Access to insurance navigation support through the State Health Insurance Assistance Program (SHIP).

Medicare enrollment is complex, particularly for low-income individuals who are dually eligible for Medicare and Medicaid, and the wrong plan choice can adversely impact beneficiaries' out-of-pocket costs and access to providers and medications. The State Health Insurance Assistance Program (SHIP) is a federal program that provides counseling on Medicare coverage, but the degree to which SHIP services are accessible to low-income beneficiaries is unknown. We interviewed SHIP counselors and coordinators to characterize factors affecting access to and quality of SHIP services for low-income beneficiaries. Availability of volunteers was cited as the primary barrier to SHIP services. Topics related to dual eligibility for Medicare and Medicaid were frequently covered in counseling sessions, and staff expressed a desire for more training related to Medicaid and integrated-care programs. Our results suggest that additional counselors and increased training on topics relevant to dually eligible individuals may improve SHIP's ability to provide health insurance-related information to low-income Medicare beneficiaries.

Pan-cancer proteogenomics expands the landscape of therapeutic targets.

Fewer than 200 proteins are targeted by cancer drugs approved by the Food and Drug Administration (FDA). We integrate Clinical Proteomic Tumor Analysis Consortium (CPTAC) proteogenomics data from 1,043 patients across 10 cancer types with additional public datasets to identify potential therapeutic targets. Pan-cancer analysis of 2,863 druggable proteins reveals a wide abundance range and identifies biological factors that affect mRNA-protein correlation. Integration of proteomic data from tumors and genetic screen data from cell lines identifies protein overexpression- or hyperactivation-driven druggable dependencies, enabling accurate predictions of effective drug targets. Proteogenomic identification of synthetic lethality provides a strategy to target tumor suppressor gene loss. Combining proteogenomic analysis and MHC binding prediction prioritizes mutant KRAS peptides as promising public neoantigens. Computational identification of shared tumor-associated antigens followed by experimental confirmation nominates peptides as immunotherapy targets. These analyses, summarized at https://targets.linkedomics.org, form a comprehensive landscape of protein and peptide targets for companion diagnostics, drug repurposing, and therapy development.

Effect of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act Scribes Trial on Emergency Department Provider Productivity and Patient Throughput Times.

BACKGROUND: To help improve access to care, section 507 of the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act of 2018 mandated a 2-year trial of medical scribes in the Veterans Health Administration (VHA). OBJECTIVE: The impact of scribes on provider productivity and patient throughput time in VHA emergency departments (EDs) was evaluated. METHODS: A clustered randomized trial was designed using intent-to-treat difference-in-differences analysis. The intervention period was from June 30, 2020 to July 1, 2022. The trial included six intervention and six comparison ED clinics. Two ED providers who volunteered to participate in the trial were assigned two scribes each. Scribes assisted providers with documentation and visit-related activities. The outcomes were provider productivity and patient throughput time per clinic-pay period. RESULTS: Randomization to intervention resulted in decreased provider productivity and increased patient throughput time. In adjusted regression models, randomization to scribes was associated with a decrease of 8.4 visits per full-time equivalent (95% confidence interval [CI] 12.4-4.3; p < 0.001) and 0.5 patients per day per provider (95% CI 0.8-0.3; p < 0.001). Intervention was associated with increases in length of stay of 29.1 min (95% CI 21.2-36.9 min; p < 0.001), 6.3 min in door to doctor (95% CI 2.9-9.6 min; p < 0.001), 19.5 min in door to disposition (95% CI 13.2-25.9 min; p < 0.001), and 13.7 min in doctor to disposition (95% CI 8.8-18.6 min; p < 0.001). CONCLUSIONS: Scribes were associated with decreased provider productivity and increased patient throughput time in VHA EDs. Although scribes may have contributed to improvements in other dimensions of quality, further examination of the ways in which scribes were used is advisable before widespread adoption in VHA EDs.

Effect of mental health staffing inputs on initiation of care among recently separated Veterans.

