Psychological Harms and Treatment of Sexual Assault and Sexual Harassment in Adults: Systematic and Scoping Reviews to Inform Improved Care for Military Populations.

Victims of sexual assault and sexual harassment often experience a variety of psychological outcomes and mental health symptoms related to posttraumatic stress disorder (PTSD), depression, anxiety, substance abuse, suicidal ideation, and self-harm. Sexual trauma also might affect careers. Despite a need to address these harms, some service members have reported that connecting to health care or mental health services following sexual assault or sexual harassment can be difficult-in part because of a lack of leadership support. Given these persistent challenges, the Psychological Health Center of Excellence identified an urgent need to better understand research that is pertinent to sexual assault and sexual harassment during military service so that the U.S. Department of Defense and the military services can improve the health care response for service members. RAND researchers investigated and synthesized relevant research in three topic areas: (1) the effectiveness of psychotherapy treatments designed for adult victims of sexual assault or sexual harassment in military settings; (2) barriers faced by U.S. military members to accessing and remaining in mental health care settings; and (3) associations between sexual assault or sexual harassment and mental health conditions.

Access to Health Care Among TRICARE-Covered Children.

TRICARE, the U.S. Department of Defense insurance program for eligible service members and their dependents, provides health care coverage to nearly 2 million children under the age of 18. Survey data and prior evaluations indicate that TRICARE-covered children face challenges in accessing pediatric health care, with the greatest challenges among children who have experienced frequent relocations and children with special health care needs. However, TRICARE has not measured pediatric patient experiences in accessing care since 2010. To fill this gap, RAND researchers analyzed national survey data on the experiences of caregivers of TRICARE-covered children and children with commercial insurance, public insurance, and no insurance to identify differences in access to pediatric care, necessary referrals, care coordination support, ability to pay medical bills, and other factors. Additional analyses highlight variations between children with different TRICARE plans, between children who have changed addresses more and less frequently, and between children with special health care needs and those without. The findings should help inform efforts to increase access to care for children across the Military Health System, as well as improvements to programs designed to support military families during relocations and those with children who have special health care needs.

Practice Expense Data Collection and Methodology: Phase II Final Report.

Each year, Medicare allocates tens of billions of dollars for indirect practice expense (PE) across services on the basis of data from the Physician Practice Information (PPI) Survey, which reflects 2006 expenses. Because these data are not regularly updated, and because there have been significant changes in the U.S. economy and health care system since 2006, there are concerns that continued reliance on PPI Survey data might result in PE payments that do not accurately capture the resources that are typically required to provide services. In this final phase of a study on PE methodology, the authors address how the Centers for Medicare & Medicaid Services (CMS) might improve the methodology used in PE rate-setting, update data that inform PE rates, or both. The authors conclude that this information is best provided by a survey; therefore, they focus on the advantages and disadvantages of survey-based approaches. They also describe the use of a lean model survey instrument, as well as partnering with another agency to collect data. Finally, the authors describe a virtual town hall meeting held in June 2021 to give stakeholders an opportunity to provide feedback on PE data collection and rate-setting. The system of data and methods that CMS uses to support PE rate-setting is complex; thus, CMS must take into account a number of competing priorities when considering changes to the system. With this in mind, the authors offer a number of near- and longer-term recommendations.

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.

In New England, Partisan Differences In ACA Marketplace Participation And Potential Financial Harm.

Political orientation can be a powerful motivator of certain health care decisions. This study examines how political orientation was associated with decisions to use the Affordable Care Act Marketplaces to enroll in nongroup health insurance plans and whether it was also associated with adverse financial consequences. We used administrative records and surveys of nongroup Marketplace enrollees from a large insurer in New England. Enrollees were categorized as Republican, Democrat, or independent through self-identification or were assigned to one of the political parties after responding to a political preference question. Republican enrollees were less likely than Democratic enrollees of comparable subsidy eligibility to enroll through the Marketplaces and receive subsidies. Among income-eligible enrollees, Republican subscribers received $66 per month less in premium subsidies than Democratic subscribers, equivalent to roughly $800 per year. However, this result varied by subgroups in the parties, and our results suggest that party effects on decision making may inversely relate to the magnitude of the financial consequence. Navigating the ongoing political polarization in the United States requires optimizing public policies, as well as the associated education and outreach, to ensure maximal efficacy regardless of political orientation.

Obstetrician-Gynecologist Views of Pregnancy-Related Medication Safety.

