An epidemic of cataract surgery in Korea: the effects of private health insurance on the National Health Insurance Service.

OBJECTIVES: In Korea, the National Health Insurance Service (NHIS) covers essential healthcare expenses, including cataract surgery. To address concerns that private health insurance (PHI) might have inflated the need for such procedures, we investigated the extent of the PHI-attributable increase in cataract surgery and its impact on NHIS-reimbursed expenses. METHODS: This retrospective, observational study uses nationwide claims data for cataract surgery from 2016 to 2020. We examined trends in utilization and cost, and we estimated the excess numbers of (1) cataract operations attributable to PHI and (2) types of intraocular lenses used for cataract surgery in 2020. RESULTS: Between 2016 and 2020, a 36.8% increase occurred in the number of cataract operations, with increases of 63.5% and 731.8% in the total healthcare costs reimbursed by NHIS and PHI, respectively. Over a 5-year period, the surgical rate per 100,000 people doubled for patients aged <65 years (from 328 in 2016 to 664 in 2020). Among the 619,771 cases in 2020 of cataract surgery reimbursed by the Korean diagnosis-related group system, more non-NHIS-covered intraocular lenses were used for patients aged <65 years than ≥65 years (68.1 vs. 14.2%). In 2020 alone, an estimated 129,311 excess operations occurred, accounting for an excess cost of US$115 million. CONCLUSIONS: A dramatic increase in the number and cost of cataract operations has occurred over the last 5 years. The PHI-related increase in operations resulted in increased costs to NHIS. Measures to curtail the non-indicated use of cataract surgery should be implemented regarding PHI.

Impact of Lung Cancer on Health-Related Quality of Life, Financial Toxicity, and Household Economics in Patients From the Public and the Private Healthcare Sector in Argentina.

OBJECTIVES: Non-small cell lung cancer (NSCLC) is Argentina's first cause of cancer death. Most patients have an advanced stage at diagnosis, with poor expected survival. This study aimed to characterize the health-related quality of life (HRQOL) and economic impact of patients treated in the private healthcare sector and compare it with that of the public sector. METHODS: We undertook an observational cross-sectional study that extended a previous study to a referral private center in Argentina. Outcomes included the EuroQol EQ-5D-3L (to assess HRQOL), Comprehensive Score for Financial Toxicity (financial toxicity instrument), Work Productivity and Activity Impairment - General Health (to assess productivity loss), and out-of-pocket expenses in adults diagnosed of NSCLC. RESULTS: We included 30 consecutive patients from a private healthcare center (July 2021 to March 2022), totaling 131 patients (n = 101 from previous public study). The whole sample had low quality of life and relevant economic impact. Patients in the private healthcare sector showed lower disease severity and higher educational level and household income. In addition, private healthcare system patients showed higher utility (0.77 vs 0.73; P < .05) and lower impairment of daily activities (41% vs 59%; P = .01). Private health system patients also showed lower financial toxicity as measured by the Comprehensive Score for Financial Toxicity score (23.9 vs 20.14; P < .05) but showed no differences when financial toxicity was assessed as a dichotomic variable. CONCLUSIONS: Although patients with NSCLC treated in a private healthcare center in Argentina showed a relevant HRQOL and economic impact, this impact was smaller than the one observed in publicly funded hospitals.

Beyond the dichotomy: How ride-hailing competes with and complements public transport.

Since ride-hailing has become an important travel alternative in many cities worldwide, a fervent debate is underway on whether it competes with or complements public transport services. We use Uber trip data in six cities in the United States and Europe to identify the most attractive public transport alternative for each ride. We then address the following questions: (i) How does ride-hailing travel time and cost compare to the fastest public transport alternative? (ii) What proportion of ride-hailing trips do not have a viable public transport alternative? (iii) How does ride-hailing change overall service accessibility? (iv) What is the relation between demand share and relative competition between the two alternatives? Our findings suggest that the dichotomy-competing with or complementing-is false. Though the vast majority of ride-hailing trips have a viable public transport alternative, between 20% and 40% of them have no viable public transport alternative. The increased service accessibility attributed to the inclusion of ride-hailing is greater in our US cities than in their European counterparts. Demand split is directly related to the relative competitiveness of travel times i.e. when public transport travel times are competitive ride-hailing demand share is low and vice-versa.

Space-time clustering-based method to optimize shareability in real-time ride-sharing.