OBJECTIVE: To estimate a causal relationship between mental health staffing and time to initiation of mental health care for new patients. DATA SOURCES AND STUDY SETTING: As the largest integrated health care delivery system in the United States, the Veterans Health Administration (VHA) provides a unique setting for isolating the effects of staffing on initiation of mental health care where demand is high and out-of-pocket costs are not a relevant confounder. We use data from the Department of Defense and VHA to obtain patient and facility characteristics and health care use. STUDY DESIGN: To isolate exogenous variation in mental health staffing, we used an instrumental variables approach-two-stage residual inclusion with a discrete time hazard model. Our outcome is time to initiation of mental health care after separation from active duty (first appointment) and our exposure is mental health staffing (standardized clinic time per 1000 VHA enrollees per pay period). DATA COLLECTION/EXTRACTION METHODS: Our cohort consists of all Veterans separating from active duty between July 2014 and September 2017, who were enrolled in the VHA, and had at least one diagnosis of post-traumatic stress disorder, major depressive disorder, and/or substance use disorder in the year prior to separation from active duty (N = 54,209). PRINCIPAL FINDINGS: An increase of 1 standard deviation in mental health staffing results in a higher likelihood of initiating mental health care (adjusted hazard ratio: 3.17, 95% confidence interval: 2.62, 3.84, p < 0.001). Models stratified by tertile of mental health staffing exhibit decreasing returns to scale. CONCLUSIONS: Increases in mental health staffing led to faster initiation of care and are especially beneficial in facilities where staffing is lower, although initiation of care appears capacity-limited everywhere.

Association between Child Tax Credit advance payments and food insufficiency in households experiencing economic shocks.

The COVID-19 pandemic brought increases in economic shocks due to poor health and lost employment, which reduced economic well-being, especially in households with children. The American Rescue Plan Act of 2021 expanded Child Tax Credit (CTC) payments to include eligibility for the lowest income households, boosted benefit levels, and provided monthly advance payments to households with children. Using Census Household Pulse Survey respondent data from January 2021 to July 2022, we evaluated the association between these advance CTC monthly payments and food insufficiency among households with children experiencing health- or employment-related economic shocks (defined as missed work due to COVID-19/other illness or COVID-19-related employer closure/layoff/furlough). Using a triple difference design, we found that the advance CTC was associated with greater reductions in food insufficiency among households with children experiencing economic shocks both compared with households without children and with households with children not experiencing economic shocks. Permanently expanding the advance CTC could create resilience to economic shocks during disease outbreaks, climate disasters, and recessions.

Comparison of Full-Time Equivalent and Clinic Time Labor Input Measures in Productivity Metrics.

GOAL: A lack of improvement in productivity in recent years may be the result of suboptimal measurement of productivity. Hospitals and clinics benefit from external benchmarks that allow assessment of clinical productivity. Work relative value units have long served as a common currency for this purpose. Productivity is determined by comparing work relative value units to full-time equivalents (FTEs), but FTEs do not have a universal or standardized definition, which could cause problems. We propose a new clinical labor input measure-"clinic time"-as a substitute for using the reported measure of FTEs. METHODS: In this observational validation study, we used data from a cluster randomized trial to compare FTE with clinic time. We compared these two productivity measures graphically. For validation, we estimated two separate ordinary least squares (OLS) regression models. To validate and simultaneously adjust for endogeneity, we used instrumental variables (IV) regression with the proportion of days in a pay period that were federal holidays as an instrument. We used productivity data collected between 2018 and 2020 from Veterans Health Administration (VA) cardiology and orthopedics providers as part of a 2-year cluster randomized trial of medical scribes mandated by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018. PRINCIPAL FINDINGS: Our cohort included 654 unique providers. For both productivity variables, the values for patients per clinic day were consistently higher than those for patients per day per FTE. To validate these measures, we estimated separate OLS and IV regression models, predicting wait times from the two productivity measures. The slopes from the two productivity measures were positive and small in magnitude with OLS, but negative and large in magnitude with IV regression. The magnitude of the slope for patients per clinic day was much larger than the slope for patients per day per FTE. Current metrics that rely on FTE data may suffer from self-report bias and low reporting frequency. Using clinic time as an alternative is an effective way to mitigate these biases. PRACTICAL APPLICATIONS: Measuring productivity accurately is essential because provider productivity plays an important role in facilitating clinic operations outcomes. Most importantly, tracking a more valid productivity metric is a concrete, cost-effective management tactic to improve the provision of care in the long term.

The Association Between Hospital-Based Food Pantry Use and Subsequent Emergency Department Utilization Among Medicaid Patients With Diabetes.

We explored the association between the use of a hospital-based food pantry and subsequent emergency department (ED) utilization among Medicaid patients with diabetes in a large safety-net health system. Leveraging 2015-2019 electronic health record data, we used a staggered difference-in-differences approach to measure changes in ED use before vs after food pantry use. Food pantry use was associated with a 7.3 percentage point decrease per patient per quarter (95% confidence interval, -13.8 to -0.8) in the probability of subsequent ED utilization ( P = .03). Addressing food insecurity through hospital-based food pantries may be one mechanism for reducing ED use among low-income patients with diabetes.

