Health outcomes, health services utilization, and costs consequences of medicare uninsurance among migrants in Canada: a systematic review.

BACKGROUND: Medically uninsured groups, many of them migrants, reportedly delay using healthcare services due to costs and often face preventable health consequences. This systematic review sought to assess quantitative evidence on health outcomes, health services use, and health care costs among uninsured migrant populations in Canada. METHODS: OVID MEDLINE, Embase, Global Health, EconLit, and grey literature were searched to identify relevant literature published up until March 2021. The Cochrane Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool was used to assess the quality of studies. RESULTS: Ten studies were included. Data showed that there are differences among insured and uninsured groups in reported health outcomes and health services use. No quantitative studies on economic costs were captured. CONCLUSIONS: Our findings indicate a need to review policies regarding accessible and affordable health care for migrants. Increasing funding to community health centers may improve service utilization and health outcomes among this population.

Patient-Centered Care Through Nurse Practitioner-Led Integrated Behavioral Health: A Case Study.

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic-practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

Insurance status and access to cervical cancer treatment in a specialized cancer center in Mexico.

To describe access to complete treatment in women with cervical cancer and state-sponsored insurance versus no insurance. We conducted a retrospective observational study. The source population consisted of women treated for cervical cancer from January 2000 to December 2015 in a tertiary care hospital. We included 411 women with state-sponsored insurance and 400 without insurance. We defined access to cervical cancer treatment as complete treatment (according NCCN/ESMO (National Comprehensive Cancer Network/European Society for Medical Oncology) standards) and timely initiation of treatment (less than 4 weeks). Clinical and sociodemographic characteristics were described and analyzed with logistic regression using complete treatment as the main outcome. A total of 811 subjects were included, the median age was 46 (IQR (Interquartile range) 42-50) years. Most of them were married (36.1%), unemployed (50.4%), and had completed primary school (44.0%). The most common clinical stages at diagnosis were II (38.2%) and III (24.7%). In the adjusted regression model, being married (OR (odds ratio): 4.3, 95% CI (confidence interval): 1.74-10.61) and having paid employment (OR: 2.79, 95% CI: 1.59-4.90) or state-sponsored insurance (OR: 1.54, 95% CI: 1.04-2.26) were positively associated with the possibility of having a complete treatment. Women with insurance were likely to be younger and receive timely treatment compared with uninsured women. Complete treatment was associated to insurance status and advanced stages of cervical cancer. State-sponsored insurance improves access to complete treatment. Government policies are needed to avoid social and economic inequity and provide better management of cervical cancer in our country.

Comparing race and ethnicity across safety-net and non-safety net practices pre- and post-an HIV screening alert.

CONTEXT: Societal and economic burdens of human immunodeficiency virus (HIV) continue to grow, even as treatments and prevention for this disease becomes more readily available and efficacious. HIV screening is more likely to be performed in minority (including Black) patient populations compared to whites. The likelihood of getting screened also depends on primary care practice attributes. OBJECTIVE: Evaluate HIV screening demographics by safety-net and non-safety net practices. STUDY DESIGN and ANALYSIS: Pre-post analysis. SETTING: Atrium Health is a non-profit, vertically integrated healthcare system with approximately 16 million patient encounters per year across the Southeast US. POPULATION STUDIED: Twelve primary care practices, including four safety-net practices serving predominantly Medicaid and uninsured patients, with over 115,00 patients between the ages of 18 and 64 were selected for the educational intervention. INTERVENTION/INSTRUMENT: A system-wide electronic medical record alert prompting HIV screening was implemented in October 2017 targeting adults between 18-64 years old. In addition to the system alert, a provider peer-to-peer educational program detailing HIV disease epidemiology, screening recommendations, and algorithms to guide screening efforts was developed. OUTCOME MEASURES: HIV screenings. RESULTS: From October 2016- April 2017, 3,413 patients were screened for HIV at the twelve participating primary care practices. Immediately after the HIV alert activation, from October 2017 - April 2018, 6,256 patients were screened, resulting in an 83% increase in screening. However, increases were different based on practice type, race and ethnicity. Black patients in safety net clinics had higher screening rates prior to the alert and showed less of an increase in screening (37%) compared to whites (102%) after the alert was activated. Hispanic/Latino patients showed similar increases at both safety net (99%) and non-safety net (108%) practices. Both Black and white patients showed larger increases of 99% and 139% in non-safety net clinics. Chi-squared analysis comparing the percentage of patients screened during these time periods was significantly different (p=0.001). CONCLUSION: While race and practice characteristics influence the likelihood of HIV screening, EMR modifications and provider education can significantly enhance screening and care for patients with HIV regardless of race and practice type.

