Respiratory Syncytial Virus Bronchiolitis Hospitalizations in Young Infants After the Introduction of Paid Family Leave in New York State, 2015‒2019.

Objectives. To determine if the introduction of New York State's 8-week paid family leave policy on January 1, 2018, reduced rates of hospitalizations with respiratory syncytial virus (RSV) bronchiolitis or any acute lower respiratory tract infection among young infants. Methods. We conducted an interrupted time series analysis using New York State population-based, all-payer hospital discharge records, October 2015 to December 2019. We estimated the change in monthly hospitalization rates for RSV bronchiolitis and for any acute lower respiratory tract infection among infants aged 8 weeks or younger after the introduction of paid family leave while controlling for temporal trends and RSV seasonality. We modeled RSV hospitalization rates in infants aged 1 year as a control. Results. Hospitalization rates for RSV bronchiolitis and any acute lower respiratory tract infection decreased by 30% after the introduction of paid family leave (rate ratio [RR] = 0.71; 95% confidence interval [CI] = 0.54, 0.94; and RR = 0.72; 95% CI = 0.59, 0.88, respectively). There were no such reductions in infants aged 1 year (RR = 0.98; 95% CI = 0.72, 1.33; and RR = 1.17; 95% CI = 1.03, 1.32, respectively). Conclusions. State paid family leave was associated with fewer RSV-associated hospitalizations in young infants. (Am J Public Health. 2022;112(2):316-324. https://doi.org/10.2105/AJPH.2021.306559).

Health Benefits In 2020: Premiums In Employer-Sponsored Plans Grow 4 Percent; Employers Consider Responses To Pandemic.

The annual Kaiser Family Foundation Employer Health Benefits Survey is the benchmark survey of the cost and coverage of employer-sponsored health benefits in the United States. The 2020 survey was designed and largely fielded before the full extent of the coronavirus disease 2019 (COVID-19) pandemic had been felt by employers. Data collection took place from mid-January through July, with half of the interviews being completed in the first three months of the year. Most of the key metrics that we measure-including premiums and cost sharing-reflect employers' decisions made before the full impacts of the pandemic were felt. We found that in 2020 the average annual premium for single coverage rose 4 percent, to $7,470, and the average annual premium for family coverage also rose 4 percent, to $21,342. Covered workers, on average, contributed 17 percent of the cost for single coverage and 27 percent of the cost for family coverage. Fifty-six percent of firms offered health benefits to at least some of their workers, and 64 percent of workers were covered at their own firm. Many large employers reported having "very broad" provider networks, but many recognized that their largest plan had a narrower network for mental health providers.

Employment-Based, For-Profit Health Care in a Pandemic.

The emergence of Covid-19 in the United States has revealed a critical weakness in the health care system in the United States. The majority of people in the nation receive health care via employment-based health insurance from providers in a competitive market. However, neither employment-based health care nor a competitive health care market can adequately provide treatment during a global pandemic. Employment-based health care will fail to provide care for a large number of people in any destabilizing economic event, including a pandemic. Competitive for-profit health care systems distribute limited goods based on markets rather than health care needs. If a global pandemic results in unusually high demand for specific medical supplies, then these will be distributed suboptimally. The combined risk of suboptimal distribution of needed goods and a significant drop in health care access in a global pandemic indicates that the U.S. health care system has serious vulnerabilities that need to be addressed.

Medical Costs and Health Care Utilization Among Self-Insured Members with Carve-In Versus Carve-Out Pharmacy Benefits.

