Impact of income-based public drug coverage deductibles on adherence to asthma medications.

BACKGROUND: Cost-related nonadherence to medications can be a barrier to asthma management. OBJECTIVE: To quantify the impact of public drug plan deductibles on adherence to asthma medications. METHODS: We used a quasi-experimental regression discontinuity analysis to determine whether thresholds in deductibles for public drug coverage, determined on the basis of annual household income, decreased medication use among lower-income children and adults with asthma in British Columbia from 2013 to 2018. Using dispensed medication records, we evaluated deductible thresholds at annual household incomes of $15,000 (a deductible increase from 0% to 2% of annual household income), and $30,000 (a deductible increase from 2% to 3% annual household income). We evaluated medication costs, use, the ratio of inhaled corticosteroids-containing controller medications to total medications, excessive use of short-acting ß-agonists, and the proportion of days covered by controller therapies. All costs are reported in 2020 Canadian dollars. RESULTS: Overall, 88,935 individuals contributed 443,847 person-years of follow-up (57% of female sex, mean age 31 years). Public drug subsidy decreased by -$41.74 (95% CI, -$28.34 to -$55.13) at the $15,000-deductible threshold, a 28% reduction, and patient costs increased by $48.45 (95% CI, $35.37-$61.53). The $30,000 deductible threshold did not affect public drug costs (P = .31), but patient costs increased by $27.65 (95% CI, $15.22-$40.09), which is an 11% increase. Asthma-related medication use, inhaled corticosteroids-to-total medication ratio, excessive use of short-acting ß-agonists, and proportion of days covered by controller therapies were not impacted by deductible thresholds. CONCLUSION: Income-based deductibles reduced public drug costs with no effect on asthma-related medication use, adherence to controller therapies, or excessive reliever therapy use in lower-income individuals with asthma.

Trends and postoperative outcomes of thyroidectomy after expansion and rise of health insurance deductibles in the fiscal year.

BACKGROUND: The purpose of this study is to evaluate a relationship between expansion of High Deductible Health Plans (HDHPs) and the number of thyroid surgery cases with associated postoperative outcomes in the fiscal year. METHODS: Data from TriNetX was used to evaluate the trends in thyroid surgery from 2005 and 2021 between the end of the year (Quarter 4) and the beginning of the year (Quarter 1). Risk of postoperative outcomes were statistically interrogated. RESULTS: The average rate of thyroid surgery in cases/year between Quarter 4 and Quarter 1 was similar after expansion of HDHPs (152; 146; p = 0.64). There was no increased risk of postoperative complications. The rate of surgery decreased significantly for patients with Medicare after implementation of the revised American Thyroid Association (ATA) guidelines (Quarter 4: p = 0.03; Quarter 1: p = 0.02). CONCLUSIONS: Patients are less likely to delay thyroid surgery at the end of the year despite higher deductibles.

High Deductibles are Associated With Severe Disease, Catastrophic Out-of-Pocket Payments for Emergency Surgical Conditions.

BACKGROUND: Out-of-pocket spending has risen for individuals with private health insurance, yet little is known about the unintended consequences that high levels of cost-sharing may have on delayed clinical presentation and financial outcomes for common emergency surgical conditions. METHODS: In this retrospective analysis of claims data from a large commercial insurer (2016-2019), we identified adult inpatient admissions following emergency department presentation for common emergency surgical conditions (eg, appendicitis, cholecystitis, diverticulitis, and intestinal obstruction). Primary exposure of interest was enrollment in a high-deductible health insurance plan (HDHP). Our primary outcome was disease severity at presentation-determined using ICD-10-CM diagnoses codes and based on validated measures of anatomic severity (eg, perforation, abscess, diffuse peritonitis). Our secondary outcome was catastrophic out-of-pocket spending, defined by the World Health Organization as out-of-pocket spending >10% of annual income. RESULTS: Among 43,516 patients [mean age 48.4 (SD: 11.9) years; 51% female], 41% were enrolled HDHPs. Despite being younger, healthier, wealthier, and more educated, HDHP enrollees were more likely to present with more severe disease (28.5% vs 21.3%, P <0.001; odds ratio (OR): 1.34, 95% CI: 1.28-1.42]); even after adjusting for relevant demographics (adjusted OR: 1.23, 95% CI: 1.18-1.31). HDHP enrollees were also more likely to incur 30-day out-of-pocket spending that exceeded 10% of annual income (20.8% vs 6.4%, adjusted OR: 3.93, 95% CI: 3.65-4.24). Lower-income patients, Black patients, and Hispanic patients were at highest risk of financial strain. CONCLUSIONS: For privately insured patients presenting with common surgical emergencies, high-deductible health plans are associated with increased disease severity at admission and a greater financial burden after discharge-especially for vulnerable populations. Strategies are needed to improve financial risk protection for common surgical emergencies.

