Association between physician age and patterns of end-of-life care among older Americans.

BACKGROUND: End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. METHODS: We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL. RESULTS: Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001). CONCLUSIONS: We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.

Changes in Site of Death Among Older Adults Without a COVID-19 Diagnosis During the COVID-19 Pandemic.

BACKGROUND: Understanding how the coronavirus disease 2019 (COVID-19) pandemic affected site of death-an important patient-centered outcome related to end-of-life care-would inform healthcare system resiliency in future public health emergencies. OBJECTIVE: To evaluate the changes in site of death during the COVID-19 pandemic among older adults without a COVID-19 diagnosis. DESIGN: Using a quasi-experimental difference-in-differences method, we estimated net changes in site of death during the pandemic period (March-December 2020) from the pre-pandemic period (January-February 2020), using data on the same months in prior years (2016-2019) as the control. PARTICIPANTS: A 20% sample of Medicare Fee-for-Service beneficiaries aged 66 years and older who died in 2016-2020. We excluded beneficiaries with a hospital diagnosis of COVID-19. MAIN MEASURES: We assessed each of the following sites of death separately: (1) home or community; (2) acute care hospital; and (3) nursing home. KEY RESULTS: We included 1,133,273 beneficiaries without a hospital diagnosis of COVID-19. We found that the proportion of Medicare beneficiaries who died at home or in the community setting increased (difference-in-differences [DID] estimate, + 3.1 percentage points [pp]; 95% CI, + 2.6 to + 3.6 pp; P < 0.001) and the proportion of beneficiaries who died (without COVID-19 diagnosis) in an acute care hospital decreased (- 0.8 pp; 95% CI, - 1.2 to - 0.4 pp; P < 0.001) during the pandemic. We found no evidence that the proportion of deaths in nursing homes changed during the pandemic. CONCLUSIONS: Using national data on older adults without a COVID-19 diagnosis, we found that site of death shifted toward home or community settings during the COVID-19 pandemic. Our findings may inform clinicians and policymakers in supporting end-of-life care during future public health emergencies.

Association between physicians' geriatric training and patterns of end-of-life care delivered to persons with dementia.

BACKGROUND: Geriatric training is designed to prepare physicians to meet the complex needs of older adults, including persons with dementia at the end-of-life (EOL) stage. We sought to compare patterns of EOL care delivered to persons with dementia between physicians with versus without geriatric training. METHODS: We conducted a cross-sectional study of a 20% random sample of fee-for-service Medicare beneficiaries with dementia who died in 2016-2018 (n = 99,631). We attributed beneficiaries to a physician who had the largest number of primary care visits during the last 6 months of life and determined whether the physician was trained in geriatrics. Our outcome measures included: (i) advance care planning (ACP) and palliative care (e.g., ACP, hospice enrollment in the last 90 days of life), and (ii) high-intensity EOL care (e.g., emergency department visits or hospital admissions in the last 30 days of life). RESULTS: Beneficiaries with dementia under the care of physicians with geriatric training had a higher proportion of ACP (adjusted proportion, 15.8% vs. 13.0%; p < 0.001 after accounting for multiple comparisons), palliative care counseling (22.4% vs. 20.9%; p = 0.01), and hospice enrollment (63.7% vs. 60.6%; p < 0.001). Geriatric training was also associated with a lower proportion of emergency department visits (55.1% vs. 59.1%; p < 0.001), hospital admissions (48.8% vs. 52.3%; p < 0.001), ICU admissions (24.9% vs. 27.4%; p < 0.001), use of mechanical ventilation (11.2% vs. 13.0%; p < 0.001), and use of cardiopulmonary resuscitation (2.1% vs. 2.4%; p = 0.03) in the last 30 days of life. There was no evidence that the placement of feeding tubes differed between the two groups. CONCLUSIONS: Physicians' geriatric training was associated with the receipt of more ACP and palliative care and less intensive EOL care among persons with dementia. Provision of geriatric training for physicians may have the potential to improve the quality of EOL care delivered to persons with dementia.