Metabolic Disease and The Risk of Post-COVID Conditions: A Retrospective Cohort Study.

Objective: To examine the influence of having a baseline metabolic disorder (diabetes, hypertension, and/or obesity) on the risk of developing new clinical sequelae potentially related to SARS-CoV-2 in a large sample of commercially insured adults in the US. Design setting and participants: Deidentified data were collected from the IBM/Watson MarketScan Commercial Claims and Encounters (CCAE) Databases and Medicare Supplemental and Coordination of Benefits (MDCR) Databases from 2019 to 2021. A total of 839,344 adults aged 18 and above with continuous enrollment in the health plan were included in the analyses. Participants were grouped into four categories based on their COVID-19 diagnosis and whether they had at least one of the three common metabolic disorders at baseline (diabetes, obesity, or hypertension). Measures and methods: ICD-10-CM codes were used to determine new symptoms and conditions after the acute phase of SARS-CoV-2 infection, defined as ending 21 days after initial diagnosis date, or index period for those who did not have a COVID-19 diagnosis. Propensity score matching (PSM) was used to create comparable reference groups. Cox proportional hazard models were conducted to estimate hazard ratios and 95% confidence intervals. Results: Among the 772,377 individuals included in the analyses, 36,742 (4.8%) without and 20,912 (2.7%) with a baseline metabolic disorder were diagnosed with COVID-19. On average, COVID-19 patients with baseline metabolic disorders had more 2.4 more baseline comorbidities compared to those without baseline metabolic disorders. Compared to adults with no baseline metabolic condition, the risks of developing new clinical sequelae were highest among COVID-19 patients with a baseline metabolic condition (HRs ranging from 1.51 to 3.33), followed by those who had a baseline metabolic condition but with no COVID-19 infection (HRs ranging from 1.33 to 2.35), and those who had COVID-19 but no baseline metabolic condition (HRs ranging from 1.34 to 2.85). Conclusions: In a large national cohort of commercially insured adults, COVID-19 patients with a baseline metabolic condition had the highest risk of developing new clinical sequelae post-acute infection phase, followed by those who had baseline metabolic condition but no COVID-19 infection and those who had COVID-19 but no baseline metabolic disorder.

Costs and Productivity Benefits of the Department of Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks Act Scribes Trial.

OBJECTIVES: To improve access, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 mandated a 2-year study of medical scribes in Veterans Health Administration specialty clinics and emergency departments. Medical scribes are employed in clinical settings with the goals of increasing provider productivity and satisfaction by minimizing physicians' documentation burden. Our objective is to quantify the economic outcomes of the MISSION Act scribes trial. METHODS: A cluster-randomized trial was designed with 12 Department of Veterans Affairs (VA) medical centers randomized into the intervention. We estimated the total cost of the trial, cost per scribe-year, and projected cost of hiring additional physicians to achieve the observed scribe productivity benefits in relative value units and visits per full-time-equivalent over the 2-year intervention period (June 30, 2020 to July 1, 2022). RESULTS: The estimated cost of the trial was $4.6 million, below the Congressional Budget Office estimate of $5 million. A full-time scribe-year cost approximately $74 600 through contracting and $62 900 through VA hiring. Randomization into the trial led to an approximate 30% increase in productivity in cardiology and 20% in orthopedics. The projected incremental cost of using additional physicians instead of scribes to achieve the same productivity benefits was nearly $1.7 million more, or 75% higher, than the observed cost of scribes in cardiology and orthopedics. CONCLUSIONS: As the largest randomized trial of scribes to date, the MISSION Act scribes trial provides important evidence on the costs and benefits of scribes. Improving productivity enhances access and scribes may give VA a new tool to improve productivity in specialty care at a lower cost than hiring additional providers.

Potential inequities in access to in-person SHIP counseling services.