Insurance type is associated with appropriate use of surgical and adjuvant care for differentiated thyroid carcinoma.

BACKGROUND: We aimed to characterize the association between differentiated thyroid cancer (DTC) patient insurance status and appropriateness of therapy (AOT) regarding extent of thyroidectomy and radioactive iodine (RAI) treatment. METHODS: The National Cancer Database was queried for DTC patients diagnosed between 2010 and 2016. Adjusted odds ratios (AOR) for AOT, as defined by the American Thyroid Association guidelines, and hazard ratios (HR) for overall survival (OS) were calculated. A difference-in-differences (DD) analysis examined the association of Medicaid expansion with outcomes for low-income patients aged <65. RESULTS: A total of 224,500 patients were included. Medicaid and uninsured patients were at increased risk of undergoing inappropriate therapy, including inappropriate lobectomy (Medicaid 1.36, 95% confidence interval [CI]: 1.21-1.54; uninsured 1.30, 95% CI: 1.05-1.60), and under-treatment with RAI (Medicaid 1.20, 95% CI: 1.14-1.26; uninsured 1.44, 95% CI: 1.33-1.55). Inappropriate lobectomy (HR 2.0, 95% CI: 1.7-2.3, P < .001) and under-treatment with RAI (HR 2.3, 95% CI: 2.2-2.5, P < .001) were independently associated with decreased survival, while appropriate surgical resection (HR 0.3, 95% CI: 0.3-0.3, P < .001) was associated with improved odds of survival; the model controlled for all relevant clinico-pathologic variables. No difference in AOT was observed in Medicaid expansion versus non-expansion states with respect to surgery or adjuvant RAI therapy. CONCLUSION: Medicaid and uninsured patients are at significantly increased odds of receiving inappropriate treatment for DTC; both groups are at a survival disadvantage compared with Medicare and those privately insured.

Awareness, Use and Outlook of Complementary and Alternative Medicine (CAM) Options in an Underserved, Uninsured Minority Cancer Patient Population.

Integrative oncology aims to coordinate the delivery of conventional medicine and evidence-supported complementary and alternative medicine (CAM) to patients receiving cancer care. This field developed out of an increased interest in CAM usage among cancer patients. However, CAM use among medically underserved cancer patients remains to be well characterized. We evaluated CAM awareness as well as prevalence and characteristics of CAM use in 170 consecutive, medically underserved cancer patients presenting to a large, academic, inner-city cancer clinic, using a survey tool. Fifty-three participants declined participation and 17 survey results were incomplete. Therefore, 100 survey results were included in the final analysis. There were 65 males and 35 females in the survey with a mean age of 64.2 years. About 98% of the respondents were African American while 2% identified themselves as Hispanic. About 45% of patients had metastatic cancer, 24% had early-stage disease while 31% of patients were not aware of the stage of their cancer. About 55% patients had elementary school or lower level of education while only 16% had a college degree or higher. About 92% of respondents were unemployed. Some knowledge of CAM was reported by 22% of patients, while CAM use was reported in only 16% of patients. Female sex and college degree were significantly associated with CAM use. The most commonly used CAM modality was meditation (56%), followed by herbal remedies (31%), yoga (31%), and acupuncture (12%). Among CAM users, a majority used multiple CAM therapies. All users reported benefit from CAM use. Emotional wellbeing was the most common benefit followed by improvement in treatment related adverse effects, chemotherapy related symptoms, pain, and sleep. Even though the majority of our surveyed patients never used CAM, 90% of non-users were interested in gaining more information about the various CAM options and exploring its use and potential benefits. The majority (70%) wanted their primary oncologist to provide information about CAM options and discuss its safety and potential complementary benefit in management of their cancer and associated symptoms.