Timing and setting of billed advance care planning among Medicare decedents in 2017-2019.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) began to reimburse clinicians for advance care planning (ACP) discussions, effective January 1, 2016. We sought to characterize the timing and setting of first-billed ACP discussions among Medicare decedents to inform future research on ACP billing codes. METHODS: Using a random 20% sample of Medicare fee-for-service beneficiaries aged 66 years and older who died in 2017-2019, we described the timing (relative to death) and setting (inpatient, nursing home, office, or outpatient with or without Medicare Annual Wellness Visit [AWV], home or community, or elsewhere) of the first-billed ACP discussion for each beneficiary. RESULTS: Our study included 695,985 decedents (mean [SD] years of age, 83.2 [8.8]; 54.2% female); the proportion of decedents who had at least one billed ACP discussion increased from 9.7% in 2017 to 21.9% in 2019. We found that the proportion of first-billed ACP discussions held during the last month of life decreased from 37.0% in 2017 to 26.2% in 2019, while the proportion of first-billed ACP discussions held more than 12 months before death increased from 11.1% in 2017 to 35.2% in 2019. We also found that the proportion of first-billed ACP discussions held in the office or outpatient setting along with AWV increased over time (from 10.7% in 2017 to 14.1% in 2019), while the proportion held in the inpatient setting decreased (from 41.7% in 2017 to 38.0% in 2019). CONCLUSIONS: We found that with increasing exposure to the CMS policy change, uptake of the ACP billing code has increased; first-billed ACP discussions are occurring sooner before the end-of-life stage and are more likely to occur with AWV. Future studies should evaluate changes in ACP practice patterns, rather than only an increasing uptake in ACP billing codes, following the policy implementation.

Life satisfaction among persons living with dementia and those without dementia.

BACKGROUND: Despite possible major adverse cognitive, physical, social, and behavioral consequences, little is known about how persons living with dementia perceive satisfaction with life, a key component of well-being. We sought to examine (i) whether persons living with dementia perceive a lower level of satisfaction compared to their peers without dementia and (ii) whether the associations between individual characteristics and life satisfaction are different between persons living with and without dementia. METHODS: Using a nationally representative sample of community-dwelling older adults aged ≥70 years in the U.S. from the Health and Retirement Study, we compared scores on the Satisfaction with Life Scale (SWLS), a self-reported 5-item scale ranging from 1 to 7 (more satisfaction), between persons with probable dementia (n = 341) and those without (n = 5530), adjusting for individual characteristics. We also tested whether the associations between the individual characteristics and SWLS differ by dementia status. RESULTS: Scores on SWLS did not differ between persons with probable dementia and those without when adjusting for individual characteristics including limitations in activities of daily living (ADL) (adjusted difference, -0.09; 95% CI, -0.33 to +0.15; p-value, 0.45). However, dementia status was associated with lower life satisfaction through the mediation of limitations in ADL (total effect, -0.29; bootstrapped 95% CI, -0.47 to -0.12). Most individual characteristics associated with lower life satisfaction were similar in the two groups, including younger age, more limitations in ADL, and depression. Less wealth was associated with lower satisfaction among persons without dementia but not among those with probable dementia. CONCLUSIONS: Dementia status was only modestly associated with lower life satisfaction through the mediation of limitations in ADL among participants who were able to provide response. Future research is warranted to determine whether life satisfaction can be used as a meaningful outcome when evaluating well-being among persons living with dementia.

Deep Light Field Spatial Super-Resolution Using Heterogeneous Imaging.

