Racial and Ethnic Differences in Insurer Classification of Nonemergent Pediatric Emergency Department Visits.

Importance: Government and commercial health insurers have recently enacted policies to discourage nonemergent emergency department (ED) visits by reducing or denying claims for such visits using retrospective claims algorithms. Low-income Black and Hispanic pediatric patients often experience worse access to primary care services necessary for preventing some ED visits, raising concerns about the uneven impact of these policies. Objective: To estimate potential racial and ethnic disparities in outcomes of Medicaid policies for reducing ED professional reimbursement based on a retrospective diagnosis-based claims algorithm. Design, Setting, and Participants: This simulation study used a retrospective cohort of pediatric ED visits (aged 0-18 years) for Medicaid-insured children and adolescents appearing in the Market Scan Medicaid database between January 1, 2016, and December 31, 2019. Visits missing date of birth, race and ethnicity, professional claims data, and Current Procedural Terminology codes of billing level of complexity were excluded, as were visits that result in admission. Data were analyzed from October 2021 to June 2022. Main Outcomes and Measures: Proportion of ED visits algorithmically classified as nonemergent and simulated per-visit professional reimbursement after applying a current reimbursement reduction policy for potentially nonemergent ED visits. Rates were calculated overall and compared by race and ethnicity. Results: The sample included 8 471 386 unique ED visits (43.0% by patients aged 4-12 years; 39.6% Black, 7.7% Hispanic, and 48.7% White), of which 47.7% were algorithmically identified as potentially nonemergent and subject to reimbursement reduction, resulting in a 37% reduction in ED professional reimbursement across the study cohort. More visits by Black (50.3%) and Hispanic (49.0%) children were algorithmically identified as nonemergent when compared with visits by White children (45.3%; P < .001). Modeling the impact of the reimbursement reductions across the cohort resulted in expected per-visit reimbursement that was 6% lower for visits by Black children and 3% lower for visits by Hispanic children relative to visits by White children. Conclusions and Relevance: In this simulation study of over 8 million unique ED visits, algorithmic approaches for classifying pediatric ED visits that used diagnosis codes identified proportionately more visits by Black and Hispanic children as nonemergent. Insurers applying financial adjustments based on these algorithmic outputs risk creating uneven reimbursement policies across racial and ethnic groups.

Open-globe injury caused by barbed fish hook repaired using the back-out method: a report of two cases.

Fish hook open-globe injuries (OGIs) are challenging to repair surgically because of the backward-projecting barb near the hook's point that prevents withdrawal of the hook. The most commonly reported ophthalmic surgical technique for removal of barbed hooks is advance-and-cut, wherein the fish hook is pushed through an iatrogenic wound to the exterior of the globe, the barb is cut off, and the shank is backed out of the entry wound. We report 2 cases of zone I OGIs with retained fish hooks successfully repaired using the back-out technique. This strategy involves enlarging the entry wound to allow the entire hook and barb to be backed out, decreasing iatrogenic injuries and eliminating the need for wire cutters.

The Influence of Medicare for All on Reimbursement for Emergency Care Treat-and-Release Visits.

STUDY OBJECTIVE: Single-payer health care is supported by most Americans, but the effect of single payer on any particular sector of the health care market has not been well explored. We examine the effect of 2 potential single-payer designs, Medicare for All and an alternative including Medicare and Medicaid, on total payments and out-of-pocket spending for treat-and-release emergency care (patients discharged after an emergency department [ED] visit). METHODS: We used the 2013 to 2016 Medical Expenditure Panel Survey to determine estimates of payments made for ED visits by insurance type, and the 2015 National Hospital Ambulatory Medical Care Survey to estimate the proportion of ED visits covered by each insurance type. RESULTS: We found that total payments were predicted to increase from $85.5 billion to $89.0 billion (range $81.3 to $99.8 billion) in the Medicare-only scenario and decrease to $79.4 billion (range $71.6 to $87.2 billion) under Medicare/Medicaid, whereas out-of-pocket costs were predicted to decrease from $116 per visit to $45 with Medicare and to $36 with Medicare/Medicaid. CONCLUSION: In this study of ED treat-and-release patients, a transition to a Medicare for All system may increase ED reimbursement and reduce consumer out-of-pocket costs, whereas a system that maintains Medicaid in addition to Medicare could reduce total payments for emergency care.

Extreme Risk Protection Orders: An Opportunity to Improve Gun Violence Prevention Training.

States are increasingly enacting extreme risk protection order (ERPO) laws, also known as "red flag" or gun violence restraining order laws, as one part of a multidisciplinary approach to address the national gun violence epidemic. Passed into law in more than 10 states and under consideration by legislatures in approximately 30 others, ERPO laws create a legal process to temporarily remove firearms from people who may pose a risk to themselves or others. By enabling family or household members, law enforcement, and, in some cases, health care professionals to petition courts when they are concerned about a potential crisis, these laws can potentially prevent firearm-related violence and save lives. Most states with ERPO laws do not give health care professionals a direct role in filing petitions; still, physicians may serve as a resource for patients or their families by counseling on firearm safety and raising awareness of this legal pathway. In this way, the success of ERPO laws depends, in part, on the ability of physicians to accurately assess risk. However, physicians are often not proficient in making these types of risk assessments, largely because of insufficient training, particularly in the context of firearm-related violence. The authors review the literature on physician skill in violence-related risk assessment, medical education in gun violence prevention, and the capacity for training to improve such risk assessments. The authors then make recommendations for integrating focused gun violence prevention training into undergraduate, graduate, and continuing medical education, reviewing notable examples.

IDH mutant gliomas escape natural killer cell immune surveillance by downregulation of NKG2D ligand expression.

BACKGROUND: Diffuse gliomas are poorly immunogenic, fatal brain tumors. The basis for insufficient antitumor immunity in diffuse gliomas is unknown. Gain-of-function mutations in isocitrate dehydrogenases (IDH1 and IDH2) promote diffuse glioma formation through epigenetic reprogramming of a number of genes, including immune-related genes. Here, we identify epigenetic dysregulation of natural killer (NK) cell ligand genes as significant contributors to immune escape in glioma. METHODS: We analyzed the database of The Cancer Genome Atlas for immune gene expression patterns in IDH mutant or wild-type gliomas and identified differentially expressed immune genes. NKG2D ligand expression levels and NK cell-mediated lysis were measured in IDH mutant and wild-type patient-derived glioma stem cells and genetically engineered astrocytes. Finally, we assessed the impact of hypomethylating agent 5-aza-2'deoxycytodine (decitabine) as a potential NK cell sensitizing agent in IDH mutant cells. RESULTS: IDH mutant glioma stemlike cell lines exhibited significantly lower expression of NKG2D ligands compared with IDH wild-type cells. Consistent with these findings, IDH mutant glioma cells and astrocytes are resistant to NK cell-mediated lysis. Decitabine increases NKG2D ligand expression and restores NK-mediated lysis of IDH mutant cells in an NKG2D-dependent manner. CONCLUSIONS: IDH mutant glioma cells acquire resistance to NK cells through epigenetic silencing of NKG2D ligands ULBP1 and ULBP3. Decitabine-mediated hypomethylation restores ULBP1 and ULBP3 expression in IDH mutant glioma cells and may provide a clinically useful method to sensitize IDH mutant gliomas to NK cell-mediated immune surveillance in patients with IDH mutated diffuse gliomas.