BACKGROUND: Pharmacy benefit can be purchased as part of an integrated medical and pharmacy health package-a carve-in model-or purchased separately and administered by an external pharmacy benefit manager-a carve-out model. Limited peer-reviewed information is available assessing differences in use and medical costs among carve-in versus carve-out populations. OBJECTIVE: To compare total medical costs per member per year (PMPY) and utilization between commercially self-insured members receiving carve-in to those receiving carve-out pharmacy benefits overall and by 7 chronic condition subgroups. METHODS: This study used deidentified data of members continuously enrolled in Cambia Health Solutions self-insured Blue plans without benefit changes from 2017 through 2018. Cambia covers 1.6 million members in Oregon, Washington, Idaho, and Utah. The medical cost PMPY comparison was performed using multivariable general linear regression with gamma distribution adjusting for age, gender, state, insured group size, case or disease management enrollment, 7 chronic diseases, risk score (illness severity proxy), and plan paid to total paid ratio (benefit richness proxy). Medical event objectives were assessed using multivariable logistic regression comparing odds of hospitalization and emergency department (ED) visit adjusting for the same covariates. Sensitivity analyses repeated the medical cost PMPY comparison excluding high-cost members, greater than $250,000 annually. Chronic condition subgroup analyses were performed using the same methods separately for members having asthma, coronary artery disease, chronic obstructive pulmonary disease, heart failure, diabetes mellitus, depression, and rheumatoid arthritis. RESULTS: There were 205,835 carve-in and 125,555 carve-out members meeting study criteria. Average age (SD) was 34.2 years (18.6) and risk score (SD) 1.1 (2.3) for carve-in versus 35.2 years (19.3) and 1.1 (2.4), respectively, for carve-out. Members with carve-in benefits had lower medical costs after adjustment (4%, P < 0.001), translating into an average $148 lower medical cost PMPY ($3,749 carve-out vs. $3,601 carve-in annualized). After adjustment, the carve-in group had an estimated 15% (P < 0.001) lower hospitalization odds and 7% (P < 0.001) lower ED visit odds. Of 7 chronic conditions, significantly lower costs (12%-17% lower), odds of hospitalization (22%-36% lower), and odds of ED visit (16%-20% lower) were found among members with carve-in benefits for 5 conditions (all P < 0.05). CONCLUSIONS: These findings suggest that integrated, carve-in pharmacy and medical benefits are associated with lower medical costs, fewer hospitalizations, and fewer ED visits. This study focused on associations, and defining causation was not in scope. Possible reasons for these findings include plan access to both medical and pharmacy data and data-informed care management and coordination. Future research should include investigation of integrated data use and its effect across the spectrum of integrated health plan offerings, provider partnerships, and analytic strategies, as well as inclusion of analyzing pharmacy costs to encompass total cost of care. DISCLOSURES: This study received no external funding. The study was jointly conducted by employees of Cambia Health Solutions and Prime Therapeutics, a pharmacy benefit manager servicing Cambia Health Solutions. Smith, Lam, Lockwood, and Pegus are employees of Cambia Health Solutions. Qiu and Gleason are employees of Prime Therapeutics.

Employer-perspective cost comparison of surgical treatments for abnormal uterine bleeding.

Aim: To estimate direct and indirect costs of surgical treatment of abnormal uterine bleeding (AUB) from a self-insured employer's perspective. Methods: Employer-sponsored insurance claims data were analyzed to estimate costs owing to absence and short-term disability 1 year following global endometrial ablation (GEA), outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH). Results: Costs for women who had GEA are substantially less than costs for women who had either OPH or IPH, with the difference ranging from approximately $7700 to approximately $10,000 for direct costs and approximately $4200 to approximately $4600 for indirect costs. Women who had GEA missed 21.8-24.0 fewer works days. Conclusion: Study results suggest lower healthcare costs associated with GEA versus OPH or IPH from a self-insured employer perspective.

Evolution of the TRICARE Pharmacy Benefit: A Decade of Change.

TRICARE is the military's health plan that provides coverage to 9.4 million active duty and retired uniformed services personnel and their family members. The TRICARE pharmacy benefit has undergone many changes in the last decade. These changes include assigning newly approved drugs to nonformulary status after regulatory approval, the addition of weight loss medications to the benefit, channel management point-of-service requirements for some medications, and copay increases. Several initiatives have resulted in significant cost avoidance to the Department of Defense (DoD). The purpose of this article is to discuss the changes to the TRICARE pharmacy benefit, describe the continual challenges, and estimate cost savings associated with implementation of these changes. DoD implemented its 3-tier Uniform Formulary in 2005. Since then, many changes have been enacted, including more extensive use of prior authorization, step therapy, and quantity limits; coverage of over-the-counter medications; the retail refund program; coverage of vaccines and smoking cessation agents; mandatory mail/military treatment facility requirements; rapid review and initial nonformulary status for newly approved innovator drugs; revisions to the compounded drug benefit; initial deployment of a new medical record system; coverage of weight loss medications; and the ability to exclude medications from the Uniform Formulary. Although the TRICARE pharmacy benefit has evolved significantly, the focus remains on the beneficiaries, with an overall goal of providing integrated, affordable, and high quality health services for the Military Health System. Challenges for the future include maximizing clinical effectiveness in the face of rising pharmaceutical costs and cost avoidance, while supporting the needs of TRICARE beneficiaries. DISCLOSURES: No outside funding supported this study. The authors declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. The information discussed here represents the views of the authors and does not necessarily reflect the views of the Defense Health Agency (DHA), the Department of Defense (DoD), or the Departments of the Army, Navy, and Air Force. The authors have nothing to disclose that presents a potential conflict of interest.