Innovative Cancer Survivorship Services for Rural and Underserved Communities.

In 2006, the Institute of Medicine recognized that cancer survivors faced complex physical and emotional health problems, often overlooked or inadequately managed. In Texas, access to programs specifically designed to address unique needs of cancer survivors is almost nonexistent for low-income uninsured or underinsured patients. In response to the unmet care needs of underserved cancer centers, Moncrief Cancer Institute, an affiliate of the National Cancer Institute-designated UT Southwestern Harold C. Simmons Comprehensive Cancer Center, established a community-based program using a survivorship care model similar to those offered in academic medical centers. Understanding that a one-size-fits-all approach could not successfully meet the needs across the service area, the cancer survivorship service line was mobilized to provide flexibility in delivery without sacrificing quality of care. The program continues to evolve, extending the foremost scientific information and resources into the communities it serves.

Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions.

Importance: Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care. Objective: To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions. Design, Setting, and Participants: This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020. Main Outcomes and Measures: Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders. Results: Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions. Conclusions and Relevance: Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.

How we coordinate care for uninsured children with nonmalignant hematologic disorders.

Providing medical care for uninsured children with nonmalignant hematologic diagnoses presents unique challenges to medical providers and multidisciplinary staff. Financial and psychosocial stressors can hinder optimal care of the uninsured child. Maximizing coverage of medical costs through patient enrollment in state and charity care programs and capitalizing upon community partnerships can help providers achieve comprehensive care for these children. Collaboration between primary care providers, subspecialists, and multidisciplinary teams can be optimized to facilitate provision of hematology care for uninsured children. We detail our experience in establishing these collaborations to improve access to subspecialty care for children with nonmalignant hematologic disorders.

Determinants of attitude and intention towards private health insurance: a comparison of insured and uninsured young adults in Australia.

BACKGROUND: Since the introduction in 1984 of Australia's publicly-funded universal healthcare system, Medicare, healthcare financing has relied on a mix of public and private sources to meet the needs of the population (Sowa et al., Appl Health Econ Health Policy 15:31-41, 2018). However, in recent years, there has been a decline in the number of Australians choosing to purchase private health insurance (PHI), particularly within the young adult age group with the proportion of insurance customers aged 20 to 29 falling from 10.3 to 9.4% between 2012 and 2017 (Sivey, The Conversation, 2017). Young adults are critical to private health insurance funding models as their involvement offsets the drawdown by older adults (Dalzell and Borys, ABC News, 2019). While this issue is widely reported in the Australian media, few empirical studies have explored the factors that enable or constrain young adults' enrolment in PHI. METHODS: To address the scarcity of research about the motivational factors behind young adult decision-making, this study conducted a survey of 594 Australian young adults aged between 18 and 30 years. Within this age group, the survey sought an equal split of participants who were members and non-members of PHI schemes. CONCLUSION: The findings identified perceived value and trust in insurers as additional motivational factors alongside traditional measures of recognition of the problem and involvement in the problem. Differences between the insured and uninsured groups were identified which help to shape a more holistic understanding of the key motivational factors and barriers in relation to Australian young adults' enrolment in PHI.

Association of medicaid expansion of the Affordable Care Act with the stage at diagnosis and treatment of papillary thyroid cancer: A difference-in-differences analysis.

BACKGROUND: The Affordable Care Act's (ACA) Medicaid expansion has increased insurance coverage and improved various cancer outcomes. Its impact in papillary thyroid cancer (PTC) remains unclear. METHODS: Non-elderly patients (40-64 years-old) with PTC living in low-income areas either in a 2014 expansion, or a non-expansion state were identified from the National Cancer Database between 2010 and 2016. Insurance coverage, stage at diagnosis, and RAI administration were analyzed using a difference-in-differences analysis. RESULTS: 10,644 patients were included. Compared with non-expansion states, the percentage of uninsured patients (adjusted-DD -2.6% [95%-CI -4.3to-0.8%],p = 0.004) and patients with private insurance decreased, and those with Medicaid coverage increased (adjusted-DD 9.7% [95%-CI 6.9-12.5%],p < 0.001) in expansion states after ACA implementation. The percentage of patients with pT1 did not differ between expansion and non-expansion states; neither did the use of RAI. CONCLUSIONS: Medicaid expansion has resulted in a smaller uninsured population in PTC patients, but without earlier disease presentation nor change in RAI treatment.