Individuals Eligible for Lung Cancer Screening Less Likely to Receive Screening When Enrolled in Health Plans With Deductibles.

BACKGROUND: In 2015, the Centers for Medicare & Medicaid Services and commercial insurance plans began covering lung cancer screening (LCS) without patient cost-sharing for all plans. We explore the impact of enrolling into a deductible plan on the utilization of LCS services despite having no out-of-pocket cost requirement. METHODS: This retrospective study analyzed data from the Population-based Research to Optimize the Screening Process Lung Consortium. Our cohort included non-Medicare LCS-eligible individuals enrolled in managed care organizations between February 5, 2015, and February 28, 2019. We estimate a series of sequential logistic regression models examining utilization across the sequence of events required for baseline LCS. We report the marginal effects of enrollment into deductible plans compared with enrollment in no-deductible plans. RESULTS: The total effect of deductible plan enrollment was a 1.8 percentage-point (PP) decrease in baseline LCS. Sequential logistic regression results that explore each transition separately indicate deductible plan enrollment was associated with a 4.3 PP decrease in receipt of clinician visit, a 1.7 PP decrease in receipt of LCS order, and a 7.0 PP decrease in receipt of baseline LCS. Reductions persisted across all observable races and ethnicities. CONCLUSIONS: These findings suggest individuals enrolled in deductible plans are more likely to forgo preventive LCS services despite requiring no out-of-pocket costs. This result may indicate that increased cost-sharing is associated with suboptimal choices to forgo recommended LCS. Alternatively, this effect may indicate individuals enrolling into deductible plans prefer less health care utilization. Patient outreach interventions at the health plan level may improve LCS.

High-deductible Health Plans and Nonfatal Opioid Overdose.

OBJECTIVES: Opioid-related overdose is a public health emergency in the United States. Meanwhile, high-deductible health plans (HDHPs) have become more prevalent in the United States over the last 2 decades, raising concern about their potential for discouraging high-need populations, like those with opioid use disorder (OUD), from engaging in care that may mitigate the probability of overdose. This study assesses the impact of an employer offering an HDHP on nonfatal opioid overdose among commercially insured individuals with OUD in the United States. RESEARCH DESIGN: We used deidentified insurance claims data from 2007 to 2017 with 97,788 person-years. We used an intent-to-treat, difference-in-differences regression framework to estimate the change in the probability of a nonfatal opioid overdose among enrollees with OUD whose employers began offering an HDHP insurance option during the study period compared with the change among those whose employer never offered an HDHP. We also used an event-study model to account for dynamic time-varying treatment effects. RESULTS: Across both comparison and treatment groups, 2% of the sample experienced a nonfatal opioid overdose during the study period. Our primary model and robustness checks revealed no impact of HDHP offer on the probability of a nonfatal overdose. CONCLUSIONS: Our study suggests that HDHP offer was not associated with an observed increase in the probability of nonfatal opioid overdose among commercially insured person-years with OUD. However, given the strong evidence that medications for OUD (MOUD) can reduce the risk of overdose, research should explore which facets of insurance design may impact MOUD use.

Alleviating Financial Hardships Associated with High-Deductible Health Plans for Adults with Chronic Conditions Through Health Savings Accounts.

