Deductible double jeopardy: patients may pay more out of pocket when pregnancy crosses 2 years.

OBJECTIVES: This study explores the concern that annual high-deductible commercial insurance plan design may yield higher out-of-pocket costs when an episode of maternity care spans 2 years, exposing patients to their cost-sharing limits twice during their episode of care. STUDY DESIGN: Cross-sectional study of Health Care Cost Institute commercial claims. METHODS: The study sample comprises 1,379,300 deliveries among high-deductible health plan enrollees in years 2012 through 2021. Patients' mean cost sharing is calculated across all service types for 3 time periods: (1) delivery hospitalization, (2) maternity episode from 40 weeks prior to delivery hospitalization through 12 weeks after discharge, and (3) extended period spanning 3 years from January of the year before delivery through December of the year after delivery. RESULTS: For each of the 3 episode measurements, mean out-of-pocket spending is highest among those who deliver in January and declines in each subsequent month until August and September (the delivery months with most pregnancy and postpartum periods within the same year), then flattens for the remainder of the year. Mean cost sharing for the maternity episode was $6308 in January and $4998 in December, a difference of $1310. Patients delivering in January also had mean out-of-pocket costs $1491 greater for delivery hospitalization and $1005 greater over the 3-year period than patients delivering in December. CONCLUSIONS: Higher out-of-pocket spending is observed when patients face their cost-sharing limits twice within an episode of maternity care, and this difference persists even when evaluating 3 calendar years of patients' out-of-pocket spending.

Insurers negotiate lower hospital prices for HIX than for commercial groups.

OBJECTIVES: This study investigates a sample of the pricing data released by hospitals under the price transparency law effective January 2021 to better understand the prices paid by health insurance exchange (HIX) plans relative to commercial group and Medicare Advantage plans. STUDY DESIGN: Cross-sectional analysis of hospital pricing data. METHODS: We compared allowed amounts for 25 common inpatient services and 56 common outpatient services across 22 hospital-insurer dyads, selected by the availability of plan-specific pricing data from the top 100 hospitals by bed counts and the top 100 hospitals by gross revenue based on 2017 CMS data. RESULTS: Insurers in our sample generally negotiated allowed amounts for their HIX plans that were lower than their commercial group rates and well above their Medicare Advantage contracts within the same hospital. CONCLUSIONS: Allowed amounts for HIX plans were generally lower than commercial group rates and higher than Medicare Advantage rates. Better information on HIX pricing is needed as the federal government and states consider additional ways to expand health care coverage, such as public options or expanded Medicaid or Medicare eligibility.

Climate Change and State of the Science for Children's Health and Environmental Health Equity.

INTRODUCTION: Climate change is impacting the physical and mental health of children and families. This is a state of the science update regarding the impacts of climate change for pediatric-focused health care providers and advanced practice registered nurses. METHOD: Using an equity lens, the authors reviewed and synthesized current literature regarding the adverse impacts of climate change. RESULTS: The poor and communities of color are disproportionately impacted by climate change. Physical health impacts include increased vector and water-born infectious diseases, increases in asthma and respiratory infections, and undernutrition. Social disruptions lead to human trafficking. Climate change is associated with mental health concerns, including anxiety and posttraumatic stress after natural disasters. DISCUSSION: As clinicians, pediatric-focused providers, and advanced practice registered nurses should use multipronged and interdisciplinary approaches to address or prevent the adverse impacts of climate change. Advocacy at all government levels is necessary to safeguard children and vulnerable populations.

Lifetime Economic Burden of Crohn's Disease and Ulcerative Colitis by Age at Diagnosis.

BACKGROUND & AIMS: Understanding the burden of Crohn's disease (CD) and ulcerative colitis (UC) is important for measuring treatment value. We estimated lifetime health care costs incurred by patients with CD or UC by age at diagnosis. METHODS: We collected data from 78,620 patients with CD, 85,755 with UC, and propensity score-matched control subjects from the Truven Health MarketScan insurance claims databases (2008‒2015). Total medical (inpatient, outpatient) and pharmacy costs were captured. Cost variations over a lifetime were estimated in cost-state Markov models by age at diagnosis, adjusted to 2016 U.S. dollars and discounted at 3% per annum. We measured lifetime total and lifetime incremental cost (the difference between costs of CD or UC patients vs matched controls). RESULTS: For CD, the lifetime incremental cost was $707,711 among patients who received their diagnosis at 0‒11 years, and $177,614 for patients 70 years or older, averaging $416,352 for a diagnosis at any age. Lifetime total cost was $622,056, consisting of outpatient ($273,056), inpatient ($164,298), pharmacy ($163,722), and emergency room (ER) ($20,979) costs. For UC, the lifetime incremental cost was $369,955 among patients who received their diagnosis at 0‒11 years, and $132,396 for individuals 70 years or older, averaging $230,102 for a diagnosis at any age. Lifetime total cost was $405,496, consisting of outpatient ($163,670), inpatient ($123,190), pharmacy ($105,142), and ER ($13,493) costs. Therefore, the prevalent populations of patients with CD or UC in the United States in 2016 are expected to incur lifetime total costs of $498 billion and $377 billion, respectively. CONCLUSIONS: Using a Markov model, we estimated lifetime costs for patients with CD or UC to exceed previously published estimates. Individuals who receive a diagnosis of CD or UC at an early age (younger than 11 years) incur the highest lifetime cost burden. Advancing management strategies may significantly improve patient outcomes and reduce lifetime health care spending.

