Cancer Screening after the Adoption of Paid-Sick-Leave Mandates.

BACKGROUND: By the end of 2022, nearly 20 million workers in the United States have gained paid-sick-leave coverage from mandates that require employers to provide benefits to qualified workers, including paid time off for the use of preventive services. Although the lack of paid-sick-leave coverage may hinder access to preventive care, current evidence is insufficient to draw meaningful conclusions about its relationship to cancer screening. METHODS: We examined the association between paid-sick-leave mandates and screening for breast and colorectal cancers by comparing changes in 12- and 24-month rates of colorectal-cancer screening and mammography between workers residing in metropolitan statistical areas (MSAs) that have been affected by paid-sick-leave mandates (exposed MSAs) and workers residing in unexposed MSAs. The comparisons were conducted with the use of administrative medical-claims data for approximately 2 million private-sector employees from 2012 through 2019. RESULTS: Paid-sick-leave mandates were present in 61 MSAs in our sample. Screening rates were similar in the exposed and unexposed MSAs before mandate adoption. In the adjusted analysis, cancer-screening rates were higher among workers residing in exposed MSAs than among those in unexposed MSAs by 1.31 percentage points (95% confidence interval [CI], 0.28 to 2.34) for 12-month colorectal cancer screening, 1.56 percentage points (95% CI, 0.33 to 2.79) for 24-month colorectal cancer screening, 1.22 percentage points (95% CI, -0.20 to 2.64) for 12-month mammography, and 2.07 percentage points (95% CI, 0.15 to 3.99) for 24-month mammography. CONCLUSIONS: In a sample of private-sector workers in the United States, cancer-screening rates were higher among those residing in MSAs exposed to paid-sick-leave mandates than among those residing in unexposed MSAs. Our results suggest that a lack of paid-sick-leave coverage presents a barrier to cancer screening. (Funded by the National Cancer Institute.).

Características del servicio social para profesionales médicos en los estados andinos / Characteristics of compulsory service programs for medical professionals in the Andean states

INTRODUCCIÓN: Se ha estudiado poco sobre el impacto de los programas de servicio social en salud en el desarrollo profesional de médicos de los Estados Andinos (Argentina, Bolivia, Chile, Colombia, Ecuador, Perú y Venezuela), programas cuya finalidad es incrementar los recursos humanos en salud en zonas rurales y remotas. OBJETIVO: Describir la normativa de los programas de servicio social para profesionales médicos de los Estados Andinos. MÉTODOS: Se realizó una revisión bibliográfica de documentos normativos concernientes al servicio social para profesionales médicos en sitios web de gobiernos de los Estados Andinos, con la finalidad de obtener información la condición de servicio, financiamiento del programa/remuneraciones y modos de adjudicación. Adicionalmente, se empleó el motor de búsqueda PubMed para complementar la información sobre servicios sociales obligatorios en estos países. RESULTADOS: El servicio social para profesionales médicos está establecido bajo un marco normativo en todos los Estados Andinos, a excepción de Argentina, donde no existe este programa. Los participantes perciben una remuneración, salvo en Bolivia, donde el servicio es realizado por estudiantes. Los sistemas de adjudicación para estos programas son heterogéneos, siendo que en algunos Estados Andinos existe asignación de plazas según criterios meritocráticos. La participación en programas sociales en salud condiciona el ejercicio profesional (Ecuador, Colombia y Venezuela) y el poder realizar una especialización (Chile y Perú). CONCLUSIONES: Se requiere estudiar del impacto de estos programas en el desarrollo profesional del participante, con el objetivo de implementar estrategias de mejora adecuadas a sus contextos particulares.

