State Standards for Insurance Access to Oncologists.

As the market for health insurance plans expands, each state is responsible for setting standards to ensure that plans contain adequate coverage for cancer care. Little is currently known about what criteria states use for network adequacy of insurance plans. We contacted representatives of the Department of Insurance (or equivalent) for 50 states and the District of Columbia, as well as searched official state websites to compile data on network adequacy standards for cancer care nationwide. The standards of 16 (31.4%) states contained only qualitative elements for access to an oncologist (eg, "reasonable access"), 7 (13.7%) states included only quantitative elements (eg, travel distance and time restrictions), and 24 (47.1%) states included standards with both qualitative and quantitative elements. Standards from 4 states were not available. States should make certain that robust, transparent protections exist to ensure that patients are able to access high-quality cancer care without experiencing the financial toxicity associated with out-of-network billing.

Costs for Colon Cancer Treatment Comparing Benefit Types and Care Sources in the US Military Health System.

INTRODUCTION: Cancer is one of the leading causes of morbidity and mortality in the USA, contributing largely to US healthcare spending. Provision of services (direct or purchased) and insurance benefit type may impact cost for cancer care. As a common cause of cancer in both men and women, we aim to compare colon cancer treatment costs between insurance benefit types and care sources in the US Military Health System (MHS) to better understand whether and to what extent these system factors impact cancer care costs. MATERIALS AND METHODS: Department of Defense Central Cancer Registry records and MHS Data Repository administrative claims were used to identify MHS beneficiaries aged 18-64 who were diagnosed with primary colon adenocarcinoma and received treatment between 2003 and 2008. The data linkage was approved by the Institutional Review Boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health. Costs to the MHS for each claim related to cancer treatment were extracted from the linked data and adjusted to 2008 USD. We used quantile regression models to compare median cancer treatment costs between benefit types and care sources (direct, purchased, or both), adjusted for demographic, tumor, and treatment characteristics. RESULTS: The median per capita (n = 801) costs for colon cancer care were $60,321 (interquartile range $24,625, $159,729) over a median follow-up of 1.7 years. The model-estimated treatment costs were similar between benefit types. Patients using direct care had significantly lower estimated median costs [$34,145 (standard error $4,326)] than patients using purchased care [$106,395 ($10,559)] or both care sources [$82,439 ($13,330)], controlled for patient demographic, tumor, and treatment characteristics. Differences in cost by care source were noted for patients with later stage tumors and by treatment type. Relative costs were 2-3 times higher for purchased care compared to direct care for patients with late-stage tumors and for patients receiving chemotherapy or radiation treatment. CONCLUSIONS: In the MHS, median cost for colon cancer treatment was lower in direct care compared to purchased care or patients using a combination of direct and purchased care. The variation in cancer treatment costs between care sources may be due to differences in treatment incentives or capabilities. Additional studies on cost differences between direct and purchased services are needed to understand how provision of care affects cancer treatment costs and to identify possible targets for cost reduction.

The continuum of breast cancer care and outcomes in the U.S. Military Health System: an analysis by benefit type and care source.

PURPOSE: This study investigates transition rates between breast cancer diagnosis, recurrence, and death by insurance benefit type and care source in U.S. Military Health System (MHS). METHODS: The MHS data repository and central cancer registry linked data were used to identify women aged 40-64 with histologically confirmed breast cancer between 2003 and 2007. Three-state continuous time Markov models were used to estimate transition rates and transition rate ratios (TRRs) by TRICARE benefit type (Prime or non-Prime) and care source (direct, purchased, or both), adjusted for demographic, tumor, and treatment variables. RESULTS: Analyses included 2668 women with transitions from diagnosis to recurrence (n = 832), recurrence to death (n = 79), and diagnosis to death without recurrence (n = 91). Compared to women with Prime within each care source, women with non-Prime using both care sources had higher transition rates (TRR 1.47, 95% CI 1.03, 2.10). Compared to those using direct care within each benefit type, women utilizing both care sources with non-Prime had higher transition rates (TRR 1.86, 95% CI 1.11, 3.13), while women with Prime utilizing purchased care had lower transition rates (TRR 0.82, 95% CI 0.68, 0.98). CONCLUSIONS: In the MHS, women with non-Prime benefit plans compared to Prime had higher transition rates along the breast cancer continuum among both care source users. Purchased care users had lower transition rates than direct care users among Prime beneficiaries. IMPLICATIONS FOR CANCER SURVIVORS: Benefit plan and care source may be associated with breast cancer progression. Further research is needed to demonstrate differences in survivorship.

Benefit Type and Care Source in Relation to Mammography Screening and Breast Cancer Stage at Diagnosis Among DoD Beneficiaries.