Real-time ride-sharing has become popular in recent years. However, the underlying optimization problem for this service is highly complex. One of the most critical challenges when solving the problem is solution quality and computation time, especially in large-scale problems where the number of received requests is huge. In this paper, we rely on an exact solving method to ensure the quality of the solution, while using AI-based techniques to limit the number of requests that we feed to the solver. More precisely, we propose a clustering method based on a new shareability function to put the most shareable trips inside separate clusters. Previous studies only consider Spatio-temporal dependencies to do clustering on the mobility service requests, which is not efficient in finding the shareable trips. Here, we define the shareability function to consider all the different sharing states for each pair of trips. Each cluster is then managed with a proposed heuristic framework in order to solve the matching problem inside each cluster. As the method favors sharing, we present the number of sharing constraints to allow the service to choose the number of shared trips. To validate our proposal, we employ the proposed method on the network of Lyon city in France, with half-million requests in the morning peak from 6 to 10 AM. The results demonstrate that the algorithm can provide high-quality solutions in a short time for large-scale problems. The proposed clustering method can also be used for different mobility service problems such as car-sharing, bike-sharing, etc.

Measuring the quality of dental care among privately insured children in the United States.

OBJECTIVE: To examine whether quality of dental care varies by age and over time and whether community-level characteristics explain these patterns. DATA SOURCE: Deidentified medical and dental claims from a commercial insurer from January 2015 to December 2019. STUDY DESIGN: A retrospective cohort study. The primary outcome was a composite quality score, derived from seven dental quality measures (DQMs), with higher values corresponding to better quality. Hierarchical regression models identified person- and zip code-level factors associated with the quality. DATA COLLECTION/EXTRACTION METHODS: Continuously enrolled US dental insurance beneficiaries younger than 21 years of age. PRINCIPAL FINDINGS: Quality was assessed for 4.88 million person-years covering 1.31 million persons. Overall quality slightly improved over time, mostly driven by substantial improvements among children aged 0-5 years by 0.153 points/year (95% confidence interval [CI]:0.151, 0.156). Quality was poorest and declined over time among adolescents with only 20.5% of DQMs met as compared to 42.6% among aged 0-5 years in 2019. Dental professional shortage, median household income, percentages of African Americans, unemployed, and less-educated populations at the zip code level were associated with the composite score. CONCLUSION: Quality of dental care among adolescents remains low, and place of residence influenced the quality. Increasing the supply of dentists and oral health promotion strategies targeting adolescents and low-performing localities should be explored.

Trends, wealth inequalities and the role of the private sector in caesarean section in the Middle East and North Africa: A repeat cross-sectional analysis of population-based surveys.

OBJECTIVE: To examine trends and variations of caesarean section by economic status and type of healthcare facility in Arab countries in the Middle East and North Africa (MENA). METHODS: Secondary data analysis of nationally representative household surveys conducted between 2008-2020 across nine Arab countries in the MENA region. The study population was women aged 15-49 years with a live birth in the two years preceding the survey. Temporal changes in the proportion of deliveries by caesarean section in each country were calculated using generalised linear models and presented as risk differences (RD) with 95% confidence intervals (95%CI). Caesarean section was disaggregated by household wealth index and type of healthcare facility. RESULTS: Use of caesarean section ranged from 57.3% (95%CI:55.6-59.1%) in Egypt to 5.7% of births (95%CI:4.9-6.6%) in Yemen. Overall, the use of caesarean section has increased across the MENA region, except in Jordan, where there was no evidence of change (RD -2.3 (95%CI: -6.0 ‒1.4)). Across most countries, caesarean section use was highest in the richest quintile compared to the poorest quintile, for example, 42.8% (95%CI:38.0-47.6%) vs. 22.6% (95%CI:19.6-25.9%) in Iraq, respectively. Proportion of caesarean section was higher in private sector facilities compared to public sector: 21.8% (95%CI:18.2-25.9%) vs. 15.7% (95%CI:13.3-18.4%) in Yemen, respectively. CONCLUSION: Variations in caesarean section exist within and between Arab countries, and it was more commonly used amongst the richest quintiles and in private healthcare facilities. The private sector has a prominent role in observed trends. Urgent policies and interventions are required to address non-medically indicated intervention.

In search of the last malaria cases: ethnographic methods for community and private-sector engagement in malaria elimination in Vietnam, Laos, and Cambodia.

