Impact of the COVID-19 pandemic on regular emergency department users.

OBJECTIVES: Regular users of the emergency department (ED) include both patients who could be better served in lower-acuity settings and those with high-severity conditions. ED use decreased during the COVID-19 pandemic, but patterns among regular ED users are unknown. To determine the impact of the COVID-19 pandemic on this population, we examined quarterly postpandemic ED utilization among prepandemic regular ED users. Key subgroups included prepandemic ED users with regular visits for (1) low-severity conditions and (2) high-severity conditions. STUDY DESIGN: An event study design with COVID-19 and historic controls cohorts. METHODS: We identified 4710 regular ED users at baseline and followed their ED utilization for 7 quarters. We used a generalized estimating equations model to compare the relative quarterly percent difference in ED visit rates between the COVID-19 and historic controls cohorts. RESULTS: The first postpandemic quarter was associated with the largest decline in ED visits, at -36.0% (95% CI, -42.0% to -29.3%) per regular ED user overall, -52.2% (95% CI, -69.4% to -25.3%) among high-severity users, and -29.6% (95% CI, -39.8% to -17.8%) among low-severity users. However, use did not statistically differ from expected levels after 5 quarters among all regular ED users, 1 quarter among high-severity users, and 3 quarters among regular low-severity users. CONCLUSIONS: Initial reductions among regular high-severity ED users raise concern for harm from delayed or missed care but did not result in increased high-severity visits later. Nonsustained declines among regular low-severity ED users suggest barriers to and opportunities for redirecting nonurgent ED use to lower-acuity settings.

Health Insurance Navigation Tools Intervention: A Pilot Trial Within the Childhood Cancer Survivor Study.

PURPOSE: Childhood cancer survivors are at increased risk for underinsurance and health insurance-related financial burden. Interventions targeting health insurance literacy (HIL) to improve the ability to understand and use health insurance are needed. METHODS: We codeveloped a four-session health insurance navigation tools (HINT) intervention, delivered synchronously by a patient navigator, and a corresponding booklet. We conducted a randomized pilot trial with survivors from the Childhood Cancer Survivor Study comparing HINT with enhanced usual care (EUC; booklet). We assessed feasibility, acceptability, and preliminary efficacy (HIL, primary outcome; knowledge and confidence with health insurance terms and activity) on a 5-month survey and exit interviews. RESULTS: Among 231 invited, 82 (32.5%) survivors enrolled (53.7% female; median age 39 years, 75.6% had employer-sponsored insurance). Baseline HIL scores were low (mean = 28.5; 16-64; lower scores better); many lacked knowledge of Affordable Care Act (ACA) provisions. 80.5% completed four HINT sessions, and 93.9% completed the follow-up survey. Participants rated HINT's helpfulness a mean of 8.9 (0-10). Exit interviews confirmed HINT's acceptability, specifically its virtual and personalized delivery and helpfulness in building confidence in understanding one's coverage. Compared with EUC, HINT significantly improved HIL (effect size = 0.94. P < .001), ACA provisions knowledge (effect size = 0.73, P = .003), psychological financial hardship (effect size = 0.64, P < .006), and health insurance satisfaction (effect size = 0.55, P = .03). CONCLUSION: Results support the feasibility and acceptability of a virtual health insurance navigation program targeted for childhood survivors to improve HIL. Randomized trials to assess the efficacy and sustainability of health insurance navigation on HIL and financial burden are needed.

Trends in High-Acuity Cardiovascular Events During the COVID-19 Pandemic.

This cohort study describes changes in myocardial infarction and stroke hospitalizations as well as congestive heart failure, angina, and transient ischemic attack incidents months before and after March 2020 among insured people in New England.

Gaps in the Vision Screening Pathway for School-Aged US Children.

This cross-sectional study uses a nationally representative survey of the US pediatric population to identify gaps in the vision screening pathway.

Racial and ethnic disparities in early mortality among patients with inborn errors of immunity.

BACKGROUND: Racial and ethnic disparities in life expectancy in the United States have been widely documented. To date, there remains a paucity of similar data in patients with inborn errors of immunity (IEIs). OBJECTIVE: Our aim was to examine racial and ethnic differences in mortality due to an IEI in the United States. METHODS: We analyzed National Center for Health Statistics national mortality data from 2003 to 2018. We quantified age-adjusted death rate and age-specific death rate as a result of an IEI for each major racial and ethnic group in the United States and examined the association of race and ethnicity with death at a younger age. RESULTS: From 2003 to 2018, IEIs were reported as the underlying or contributing cause of death in 14,970 individuals nationwide. The age-adjusted death rate was highest among Black patients (4.25 per 1,000,000 person years), compared with 2.01, 1.71, 1.50, and 0.92 per 1,000,000 person years for White, American Indian/Alaska Native, Hispanic, and Asian/Pacific Islander patients, respectively. The odds of death before age 65 years were greatest among Black patients (odds ratio [OR] = 5.15 [95% CI = 4.61-5.76]), followed by American Indian/Alaska Native patients (OR = 3.58 [95% CI = 2.30-5.82]), compared with White patients. The odds of death before age 24 years were greater among Hispanic patients than among non-Hispanic patients (OR = 3.60 [95% CI = 3.08-4.18]). CONCLUSION: Our study highlights racial and ethnic disparities in mortality due to an IEI and the urgent need to further identify and systematically remove barriers in care for historically marginalized patients with IEIs.