Risk of cervical precancer and cancer among uninsured and underserved women from 2009 to 2017.

BACKGROUND: New guidelines for managing cervical precancer among women in the United States use risk directly to guide clinical actions for individuals who are being screened. These risk-based management guidelines have previously only been based on risks from a large integrated healthcare system. We present here data representative of women of low income without continuous insurance coverage to inform the 2019 guidelines and ensure applicability. OBJECTIVE: We examined the risks of high-grade precancer after human papillomavirus and cytology tests in underserved women and assessed the applicability of the 2019 guidelines to this population. STUDY DESIGN: We examined cervical cancer screening and follow-up data among 363,546 women enrolled in the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program from 2009 to 2017. We estimated the immediate (prevalent) risks of cervical intraepithelial lesion grade 3 or cancer by using prevalence-incidence mixture models. Risks were estimated for each combination of human papillomavirus and cytology result and were stratified by screening history. We compared these risks with published estimates used in new risk-based management guidelines. RESULTS: Women who were up-to-date with their screening, defined as being screened with cytology within the past 5 years, had immediate risks of cervical intraepithelial neoplasia grade 3 or higher similar to that of women at Kaiser Permanente Northern California, whose data were used to develop the management guidelines. However, women in the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program had greater immediate risks if they were never screened or not up-to-date with their screening. CONCLUSION: New cervical risk-based management guidelines are applicable for underinsured and uninsured women with a low income in the United States who are up-to-date with their screening. The increased risk observed here among women who received human papillomavirus-positive, high-grade cytology results, who were never screened, or who were not up-to-date with their cervical cancer screening, led to a recommendation in the management guidelines for immediate treatment among these women.

Outcomes Among Minority Patients With Metastatic Colorectal Cancer in a Safety-net Health Care System.

BACKGROUND: Metastatic colorectal cancer (CRC) outcomes continue to improve, but they vary significantly by race and ethnicity. We hypothesize that these disparities arise from unequal access to care. MATERIALS AND METHODS: The Harris Health System (HHS) is an integrated health delivery network that provides medical care to the underserved, predominantly minority population of Harris County, Texas. As the largest HHS facility and an affiliate of Baylor College of Medicine's Dan L. Duncan Comprehensive Cancer Center, Ben Taub Hospital (BTH) delivers cancer care through multidisciplinary subspecialty that prioritize access to care, adherence to evidence-based clinical pathways, integration of supportive services, and mitigation of financial toxicity. We performed a retrospective analysis of minority patients diagnosed with and treated for metastatic CRC at BTH between January 2010 and December 2012. Kaplan-Meier survival curves were compared with survival curves from randomized control trials reported during that time period. RESULTS: We identified 103 patients; 40% were black, 49% were Hispanic, and 12% were Asian or Middle Eastern. Thirty-five percent reported a language other than English as their preferred language. Seventy-four percent of patients with documented coverage status were uninsured. Eighty-four percent of patients received standard chemotherapy with a clinician-reported response rate of 63%. Overall survival for BTH patients undergoing chemotherapy was superior to that of subjects enrolled in the CRYSTAL (Cetuximab Combined with Irinotecan in First-Line Therapy for Metastatic Colorectal Cancer) trial (median, 24.0 vs. 19.9 months; P = .014). CONCLUSION: HHS provides a health delivery infrastructure through which minority patients with socioeconomic challenges experience clinical outcomes comparable with highly selected patients enrolled in randomized control trials. Efforts to resolve CRC disparities should focus on improving access of at-risk populations to high-quality comprehensive cancer care.

Prevalence and factors associated with health insurance coverage in resource-poor urban settings in Nairobi, Kenya: a cross-sectional study.