BACKGROUND: Type of insurance and out-of-pocket costs influence the use of medical care. Specifically, type of insurance can impact an individual's likelihood of receiving a screening mammogram. Additionally, variation in tumor stage at diagnosis exists for patients with different types of insurance. It is not clear whether different benefit types and care sources differ in breast cancer care and outcomes among Department of Defense (DoD) beneficiaries. METHODS: The objective of this study was to examine differences in screening mammography and tumor stage at diagnosis between different benefit types (TRICARE Prime vs. non-Prime) and among different care sources (direct care, purchased care, and both) in the DoD Military Health System. Study subjects were women 40 to 64 years of age, diagnosed with malignant breast cancer between 2003 and 2007. Multivariable logistic regression analyses were conducted to assess differences by benefit type and care source in receipt of screening mammography before diagnosis and tumor stage at diagnosis. FINDINGS: A total of 2,668 women were included in this study. Patients with Prime were more likely to receive a screening mammography and have an earlier tumor stage than those with non-Prime. Women with direct care were more likely to have an earlier tumor stage but less likely to receive a screening mammogram than those with purchased care. DISCUSSION: In an equal access health care system, the use of mammography screening and tumor stage at diagnosis may differ by benefit type and care source among DoD beneficiaries. To our knowledge, this was the first study to assess mammography screening and tumor stage differences by benefit type and care source in the Military Health System. Although underlying reasons for the differences are not clear, they may be related to out-of-pocket costs, distance from medical treatment facilities, and frequency of doctor visits for other medical problems. Further research is needed to assess these differences and related factors among DoD beneficiaries.

Retirement and its consequences for women's health in Australia.

Understanding the health consequences of retirement is important, as many developed countries have already started raising state pension eligibility age, with the intention to induce postponed retirement. This paper estimates the causal effect of retirement on the health outcomes of older women in Australia, utilising the exogenous variation in retirement induced by the change in age eligibility for the Australian Age Pension. Using a sample of 19,185 observations for 3771 women from waves 2001-2011 of the Household, Income and Labour Dynamics in Australia (HILDA) Survey, we show that retirement status has positive and significant effects on women's self-reported health, physical and mental health outcomes. We also find that longer time spent in retirement confers clear additional health benefits. We show that retirement affects physical and mental health in diverse ways and that the estimated positive health effects of retirement are coincidental with increased post-retirement physical activity and reduced smoking. Our finding that retirement can improve health suggests that the welfare losses from working life prolongation policies will be larger than currently though when we include the cost of the foregone health improvements.

The Role of Physician Recommendations and Public Policy in Human Papillomavirus Vaccinations.

BACKGROUND: Immunization rates for human papillomavirus (HPV) infections remain low among teenagers despite strong evidence of the effectiveness of vaccines. Physician recommendations of the vaccine are far from universal. Several states have enacted policies that mandate HPV vaccination or distribute educational materials. OBJECTIVES: To provide policy makers, physicians, and researchers information on the relative importance of physician recommendations and early state-level policies to promote HPV vaccinations among targeted age groups. METHODS: We first use probit models to determine the strongest correlates of immunization in a nationally representative US sample of teenagers. We then use instrumental variable probit models to determine the direct role that physician recommendations play in vaccination using plausibly exogenous physician encounters that are likely not the result of more health-conscious parents seeking out information on the vaccine. RESULTS: We show that children in the targeted age range who are more likely to encounter physicians for reasons other than seeking out the vaccine, such as through mandatory wellness exams or previous asthma diagnoses, are significantly more likely to get the vaccine. There is no consistent evidence that the state policies we analyze have been effective. CONCLUSION: Encouraging recommendations by physicians may be the most effective path toward increasing HPV vaccination. State-level mandates and policies are yet to exhibit effectiveness.

Adherence to postoperative surveillance guidelines after endovascular aortic aneurysm repair among Medicare beneficiaries.