Using Cost Conversations to Address Financial Toxicity in Pediatric Asthma Care: Findings From a Survey of Caregivers.

INTRODUCTION: Asthma care teams are well-positioned to help caregivers address financial toxicity in pediatric asthma care, although discussing cost can be challenging. We sought to characterize cost conversations in pediatric asthma specialty care. METHOD: We surveyed 45 caregivers of children aged 4-17 with asthma. Eligible caregivers reported costs concerns and had accompanied their child to a multisite asthma specialty practice in North Carolina. RESULTS: About one-third of caregivers reported a cost conversation (36%). Cost conversations were less common among caregivers whose child had public versus private health insurance (16% vs. 56%), who attended a telehealth versus in-person visit (6% vs. 52%), or who did not versus did want a conversation (19% vs. 77%, all p < .05). Common cost conversation topics were medications and equipment like spacers. DISCUSSION: Our findings suggest cost conversations may be relatively uncommon in pediatric asthma care, particularly for publicly insured patients and telehealth visits.

"You Have to Rob Peter to Pay Paul So Your Kid Can Breathe": Using Qualitative Methods to Characterize Trade-Offs and Economic Impact of Asthma Care Costs.

BACKGROUND: Economic analyses often focus narrowly on individual patients' health care use, while overlooking the growing economic burden of out-of-pocket costs for health care on other family medical and household needs. OBJECTIVE: The aim of this study was to explore intrafamilial trade-offs families make when paying for asthma care. RESEARCH DESIGN: In 2018, we conducted telephone interviews with 59 commercially insured adults who had asthma and/or had a child with asthma. We analyzed data qualitatively via thematic content analysis. PARTICIPANTS: Our purposive sample included participants with high-deductible and no/low-deductible health plans. We recruited participants through a national asthma advocacy organization and a large nonprofit regional health plan. MEASURES: Our semistructured interview guide explored domains related to asthma adherence and cost burden, cost management strategies, and trade-offs. RESULTS: Participants reported that they tried to prioritize paying for asthma care, even at the expense of their family's overall financial well-being. When facing conflicting demands, participants described making trade-offs between asthma care and other health and nonmedical needs based on several criteria: (1) short-term needs versus longer term financial health; (2) needs of children over adults; (3) acuity of the condition; (4) effectiveness of treatment; and (5) availability of lower cost alternatives. CONCLUSIONS: Our findings suggest that cost-sharing for asthma care often has negative financial consequences for families that traditional, individually focused economic analyses are unlikely to capture. This work highlights the need for patient-centered research to evaluate the impact of health care costs at the family level, holistically measuring short-term and long-term family financial outcomes that extend beyond health care use alone.

Vaccine Mandates and Influenza Vaccination During the Pandemic.

OBJECTIVES: To determine whether a state influenza vaccine mandate and elevated community coronavirus disease 2019 (COVID-19) severity affected a child's probability of receiving an influenza vaccine during the 2020-2021 influenza season, given the child's previous vaccination history. METHODS: Longitudinal cohort study using enrollment and claims data of 71 333 children aged 6 months to 18 years living in Massachusetts, New Hampshire, and Maine, from a regional insurer. Schoolchildren in Massachusetts were exposed to a new influenza vaccine mandate in the 2020-2021 season. Community COVID-19 severity was measured using county-level total cumulative confirmed case counts between March 2020 and August 2020 and linked by zip codes. The primary outcome of interest was a claim for any influenza vaccine in the 2020-2021 season. RESULTS: Children living in a state with a vaccine mandate during the 2020-2021 influenza season had a higher predicted probability of receiving an influenza vaccine than those living in states without a mandate (47.7%, confidence interval 46.4%-49.0%, vs 21.2%, confidence interval 18.8%-23.6%, respectively, for previous nonvaccinators, and 78.2%, confidence interval 77.4%-79.0%, vs 58.2%, confidence interval 54.7%-61.7%, for previous vaccinators); the difference was 6.5 percentage points greater among previous nonvaccinators (confidence interval 1.3%-11.7%). Previously vaccinated children had a lower predicted probability of receiving an influenza vaccine if they lived in a county with the highest COVID-19 severity compared with a county with low COVID-19 severity (72.1%, confidence interval 70.5%-73.7%, vs 77.3%, confidence interval 74.7%-79.9%). CONCLUSIONS: Strategies to improve uptake of influenza vaccination may have differential impact based on previous vaccination status and should account for community factors.