The economic burden of switching targeted disease-modifying anti-rheumatic drugs among rheumatoid arthritis patients.

AIMS: To estimate real world healthcare costs and resource utilization of rheumatoid arthritis (RA) patients associated with targeted disease modifying anti-rheumatic drugs (tDMARD) switching in general and switching to abatacept specifically. MATERIALS AND METHODS: RA patients initiating a tDMARD were identified in IMS PharMetrics Plus health insurance claims data (2010-2016), and outcomes measured included monthly healthcare costs per patient (all-cause, RA-related) and resource utilization (inpatient stays, outpatient visits, emergency department [ED] visits). Generalized linear models were used to assess (i) average monthly costs per patient associated with tDMARD switching, and (ii) among switchers only, costs of switching to abatacept vs tumor necrosis factor inhibitors (TNFi) or other non-TNFi. Negative binomial regressions were used to determine incident rate ratios of resource utilization associated with switching to abatacept. RESULTS: Among 11,856 RA patients who initiated a tDMARD, 2,708 switched tDMARDs once and 814 switched twice (to a third tDMARD). Adjusted average monthly costs were higher among patients who switched to a second tDMARD vs non-switchers (all-cause: $4,785 vs $3,491, p < .001; RA-related: $3,364 vs $2,297, p < .001). Monthly RA-related costs were higher for patients switching to a third tDMARD compared to non-switchers remaining on their second tDMARD ($3,835 vs $3,383, p < .001). Switchers to abatacept had significantly lower RA-related monthly costs vs switchers to TNFi ($3,129 vs $3,436, p = .021), and numerically lower all-cause costs ($4,444 vs $4,741, p = 0.188). Switchers to TNFi relative to abatacept had more frequent inpatient stays after switch (incidence rate ratio (IRR) = 1.85, p = .031), and numerically higher ED visits (IRR = 1.32, p = .093). Outpatient visits were less frequent for TNFi switchers (IRR = 0.83, p < .001) compared to switchers to abatacept. LIMITATIONS AND CONCLUSIONS: Switching to another tDMARD was associated with higher healthcare costs. Switching to abatacept, however, was associated with lower RA-related costs, fewer inpatient stays, but more frequent outpatient visits compared to switching to a TNFi.

Cost sharing for antiepileptic drugs: medication utilization and health plan costs.

OBJECTIVES: To examine the association between health plan out-of-pocket (OOP) costs for antiepileptic drugs and healthcare utilization (HCU) and overall plan spending among US-based commercial health plan beneficiaries with epilepsy. STUDY DESIGN: Retrospective cohort. METHODS: The Truven MarketScan Commercial Claims database for January 1, 2009, to June 30, 2015, was used. Patients 65 years or younger with epilepsy and at least 12 months of continuous enrollment before index (date meeting first epilepsy diagnostic criteria) were included. Analyses were adjusted for age group, gender, beneficiary relationship, insurance plan type, and Charlson Comorbidity Index score. Primary outcomes included proportion of days covered (PDC), HCU, and healthcare spending in 90-day postindex periods. Associations between OOP costs and mean PDC, HCU, and plan healthcare spending per 90-day period were estimated. RESULTS: Across 5159 plans, 187,241 beneficiaries met eligibility criteria; 54.3% were female, 41.7% were aged 45 to 65 years, and 62.4% were in preferred provider organization plans. Across postindex 90-day periods, mean (SD) PDC, epilepsy-specific hospitalizations, outpatient visits, and emergency department visits were 0.85 (0.26), 0.02 (0.13), 0.34 (0.47), and 0.05 (0.22), respectively. Median (interquartile range) spending per 90-day period was $1488 ($459-$4705); median epilepsy-specific spending was $139 ($18-$623). Multivariable linear regression without health plan fixed effects revealed that higher OOP spending was associated with a decrease in PDC (coefficient, -0.008; 95% CI, -0.009 to -0.006; P <.001) and an increase in overall spending (218.6; 95% CI, 47.9-389.2; P = .012). Health plan fixed effects model estimates were similar, except for epilepsy-specific spending, which was significant (120.6; 95% CI, 29.2-211.9; P = .010). CONCLUSIONS: Increases in beneficiaries' OOP costs led to higher overall spending and lower PDC.