OBJECTIVE: After endovascular aortic aneurysm repair (EVAR), the Society for Vascular Surgery recommends a computed tomography (CT) scan ≤30 days, followed by annual imaging. We sought to describe long-term adherence to surveillance guidelines among United States Medicare beneficiaries and determine patient and hospital factors associated with incomplete surveillance. METHODS: We analyzed fee-for-service Medicare claims for patients receiving EVAR from 2002 to 2005 and collected all relevant postoperative imaging through 2011. Additional data included patient comorbidities and demographics, yearly hospital volume of abdominal aortic aneurysm repair, and Medicaid eligibility. Allowing a grace period of 3 months, complete surveillance was defined as at least one CT or ultrasound assessment every 15 months after EVAR. Incomplete surveillance was categorized as gaps for intervals >15 months between consecutive images as or lost to follow-up if >15 months elapsed after the last imaging. RESULTS: Our cohort comprised 9695 patients. Median follow-up duration was 6.1 years. A CT scan ≤30 days of EVAR was performed in 3085 (31.8%) patients and ≤60 days in 60.8%. The median time to the postoperative CT was 38 days (interquartile range, 25-98 days). Complete surveillance was observed in 4169 patients (43.0%). For this group, the mean follow-up time was shorter than for those with incomplete surveillance (3.4 ± 2.74 vs 6.5 ± 2.1 years; P < .001). Among those with incomplete surveillance, follow-up became incomplete at 3.3 ± 1.9 years, with 57.6% lost to follow-up, 64.1% with gaps in follow-up (mean gap length, 760 ± 325 days), and 37.6% with both. A multivariable analysis showed incomplete surveillance was independently associated with Medicaid eligibility (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.29-1.55; P < .001), low-volume hospitals (HR, 1.12; 95% CI, 1.05-1.20; P < .001), and ruptured abdominal aortic aneurysm (HR, 1.51; 95% CI, 1.24-1.84; P < .001). CONCLUSIONS: Postoperative imaging after EVAR is highly variable, and less than half of patients meet current surveillance guidelines. Additional studies are necessary to determine if variability in postoperative surveillance affects long-term outcomes.

Gender, race, and variation in the evaluation of microscopic hematuria among Medicare beneficiaries.

BACKGROUND: Female gender and black race are associated with delayed diagnosis and inferior survival in patients with bladder cancer. OBJECTIVE: We aimed to determine the association between gender, race, and evaluation of microscopic hematuria (an early sign of bladder cancer). DESIGN AND PARTICIPANTS: This was a cohort study using a 5 % random sample of fee-for-service Medicare beneficiaries diagnosed with incident hematuria (International Classification of Diseases, Ninth Revision [ICD-9] code 599.7x) between January 2009 and June 2010 in a primary care setting. Beneficiaries with pre-existing explanatory diagnoses or genitourinary procedures were excluded. MAIN MEASURES: The main endpoint was completeness of the hematuria evaluation in the 180 days after diagnosis. Evaluations were categorized as complete, incomplete, or absent based on receipt of relevant diagnostic procedures and imaging studies. KEY RESULTS: In all, 9,211 beneficiaries met the study criteria. Hematuria evaluations were complete in 14 %, incomplete in 21 %, and absent in 65 % of subjects. Compared to males, females were less likely to have a procedure (26 vs. 12 %), imaging (41 vs. 30 %), and a complete evaluation (22 vs. 10 %) (p < 0.001 for each comparison). Receipt of a complete evaluation did not differ by race. Controlling for baseline characteristics, a complete evaluation was less likely in white women (OR, 0.40 [95 % CI, 0.35-0.46]) and black women (OR, 0.46 [95 % CI, 0.29-0.70]) compared to white men; no difference was found between black and white men. CONCLUSIONS: Women are less likely than men to undergo a complete and timely hematuria evaluation, a finding likely relevant to women's more advanced stage at bladder cancer diagnosis. System-level process improvement between providers of urologic and primary care in the evaluation of hematuria may benefit women harboring malignancy.

Insurance company denial of payment and enforced changes in the type and dose of opioid analgesics for patients with cancer pain.

Opioids are the mainstay of treatment for moderate to severe cancer pain. The variations in average monthly cost can make it difficult for most patients to procure them without adequate insurance coverage. There are increasing numbers of denials of payment and statements made by insurance agents and other sources regarding inappropriate opioid use, resulting in severe pain and emotional distress for cancer patients and their families. This case series describes five events where the insurer was a major barrier to opioid access.

An evaluation of health benefit modification in Taft-Hartley health and welfare funds: implications for encouraging tobacco-cessation coverage.