Light field (LF) imaging expands traditional imaging techniques by simultaneously capturing the intensity and direction information of light rays, and promotes many visual applications. However, owing to the inherent trade-off between the spatial and angular dimensions, LF images acquired by LF cameras usually suffer from low spatial resolution. Many current approaches increase the spatial resolution by exploring the four-dimensional (4D) structure of the LF images, but they have difficulties in recovering fine textures at a large upscaling factor. To address this challenge, this paper proposes a new deep learning-based LF spatial super-resolution method using heterogeneous imaging (LFSSR-HI). The designed heterogeneous imaging system uses an extra high-resolution (HR) traditional camera to capture the abundant spatial information in addition to the LF camera imaging, where the auxiliary information from the HR camera is utilized to super-resolve the LF image. Specifically, an LF feature alignment module is constructed to learn the correspondence between the 4D LF image and the 2D HR image to realize information alignment. Subsequently, a multi-level spatial-angular feature enhancement module is designed to gradually embed the aligned HR information into the rough LF features. Finally, the enhanced LF features are reconstructed into a super-resolved LF image using a simple feature decoder. To improve the flexibility of the proposed method, a pyramid reconstruction strategy is leveraged to generate multi-scale super-resolution results in one forward inference. The experimental results show that the proposed LFSSR-HI method achieves significant advantages over the state-of-the-art methods in both qualitative and quantitative comparisons. Furthermore, the proposed method preserves more accurate angular consistency.

Client-Oriented Blind Quality Metric for High Dynamic Range Stereoscopic Omnidirectional Vision Systems.

A high dynamic range (HDR) stereoscopic omnidirectional vision system can provide users with more realistic binocular and immersive perception, where the HDR stereoscopic omnidirectional image (HSOI) suffers distortions during its encoding and visualization, making its quality evaluation more challenging. To solve the problem, this paper proposes a client-oriented blind HSOI quality metric based on visual perception. The proposed metric mainly consists of a monocular perception module (MPM) and binocular perception module (BPM), which combine monocular/binocular, omnidirectional and HDR/tone-mapping perception. The MPM extracts features from three aspects: global color distortion, symmetric/asymmetric distortion and scene distortion. In the BPM, the binocular fusion map and binocular difference map are generated by joint image filtering. Then, brightness segmentation is performed on the binocular fusion image, and distinctive features are extracted on the segmented high/low/middle brightness regions. For the binocular difference map, natural scene statistical features are extracted by multi-coefficient derivative maps. Finally, feature screening is used to remove the redundancy between the extracted features. Experimental results on the HSOID database show that the proposed metric is generally better than the representative quality metric, and is more consistent with the subjective perception.

Quantifying Balance Billing for Out-of-Network Behavioral Health Care in Employer-Sponsored Insurance.

OBJECTIVE: The study estimated balance billing for out-of-network behavioral health claims and described subscriber characteristics associated with higher billing. METHODS: Claims data (2011-2014) from a national managed behavioral health organization's employer-sponsored insurance (N=196,034 family-years with out-of-network behavioral health claims) were used to calculate inflation-adjusted annual balance billing-the submitted amount (charged by provider) minus the allowed amount (insurer agreed to pay plus patient cost-sharing) and any discounts offered by the provider. Among family-years with complete sociodemographic data (N=68,659), regressions modeled balance billing as a function of plan and provider supply, subscriber and family-year, and employer characteristics. A two-part model accounted for family-years without balance billing. RESULTS: Among the 50% of family-years with balance billing, mean±SD balance billing was $861±$3,500 (median, $175; 90th percentile, $1,684). Adjusted analysis found balance billing was higher ($523 higher, 95% confidence interval [CI]=$340, $705) for carve-out versus carve-in plans and for health maintenance organization (HMO) enrollees versus non-HMO enrollees ($156, 95% CI=$75, $237); for subscribers with a bachelor's degree, compared with an associate's degree or with a high school diploma or lower (between $172 [95% CI=$228, $116] and $224 [95% CI=$284, $163] higher, respectively); and for subscribers ages 45-54, compared with those ages 35-44 and 18-24 (between $57 [95% CI=$103, $10] and $290 [95% CI=$398, $183] higher, respectively). Balance billing was lower in states with more in-network providers per capita (-$8, 95% CI=-$10, -$5). CONCLUSIONS: Balance billing for out-of-network behavioral health claims may be burdensome. Expanded behavioral health networks may improve access.