Spillover Effects From A Consumer-Based Intervention To Increase High-Value Preventive Care.

Increasing the use of high-value medical services and reducing the use of services with little or no clinical value are key goals for efficient health systems. Yet encouraging the use of high-value services may unintentionally affect the use of low-value services. We examined the likelihood of high- and low-value service use in the first two years after an insurance benefit change in 2011 for one state's employees that promoted use of high-value preventive services. In the intervention group, compared to a control sample with stable benefit plans, in year 1 the likelihood of high-value service use increased 11.0 percentage points, and the likelihood of low-value service use increased 7.9 percentage points. For that year we associated 74 percent of the increase in high-value services and 57 percent of the increase in low-value services with greater use of preventive visits. Our results imply that interventions aimed at increasing receipt of high-value preventive services can cause spillovers to low-value services and should include deterrents to low-value care as implemented in later years of this program.

Paying Patients To Switch: Impact Of A Rewards Program On Choice Of Providers, Prices, And Utilization.

Employers and insurers are experimenting with benefit strategies that encourage patients to switch to lower-price providers. One increasingly popular strategy is to financially reward patients who receive care from such providers. We evaluated the impact of a rewards program implemented in 2017 by twenty-nine employers with 269,875 eligible employees and dependents. For 131 elective services, patients who received care from a designated lower-price provider received a check ranging from $25 to $500, depending on the provider's price and service. In the first twelve months of the program we found a 2.1 percent reduction in prices paid for services targeted by the rewards program. The reductions in price resulted in savings of $2.3 million, or roughly $8 per person, per year. These effects were primarily seen in magnetic resonance imaging and ultrasounds, with no observed price reduction among surgical procedures.

Incentives, Mandates, and Taxes: When Doing More Equates to Learning More.

A recent District Court decision held that the Affordable Care Act (ACA), absent a tax penalty relating to the individual mandate, was unconstitutional. This follows on a Circuit Court decision that the ACA wellness provisions should be nullified. This editorial reviews the similarities and differences between the rulings and asks if a reasonable person would believe that offering financial incentives aimed at supporting a modicum of effort at self-care is rational. One survey of employers and health care consumers indicates 91 percent of those surveyed agree that wellness programs are a perk that helps employees improve health and, interestingly, the same percent agree these programs are sponsored by employers to cut costs. Where some may view the cost containment objectives of employee wellness as dubious, it's a minority view. Still, some minorities should and do carry inordinate sway in public health such as the small percent of those living with chronic conditions who are unwilling to participate in a healthy living program that is associated with their receiving full benefits. Are incentives a worthwhile strategy if they fail to motivate those who would benefit most from health improvement?

Why aren't more employers implementing reference-based pricing benefit design?

OBJECTIVES: There is robust evidence that implementation of reference-based pricing (RBP) benefit design decreases spending. This paper investigates employer adoption of RBP as a strategy to improve the value of patients' healthcare choices, as well as facilitators and barriers to the adoption of RBP by employers. STUDY DESIGN: We conducted a qualitative study using 12 in-depth interviews with human resources executives or their representatives at large- or medium-sized self-insured employers. METHODS: Interviews were conducted and recorded over the phone between March 2017 and May 2017. Interviewees were asked about their adoption of RBP and facilitators and barriers to adoption. We applied thematic analysis to the transcripts. RESULTS: Despite broad employer awareness of RBP's potential for cost savings, few employers are including RBP in their benefit design. The major barriers to RBP adoption were the complexity of RBP benefit design, concern that employees could face catastrophic out-of-pocket costs, lack of a business case for implementation, and concern that RBP could hurt the employer's competitiveness in the labor market. The few employers that have adopted RBP have implemented extensive, year-round employee education campaigns and invested in multipronged and proactive decision support to help employees navigate their choices. CONCLUSIONS: Unless several fundamental barriers are addressed, uptake of RBP will likely continue to be low. Our findings suggest that simplifying benefit design, providing employees protection against very high out-of-pocket costs, understanding which decision-support strategies are most effective, and enhancing the business case could facilitate wider employer adoption of RBP.

Does experience rating reduce sickness and disability claims? Evidence from policy kinks.