BACKGROUND: Despite significant strides made in reducing malaria morbidity and mortality in the Greater Mekong Subregion, malaria transmission continues amongst the most 'hard-to-reach', such as forest-goers and mobile and migrant populations, who face access obstacles to malaria diagnosis and treatment. As such, regional malaria elimination strategies endeavour to incorporate the private sector and local communities in improving surveillance and detection of the last malaria cases in remote forested areas. The question remains, however, whether such strategies can reach these hard-to-reach populations and effectively reduce their disproportionate burden of malaria. This paper evaluates the strategy of community and private sector engagement in a malaria elimination project in Vietnam, Laos, and Cambodia. METHODS: Ethnographic research, incorporating in-depth interviews, participant observations with informal discussions, and group discussions were conducted in Bu Gia Map commune, Binh Phuc province of Vietnam; in Phouvong district, Attapeu province of Laos; and, in nine newly established and informal communities in the provinces of Mondul Kiri, Steung Treng, Kratie, Kampong Thom, and Prah Vihear of Cambodia. RESULTS: Different types of factors limited or enhanced the effectiveness of the participatory approaches in the different settings. In Vietnam, inter-ethnic tensions and sensitivity around forest-work negatively affected local population's health-seeking behaviour and consequent uptake of malaria testing and treatment. In Laos, the location of the project collaborative pharmacies in the district-centre were a mismatch for reaching hard-to-reach populations in remote villages. In Cambodia, the strategy of recruiting community malaria-workers, elected by the community members, did manage to reach the remote forested areas where people visited or stayed. CONCLUSIONS: 'Hard-to-reach' populations remain hard to reach without proper research identifying the socio-economic-political environment and the key dynamics determining uptake in involved communities and populations. Solid implementation research with a strong ethnographic component is required to tailor malaria elimination strategies to local contexts.

A retrospective, observational study of medicolegal cases against obstetricians and gynaecologists in South Africa's private sector.

BACKGROUND:  The viability of obstetric practice in the private sector has been threatened as a result of steep increases in professional indemnity fees over the past 10 years. Despite this, empirical research investigating key aetiological factors to target risk management interventions has been lacking. OBJECTIVES: To explore private practice medicolegal data linked to obstetricians and gynaecologists (O&Gs) to identify factors in clinical practice associated with claims, for the purposes of guiding future research and risk management solutions. METHODS:  This was a retrospective, observational study of private sector O&Gs' medicolegal case histories. All incidents declared to a prominent local professional indemnity insurer were categorised in terms of medicolegal case type, as well as clinical parameters. To allow for risk-adjusted calculations of case incidence, year of entry into private practice was estimated for all practitioners. RESULTS:  Steep increases in medicolegal investigations and demands were demonstrated for both obstetrics- and gynaecology-related cases from about 2003 to 2012. Whereas the total numbers of claims, regulatory complaints and requests for records were similar for obstetrics and gynaecology in recent years (accounting for 52% v. 48% of known cases, respectively), a significantly greater percentage of demands and paid settlements related to gynaecology rather than obstetrics (58% and 76% v. 42% and 24% of cases, respectively). In obstetrics, about half of all cases on record with a paid settlement were in the context of severe neonatal birth-related neurological injury (n=9). For gynaecology, procedure-related complications accounted for 92% of settlements, of which at least 41% were for intraoperative injuries to internal organs and vessels. Laparoscopic procedures were most frequently associated with such intraoperative injuries, followed by vaginal and abdominal hysterectomies/oophorectomies and caesarean sections. For O&Gs in private practice for >2 years, 50/458 (11%) accounted for 138/228 (61%) of demands over a 10-year period. CONCLUSIONS:  The higher number of gynaecological demands and settlements in comparison with obstetric cases was unexpected and is contrary to international experiences and public sector findings, calling for more research to identify reasons for this finding. Other than further exploring surgical outcomes in private sector gynaecological patients, aspects of surgical training and accreditation standards in gynaecology may need review. Regarding birth-related injuries, the contribution of system failures needs quantification and further interrogation. The high contribution towards the medicolegal burden by a small group of practitioners suggests a need for doctor-focused interventions, including strengthening of peer review and regulatory oversight.

Availability, affordability and stock-outs of commodities for the treatment of snakebite in Kenya.

BACKGROUND: Annually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya. METHODOLOGY/PRINCIPAL FINDINGS: This study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day's wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days' wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible. CONCLUSIONS: Access to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.