Comparing Gold-standard Copayment and Coinsurance Values From Claims Processing Engines to Values Derived From Behavioral Health Claims Databases.

BACKGROUND: While researchers use patient expenditures in claims data to estimate insurance benefit features, little evidence exists to indicate whether the resulting measures are accurate. OBJECTIVE: To develop and test an algorithm for deriving copayment and coinsurance values from behavioral health claims data. SUBJECTS: Employer-sponsored insurance plans from 2011 to 2013 for a national managed behavioral health organization (MBHO). MEASURES: Twelve benefit features, distinguishing between carve-in and carve-out, in-network and out-of-network, inpatient and outpatient, and copayment and coinsurance, were created. Measures drew from claims (claims-derived measures), and benefit feature data from a claims processing engine database (true measures). STUDY DESIGN: We calculate sensitivity and specificity of the claims-derived measures' ability to accurately determine if a benefit feature was required and for plan-years requiring the benefit feature, the accuracy of the claims-derived measures. Accuracy rates using the minimum, 25th, 50th, 75th, and maximum claims value for a plan-year were compared. PRINCIPAL FINDINGS: Sensitivity (82% or higher for all but 3 benefit features) and specificity (95% or higher for all but 2 benefit features) were relatively high. Accuracy rates were highest using the 75th or maximum claims value, depending on the benefit feature, and ranged from 69% to 99% for all benefit features except for out-of-network inpatient coinsurance. CONCLUSIONS: For most plan-years, claims-derived measures correctly identify required specialty mental health copayments and coinsurance, although the claims-derived measures' accuracy varies across benefit design features. This information should be considered when creating claims-derived benefit features to use for policy analysis.

Stereo Video Quality Metric Based on Multi-Dimensional Analysis.

Stereo video has been widely applied in various video systems in recent years. Therefore, objective stereo video quality metric (SVQM) is highly necessary for improving the watching experience. However, due to the high dimensional data in stereo video, existing metrics have some defects in accuracy and robustness. Based on the characteristics of stereo video, this paper considers the coexistence and interaction of multi-dimensional information in stereo video and proposes an SVQM based on multi-dimensional analysis (MDA-SVQM). Specifically, a temporal-view joint decomposition (TVJD) model is established by analyzing and comparing correlation in different dimensions and adaptively decomposes stereo group of frames (sGoF) into different subbands. Then, according to the generation mechanism and physical meaning of each subband, histogram-based and LOID-based features are extracted for high and low frequency subband, respectively, and sGoF quality is obtained by regression. Finally, the weight of each sGoF is calculated by spatial-temporal energy weighting (STEW) model, and final stereo video quality is obtained by weighted summation of all sGoF qualities. Experiments on two stereo video databases demonstrate that TVJD and STEW adopted in MDA-SVQM are convincible, and the overall performance of MDA-SVQM is better than several existing SVQMs.

Impact of the 2016 Election on the Quality of Life of Sexual and Gender Minority Adults: A Difference-in-Differences Analysis.

Purpose: The 2016 U.S. election significantly changed the political landscape for sexual and gender minority (SGM) individuals. The current study assessed the consequences of the election and transition to a new overtly discriminatory administration on the health-related quality of life of SGM adults compared with their cisgender and heterosexual counterparts. Methods: The study used repeated cross-sectional data from the 17 states that administered the sexual orientation and gender identity module in the 2015 and 2018 Behavioral Risk Factor Surveillance System surveys. The sample included 268,851 adult respondents: 12,006 SGM adults (5.35%) and 256,845 cisgender and heterosexual adults (94.65%). Outcomes were frequent (≥14 days in the last month) physical distress, mental distress, limited activity, and/or fair/poor general health. Difference-in-differences estimates were calculated from logistic regression models, controlling for sociodemographic, health care coverage, and chronic medical condition confounders. Results: Compared with the cisgender and heterosexual population, frequent mental distress among SGM adults increased by 5% points, corresponding to a relative increase of 32.5% (p < 0.001) from 2015. Rates of frequent physical distress, limited activity, and fair/poor general health were not significantly altered between the two populations. Gender minority adults were most negatively affected with a relative increase in frequent mental distress of 117.5% (p < 0.001). Conclusions: The 2016 U.S. election and administration changeover were associated with a substantial increase in the proportion of SGM adults reporting frequent mental distress. These data provide empirical evidence as to the psychological effects of an abrupt political realignment on SGM mental health.