OBJECTIVES: Counseling and education on Medicare coverage options are available through the federal State Health Insurance Assistance Program (SHIP), but little is known about the population that SHIP reaches. STUDY DESIGN: Cross-sectional study. METHODS: Using a novel data source on SHIP counseling site locations, we characterized the availability of in-person SHIP counseling by zip code tabulation area (ZCTA) and used linear regression and t tests to evaluate whether SHIP counseling sites are disproportionately located in higher-income communities. RESULTS: Our sample included 1511 SHIP counseling sites. More than half (63%) of the localities in our sample have a SHIP site within the ZCTA or county. Twenty-four percent do not have a SHIP site within the county but have one in an adjacent county. The remaining 13% do not have a nearby SHIP site. There is a disproportionate number of individuals eligible for Medicare in localities without a SHIP site. Moreover, the population living in areas without in-person SHIP sites is more likely to have low income and fewer years of education than the population living in areas with a SHIP site. CONCLUSIONS: These results suggest that there are areas where in-person SHIP service expansion or other additional navigation support may be warranted.

A dataset of geocoded Medicaid office locations in the United States.

Medicaid is the largest health insurance program in the United States, covering more than 86 million Americans as of early 2023, and is key for progress towards health equity. Although policy changes like Medicaid expansion have significantly expanded the number of people who are eligible for Medicaid, the administrative burdens of enrolling in and renewing coverage can be substantial. Although many applications are now submitted online, physical access to Medicaid offices still plays a critical role in understanding eligibility, getting help in applying, and navigating required documentation for both initial enrollment and redetermination of eligibility. However, as more government functions have moved online, in-person office locations and/or staff may have been cut to reduce costs, and gentrification has shifted where minoritized, marginalized, and/or low-income populations live, it is unclear if the key local connection point between residents and Medicaid has been maintained. To our knowledge, no single source of Medicaid office locations has been assembled and made available for research purposes. Our objective was to identify and geocode all public-facing Medicaid offices in the United States, which can then be paired with other spatial data (e.g., demographics, Medicaid participation, health care use, health outcomes) to explore policy-relevant research questions. We identified Medicaid office addresses in all 50 states and the District of Columbia by searching state government websites (e.g., Department of Health and Human Services or analogous state agency). Our corpus of Medicaid office addresses was then geocoded using the Census Geocoder with unresolved addresses investigated and/or manually geocoded using Google Maps. After deduplication (e.g., where multiple counties share a single office) and removal of mailing addresses (e.g., PO Boxes), our final dataset includes 3026 Medicaid office locations.

Targeting IDH2R140Q and other neoantigens in acute myeloid leukemia.

ABSTRACT: For patients with high-risk or relapsed/refractory acute myeloid leukemia (AML), allogeneic stem cell transplantation (allo-HSCT) and the graft-versus-leukemia effect mediated by donor T cells, offer the best chance of long-term remission. However, the concurrent transfer of alloreactive T cells can lead to graft-versus-host disease that is associated with transplant-related morbidity and mortality. Furthermore, ∼60% of patients will ultimately relapse after allo-HSCT, thus, underscoring the need for novel therapeutic strategies that are safe and effective. In this study, we explored the feasibility of immunotherapeutically targeting neoantigens, which arise from recurrent nonsynonymous mutations in AML and thus represent attractive targets because they are exclusively present on the tumor. Focusing on 14 recurrent driver mutations across 8 genes found in AML, we investigated their immunogenicity in 23 individuals with diverse HLA profiles. We demonstrate the immunogenicity of AML neoantigens, with 17 of 23 (74%) reactive donors screened mounting a response. The most immunodominant neoantigens were IDH2R140Q (n = 11 of 17 responders), IDH1R132H (n = 7 of 17), and FLT3D835Y (n = 6 of 17). In-depth studies of IDH2R140Q-specific T cells revealed the presence of reactive CD4+ and CD8+ T cells capable of recognizing distinct mutant-specific epitopes restricted to different HLA alleles. These neo-T cells could selectively recognize and kill HLA-matched AML targets endogenously expressing IDH2R140Q both in vitro and in vivo. Overall, our findings support the clinical translation of neoantigen-specific T cells to treat relapsed/refractory AML.

Incongruity between T cell receptor recognition of breast cancer hotspot mutations ESR1 Y537S and D538G following exogenous peptide loading versus endogenous antigen processing.