The utilisation of public and private health care among Australian women with diabetes: Findings from the 45 and Up Study.

AIM: To describe the prevalence of health care utilisation and out-of-pocket expenditure associated with the management of diabetes among Australian women aged 45 years and older. DESIGN: Cross-sectional survey design. METHODS: The questionnaire was administered to 392 women (a cohort of the 45 and Up Study) reporting a diagnosis of diabetes between August and November 2016. It asked about the use of conventional medicine, complementary medicine (CM) and self-prescribed treatments for diabetes and associated out-of-pocket spending. RESULTS: Most women (88.3%; n = 346) consulted at least one health care practitioner in the previous 12 months for their diabetes; 84.6% (n = 332) consulted a doctor, 44.4% (n = 174) consulted an allied health practitioner, and 20.4% (n = 80) consulted a CM practitioner. On average, the combined annual out-of-pocket health care expenditure was AU$492.6 per woman, which extrapolated to approximately AU$252 million per annum. Of this total figure, approximately AU$70 million was spent on CM per annum. CONCLUSIONS: Women with diabetes use a diverse range of health services and incur significant out-of-pocket expense to manage their health. The degree to which the health care services women received were coordinated, or addressed their needs and preferences, warrants further exploration. Limitations of this study include the use of self-report and inability to generalise findings to other populations.

How wide is the gap? Examining gender income disparities among private career college graduates.

Research on gender wage gaps among recent graduates in Canada has ignored the private career college (PCC) sector. By virtue of the structure, composition and positioning of PCCs in Canada, along with the occupations they service, we argue that PCC graduates are an interesting population through which to study gender disparities. Drawing on an underutilized but rich dataset, we perform a series of exploratory multivariate analyses and estimate a gender income gap of approximately 5.3%. Though modest, this gap survives extensive robustness checks, with few notable exceptions. We theorize the implications of our findings for future policymaking and research.

Les recherches sur les écarts salariaux entre les sexes parmi les nouveaux diplômés au Canada ont ignoré le secteur des collèges privés d'enseignement professionnel (CPIP). En raison de la structure, de la composition et du positionnement des PCC au Canada, ainsi que des professions qu'ils desservent, nous soutenons que les diplômés des PCC constituent une population intéressante pour l'étude des disparités entre les sexes. En nous appuyant sur un ensemble de données sous-utilisé mais riche, nous effectuons une série d'analyses exploratoires multivariées et estimons un écart de revenu entre les sexes d'environ 5,3 %. Bien que modeste, cet écart résiste à des contrôles de robustesse approfondis, à quelques exceptions notables près. Nous théorisons les implications de nos résultats pour l'élaboration des politiques et la recherche futures.

Evaluating essential medicines for treating childhood cancers: availability, price and affordability study in Ghana.

INTRODUCTION: Access to childhood cancer medicines is a critical global health challenge. There is a lack of sufficient context-specific data in Ghana on access to essential medicines for treating childhood cancers. Here, we present an analysis of essential cancer medicine availability, pricing, and affordability using the pediatric oncology unit of a tertiary hospital as the reference point. METHOD: Data on prices and availability of 20 strength-specific essential cancer medicines and eight non-cancer medicines were evaluated using the modified World Health Organization (WHO)/Health Action International method. Two pharmacies in the hospital and four private pharmacies around the hospital were surveyed. We assessed their median price ratio using the WHO international reference price guide. The number of days wages per the government daily wage salary was used to calculate the affordability of medicines. RESULTS: The mean availability of essential cancer medicines and non-cancer medicines at the hospital pharmacies were 27 and 38% respectively, and 75 and 84% respectively for private pharmacies. The median price ratio of cancer medicines was 1.85, and non-cancer medicines was 3.75. The estimated cost of medicines for treating a 30 kg child with Acute lymphoblastic leukaemia was GHÈ» 4928.04 (US$907.56) and GHÈ» 4878.00 (US$902.62) for Retinoblastoma, requiring 417 and 413-days wages respectively for the lowest-paid unskilled worker in Ghana. CONCLUSION: The mean availability of cancer medicines at the public and private pharmacies were less than the WHO target of 80%. The median price ratio for cancer and non-cancer medicines was less than 4, yet the cost of medicines appears unaffordable in the local setting. A review of policies and the establishment of price control could improve availability and reduce medicines prices for the low-income population.

Costing electronic private sector malaria surveillance in the Greater Mekong Subregion.