Blind Tone-Mapped Image Quality Assessment Based on Regional Sparse Response and Aesthetics.

High dynamic range (HDR) images give a strong disposition to capture all parts of natural scene information due to their wider brightness range than traditional low dynamic range (LDR) images. However, to visualize HDR images on common LDR displays, tone mapping operations (TMOs) are extra required, which inevitably lead to visual quality degradation, especially in the bright and dark regions. To evaluate the performance of different TMOs accurately, this paper proposes a blind tone-mapped image quality assessment method based on regional sparse response and aesthetics (RSRA-BTMI) by considering the influences of detail information and color on the human visual system. Specifically, for the detail loss in a tone-mapped image (TMI), multi-dictionaries are first designed for different brightness regions and whole TMI. Then regional sparse atoms aggregated by local entropy and global reconstruction residuals are presented to characterize the regional and global detail distortion in TMI, respectively. Besides, a few efficient aesthetic features are extracted to measure the color unnaturalness of TMI. Finally, all extracted features are linked with relevant subjective scores to conduct quality regression via random forest. Experimental results on the ESPL-LIVE HDR database demonstrate that the proposed RSRA-BTMI method is superior to the existing state-of-the-art blind TMI quality assessment methods.

Carve-out plan financial requirements associated with national behavioral health parity.

OBJECTIVES: To examine changes in carve-out financial requirements (copayments, coinsurance, use of deductibles, and out-of-pocket maxima) following the Mental Health Parity and Addiction Equity Act (MHPAEA). DATA SOURCE/STUDY SETTING: Specialty mental health benefit design information for employer-sponsored carve-out plans from a national managed behavioral health organization's claims processing engine (2008-2013). STUDY DESIGN: This pre-post study reports linear and logistic regression as the main analysis. DATA COLLECTION/EXTRACTION METHODS: NA. PRINCIPAL FINDINGS: Copayments for in-network emergency room (-$44.9, 95% CI: -78.3, -11.5; preparity mean: $56.2), outpatient services (eg, individual psychotherapy: -$7.4, 95% CI: -10.5, -4.2; preparity mean: $17.8), and out-of-network coinsurance for emergency room (-11 percentage points, 95% CI: -16.7, -5.4; preparity mean: 38.8 percent) and outpatient (eg, individual psychotherapy: -5.8 percentage points, 95% CI: -10.0, -1.6; preparity mean 41.0 percent) decreased. Probability of family OOP maxima use (29 percentage points, 95% CI: 19.3, 38.6; preparity mean: 36 percent) increased. In-network outpatient coinsurance increased (eg, individual psychotherapy: 4.5 percentage points, 95% CI: 1.1, 7.9; preparity mean: 2.7 percent), as did probability of use of family deductibles (15 percentage points, 95% CI: 6.1, 23.3; preparity mean: 38 percent). CONCLUSIONS: MHPAEA was associated with increased generosity in most financial requirements observed here. However, increased use of deductibles may have reduced generosity for some patients.

The Mental Health Parity and Addiction Equity Act evaluation study: Child and adolescent behavioral health service expenditures and utilization.