BACKGROUND: An estimated one fifth of all U.S. adult smokers receive health benefits through insurance plans administered by Taft-Hartley Health and Welfare Funds. Most funds do not offer comprehensive tobacco-cessation services to fund participants despite evidence that doing so would be cost effective and save lives. PURPOSE: This paper examines the decision-making processes of Minnesota-based fund trustees and advisors to identify factors that influence decisions about modifications to benefits. METHODS: Formative data about the process by which funds make health benefit modifications were collected in 2007-2008 from 25 in-depth key informant interviews with fund trustees and a cross-section of fund advisors, including administrators, attorneys, and healthcare business consultants. Analyses were performed using a general inductive approach to identify conceptual themes, employing qualitative data analysis software. RESULTS: The most commonly cited factors influencing trustees' decisions about health plan benefit modifications-including modifications regarding tobacco-cessation benefits-were benefit costs, participants' demand for services, and safeguarding participants' health. Barriers included information gaps, concerns about participants' response, and difficulty projecting benefit utilization and success. Advisors wielded considerable influence in decision-making processes. CONCLUSIONS: Trustees relied on a small pool of business, legal, and administrative advisors to provide guidance and recommendations about possible health plan benefit modifications. Providing advisors with evidence-based information and resources about benefit design, cost/return-on-investment (ROI), effectiveness, and promotion may be an effective means to influence funds to provide comprehensive tobacco-cessation benefits.

Insurance data for research in companion animals: benefits and limitations.

The primary aim of this article is to review the use of animal health insurance data in the scientific literature, especially in regard to morbidity or mortality in companion animals and horses. Methods and results were compared among studies on similar health conditions from different nations and years. A further objective was to critically evaluate benefits and limitations of such databases, to suggest ways to maximize their utility and to discuss the future use of animal insurance data for research purposes. Examples of studies on morbidity, mortality and survival estimates in dogs and horses, as well as neoplasia in dogs, are discussed.We conclude that insurance data can and should be used for research purposes in companion animals and horses. Insurance data have been successfully used, e.g. to quantify certain features that may have been hitherto assumed, but unmeasured. Validation of insurance databases is necessary if they are to be used in research. This must include the description of the insured population and an evaluation of the extent to which it represents the source population. Data content and accuracy must be determined over time, including the accuracy/consistency of diagnostic information. Readers must be cautioned as to limitations of the databases and, as always, critically appraise findings and synthesize information with other research. Similar findings from different study designs provide stronger evidence than a sole report. Insurance data can highlight common, expensive and severe conditions that may not be evident from teaching hospital case loads but may be significant burdens on the health of a population.

Social construction of disability and substance abuse within public disability benefit systems.

Federal legislation passed in 1996 in the United States changed the eligibility criteria for public disability benefit programmes. After 1996, persons with a primary diagnosis of substance abuse no longer qualified to receive disability benefits. Using a framework of social construction, a qualitative comparative analysis examines how the national disability systems of eight countries - Australia, Canada, Germany, Japan, the Netherlands, South Africa, Sweden, the United Kingdom, and the US - address issues of substance abuse. The US is the only country among the focal countries that does not currently allow disability benefits to be awarded to those with primary conditions of substance use disorders. International experience in providing disability benefits to persons with substance use disorders can inform US policy makers as to how the current US federal disability benefit system might be expanded to be more inclusive of persons with substance abuse disorders.

[Discussing a "two-tiered medical system": a statement]. / "Zwei-klassen-Medizin"--ein Beitrag zur Versachlichung der Diskussion.

The criticism of a "two-tiered medical system" is a political slogan, which is also not exactly defined. However, for the public discussion this is not of further importance because talking about a "two-tiered medical system" has a priori a negative impact; in particular in times when people's fears surrounding medical care in Germany are great. Especially in a public health insurance system, insured people worry that in the future they will only receive the most essential medical services, rather than all services that are deemed reasonable and medically appropriate. One of the central themes in the discussion of a "two-tiered medical system" that causes disputes (or animosity) between privately and publicly insured persons arises when comparing differences in waiting periods to see a doctor and additional medical treatments made available to the privately insured. Critics of the "two-tiered medical system" envision a "one-tiered medical system"; one in which every person receives uniform healthcare, and in which the "purchase" of additional medical treatments is not permitted. However, the "one-tiered medical system" remains a theoretical construct. Service differences based on price differences are the reality. So the problem of the "two-tiered medical system" manifests itself only when those services that go beyond the basic care (privately offered services) negatively impact basic care, and/or displace basic care offerings. An example of this would be when a publicly insured patient has to wait longer to see a doctor because preference is given to privately insured patients. Economically speaking, negative external effects come into play. This causality has not been found or proven to be present in the German healthcare system. It exists neither in the inpatient nor in the outpatient healthcare sector. There is no basis to the claim that there is a difference in treatment favouring private patients with detrimental effects to non-privately insured patients. Therefore the claim that a "two tiered medical system" exists is negated. On the contrary: In the German health care system treatment differences above and beyond the basic services lead to an advantage for publicly insured patients. There are no negative, but rather positive external effects. This is mainly attributed to the increased doctors' revenue in the outpatient sector which amounted to Euro 4.4 billion in 2006 alone. Therefore, private patients subsidise the public insurance by funding a disproportionately high share of doctors' budgets.