T cell receptor engineered T cell (TCR T) therapies have shown recent efficacy against certain types of solid metastatic cancers. However, to extend TCR T therapies to treat more patients across additional cancer types, new TCRs recognizing cancer-specific antigen targets are needed. Driver mutations in AKT1, ESR1, PIK3CA, and TP53 are common in patients with metastatic breast cancer (MBC) and if immunogenic could serve as ideal tumor-specific targets for TCR T therapy to treat this disease. Through IFN-γ ELISpot screening of in vitro expanded neopeptide-stimulated T cell lines from healthy donors and MBC patients, we identified reactivity towards 11 of 13 of the mutations. To identify neopeptide-specific TCRs, we then performed single-cell RNA sequencing of one of the T cell lines following neopeptide stimulation. Here, we identified an ESR1 Y537S specific T cell clone, clonotype 16, and an ESR1 Y537S/D538G dual-specific T cell clone, clonotype 21, which were HLA-B*40:02 and HLA-C*01:02 restricted, respectively. TCR Ts expressing these TCRs recognized and killed target cells pulsed with ESR1 neopeptides with minimal activity against ESR1 WT peptide. However, these TCRs failed to recognize target cells expressing endogenous mutant ESR1. To investigate the basis of this lack of recognition we performed immunopeptidomics analysis of a mutant-overexpressing lymphoblastoid cell line and found that the ESR1 Y537S neopeptide was not endogenously processed, despite binding to HLA-B*40:02 when exogenously pulsed onto the target cell. These results indicate that stimulation of T cells that likely derive from the naïve repertoire with pulsed minimal peptides may lead to the expansion of clones that recognize non-processed peptides, and highlights the importance of using methods that selectively expand T cells with specificity for antigens that are efficiently processed and presented.

Measuring restrictiveness of Medicare Advantage networks: A claims-based approach.

OBJECTIVE: To develop and validate a measure of provider network restrictiveness in the Medicare Advantage (MA) population. DATA SOURCES: Prescription drug event data and beneficiary information for Part D enrollees from the Center for Medicare and Medicaid Services, along with prescriber identifiers; geographic variables from the Area Health Resources Files. STUDY DESIGN: A prediction model was used to predict the unique number of primary care providers that would have been seen by MA beneficiaries absent network restrictions. The model was trained and validated on Traditional Medicare (TM) beneficiaries. A pseudo-Poisson and a random forest model were evaluated. An observed-to-expected (O/E) ratio was calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based the TM prediction model. Multivariable linear models were used to assess the relationship between network restrictiveness and plan and market factors. DATA COLLECTION/EXTRACTION METHODS: Prescription drug event data were obtained for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017. PRINCIPAL FINDINGS: Health Maintenance Organization plans were more restrictive (O/E = 55.5%; 95% CI 55.3%-55.7%) than Health Maintenance Organization-Point of Service plans (67.2%; 95% CI 66.7%-67.8%) or Preferred Provider Organization plans (74.7%; 95% CI 74.3%-75.1%), and rural areas had more restrictive networks (31.6%; 95% CI 29.0%-34.2%) than metropolitan areas (61.5%; 95% CI 61.3%-61.7%). Multivariable results confirmed these findings, and also indicated that increased provider supply was associated with less restrictive networks. CONCLUSIONS: We developed a means of estimating provider network restrictiveness in MA from claims data. Our results validate the approach, providing confidence for wider application (e.g., for other markets and specialties) and use for regulation.

Finding social need-les in a haystack: ascertaining social needs of Medicare patients recorded in the notes of care managers.

BACKGROUND: Unmet social needs may impair health and access to health care, and intervening on these holds particular promise in high-risk patient populations, such as those with multiple chronic conditions. Our objective was to identify social needs in a patient population at significant risk-Medicare enrollees with multiple chronic illnesses enrolled in care management services-and measure their prevalence prior to any systematic screening. METHODS: We partnered with Renova Health, an independent Medicare Chronic Care Management (CCM) provider with patients in 10 states during our study period (January 2017 through August 2020). Our data included over 3,000 Medicare CCM patients, representing nearly 20,000 encounters. We used a dictionary-based natural language processing approach to ascertain the prevalence of six domains of barriers to care (food insecurity, housing instability, utility hardship) and unmet social needs (health care affordability, need for supportive services, transportation) in notes taken during telephonic Medicare CCM patient encounters. RESULTS: Barriers to care, specifically need for supportive services (2.4%) and health care affordability (0.8%), were the most prevalent domains identified. Transportation as a barrier to care came up relatively less frequently in CCM encounters (0.1%). Unmet social needs were identified at a comparatively lower rate, with potential housing instability (0.3%) flagged most followed by potential utility hardship (0.2%) and food insecurity (0.1%). CONCLUSIONS: There is substantial untapped opportunity to systematically screen for social determinants of health and unmet social needs in care management.

Medicaid policy data for evaluating eligibility and programmatic changes.