BACKGROUND: High-deductible health plans (HDHPs) are becoming increasingly common, but their financial implications for enrollees with and without chronic conditions and the mitigating effects of health savings accounts (HSAs) are relatively unknown. OBJECTIVE: Our aim was to compare financial hardship between non-HDHPs and HDHPs with and without HSAs, stratified by enrollees' number of chronic conditions. DESIGN: We used data from 2015 to 2018 Medical Expenditure Panels Surveys (MEPS) to compare rates of financial hardship across individuals with HDHPs and non-HDHPs using linear and logistic regression models. PARTICIPANTS: A nationally representative sample of 30,981 adults aged 18-64 enrolled in HDHPs and non-HDHPs. MAIN MEASURES: We examined several measures of financial hardship, including total yearly out-of-pocket medical spending as well as rates of delaying medical care or prescriptions in the past year due to cost, forgoing medical care or prescriptions in the past year due to cost, paying medical bills over time, or having problems paying medical bills. We compared rates using the non-HDHP as the control. KEY RESULTS: On most measures, HDHPs are associated with greater financial hardship compared to non-HDHPs, including average annual out-of-pocket spending of $637 for non-HDHPs, $939 for HDHPs with HSAs, and $825 for HDHPs without HSAs (p < 0.01). However, for HDHP enrollees with multiple chronic conditions, having an HSA was associated with less financial hardship (p < 0.05). CONCLUSIONS: Our findings suggest that HSAs may be most beneficial for those with chronic conditions, in part due to the tax benefits they offer as well as the fact that those with chronic conditions are more likely to take advantage of their HSAs than their younger, healthier counterparts. However, as HDHPs are more likely to be correlated with worse financial outcomes regardless of health status, recent trends of increasing participation may be a reason for concern.

Impact of Coinsurance Reduction Policy on Healthcare Utilization Among Children Under 15.

BACKGROUND: On October 1, 2017, a new coinsurance reduction policy for children under 15 was introduced to minimize the lack of inpatient medical services for economic reasons and secure children's access to medical care. METHODS: This study analyzes the effect of this coinsurance reduction policy on healthcare utilization using data from the National Health Insurance Service-National Sample Cohort between 2015 and 2019. Groups were classified by 3 case groups and a control group according to age. The dependent variables were inpatient cost, admission, length of hospitalization, outpatient cost and visit, and total cost. The difference-in-differences method was used to examine changes in healthcare utilization among the case and control groups after policy implementation. RESULTS: Children of the age group 1-5 exhibited an increase in inpatient services and a decrease in outpatient services. There was a 16.17% increase in inpatient cost, 8.55% increase in inpatient admission, 10.67% increase in inpatient length of hospitalization, -9.14% decline in outpatient cost, and -6.79% decline in outpatient visits. Regarding children in the age groups of 6-10 and 11-15, the effect of the policy was inconclusive. CONCLUSION: The reduction in coinsurance rate policy in hospitalization among children has increased inpatient services and reduced outpatient services for 1-5-year-olds-a substitute effect was observed in this group. There is need for further research to examine the long-term effects of the coinsurance reduction policy.

Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care.

BACKGROUND: Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear. METHODS: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low-deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. We performed a cumulative interrupted time-series analysis, comparing changes in annual outcomes between the HDHP and control groups before and after the index date using aggregate-level segmented regression. Members from higher-poverty neighborhoods were a subgroup of interest. RESULTS: After matching, we included 557 501 members in the HDHP group and 5 861 990 in the control group, with mean ages of 42.0 years, 48% to 49% female, and 67% to 68% non-Hispanic White individuals. Employer-mandated HDHP switches were associated with a relative decrease of 4.3% (95% CI, -5.9 to -2.7; absolute change, -4.5 [95% CI, -6.3 to -2.8] per 10 000 person-years) in nonspecific chest pain ED visits and 11.3% (95% CI, -14.0 to -8.6) decrease (absolute change, -1.7 per 10 000 person-years [95% CI, -2.1 to -1.2]) in visits leading to hospitalization. There was no significant decrease in subsequent noninvasive testing or revascularization procedures. An increase in 30-day acute myocardial infarction admissions was not statistically significant (15.9% [95% CI, -1.0 to 32.7]; absolute change, 0.3 per 10 000 person-years [95% CI, -0.01 to 0.5]) but was significant among members from higher-poverty neighborhoods. CONCLUSIONS: Employer-mandated HDHP switches were associated with decreased nonspecific chest pain ED visits and hospitalization from these ED visits, but no significant change in post-ED cardiac testing. However, HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.