INTRODUCTION: There are few studies on the impact of social service programs on health in the professional development of doctors in the Andean States (Argentina, Bolivia, Chile, Colombia, Ecuador, Peru, and Venezuela). The purpose of these programs is to increase the availability of human resources in health in rural and remote areas. OBJECTIVE: To describe the regulations of social service programs for medical professionals in the Andean countries. METHODS: We carried out a bibliographic review of normative documents concerning the social service for medical professionals using websites of governments of the Andean States as data sources. We sought to obtain information regarding service conditions, funding of these programs­including remunerations, and means of program allocation. Additionally, we used PubMed/MEDLINE to find complementary information on mandatory social services in these countries. RESULTS: Social service for medical professionals is established under a regulatory framework in all the Andean countries, except for Argentina, where this program does not exist. Participants receive remuneration (except in Bolivia, where students perform the service). The allocation systems used for these programs are heterogeneous, and in some Andean countries, the allocation is merit-based. Participation in social programs influences later professional opportunities (Ecuador, Colombia, and Venezuela) and the ability to specialize (Chile and Peru). CONCLUSIONS: It is necessary to study the impact of these programs on the professional development of the participants to design and implement quality improvement strategies tailored to each context.

Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies.

BACKGROUND: Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies. METHODS: We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation. RESULTS: Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%). CONCLUSIONS: A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.

Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia.

BACKGROUND: In 2009, mandatory folic acid fortification of bread-making flour was introduced in Australia to reduce the birth prevalence of preventable neural tube defects (NTDs) such as spina bifida. Before the introduction of the policy, modelling predicted a reduction of 14-49 NTDs each year. OBJECTIVE: Using real-world data, this study provides the first ex-post evaluation of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia. METHODS: We developed a decision tree model to compare different fortification strategies and used registry data to quantify the change in NTD rates due to the policy. We adopted a societal perspective that included costs to industry and government as well as healthcare and broader societal costs. RESULTS: We found 32 fewer NTDs per year in the post-mandatory folic acid fortification period. Mandatory folic acid fortification improved health outcomes and was highly cost effective because of the low intervention cost. The policy demonstrated improved equity in outcomes, particularly in birth prevalence of NTDs in births from teenage and indigenous mothers. CONCLUSIONS: This study calculated the value of mandatory folic acid fortification using real-world registry data and demonstrated that the attained benefit was comparable to the modelled expected benefits. Mandatory folic acid fortification (in addition to policies including advice on supplementation and education) improved equity in certain populations and was effective and highly cost effective for the Australian population.

Cross-sectional study of the financial cost of training to the surgical trainee in the UK and Ireland.

OBJECTIVES: Applications for surgical training have declined over the last decade, and anecdotally the costs of training at the expense of the surgical trainee are rising. We aimed to quantify the costs surgical trainees are expected to cover for postgraduate training. DESIGN: Prospective, cross-sectional, questionnaire-based study. SETTING/PARTICIPANTS: A non-mandatory online questionnaire for UK-based trainees was distributed nationally. A similar national questionnaire was distributed for Ireland, taking into account differences between the healthcare systems. Only fully completed responses were included. RESULTS: There were 848 and 58 fully completed responses from doctors based in the UK and Ireland, respectively. Medical students in the UK reported a significant increase in debt on graduation by 55% from £17 892 (2000-2004) to £27 655 (2010-2014) (p<0.01). 41% of specialty trainees in the UK indicated that some or all of their study budget was used to fund mandatory regional teaching. By the end of training, a surgical trainee in the UK spends on average £9105 on courses, £5411 on conferences and £4185 on exams, not covered by training budget. Irish trainees report similarly high costs. Most trainees undertake a higher degree during their postgraduate training. The cost of achieving the mandatory requirements for completion of training ranges between £20 000 and £26 000 (dependent on specialty), except oral and maxillofacial surgery, which is considerably higher (£71 431). CONCLUSIONS: Medical students are graduating with significantly larger debt than before. Surgical trainees achieve their educational requirements at substantial personal expenditure. To encourage graduates to pursue and remain in surgical training, urgent action is required to fund the mandatory requirements and annual training costs for completion of training and provide greater transparency to inform doctors of what their postgraduate training costs will be. This is necessary to increase diversity in surgery, reduce debt load and ensure surgery remains a popular career choice.