OBJECTIVES: Medicaid and the Children's Health Insurance Program (CHIP) provide health insurance coverage to more than 90 million Americans as of early 2023. There is substantial variation in eligibility criteria, application procedures, premiums, and other programmatic characteristics across states and over time. Analyzing changes in Medicaid policies is important for state and federal agencies and other stakeholders, but such analysis requires data on historical programmatic characteristics that are often not available in a form ready for quantitative analysis. Our objective is to fill this gap by synthesizing existing qualitative policy data to create a new data resource that facilitates Medicaid policy research. DATA DESCRIPTION: Our source data were the 50-state surveys of Medicaid and CHIP eligibility, enrollment, and cost-sharing policies, and budgets conducted near annually by KFF since 2000, which we coded through 2020. These reports are a rich source of point-in-time information but not operationalized for quantitative analysis. Through a review of the measures captured in the KFF surveys, we developed five Medicaid policy domains with 122 measures in total, each coded by state-quarter-1) eligibility (28 measures), 2) enrollment and renewal processes (39 measures), 3) premiums (16 measures), 4) cost-sharing (26 measures), and 5) managed care (13 measures).

Effect of a National VHA Medical Scribe Pilot on Provider Productivity, Wait Times, and Patient Satisfaction in Cardiology and Orthopedics.

BACKGROUND: Section 507 of the VA MISSION Act of 2018 mandated a 2-year pilot study of medical scribes in the Veterans Health Administration (VHA), with 12 VA Medical Centers randomly selected to receive scribes in their emergency departments or high wait time specialty clinics (cardiology and orthopedics). The pilot began on June 30, 2020, and ended on July 1, 2022. OBJECTIVE: Our objective was to evaluate the impact of medical scribes on provider productivity, wait times, and patient satisfaction in cardiology and orthopedics, as mandated by the MISSION Act. DESIGN: Cluster randomized trial, with intent-to-treat analysis using difference-in-differences regression. PATIENTS: Veterans using 18 included VA Medical Centers (12 intervention and 6 comparison sites). INTERVENTION: Randomization into MISSION 507 medical scribe pilot. MAIN MEASURES: Provider productivity, wait times, and patient satisfaction per clinic-pay period. KEY RESULTS: Randomization into the scribe pilot was associated with increases of 25.2 relative value units (RVUs) per full-time equivalent (FTE) (p < 0.001) and 8.5 visits per FTE (p = 0.002) in cardiology and increases of 17.3 RVUs per FTE (p = 0.001) and 12.5 visits per FTE (p = 0.001) in orthopedics. We found that the scribe pilot was associated with a decrease of 8.5 days in request to appointment day wait times (p < 0.001) in orthopedics, driven by a 5.7-day decrease in appointment made to appointment day wait times (p < 0.001), and observed no change in wait times in cardiology. We also observed no declines in patient satisfaction with randomization into the scribe pilot. CONCLUSIONS: Given the potential improvements in productivity and wait times with no change in patient satisfaction, our results suggest that scribes may be a useful tool to improve access to VHA care. However, participation in the pilot by sites and providers was voluntary, which could have implications for scalability and what effects could be expected if scribes were introduced to the care process without buy-in. Cost was not considered in this analysis but is an important factor for future implementation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04154462.

High Deductible Health Plans and Use of Free Preventive Services Under the Affordable Care Act.

The Affordable Care Act aimed to increase use of preventive services by eliminating cost-sharing to consumers. However, patients may be unaware of this benefit or they may not seek preventive services if they anticipate that the cost of potential diagnostic or treatment services will be too high, both more likely among those in high deductible health plans. We used nationally representative private health insurance claims (100% sample of IBM® MarketScan®) for the United States from 2006 to 2018, restricting the data to enrollment and claims for non-elderly adults who were enrolled for the full plan year. The cross-sectional sample (185 million person-years) is used to describe trends in preventive service use and costs from 2008 through 2016. The cohort sample (9 million people) focuses on the elimination of cost-sharing for certain high-value preventive services in late 2010, requiring continuous enrollment across 2010 and 2011. We examine whether HDHP enrollment is associated with use of eligible preventive services using semi-parametric difference-in-differences to account for endogenous plan selection. Our preferred model implies that HDHP enrollment was associated with a reduction of the post-ACA change in any use of eligible preventive services by 0.2 percentage points or 12.5%. Cancer screenings were unaffected but HDHP enrollment was associated with smaller increases in wellness visits, immunizations, and screening for chronic conditions and sexually transmitted infections. We also find that the policy was ineffective at reducing out-of-pocket costs for the eligible preventive services, likely due to implementation issues.