Comparing Gold-standard Copayment and Coinsurance Values From Claims Processing Engines to Values Derived From Behavioral Health Claims Databases.

BACKGROUND: While researchers use patient expenditures in claims data to estimate insurance benefit features, little evidence exists to indicate whether the resulting measures are accurate. OBJECTIVE: To develop and test an algorithm for deriving copayment and coinsurance values from behavioral health claims data. SUBJECTS: Employer-sponsored insurance plans from 2011 to 2013 for a national managed behavioral health organization (MBHO). MEASURES: Twelve benefit features, distinguishing between carve-in and carve-out, in-network and out-of-network, inpatient and outpatient, and copayment and coinsurance, were created. Measures drew from claims (claims-derived measures), and benefit feature data from a claims processing engine database (true measures). STUDY DESIGN: We calculate sensitivity and specificity of the claims-derived measures' ability to accurately determine if a benefit feature was required and for plan-years requiring the benefit feature, the accuracy of the claims-derived measures. Accuracy rates using the minimum, 25th, 50th, 75th, and maximum claims value for a plan-year were compared. PRINCIPAL FINDINGS: Sensitivity (82% or higher for all but 3 benefit features) and specificity (95% or higher for all but 2 benefit features) were relatively high. Accuracy rates were highest using the 75th or maximum claims value, depending on the benefit feature, and ranged from 69% to 99% for all benefit features except for out-of-network inpatient coinsurance. CONCLUSIONS: For most plan-years, claims-derived measures correctly identify required specialty mental health copayments and coinsurance, although the claims-derived measures' accuracy varies across benefit design features. This information should be considered when creating claims-derived benefit features to use for policy analysis.

Association Between High Deductible Health Plans and Cost-Related Non-adherence to Medications Among Americans with Diabetes: an Observational Study.

BACKGROUND: For people with diabetes, adherence to prescribed medications is essential. However, the rising prevalence of high-deductible health plans (HDHPs), and prices of diabetes medications such as insulin, could deter adherence. OBJECTIVE: To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US. DESIGN: Repeated cross-sectional survey. SETTING: National Health Interview Survey, 2011-2018. PARTICIPANTS: A total of 7469 privately insured adults ages 18-64 with diabetes who were prescribed medications and enrolled in a HDHP or a traditional commercial health plan (TCP). MAIN MEASURES: Self-reported measures of CRN were compared between enrollees in HDHPs and TCPs overall and among the subset using insulin. Analyses were adjusted for demographic and clinical characteristics using multivariable linear regression models. KEY RESULTS: HDHP enrollees were more likely than TCP enrollees to not fill a prescription (13.4% vs 9.9%; adjusted percentage point difference (AD) 3.4 [95% CI 1.5 to 5.4]); skip medication doses (11.4% vs 8.5%; AD 2.8 [CI 1.0 to 4.7]); take less medication (11.1% vs 8.8%; AD 2.3 [CI 0.5 to 4.0]); delay filling a prescription to save money (14.4% vs 10.8%; AD 3.0 [CI 1.1 to 4.9]); and to have any form of CRN (20.4% vs 15.5%; AD 4.4 [CI 2.2 to 6.7]). Among those taking insulin, HDHP enrollees were more likely to have any CRN (25.1% vs 18.9%; AD 5.9 [CI 1.1 to 10.8]). CONCLUSION: HDHPs are associated with greater CRN among people with diabetes, particularly those prescribed insulin. For people with diabetes, enrollment in non-HDHPs might reduce CRN to prescribed medications.