The ACA's Zero Cost-Sharing Mandate and Trends in Out-of-Pocket Expenditures on Well-Child and Screening Mammography Visits.

BACKGROUND: Starting in September of 2010, the Patient Protection and Affordable Care Act required most health insurance policies to cover evidence-based preventive care with no cost-sharing (no copays, coinsurance, or deductibles). It is unknown, however, whether declines in out-of-pocket costs for preventive services are large enough to prompt increases in utilization, the ultimate goal of the policy. METHODS: In this study, we use a nationally representative sample of ambulatory care visits to estimate the impact of the zero cost-sharing mandate on out-of-pocket expenditures on well-child and screening mammography visits. Estimates are made using 2-part interrupted time-series models, with well-woman visits serving as the control group because they were not covered under the zero cost-sharing mandate until after our study period. RESULTS: Results indicate a substantial reduction in out-of-pocket costs attributable to the Affordable Care Act. Between January 2011 and September 2012, the zero cost-sharing mandate reduced per-visit out-of-pocket costs for well-child visits from $18.46 to $8.08 (56%) and out-of-pocket costs for screening mammography visits from $25.43 to $6.50 (74%). No reduction was apparent for well-woman visits. CONCLUSIONS: The Affordable Care Act's zero cost-sharing mandate for preventive care has had a large impact on out-of-pocket expenditures for well-child and mammography visits. To increase preventive service use, research is needed to better understand barriers to obtaining preventive care that are not directly related to cost.

Cost-effectiveness and equity impacts of three HPV vaccination programmes for school-aged girls in New Zealand.

BACKGROUND: As with many high-income countries, vaccination coverage against human papilloma virus (HPV) infection is not high in New Zealand (NZ) at 47% in school-aged girls for three doses. We estimate the health gains, net-cost and cost-effectiveness of the currently implemented HPV national vaccination programme of vaccination dispersed across schools and primary care, and two alternatives: school-based only (assumed coverage as per Australia: 73%), and mandatory school-based vaccination but with opt-out permitted (coverage 93%). We also generate estimates by social group (sex, ethnic and deprivation group). METHODS: A Markov macro-simulation model was developed for 12-year-old girls and boys in 2011, with future health states of: cervical cancer, pre-cancer (CIN I-III), genital warts, and three other HPV-related cancers (oropharyngeal, anal, vulvar cancer). In each state health sector costs, including additional health sector costs from extra life, and quality-adjusted life years (QALYs) were accumulated. RESULTS: The current HPV vaccination programme has an estimated cost-effectiveness of NZ$18,800/QALY gained (about US$9700/QALY gained using the OECD's purchasing power parities; 95% UI: US$6900 to $33,700) compared to the status quo in NZ prior to 2008 (no vaccination, screening alone). The incremental cost-effectiveness ratio (ICER) of an intensive school-based only programme of girls, compared to the current situation, was US$33,000/QALY gained. Mandatory vaccination appeared least cost-effective (ICER compared to school-based of US$117,000/QALY gained, but with wide 95% uncertainty limits from $56,000 to $220,000). All interventions generated more QALYs per 12-year-old for Maori (indigenous population) and people living in deprived areas (range 5-25% greater QALYs gained). INTERPRETATION: A more intensive school-only vaccination programme seems warranted. Reductions in vaccine price will greatly improve cost-effectiveness of all options, possibly making a law for mandatory vaccination optimal from a health sector perspective. All interventions could reduce ethnic and socioeconomic disparities in HPV-related disease.

Tax incentives and the demand for private health insurance.