OBJECTIVE: To determine the prevalence of health insurance and associated factors among households in urban slum settings in Nairobi, Kenya. DESIGN: The data for this study are from a cross-sectional survey of adults aged 18 years or older from randomly selected households in Viwandani slums (Nairobi, Kenya). Respondents participated in the Lown scholars' study conducted between June and July 2018. SETTING: The Lown scholars' survey was nested in the Nairobi Urban Health and Demographic Surveillance System in Viwandani slums in Nairobi, Kenya. PARTICIPANTS: A total of 300 randomly sampled households participated in the survey. The study respondents comprised of either the household head, their spouses or credible adult household members. PRIMARY OUTCOME MEASURE: The primary outcome of this study was enrolment in a health insurance programme. The households were classified into two groups: those having at least one member covered by health insurance and those without any health insurance cover. RESULTS: The prevalence of health insurance in the sample was 43%. Being unemployed (adjusted OR (aOR) 0.17; p<0.05; 95% CI 0.06 to 0.47) and seeking care from a public health facility (aOR 0.50; p<0.05; 95% CI 0.28 to 0.89) was significantly associated with lower odds of having a health insurance cover. The odds of having a health insurance cover were significantly lower among respondents who perceived their health status as good (aOR 0.62; p<0.05; 95% CI 1.17 to 5.66) and those who were unsatisfied with the cost of seeking primary care (aOR 0.34; p<0.05; 95% CI 0.17 to 0.69). CONCLUSIONS: Health insurance coverage in Viwandani slums in Nairobi, Kenya, is low. As universal health coverage becomes the growing focus of Kenya's 'Big Four Agenda' for socioeconomic transformation, integrating enabling and need factors in the design of the national health insurance package may scale-up social health protection.

Ensuring HIV care to undocumented migrants in Israel: a public-private partnership case study.

BACKGROUND: Undocumented migrants in Israel, mostly originating from HIV endemic countries, are not covered by Israel's universal healthcare coverage. We initiated a Public-Private Partnership (PPP) to handle this public health and humanitarian challenge. The PPP venture included the Ministry of Health (MoH), pharmaceutical companies, pharmacies, and specialized HIV clinics, the Israeli HIV Medical Society (from the Israel Medical Association), and non-governmental organizations. This study describes the national policy process in conceptualizing and implementing access to HIV services for undocumented migrants through a PPP, and analyzes the preliminary results. METHODS: This case study describes the process of creating a temporary Public-Private Partnership to provide HIV care for undocumented migrants based on institutional records of the Department of Tuberculosis and AIDS (DTA) and memories and reflections from partners. This case was analyzed according to the OECD-DAC criteria for development assistance (relevance, effectiveness, efficiency, sustainability and impact). Demographic and serological data of patients referred between 2014 to 2018 were collected to monitor progress. and analyze preliminary medical and biological outcomes. Ethical approval was obtained from the Ministry of Health. RESULTS: Creating a policy to extend HIV care to undocumented migrants was a 15 year process that confronted several challenges within Israeli and international discourse, particularly concerning governmental response to the migration crisis. The use of a PPP model involving numerous stakeholders provided a solid, local feasibility demonstration that extending HIV care as a matter of policy would have positive implications for public health in Israel. During the first 2 years of the program (2014-2015), the MoH funded medical follow-up and the pharmaceutical companies provided antiretroviral treatment (ART) free of charge for only 100 patients at any given time, in addition to ART provided by the MoH for pregnant women. Since 2016, the MoH has fully covered this service and integrated it within the Israeli health system; this constitutes the major success of the PPP program. As of December 2018, the national program has monitored 350 patients and treated 316 (90.3%). The most prevalent disease present upon referral was Tuberculosis. CONCLUSIONS: To our knowledge, this study documents the first example of a successful PPP with government partnership in a high-income country to address undocumented migrants' lack of access to health services in general and HIV care in particular. In light of the intensification of North-South migration, this Israeli case study could be useful for other countries facing similar challenges. It also has lessons within Israel, as the country grapples with other health problems among uninsured communities.

Health disparities and chronic disease associated with anemia in free clinics: A retrospective study of uninsured patients in Tampa Bay.