BACKGROUND: Private sector malaria programmes contribute to government-led malaria elimination strategies in Cambodia, Lao PDR, and Myanmar by increasing access to quality malaria services and surveillance data. However, reporting from private sector providers remains suboptimal in many settings. To support surveillance strengthening for elimination, a key programme strategy is to introduce electronic surveillance tools and systems to integrate private sector data with national systems, and enhance the use of data for decision-making. During 2013-2017, an electronic surveillance system based on open source software, District Health Information System 2 (DHIS2), was implemented as part of a private sector malaria case management and surveillance programme. The electronic surveillance system covered 16,000 private providers in Myanmar (electronic reporting conducted by 200 field officers with tablets), 710 in Cambodia (585 providers reporting through mobile app), and 432 in Laos (250 providers reporting through mobile app). METHODS: The purpose of the study was to document the costs of introducing electronic surveillance systems and mobile reporting solutions in Cambodia, Lao PDR, and Myanmar, comparing the cost in different operational settings, the cost of introduction and maintenance over time, and assessing the affordability and financial sustainability of electronic surveillance. The data collection methods included extracting data from PSI's financial and operational records, collecting data on prices and quantities of resources used, and interviewing key informants in each setting. The costing study used an ingredients-based approach and estimated both financial and economic costs. RESULTS: Annual economic costs of electronic surveillance systems were $152,805 in Laos, $263,224 in Cambodia, and $1,310,912 in Myanmar. The annual economic cost per private provider surveilled was $82 in Myanmar, $371 in Cambodia, and $354 in Laos. Cost drivers varied depending on operational settings and number of private sector outlets covered in each country; whether purchased or personal mobile devices were used; and whether electronic (mobile) reporting was introduced at provider level or among field officers who support multiple providers for case reporting. CONCLUSION: The study found that electronic surveillance comprises about 0.5-1.5% of national malaria strategic plan cost and 7-21% of surveillance budgets and deemed to be affordable and financially sustainable.

A retail audit of mosquito control products in Busia County, western Kenya.

BACKGROUND: Approximately 70% of Kenya's population is at risk for malaria. The core vector control methods in Kenya are insecticide-treated mosquito nets (ITNs) and indoor residual spraying, with supplementary larval source management. In 2015, 21% of ITNs were accessed through the private retail sector. Despite the private sector role in supplying mosquito control products (MCPs), there is little evidence on the availability, sales trends, and consumer preferences for MCPs other than ITNs. This study, a component of a larger research programme focused on evaluating a spatial repellent intervention class for mosquito-borne disease control, addressed this evidence gap on the role of the private sector in supplying MCPs. METHODS: A cross-sectional survey was deployed in a range of retail outlets in Busia County to characterize MCP availability, sales trends, and distribution channels. The questionnaire included 32 closed-ended and four open-ended questions with short answer responses. Descriptive analysis of frequency counts and percentages was carried out to glean insights about commercially available MCPs and the weighted average rank was used to determine consumer preferences for MCPs. Open-ended data was analysed thematically. RESULTS: Retail outlets that stocked MCPs commonly stocked mosquito coils (73.0%), topical repellents (38.1%), aerosol insecticide sprays (23.8%) and ITNs (14.3%). Overall, retailers reported the profits from selling MCPs were adequate and they overwhelmingly planned to continue stocking the products. Of respondents who stocked MCPs, 96.8% responded that sales increased during long rains and 36.5% that sales also surged during short rains. ITNs and baby-size nets were often delivered by the wholesaler. Retailers of aerosol sprays, mosquito coils, and topical repellents either collected stock from the wholesaler or products were delivered to them. Other commercially available MCPs included insecticide incense sticks, electric mosquito strikers, insecticide soaps, electrically heated insecticide mats, and electric insecticide emanators, indicating a well-established market. CONCLUSIONS: The wide range of MCPs in local retail outlets within the study area suggests the need and demand for mosquito control tools, in addition to ITNs, that are affordable, easy to use and effective. The presence of a wide range of MCPs, is a promising sign for the introduction of a spatial repellent intervention class of products that meets consumer needs and preferences.

Transitions in "Privatized" Prison Health Systems: Emergency Department Visits and Hospitalizations Among Incarcerated People in Florida, 2011-2018.