We study whether the experience rating of employers' disability insurance premiums affects the inflow to disability benefits in Finland. To identify the causal effect of experience rating, we exploit kinks in the rule that specifies the degree of experience rating as a function of firm size. Using comprehensive matched employer-employee panel data, we estimate the effects of experience rating on the inflow to sickness and disability benefits. We find that experience rating has little or no effect on either of these outcomes.

Why Did Employer Coverage Fall In Massachusetts After The ACA? Potential Consequences Of A Changing Employer Mandate.

The Affordable Care Act (ACA) attempted to minimize disruptions to employer-sponsored insurance in part by implementing an employer mandate. Research has shown that employer coverage rates have been stable nationally under the ACA. Massachusetts enacted its own employer mandate in 2006 before eliminating it in 2014, in anticipation of the federal mandate. But the ACA's employer mandate was delayed until 2015 and exempted smaller firms that had been covered by the Massachusetts' mandate. In this unique policy environment, we found that the employer-sponsored insurance rate in Massachusetts fell by 2.3 percentage points after the ACA's coverage expansion took effect (2014-16), compared to the rest of the US. Coverage dropped more for middle-income workers than for lower-income workers, which suggests that crowd-out by Medicaid was not the primary factor. Employer surveys show that employer coverage offer rates declined significantly at small firms in Massachusetts beginning in 2014, but not at large firms. Our findings suggest that eliminating Massachusetts's employer mandate may have contributed to falling employer coverage rates in the state, although other policy and economic factors cannot be ruled out. These results may have implications for understanding the effects of the ACA's employer mandate and its potential repeal.

Diabetes Outpatient Care and Acute Complications Before and After High-Deductible Insurance Enrollment: A Natural Experiment for Translation in Diabetes (NEXT-D) Study.

Importance: High-deductible health plans (HDHPs) have expanded under the Affordable Care Act and are expected to play a major role in the future of US health policy. The effects of modern HDHPs on chronically ill patients and adverse outcomes are unknown. Objective: To determine the association of HDHP with high-priority diabetes outpatient care and preventable acute complications. Design, Setting, and Participants: Controlled interrupted-time-series study using a large national health insurer database from January 1, 2003, to December 31, 2012. A total of 12 084 HDHP members with diabetes, aged 12 to 64 years, who were enrolled for 1 year in a low-deductible (≤$500) plan followed by 2 years in an HDHP (≥$1000) after an employer-mandated switch were included. Patients transitioning to HDHPs were propensity-score matched with contemporaneous patients whose employers offered only low-deductible coverage. Low-income (n = 4121) and health savings account (HSA)-eligible (n = 1899) patients with diabetes were subgroups of interest. Data analysis was performed from February 23, 2015, to September 11, 2016. Exposures: Employer-mandated HDHP transition. Main Outcomes and Measures: High-priority outpatient visits, disease monitoring tests, and outpatient and emergency department visits for preventable acute diabetes complications. Results: In the 12 084 HDHP members included after the propensity score match, the mean (SD) age was 50.4 (10.0) years; 5410 of the group (44.8%) were women. The overall, low-income, and HSA-eligible diabetes HDHP groups experienced increases in out-of-pocket medical expenditures of 49.4% (95% CI, 40.3% to 58.4%), 51.7% (95% CI, 38.6% to 64.7%), and 67.8% (95% CI, 47.9% to 87.8%), respectively, compared with controls in the year after transitioning to HDHPs. High-priority primary care visits and disease monitoring tests did not change significantly in the overall HDHP cohort; however, high-priority specialist visits declined by 5.5% (95% CI, -9.6% to -1.5%) in follow-up year 1 and 7.1% (95% CI, -11.5% to -2.7%) in follow-up year 2 vs baseline. Outpatient acute diabetes complication visits were delayed in the overall and low-income HDHP cohorts at follow-up (adjusted hazard ratios, 0.94 [95% CI, 0.88 to 0.99] for the overall cohort and 0.89 [95% CI, 0.81 to 0.98] for the low-income cohort). Annual emergency department acute complication visits among HDHP members increased by 8.0% (95% CI, 4.6% to 11.4%) in the overall group, 21.7% (95% CI, 14.5% to 28.9%) in the low-income group, and 15.5% (95% CI, 10.5% to 20.6%) in the HSA-eligible group. Conclusions and Relevance: Patients with diabetes experienced minimal changes in outpatient visits and disease monitoring after an HDHP switch, but low-income and HSA-eligible HDHP members experienced major increases in emergency department visits for preventable acute diabetes complications.