This study explores possible associations of the Mental Health Parity and Addiction Equity Act (MHPAEA) with child access to behavioral health (BH) services (preimplementation = 2008-2009, transition = 2010, and post = 2011-2013). The study sample included children aged 4-17 years in self-insured "carve-in" plans from large employers. In "carve-ins," BH and medical care are covered through the same insurance plan. The unit of analysis is the person-month (N = 61,823,533). This study employs an interrupted time series model allowing for intercept and slope changes for the transition and postparity periods. Outcomes included total, plan and patient out-of-pocket (OOP) expenditures, and several categories of service utilization. Generalized estimating equations were used to account for clustering. There were significant increases in total and plan expenditures postparity. To illustrate, in July 2012, mean per-member-per-month total expenditures were predicted to be $5.65 without parity but $8.72 with parity. Patient OOP costs did not change significantly. Significant overall increases were seen for utilization of most outpatient services but not intermediate or inpatient services. Our findings suggest that the introduction of MHPAEA was associated with an increase in specialty BH service access for children without a commensurate increase in financial burden for families.

The Role of Behavioral Health Diagnoses in Adverse Selection.

OBJECTIVE: Adverse selection in medical insurance is well documented; however, little is known about the role of behavioral health. This study's objective was to examine the probability of being enrolled in the lowest-deductible plan among commercially insured patients, according to psychiatric diagnosis. METHODS: This cross-sectional study used 2012-2013 benefit design and plan choice data linked to 2011-2012 behavioral health claims for a national sample of individuals (N=116,975) and different family types (couple with at least one dependent, N=59,237; single subscriber with at least one dependent, N=19,066; couple with no dependents, N=40,917) with Optum, UnitedHealth Group "carve-in" plans. Analyses included multiple logistic regressions examining whether the individual (or family) was enrolled in the plan with the lowest deductible as functions of whether individuals (or family members) had any psychiatric diagnosis, the number of psychiatric diagnoses they had, and whether they had individual major psychiatric diagnoses. RESULTS: For individuals, having any psychiatric diagnosis was associated with an increase of about 10% in the probability of being enrolled in the lowest-deductible plan compared with having no psychiatric diagnosis (44.9% vs. 40.7%, p=0.04). Each additional psychiatric diagnosis increased this probability by three percentage points (p=0.02). A diagnosis of depression was associated with the largest increase. CONCLUSIONS: When individuals were offered the choice of a health insurance plan, having a prior psychiatric diagnosis (specifically depression) was associated with being enrolled in the lowest-deductible plans. Individuals with depression may anticipate future expenditures and select plans accordingly.

Certificate of need and the cost of competition in home healthcare markets.

We used 2010-16 Medicare Cost Reports for 10,737 freestanding home health agencies (HHAs) to examine the impact of home health (HH) and nursing home (NH) certificate-of-need (CON) laws on HHA caseload, total and per-patient variable costs. After adjusting for other HHA characteristics, total costs were higher in states with only HH CON laws ($2,975,698), only NH CON laws ($1,768,097), and both types of laws ($3,511,277), compared with no CON laws ($1,538,536). Higher costs were driven by caseloads, as CON reduced per-patient costs. Additional research is needed to distinguish whether this is due to skimping on quality vs. economies of scale.

What Happens When Employers Switch from a "Carve-Out" to a "Carve-In" Model of Managed Behavioral Health?