Objectives: The objective of this study was to assess the diagnosis and management of anemic patients in free clinics around the Tampa Bay area.Methods: In this retrospective study we extracted data including demographics, chronic diseases, and laboratory values from medical charts of uninsured patients seen in 9 free clinics from January 2016 through December 2017 in the Tampa Bay area, FL, USA. Multiple logistic regression analysis was used to assess relationships between socioeconomic variables and a documented history of anemia.Results: From two years of documented data, 6971 patients were included, of which 367 (5%) had a documented diagnosis of anemia. Most were women (315, 86%), and the median age was 41 years (6-91). Among the 367 patients with anemia,191 (52%) patients had an unspecified type of anemia, 144 (39%) were diagnosed with IDA, 16 (4%) with anemia of chronic disease, and the remaining were other uncommon causes. Only 67% (97/144) of IDA patients had documented iron replacement. Colonoscopies were documented in only 32 (9%) of all patients with anemia, and in 23 (16%) IDA patients. Several chronic diseases were statistically associated and comorbid with a diagnosis of anemia.Conclusions: Uninsured patients with IDA are prescribed iron and undergo colonoscopies at sub-optimal rates. Increasing resources, awareness, and education of providers in these settings could lead to improved treatment practices and decrease the risk of morbidity and mortality.

Disparity in the use of adjuvant radioactive iodine ablation among high-risk papillary thyroid cancer patients.

BACKGROUND: We sought to identify treatment disparities existing prior to publication of the 2015 American Thyroid Association Management Guidelines in order to identify patients with papillary thyroid cancer (PTC) at risk for receiving inadequate treatment. METHODS: Patients diagnosed with PTC from 2011 to 2013 were identified using Surveillance, Epidemiology and End Results database. High-risk disease was defined as T4, N1, or M1. Chi-square tests compared characteristics of patients with and without high-risk disease and characteristics of high-risk patients who did and did not receive radioactive iodine ablation (RAI). Likelihoods of having high-risk disease, of receiving RAI, and of cause-specific death were calculated using regression analyses. RESULTS: Sample included 32,229 individuals; 7894 (24.5%) had high-risk disease. Mean age was 50.0 years, 24,815 (77.0%) were female, and 21,318 (66.2%) were white. Odds of high-risk disease were greater among males (OR:2.04; 95% CI:1.92-2.16), Hispanics (OR:1.67; 95% CI:1.56-1.79) and Asians (OR:1.49; 95% CI:1.37-1.62), and uninsured (OR:1.24; 95% CI:1.07-1.43), and lower among patients ages 45-64 (OR:0.57; 95% CI:0.53-0.60), and ≥65 years (OR:0.54; 95% CI:0.50-0.59), and Blacks (OR:0.46; 95% CI:0.40-0.53). Most (69.3%) high-risk patients received RAI. Odds of receiving RAI were lower among patients age ≥65 years (OR:0.67; 95% CI:0.58-0.77), uninsured (OR:0.52; 95% CI:0.41-0.67), or with Medicaid (OR:0.58; 95% CI:0.50-0.69). RAI use reduced the risk of cause-specific mortality (HR:0.29; 95% CI:0.18-0.47). CONCLUSION: Knowledge of these treatment disparities will allow recognition of groups at risk for high-risk disease and receiving inadequate treatment.

Uterus at a price: Disability insurance and hysterectomy.

Taiwanese Labor, Government Employee, and Farmer Insurance programs provide 5 to 6 months of salary to enrollees who undergo hysterectomies or oophorectomies before their 45th birthday. These programs create incentives for more and earlier treatments, referred to as inducement and timing effects. Using National Health Insurance data between 1997 and 2011, we estimate these effects on surgery hazards by difference-in-difference and bunching-smoothing polynomial methods. For Government Employee and Labor Insurance, inducement is 11-12% of all hysterectomies, and timing 20% of inducement. For oophorectomies, both effects are insignificant. Enrollees' behaviors are consistent with rational choices. Each surgery qualifies an enrollee for the same benefit, but oophorectomy has more adverse health consequences than hysterectomy. Induced hysterectomies increase benefit payments and surgical costs, at about the cost of a mammogram and 5 pap smears per enrollee.