We analyze the effect of an individual insurance mandate (Medicare Levy Surcharge) on the demand for private health insurance (PHI) in Australia. With administrative income tax return data, we show that the mandate has several distinct effects on taxpayers' behavior. First, despite the large tax penalty for not having PHI coverage relative to the cost of the cheapest eligible insurance policy, compliance with mandate is relatively low: the proportion of the population with PHI coverage increases by 6.5 percentage points (15.6%) at the income threshold where the tax penalty starts to apply. This effect is most pronounced for young taxpayers, while the middle aged seem to be least responsive to this specific tax incentive. Second, the discontinuous increase in the average tax rate at the income threshold created by the policy generates a strong incentive for tax avoidance which manifests itself through bunching in the taxable income distribution below the threshold. Finally, after imposing some plausible assumptions, we extrapolate the effect of the policy to other income levels and show that this policy has not had a significant impact on the overall demand for private health insurance in Australia.

The cost-effectiveness of mandatory folic acid fortification in Australia.

The Australian government recently introduced mandatory folic acid fortification of bread to reduce the incidence of neural tube defects (NTDs). The economic evaluation of this policy contained a number of limitations. This study aimed to address the limitations and to reconsider the findings. Cost-effectiveness analysis was used to assess the cost and benefits of mandatory versus voluntary folic acid fortification. Outcomes measures were quality-adjusted life-years (QALYs), life-years gained (LYG), avoided NTD cases, and additional severe neuropathy cases. Costs considered included industry costs and regulatory costs to the government. It was estimated that mandatory fortification would prevent 31 NTDs, whereas an additional 14 cases of severe neuropathy would be incurred. Overall, 539 LYG and 503 QALYs would be gained per year of mandatory compared with voluntary fortification. Mandatory fortification was cost-effective at A$10,723 per LYG and at A$11,485 per QALY. Probabilistic sensitivity analysis showed that at A$60,000 and A$151,000 per QALY, the probability that mandatory fortification was the most cost-effective strategy was 79% and 85%, respectively. Threshold analysis of loss of consumer choice indicated that with a compensation value above A$1.21 [assuming a willingness to pay (WTP) threshold of A$60,000 per QALY] or A$3.19 (assuming a WTP threshold of A$151,000 per statistical life-year) per capita per year mandatory fortification would not be cost-effective. Mandatory fortification was found to be cost-effective; however, inclusion of the loss of consumer choice can change this result. Even with mandatory fortification, mean folate intake will remain below the recommended NTD preventive level.

Financial impact of California's new law to increase HIV screening by mandating insurance coverage.

To increase HIV testing, in 2008 California's governor signed the first piece of legislation in the USA to require private health plans to cover the cost of HIV testing regardless of whether testing is related to a primary diagnosis. This study assesses the impacts of the bill on coverage, testing rate, and cost for 22,190,000 Californians. All targeted individuals had some form of coverage for HIV testing before the mandate. If minimum expansion of coverage occurs, overall expenditures on HIV testing are projected to increase by US$554,000 in the year following the adoption of the law. If testing broadens to comply with the Centers for Disease Control and Prevention (CDC) testing guidelines, annual expenditures are projected to increase by US$10,151,000. This policy change could serve as a step toward making HIV testing a routine screening test. However, the impact of this mandate largely depends on people's awareness and willingness to adopt the CDC guidelines.