Background: Medication use among pregnant women is widespread, despite limited evidence about the teratogenicity of most medications. Improved physician-patient communication about pregnancy-related medication safety has been identified as a strategy to address this critical issue; however, little is known about physicians' knowledge, attitudes, and practices that could inform tools for information access and sharing to support such communication. The primary objective of this study is to address gaps in what is known about obstetrician-gynecologist views, practices, and needs related to accessing and sharing pregnancy-related medication safety information with patients. Materials and Methods: The basis for this study is a nationally representative, randomized survey of 506 practicing obstetrician-gynecologists. The survey was completed by mail or online between October 26, 2015 and May 8, 2016 with a 52% response rate. Data were weighted to population parameters to reduce the risk of potential nonresponse biases. Analyses included univariate distributions and comparisons between physicians in different residency cohorts using all-pairs dependent t-tests. Results: Findings point to critical features of obstetrician-gynecologist access and sharing of medication safety information. Obstetrician-gynecologists often retrieve medication safety information during a clinical visit. There is widespread provision of potentially problematic "safe lists" to patients, particularly by younger cohorts, and limited counseling for reproductive-aged patients not actively planning a pregnancy. Conclusions: To improve clinical care, physician-patient communication may be enhanced with technical and policy solutions, including improved digital information tools for retrieving and discussing information in the clinical setting; evidence-based, written information for physicians to share with patients; and encouragement for counseling all women of reproductive age receiving teratogenic medications.

Decision-Making Experiences Of Consumers Choosing Individual-Market Health Insurance Plans.

The health insurance Marketplaces established by the Affordable Care Act include features designed to simplify the process of choosing a health plan in the individual, or nongroup, insurance market. While most individual health insurance enrollees purchase plans through the federal and state-based Marketplaces, millions also purchase plans directly from an insurance carrier (off Marketplace). This study was a descriptive comparison of the decision-making processes and shopping experiences of consumers in two states who purchased a health insurance plan from the same large insurer in 2017, either through the federal Marketplaces or off Marketplace. In a survey, those who selected plans through the Marketplaces reported less difficulty finding the best or most affordable plan than did those enrolling off Marketplace. Respondents in families with chronic health conditions who enrolled through the Marketplaces reported better overall experiences than those who enrolled off Marketplace. Respondents with low health insurance literacy reported poor experiences in enrolling both through the Marketplaces and off Marketplace. Access to consumer assistance in the individual health insurance market should target off-Marketplace populations as well as all populations with low health insurance literacy.

The United States Leads Other Nations In Differences By Income In Perceptions Of Health And Health Care.

We examined income gaps in the period 2011-13 in self-assessments of personal health and health care across thirty-two middle- and high-income countries. While high-income respondents were generally more positive about their health and health care in most countries, the gap between them and low-income respondents was much bigger in some than in others. The United States has among the largest income-related differences in each of the measures we studied, which assessed both respondents' past experiences and their confidence about accessing needed health care in the future. Relatively low levels of moral discomfort over income-based health care disparities despite broad awareness of unmet need indicate more public tolerance for health care inequalities in the United States than elsewhere. Nonetheless, over half of Americans felt that income-based health care inequalities are unfair, and these respondents were significantly more likely than their compatriots to support major health system reform-differences that reflect the country's political divisions. Given the many provisions in the Affordable Care Act that seek to reduce disparities, any replacement would also require attention to disparities or risk taking a step backward in an area where the United States is in sore need of improvement.

Understanding What Makes Americans Dissatisfied With Their Health Care System: An International Comparison.

For decades, public satisfaction with the health care system has been lower in the United States than in other high-income countries. To better understand the distinctive nature of US health system satisfaction, we compared the determinants of satisfaction with the health system in the United States to those in seventeen other high-income countries by applying regression decomposition methods to survey data collected in the period 2011-13. We found that concerns related to "accessing most-preferred care" (the extent to which people feel that they can access their top preferences at a time of need) were more important to satisfaction in the United States than in other high-income countries, while the reverse was true for satisfaction with recent interactions with the health system. Differences among US socioeconomic groups in survey responses regarding access to most-preferred care suggest that wide variation in insurance coverage and generosity may play a role in these differences. While reductions in the uninsured population and the movement toward minimum health plan standards could help address some concerns about access to preferred care, our results raise the possibility of public backlash as market forces push plans toward more restricted access and higher cost sharing.

Discussing Opioid Risks With Patients to Reduce Misuse and Abuse: Evidence From 2 Surveys.

We used 2 population-representative surveys to evaluate the recommendation from recent clinical guidelines for prescribing opioid analgesics that physicians discuss the risk of long-term use disorders with patients. In nationally representative data we observed a 60% lower rate, after adjustment for covariates, in a self-reported saving of pills among respondents who say they talked with their physicians about the risks of prescription painkiller addiction (67% lower rate without adjustment). These findings suggest patient education efforts, as currently practiced in the United States, may have positive behavioral consequences that could lower the risks of prescription painkiller abuse. Future research should test these associations under controlled settings.