BACKGROUND: Since the introduction and soaring popularity of the managed behavioral healthcare (BH) "carve-out" model in the 1980s, policymakers have been concerned with their impact on access. In carve-outs, BH and medical benefits are administered separately. Earlier literature found they reduced intensity of service use while maintaining penetration rates. Recently it has become more common for employers to drop existing carve-out contracts, partly due to the Mental Health Parity and Addiction Equity Act (MHPAEA), which placed a greater administrative burden on carve-outs for parity compliance. Although prior studies focused exclusively on the impact of moving from carve-in to carve-out models, it is now more policy-relevant to understand the effects of the move from carve-out to carve-in, which may not be symmetric. Moreover, the natural experiment resulting from MHPAEA implementation may attenuate concerns about selection bias. STUDY AIMS: This study examines how specialty BH care patterns change when employees and dependents are moved from a "carve-out" plan to a "carve-in" plan. METHODS: Linked insurance claims, eligibility, plan and employer data from 2008-14 were obtained for three Optum( employers who dropped their carve-out contracts but retained their carve-in plans. A longitudinal "difference-in-differences" study design was used to compare changes in BH services use over time among individuals who were: (i) moved to carve-in plans when the employer dropped its carve-out contract (N=177,653); and (ii) enrolled in carve-in plans before and after the transition (N=58,658). Outcomes included total and inpatient expenditures, broken down by plan, patient, and total; outpatient visits for assessment, individual psychotherapy, family psychotherapy, and medication management; and days of structured outpatient care, day treatment, residential care, and acute inpatient care. We pooled person-year observations and estimated regressions including individual fixed effects, year dummies and interactions between indicators for post-transition period and whether transitioned from carve-out to carve-in. RESULTS: Relative to individuals continuously in carve-in plans, those who were transitioned experienced significant increases in inpatient utilization (beta =.02; p=.05) and patient inpatient costs (beta =2.35; p=.01) and decreases in day treatment (beta =-0.01; p=.02). Our conclusions proved robust against potential biases due to differing secular time trends and differential changes in benefits resulting from MHPAEA. DISCUSSION: The increased inpatient utilization associated with switching from carve-out to carve-in plans is consistent with previous literature. Carve-outs may use day treatment to reduce inpatient care so that increased inpatient utilization post-transition reduced demand for day treatment. Limitations include possible selection bias at the employer level; lack of data on medication and generalist use, quality, clinical endpoints and quality of life; and potential lack of generalizability. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The reduction in the use of carve-out contracts by private employers associated with MHPAEA implementation likely did not have a net negative impact and may have actually increased access to care among former carve-out enrollees in need of inpatient services. IMPLICATIONS FOR HEALTH POLICIES: Policymakers should consider and evaluate possible unintended consequences of legislation designed to improve access to care. IMPLICATIONS FOR FURTHER RESEARCH: Future work should replicate these analyses with a more representative sample.

The Effects of Three Kinds of Insurance Benefit Design Features on Specialty Mental Health Care Use in Managed Care.

BACKGROUND: Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level. METHODS: A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted. RESULTS: For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.

Racial/ethnic disparities in specialty behavioral health care treatment patterns and expenditures among commercially insured patients in managed behavioral health care plans.

OBJECTIVE: To document differences among racial/ethnic/gender groups in specialty behavioral health care (BH) utilization/expenditures; examine whether these differences are driven by probability vs intensity of treatment; and identify whether differences are explained by socioeconomic status (SES). DATA SOURCE: The cohort consists of adults continuously enrolled in Optum plans with BH benefits during 2013. STUDY DESIGN: We modeled each outcome using linear regressions among the entire sample stratified by race/ethnicity, language and gender. Then, we estimated logistic regressions of the probability that an enrollee had any spending/use in a given service category (service penetration) and linear regressions of spending/use among the user subpopulation (treatment intensity). Lastly, all analyses were rerun with SES controls. DATA COLLECTION: This study links administrative data from a managed BH organization to a commercial marketing database. PRINCIPAL FINDINGS: We found that in many cases, racial/ethnic minorities had lower specialty BH expenditures/utilization, relative to whites, primarily driven by differences in service penetration. Among women, relative to whites, Asian non-English speakers, Asian English speakers, Hispanic non-English speakers, Hispanic English speakers, and blacks had $106, $95, $90, $48, and $61 less in total expenditures. SES explained racial/ethnic differences in treatment intensity but not service penetration. CONCLUSIONS: In this population, SES was not a major driver of racial/ethnic differences in specialty BH utilization. Future studies should explore the role of other factors not studied here, such as stigma, cultural competence, and geography.