difference analysis was used to compare changes in full-year private health insurance coverage among young adults aged 19-25 years with an older cohort aged 27-34 years. Separate regressions were estimated for individuals in metropolitan and nonmetropolitan areas and were tested for a differential impact by area of residence. FINDINGS: Full-year private health insurance coverage significantly increased by 9.2 percentage points for young adults compared to the older cohort after the ACA mandate (P = .00). When stratifying the regression model by residence area, insurance coverage among young adults significantly increased by 9.0 percentage points in metropolitan areas (P = .00) and 10.1 percentage points in nonmetropolitan areas (P = .03). These changes were not significantly different from each other (P = .82), which suggests the ACA mandate's effects were not statistically different by area of residence. CONCLUSIONS: Although young adults in metropolitan and nonmetropolitan areas experienced increased access to private health insurance following the ACA's dependent coverage mandate, it did not appear to directly impact rural-urban disparities in health insurance coverage. Despite residents in both areas gaining insurance coverage, over one-third of young adults still lacked access to full-year health insurance coverage.

Parenteral nutrition associated cholestasis is earlier, more prolonged and severe in small for gestational age compared with appropriate for gestational age very low birth weight infants.

PURPOSE: We hypothesized that parenteral nutrition associated cholestasis (PNAC) would be more severe in small for gestational age (SGA) compared with appropriate for gestational age (AGA) very low birth weight (VLBW) infants. MATERIALS AND METHODS: Sixty-one VLBW infants were diagnosed as PNAC with exposure to parenteral nutrition with elevation of direct bilirubin≥2 mg/dL for ≥14 days. Twenty-one SGA infants and 40 AGA infants matched for gestation were compared. RESULTS: Compared with AGA infants, PNAC in SGA infants was diagnosed earlier (25±7 days vs. 35±14 days, p=0.002) and persisted longer (62±36 days vs. 46±27 days, p=0.048). Severe PNAC, defined as persistent elevation of direct bilirubin≥4 mg/dL for more than 1 month with elevation of liver enzymes, was more frequent in SGA than in AGA infants (61% vs. 35%, p=0.018). The serum total bilirubin and direct bilirubin levels during the 13 weeks of life were significantly different in SGA compared with AGA infants. SGA infants had more frequent (76% vs. 50%, p=0.046), and persistent elevation of alanine aminotransferase. CONCLUSION: The clinical course of PNAC is more persistent and severe in SGA infants. Careful monitoring and treatment are required for SGA infants.

Insulin pump therapy in transient neonatal diabetes mellitus.

Neonatal diabetes mellitus (NDM) is a rare disease requiring insulin treatment. Its treatment is primarily focused on maintaining adequate glycemic control and avoiding hypoglycemia. Although insulin pump therapy is frequently administered to adults and children, there is no consensus on the use of insulin pumps in NDM. A 10 day-old female infant was referred to us with intrauterine growth retardation and poor weight gain. Hyperglycemia was noted, and continuous intravenous insulin infusion was initiated. However, the patient's serum glucose levels fluctuated widely, and maintaining the intravenous route became difficult within the following weeks. Continuous subcutaneous insulin infusion with an insulin pump was introduced on the twenty-fifth day of life, and good glycemic control was achieved without any notable adverse effects including hypoglycemia. We suggest that the insulin pump is a safe and effective mode for treating NDM and its early adoption may shorten the length of hospital stays in patients with NDM.