Principles of Child Health Care Financing.

The American Academy of Pediatrics believes that the United States can and should ensure that all children, adolescents, and young adults from birth through the age of 26 years who reside within its borders have affordable access to high-quality comprehensive health care. Comprehensive, high-quality care addresses issues, challenges, and opportunities unique to children and young adults and addresses the effects of historic and present inequities. All families should have equitable access to professionals and facilities with expertise in the care of children within a reasonable distance of their residence. Payment methodologies should be structured to guarantee the economic viability of the pediatric medical home and of pediatric specialty and subspecialty practices. The recent increase in child uninsurance over the last several years is a threat to the well-being of children and families in the short- and long-term. Deficiencies in plans currently covering insured children pose similar threats. The AAP believes that the United States must not sacrifice recent hard-won gains for our children and that child health care financing should be based on the following guiding principles: (1) coverage with quality, affordable health insurance should be universal; (2) comprehensive pediatric services should be covered; (3) cost sharing should be affordable and should not negatively affect care; (4) payment should be adequate to strengthen family- and patient-centered medical homes; (5) child health financing policy should promote equity and address longstanding health and health care disparities; and (6) the unique characteristics and needs of children should be reflected.

Utilization and Spending With Preventive Drug Lists for Asthma Medications in High-Deductible Health Plans.

Importance: High-deductible health plans with health savings accounts (HDHP-HSAs) incentivize patients to use less health care, including necessary care. Preventive drug lists (PDLs) exempt high-value medications from the deductible, reducing out-of-pocket cost sharing; the associations of PDLs with health outcomes among patients with asthma is unknown. Objective: To evaluate the associations of a PDL for asthma medications on utilization, adverse outcomes, and patient spending for HDHP-HSA enrollees with asthma. Design, Setting, and Participants: This case-control study used matched groups of patients with asthma before and after an insurance design change using a national commercial health insurance claims data set from 2004-2017. Participants included patients aged 4 to 64 years enrolled for 1 year in an HDHP-HSA without a PDL in which asthma medications were subject to the deductible who then transitioned to an HDHP-HSA with a PDL that included asthma medications; these patients were compared with a matched weighted sample of patients with 2 years of continuous enrollment in an HDHP-HSA without a PDL. Models controlled for patient demographics and asthma severity and were stratified by neighborhood income. Analyses were conducted from October 2020 to June 2023. Exposures: Employer-mandated addition of a PDL that included asthma medications to an existing HDHP-HSA. Main Outcomes and Measures: Outcomes of interest were utilization of asthma medications on the PDL (controllers and albuterol), asthma exacerbations (oral steroid bursts and asthma-related emergency department use), and out-of-pocket spending (all and asthma-specific). Results: A total of 12 174 participants (mean [SD] age, 36.9 [16.9] years; 6848 [56.25%] female) were included in analyses. Compared with no PDL, PDLs were associated with increased rates of 30-day fills per enrollee for any controller medication (change, 0.10 [95% CI, 0.03 to 0.17] fills per enrollee; 12.9% increase) and for combination inhaled corticosteroid long-acting ß2-agonist (ICS-LABA) medications (change, 0.06 [95% CI, 0.01 to 0.10] fills per enrollee; 25.4% increase), and increased proportion of days covered with ICS-LABA (6.0% [0.7% to 11.3%] of days; 15.6% increase). Gaining a PDL was associated with decreased out-of-pocket spending on asthma care (change, -$34 [95% CI, -$47 to -$21] per enrollee; 28.4% difference), but there was no significant change in asthma exacerbations and no difference in results by income. Conclusions and Relevance: In this case-control study, reducing cost-sharing for asthma medications through a PDL was associated with increased adherence to controller medications, notably ICS-LABA medications used by patients with more severe asthma, but was not associated with improved clinical outcomes. These findings suggest that PDLs are a potential strategy to improve access and affordability of asthma care for patients in HDHP-HSAs.

Vision Screening Among Children With Private Insurance: 2010-2019.