Impact of High Deductible Health Plans on Continuous Buprenorphine Treatment for Opioid Use Disorder.

BACKGROUND: Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD. OBJECTIVE: To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending. DESIGN: Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group). PARTICIPANTS: Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment. MAIN MEASURES: Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits. KEY RESULTS: HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services. CONCLUSIONS: HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population.

Does coinsurance reduction influence informer-sector workers' and farmers' utilization of outpatient care? A quasi-experimental study in China.

BACKGROUND: In recent years, the Chinese government has been trying to improve informal-sector workers' and farmers' access to healthcare and reduce their financial burdens by introducing a plan of cost-sharing reduction, but the effect on outpatient care utilization remains unknown. Furthermore, scarce evidence has been provided to help understand the impact of cost-sharing reduction on healthcare use in low- and middle-income countries. The policy change of the coinsurance reduction for outpatient care from 75 to 55% for the enrollees of the Urban and Rural Residents Basic Medical Insurance in Taizhou, China in 2015 provides us a good quasi-experimental setting to explore such an impact. METHODS: We do a quasi-experimental study to explore the impact of coinsurance reduction on outpatient care use among the informal-sector workers and farmers aged 45 and above by estimating a fixed-effects negative binomial model with the difference-in-differences approach and the matching method. Heterogeneous effects in primary care clinics and for the older people aged 60 and above are also examined. Our data is from the China Health and Retirement Longitudinal Study 2013 and 2015. RESULTS: We find neither statistically significant impact of coinsurance reduction on outpatient care utilization in all health facilities for informal-sector workers and farmers aged 45 and above, nor heterogeneous effects in primary care clinics and for older people aged 60 and above. CONCLUSIONS: We conclude that the coinsurance reduction cannot effectively improve the informal-sector workers' and farmers' utilization of healthcare if the cost-sharing undertaken by patients remains high even after the reduction. Besides, improving healthcare quality in primary care clinics may play a more important role than merely introducing a cost-sharing reduction plan in enhancing the role of primary care clinics as gatekeepers. We propose that only a substantial coinsurance reduction may help influence the utilization of healthcare for informal-sector workers and farmers, and enhancing the healthcare quality in primary care clinics should be given priority in low- and middle-income countries.

A systematic umbrella review of the association of prescription drug insurance and cost-sharing with drug use, health services use, and health.

BACKGROUND: Increasing spending and use of prescription drugs pose an important challenge to governments that seek to expand health insurance coverage to improve population health while controlling public expenditures. Patient cost-sharing such as deductibles and coinsurance is widely used with aim to control healthcare expenditures without adversely affecting health. METHODS: We conducted a systematic umbrella review with a quality assessment of included studies to examine the association of prescription drug insurance and cost-sharing with drug use, health services use, and health. We searched five electronic bibliographic databases, hand-searched eight specialty journals and two working paper repositories, and examined references of relevant reviews. At least two reviewers independently screened the articles, extracted the characteristics, methods, and main results, and assessed the quality of each included study. RESULTS: We identified 38 reviews. We found consistent evidence that having drug insurance and lower cost-sharing among the insured were associated with increased drug use while the lack or loss of drug insurance and higher drug cost-sharing were associated with decreased drug use. We also found consistent evidence that the poor, the chronically ill, seniors and children were similarly responsive to changes in insurance and cost-sharing. We found that drug insurance and lower drug cost-sharing were associated with lower healthcare services utilization including emergency room visits, hospitalizations, and outpatient visits. We did not find consistent evidence of an association between drug insurance or cost-sharing and health. Lastly, we did not find any evidence that the association between drug insurance or cost-sharing and drug use, health services use or health differed by socioeconomic status, health status, age or sex. CONCLUSIONS: Given that the poor or near-poor often report substantially lower drug insurance coverage, universal pharmacare would likely increase drug use among lower-income populations relative to higher-income populations. On net, it is probable that health services use could decrease with universal pharmacare among those who gain drug insurance. Such cross-price effects of extending drug coverage should be included in costing simulations.

Federal Out-of-Network Balance Billing Legislation: Context and Implications for Radiology Practices.