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

OBJECTIVE: To determine a) if a checklist covering a diverse group of intensive care unit protocols and objectives would improve clinician consideration of these domains and b) if improved consideration would change practice patterns. DESIGN: Pre- and post observational study. SETTING: A 24-bed surgical/burn/trauma intensive care unit in a teaching hospital. PATIENTS: A total of 1399 patients admitted between June 2006 and May 2007. INTERVENTIONS: The first component of the study evaluated whether mandating verbal review of a checklist covering 14 intensive care unit best practices altered verbal consideration of these domains. Evaluation was performed using real-time bedside audits on morning rounds. The second component evaluated whether the checklist altered implementation of these domains by changing practice patterns. Evaluation was performed by analyzing data from the Project IMPACT database after patients left the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Verbal consideration of evaluable domains improved from 90.9% (530/583) to 99.7% (669/671, p < .0001) after verbal review of the checklist was mandated. Bedside consideration improved on the use of deep venous thrombosis prophylaxis (p < .05), stress ulcer prophylaxis (p < .01), oral care for ventilated patients (p < 0.01), electrolyte repletion (p < .01), initiation of physical therapy (p < .05), and documentation of restraint orders (p < .0001). Mandatory verbal review of the checklist resulted in a greater than two-fold increase in transferring patients out of the intensive care unit on telemetry (16% vs. 35%, p < .0001) and initiation of physical therapy (28% vs. 42%, p < .0001) compared with baseline practice. CONCLUSIONS: A mandatory verbal review of a checklist covering a wide range of objectives and goals at each patient's bedside is an effective method to improve both consideration and implementation of intensive care unit best practices. A bedside checklist is a simple, cost-effective method to prevent errors of omission in basic domains of intensive care unit management that might otherwise be forgotten in the setting of more urgent care requirements.

Human papillomavirus vaccine legislation in Kentucky: a policy analysis.

The purpose of this article is to discuss the problem of cervical cancer, examine policy solutions, and analyze factors that contributed to the failure of human papillomavirus (HPV) vaccine requirement legislation in Kentucky. During 2007, a Kentucky representative introduced legislation that would require HPV vaccination for all middle-school girls but allow parents to opt out for any reason. Evidence suggests that an HPV school requirement law would result in more Kentucky children being vaccinated than if there were no requirement law. However, this policy solution faced multiple factors that inhibited its ability to survive. Future proponents of HPV vaccine school requirement legislation can draw implications from Kentucky's experience. By building public support, undergoing a softening up period, and presenting a united, vocal front, proponents may be more likely to pass HPV vaccine legislation in the future.

Financing the package of services during the first decade of the national health insurance law in Israel: trends and issues.

In 1995, a National Health Insurance Law (NHIL) was enacted in Israel. It specified a mandatory package of services to be provided by the four competing private non-profit sickness funds, and secured the financing of that provision. This review discusses the main issues associated with financing of--and the sickness funds' expenditure on--the package of services and analyzes the trends during the first decade of the implementation of the NHIL. The main findings indicate that between 1995 and 2005 the "real value" of the budget of the package of services has eroded by more than a third, most of it being due to the under-updating with regard to technological advances. The steep rise in the co-payment paid by users of health services and in voluntary supplementary health insurance ownership which is offered by the sickness funds partially financed that erosion. The growth of private spending on health, including on voluntary supplementary insurance, took place in all population groups and in the lowest income-quintile in particular. Indices of the progressivity of the financing of the package of services indicate that the burden of financing has been slightly regressive. In spite of the increase in the share of the regressive private expenditure between 1997 and 2003, overall, the finance became less regressive due to the health tax becoming less regressive. In conclusion, the introduction of the Israeli NHIL was a promising social achievement, but, during its first decade and facing tight national budgets and receiving lower national priority, subsequent regulation eroded the real value of its benefits, and its principles of solidarity and equity in finance. After 10 years of experience, the system might need refreshment and policy amendments that will correspond to its original aspirations.

The effects of mandatory health insurance on equity in access to outpatient care in Indonesia.

This paper examines the effects of mandatory health insurance on access and equity in access to public and private outpatient care in Indonesia. Data from the second round of the 1997 Indonesian Family Life Survey were used. We adopted the concentration index as a measure of equity, and this was calculated from actual data and from predicted probability of outpatient-care use saved from a multinomial logit regression. The study found that a mandatory insurance scheme for civil servants (Askes) had a strongly positive impact on access to public outpatient care, while a mandatory insurance scheme for private employees (Jamsostek) had a positive impact on access to both public and private outpatient care. The greatest effects of Jamsostek were observed amongst poor beneficiaries. A substantial increase in access will be gained by expanding insurance to the whole population. However, neither Askes nor Jamsostek had a positive impact on equity. Policy implications are discussed.