Objectives. To examine rates of emergency department (ED) visits and hospitalizations among incarcerated people in Florida during a period when health care management in the state's prisons underwent transitions.Methods. We used Florida ED visit and hospital discharge data (2011-2018) to depict the trend in ED visit and hospital discharge rates among incarcerated people. We proxied incarcerated people using individuals admitted from and discharged or transferred to a court or law enforcement agency. We fitted a regression with year indicators to examine the significance of yearly changes.Results. Among incarcerated people in Florida, ED visit rates quadrupled, and hospitalization rates doubled, between 2015 and 2018, a period when no similar trends were evident in the nonincarcerated population.Public Health Implications. Increasing the amount and flexibility of payments to contractors overseeing prison health services may foster higher rates of hospital utilization among incarcerated people and higher costs, without addressing major quality of care problems. Hospitals and government agencies should transparently report on health care utilization and outcomes among incarcerated people to ensure better oversight of services for a highly vulnerable population.

Costs of Nonfatal Traumatic Brain Injury in the United States, 2016.

BACKGROUND: Traumatic brain injury (TBI) is a serious public health problem in the United States. Each year, TBIs substantially contribute to health care costs, which vary by severity. This is important to consider given the variability in recovery time by severity. RESEARCH DESIGN: This study quantifies the annual incremental health care costs of nonfatal TBI in 2016 for the US population covered by a private health insurance, Medicaid, or Medicare health plan. This study uses MarketScan and defines severity with the abbreviated injury scale for the head and neck region. Nonfatal health care costs were compared by severity. RESULTS: The estimated 2016 overall health care cost attributable to nonfatal TBI among MarketScan enrollees was $40.6 billion. Total estimated annual health care cost attributable to TBI for low severity TBIs during the first year postinjury were substantially higher than costs for middle and high severity TBIs among those with private health insurance and Medicaid. CONCLUSIONS: This study presents economic burden estimates for TBI that underscore the importance of developing strategies to prevent TBIs, regardless of severity. Although middle and high severity TBIs were more costly at the individual level, low severity TBIs, and head injuries diagnosed as "head injury unspecified" resulted in higher total estimated annual health care costs attributable to TBI.

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.

Insurance Acceptance, Appointment Wait Time, and Dermatologist Access Across Practice Types in the US.

Importance: In the 15 years since dermatology access was last investigated on a national scale, the practice landscape has changed with the rise of private equity (PE) investment and increased use of nonphysician clinicians (NPCs). Objective: To determine appointment success and wait times for patients with various insurance types at clinics with and without PE ownership. Design, Setting, and Participants: In this study, PE-owned US clinics were randomly selected and matched with 2 geographically proximate clinics without PE ownership. Researchers called each clinic 3 times over a 5-day period to assess appointment/clinician availability for a fictitious patient with a new and changing mole. The 3 calls differed by insurance type specified, which were Blue Cross Blue Shield (BCBS) preferred provider organization, Medicare, or Medicaid. Main Outcomes and Measures: Appointment success and wait times among insurance types and between PE-owned clinics and control clinics. Secondary outcomes were the provision of accurate referrals to other clinics when appointments were denied and clinician and next-day appointment availability. Results: A total of 1833 calls were made to 204 PE-owned and 407 control clinics without PE ownership across 28 states. Overall appointment success rates for BCBS, Medicare, and Medicaid were 96%, 94%, and 17%, respectively. Acceptance of BCBS (98.5%; 95% CI, 96%-99%; P = .03) and Medicare (97.5%; 95% CI, 94%-99%; P = .02) were slightly higher at PE-owned clinics (compared with 94.6% [95% CI, 92%-96%] and 92.8% [95% CI, 90%-95%], respectively, at control clinics). Wait times (median days, interquartile range [IQR]) were similar for patients with BCBS (7 days; IQR, 2-22 days) and Medicare (7 days; IQR, 2-25 days; P > .99), whereas Medicaid patients waited significantly longer (13 days; IQR, 4-33 days; P = .002). Clinic ownership did not significantly affect wait times. Private equity-owned clinics were more likely than controls to offer a new patient appointment with an NPC (80% vs 63%; P = .001) and to not have an opening with a dermatologist (16% vs 6%; P < .001). Next-day appointment availability was greater at PE-owned clinics than controls (30% vs 21%; P = .001). Conclusions and Relevance: Patients with Medicaid had significantly lower success in obtaining appointments and significantly longer wait times regardless of clinic ownership. Although the use of dermatologists and NPCs was similar regardless of clinic ownership, PE-owned clinics were more likely than controls to offer new patient appointments with NPCs.