OBJECTIVES: To describe trends in vision screening based on insurance claims for young children in the United States. METHODS: This cross-sectional study used administrative claims data from the 2010-2019 IBM MarketScan Commercial Claims and Encounters Database. We included children aged 1 to <5 years at the beginning of each calendar year. The primary outcome was a vision screening claim within 12 months for chart-based or instrument-based screening. Linear regression was used to evaluate trends over time in vision screening claims and practitioner payment. RESULTS: This study included a median of 810 048 (interquartile range, 631 523 - 1 029 481) children between 2010 and 2019 (mean [standard deviation] age, 2.5 [1.1] years; 48.7% female). The percentage of children with vision screening claims increased from 16.7% in 2010 to 44.3% in 2019 (difference, 27.5%; 95% confidence interval, 27.4% to 27.7%). Instrument-based screening claims, which were identified in <0.2% of children in 2010, increased to 23.4% of children 1 to <3 years old and 14.4% of children 3 to <5 years old by 2019. From 2013 to 2018, the average of the median practitioner payment for instrument-based screening was $23.70, decreasing $2.10 per year during this time (95% confidence interval, $0.85 to $3.34; P = .009). CONCLUSIONS: Vision screening claims among young children nearly tripled over the last decade, and this change was driven by increased instrument-based screening for children aged <3 years. Further investigation is needed to determine whether the decreasing trends in practitioner payment for screening devices will reduce the adoption of vision screening technology in clinical practice.

Use and Costs of Instrument-Based Vision Screening for US Children Aged 12 to 36 Months.

This cohort study examines patterns and out-of-pocket costs of instrument-based screening among children 12 to 36 months.

Strategies commercially-insured families use to manage the cost of asthma care: a qualitative interview study.

OBJECTIVE: Families affected by asthma report difficulty adhering to care regimens because of high medication costs, coupled with increased cost sharing required by some insurance plans. To inform efforts to support adherence, we conducted a qualitative study to explore how families manage asthma care costs. METHODS: We conducted phone interviews with commercially-insured, US adults (n = 59) who had asthma and/or a child with asthma. Our purposive sample included participants with high- and low/no-deductible health plans. We analyzed data using thematic content analysis to identify strategies for managing asthma care costs and to assess strategies' implications for adherence. RESULTS: Our analysis identified four overarching strategies for managing asthma care costs. First, participants used prevention strategies to avoid costly acute care by minimizing exposure to asthma triggers and adhering strictly to preventive medication regimens. Second, participants used shopping strategies to reduce costs, including by comparing medication prices across pharmacies, using medication coupons or free samples, and switching to lower-cost medications. Third, budgeting strategies involved putting aside funds, including in tax-exempt health savings accounts, or taking on debt to pay for care. Finally, some participants sought to reduce costs by forgoing recommended care, including by skipping medication doses or replacing prescribed medications with alternative therapies. CONCLUSION: Commercially-insured families use a wide range of strategies to manage asthma care costs, with both positive and negative implications for adherence. Our typology of asthma cost management strategies can inform insurance redesign and other interventions to help families safely reduce costs and maximize adherence to recommended care.

"Pick a Plan and Roll the Dice": A qualitative study of consumer experiences selecting a health plan in the non-group market.

Background: For consumers without access to employer-sponsored or public insurance, health plan choices in the non-group (individual) insurance market that do not meet consumer needs have the potential for negative downstream implications for health and financial well-being. Objective: This qualitative interview study sought to understand consumers' experiences and challenges with choosing a non-group health plan, among those who later had negative experiences with the plan they chose. Methods: We conducted semi-structured telephone interviews with a purposive sample of 36 participants from a large regional health insurance carrier in three states who enrolled in non-group plans in 2017 (21 in Affordable Care Act (ACA) Marketplace plans and 15 enrolled off-Marketplace). Participants were included if they reported negative experiences using their plan after enrollment, such as higher-than-expected medical costs. Interviews explored challenges choosing a plan; information needed for choosing; usefulness of available tools; and preferred format for interventions to improve plan choice experiences. We analyzed interview transcripts using thematic content analysis. Results: Study participants reported experiencing substantial challenges to choosing an insurance plan. Key barriers included understanding insurance terms, finding relevant information, and making comparisons across plans. Participants valued the ability to make comparisons across carriers when using the Marketplace websites but were less satisfied with customer service. Suggestions for improvement included greater standardization of plans and language and availability of customized one-on-one assistance. Conclusion: Findings from this study suggest that health plan selection in the non-group market presents challenges to consumers that may be addressed through enrollment assistance and improved presentation of information. Personalized assistance to find and choose coverage may lead to plan choices that better meet consumer needs and increase confidence choosing a plan in subsequent enrollment periods.

Affordability and Access Challenges Among US Subscribers to Nongroup Insurance Plans.

This cohort study assesses cost-related experiences in non-group plans purchased on or off Marketplace and variation by Marketplace enrollment, decision support use, and other characteristics.