Funding Long-Term Care in Canada: Issues and Options.

Canada's aging population is likely to result in increased health and long-term care (LTC) costs. It is estimated that between 2012 and 2046, LTC cost liability could reach almost $1.2 trillion. Many Canadians are unaware of the potential burden of LTC expenditures, and there is no consensus on who should pay for them. There are four possible options: (1) general tax revenues; (2) social insurance (employer/employee contributions); (3) private purchase of LTC insurance; and (4) private savings. This paper reviews these options as they have materialized to date in Canada and other countries. Despite the growing acuity of this issue, it seems unlikely that a universal, publicly funded approach to LTC will emerge in Canada. It is clear that federal and provincial/territorial governments must continue to explore policy options for LTC funding including public education, prevention and mitigation strategies and provision for tax-sheltered savings specifically for LTC.

Enfermedades profesionales de los trabajadores de limpieza en los hospitales: propuesta educativa para minimizar la exposición / Doenças ocupacionais dos trabalhadores de limpeza em ambiente hospitalar: proposta educativa para minimizar a exposição / Occupational diseases of workers cleaning service in hospital environment: educational proposal to minimize exposure

Objetivos: Identificar la enfermedad profesional de los trabajadores de limpieza del hospital; describir los factores causales de las enfermedades profesionales en este grupo de trabajadores, y ofrecer actividades educativas para minimizar la exposición a las enfermedades profesionales en este grupo. Métodos: Se trata de una revisión integral de la literatura de los últimos cinco años realizada en las bases de datos Lilacs , Medline y BDEnf . Se seleccionaron ocho artículos y después de la lectura y el análisis surgieron tres categorías: (1) las enfermedades profesionales, (2) los factores causales de las enfermedades profesionales, (3) Medidas educativas para minimizar la exposición Resultados:. Los trabajadores del Servicio de limpieza en sus actividades de trabajo están expuestos a todos los riesgos laborales. Las enfermedades profesionales identificadas en estos trabajadores son diversas, pero llaman la atención: los trastornos musculoesqueléticos y dermatitis. Las medidas educativas deben centrarse en la formación / educación continua. Conclusión: Se concluye que la educación continua puede ser una alternativa para minimizar los diversos riesgos laborales a que estos trabajadores están expuestos, ya que las actividades con un enfoque en la capacitación no son muy eficaces (AU)

Objetivos: Identificar as doenças ocupacionais entre os trabalhadores de limpeza hospitalar; descrever os fatores causais das doenças ocupacionais neste grupo de trabalhadores; e propor atividades educativas para minimizar a exposição às doenças ocupacionais neste grupo. Métodos: Trata-se de uma revisão integrativa de literatura dos últimos 5 anos realizada nas bases de dados Lilacs, Bdenf e Medline. Resultados: Oito artigos foram selecionados e após leitura e análise surgiram 3 categorias: (1) Doenças ocupacionais, (2) Fatores causais das doenças ocupacionais, (3) Medidas educativas para minimizar a exposição. Resultados: O trabalhador do serviço de limpeza na sua atividade laboral está exposto a todos os riscos ocupacionais. As doenças ocupacionais identificadas desses trabalhadores são diversas, mas, destaca-se: distúrbios osteomusculares e dermatites. As medidas educativas tem o foco no treinamento/educação continuada. Conclusão: Conclui-se que, a educação permanente pode ser uma alternativa para minimizar os diversos riscos ocupacionais que estes trabalhadores estão expostos, já que as atividades com foco no treinamento não estão sendo muito eficazes (AU)

Objectives: To identify the occupational disease among hospital cleaning workers; describe the causal factors of occupational diseases in this group of workers; and offer educational activities to minimize exposure to occupational diseases in this group . Methods: This is a literature integrative review of the last five years held in databases Lilacs, BDEnf and Medline. Eight articles were selected and after reading and analyzing emerged three categories: (1) Occupational diseases, (2) causal factors of occupational diseases, (3) educational measures to minimize exposure. Results: Worker cleaning service in their work activities are exposed to all occupational risks. Occupational diseases identified these workers are diverse, but stands out: musculoskeletal disorders and dermatitis. The educational measures must focus on training / continuing education. Conclusion: We conclude that continuing education can be an alternative to minimize the various occupational hazards that these workers are exposed, since activities with a focus on training are not very effective (AU)