Perceived and Observed Food Environments, Eating Behaviors, and BMI.

INTRODUCTION: This study examines relationships between perceived and observed nutrition environments, diet, and BMI, in order to examine the criterion validity of the Nutrition Environment Measures Survey-Perceived (NEMS-P). METHODS: In a cross-sectional study, perceived nutrition environments were assessed (NEMS-P) among 221 adults from four neighborhoods in the Philadelphia area in 2010 and 2011. A total of 158 food store environments were observed using the NEMS-Stores. Data analyses were conducted in 2016. Bivariate Spearman rank correlations were used to examine relationships between perceived and observed availability, quality, and price of fruits and vegetables in respondents' neighborhoods. Linear regression models were used to examine relationships between perceived neighborhood and home food environments and daily fruit and vegetable consumption and BMI. RESULTS: A significant, positive relationship was found between perceived and observed availability of fruits and vegetables in the neighborhood (r = 0.36, p<0.001). A similar relationship was seen between perceived and observed quality of fruits and vegetables (r = 0.34, p<0.001). Perceived availability and quality of fruits and vegetables in the neighborhood, and availability and accessibility of fruits and vegetables in the home, were significantly related to daily fruit and vegetable consumption. Perceived price of food in the neighborhood was significantly associated with BMI. CONCLUSIONS: Responses to a self-reported survey to assess perceived food environments related to fruits and vegetables were significantly associated with observed nutrition environments, fruit and vegetable consumption, and BMI. The perceived prices of fruits and vegetables were modestly associated with BMI and warrant further testing in prospective studies. When observations of food environments are not feasible, residents' survey responses are an acceptable indicator, with reasonable criterion validity.

The social value of childhood vaccination in the United States.

OBJECTIVES: To determine the lifetime social value of using the guideline-recommended vaccines for children born in the United States in 2009. STUDY DESIGN: This study utilized an economic model with parameter values sourced from clinical and observational data, as well as the literature. METHODS: The model quantified the health effects of routine vaccination for 14 diseases in terms of quality-adjusted life-years (QALYs) saved. The health effects were then valued by applying an economic value of a QALY. Producers' profits were estimated using data on vaccine prices, profit margins, and the number of vaccines administrated in the 2009 US birth cohort. The costs of producing the vaccines were subtracted from the value of the health effects to yield the total social value of vaccination. The producers' and consumers' shares of this social value were calculated. Sensitivity analyses were conducted to determine how results depend on underlying parameter assumptions. RESULTS: Estimates indicated that vaccination of this cohort will save 1.2 million QALYs, relative to no vaccination. Of those health gains, 88% stemmed from reduced mortality and 12% from reduced morbidity. We estimated a social value of $184.1 billion from these gains, of which $3.4 billion accrues to manufacturers as profits, while $180.7 billion accrues to the rest of society. In sensitivity analysis, the total social value ranged from $40 billion to $675 billion, and the manufacturers' share ranged from 0.3% to 11.5%. CONCLUSIONS: Policy makers should account for this social value when considering policies affecting incentives to vaccinate and develop new vaccines.

Changes in food and beverage environments after an urban corner store intervention.

OBJECTIVE: In response to the obesity epidemic, interventions to improve the food environment in corner stores have gained attention. This study evaluated the availability, quality, and price of foods in Philadelphia corner stores before and after a healthy corner store intervention with two levels of intervention intensity ("basic" and "conversion"). METHODS: Observational measures of the food environment were completed in 2011 and again in 2012 in corner stores participating in the intervention, using the Nutrition Environment Measures Survey for Corner Stores (NEMS-CS). Main analyses included the 211 stores evaluated at both time-points. A time-by-treatment interaction analysis was used to evaluate the changes in NEMS-CS scores by intervention level over time. RESULTS: Availability of fresh fruit increased significantly in conversion stores over time. Specifically, there were significant increases in the availability of apples, oranges, grapes, and broccoli in conversion stores over time. Conversion stores showed a trend toward a significantly larger increase in the availability score compared to basic stores over time. CONCLUSION: Interventions aimed at increasing healthy food availability are associated with improvements in the availability of low-fat milk, fruits, and some vegetables, especially when infrastructure changes, such as refrigeration and shelving enhancements, are offered.