Out-of-network (OON) balance billing, commonly known as surprise billing but better described as a surprise gap in health insurance coverage, occurs when an individual with private health insurance (vs a public insurer such as Medicare) is administered unanticipated care from a physician who is not in their health plan's network. Such unexpected OON care may result in substantial out-of-pocket costs for patients. Although ending surprise billing is patient centric, patient protective, and noncontroversial, passing federal legislation was challenging given its ability to disrupt insurer-physician good-faith negotiations and thus impact in-network rates. Like past proposals, the recently passed No Surprises Act takes patients out of the middle of insurer-physician OON reimbursement disputes, limiting patients' expense to standard in-network cost-sharing amounts. The new law, based on arbitration, attempts to protect good-faith negotiations between physicians and insurance companies and encourages network contracting. Radiology practices, even those that are fully in network or that never practiced surprise billing, could nonetheless be affected. Ongoing rulemaking processes will have meaningful roles in determining how the law is made operational. Physician and stakeholder advocacy has been and will continue to be crucial to the ongoing evolution of this process. © RSNA, 2021.

Non-warfarin oral anticoagulant copayments and adherence in atrial fibrillation: A population-based cohort study.

BACKGROUND: In patients with atrial fibrillation, incomplete adherence to anticoagulants increases risk of stroke. Non-warfarin oral anticoagulants (NOACs) are expensive; we evaluated whether higher copayments are associated with lower NOAC adherence. METHODS: Using a national claims database of commercially-insured patients, we performed a cohort study of patients with atrial fibrillation who newly initiated a NOAC from 2012 to 2018. Patients were stratified into low (<$35), medium ($35-$59), or high (≥$60) copayments and propensity-score weighted based on demographics, insurance characteristics, comorbidities, prior health care utilization, calendar year, and the NOAC received. Follow-up was 1 year, with censoring for switching to a different anticoagulant, undergoing an ablation procedure, disenrolling from the insurance plan, or death. The primary outcome was adherence, measured by proportion of days covered (PDC). Secondary outcomes included NOAC discontinuation (no refill for 30 days after the end of NOAC supply) and switching anticoagulants. We compared PDC using a Kruskal-Wallis test and rates of discontinuation and switching using Cox proportional hazards models. RESULTS: After weighting patients across the 3 copayment groups, the effective sample size was 17,558 patients, with balance across 50 clinical and demographic covariates (standardized differences <0.1). Mean age was 62 years, 29% of patients were female, and apixaban (43%), and rivaroxaban (38%) were the most common NOACs. Higher copayments were associated with lower adherence (P < .001), with a PDC of 0.82 (Interquartile range [IQR] 0.36-0.98) among those with high copayments, 0.85 (IQR 0.41-0.98) among those with medium copayments, and 0.88 (IQR 0.41-0.99) among those with low copayments. Compared to patients with low copayments, patients with high copayments had higher rates of discontinuation (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.08-1.19; P < .001). CONCLUSIONS: Among atrial fibrillation patients newly initiating NOACs, higher copayments in commercial insurance were associated with lower adherence and higher rates of discontinuation in the first year. Policies to lower or limit cost-sharing of important medications may lead to improved adherence and better outcomes among patients receiving NOACs.

Price Transparency in Radiology: Challenges and Opportunities to Improve.

Increasing health care consumerism has been proposed as a solution for rising U.S. health care costs. Although price transparency initiatives aim to inform patients about outof-pocket costs (OOPCs), challenges remain regarding price transparency tools, including limited accuracy of estimates, accounting for multiple payers for the same service, the need for quality measures, optimal OOPC delivery, and psychosocial consequences of OOPC information. As radiology practices consider implementing price transparency initiatives, improvements should address enhancing patients' experience with OOPC communication.

Cost sharing and the demand for health services in a regulated market.

This paper measures consumer responsiveness to cost sharing in healthcare using a regression discontinuity design. I use a novel and detailed claims-level dataset from the Colombian healthcare market, where the government exogenously determines a tier system for coinsurance rates and copays based on the enrollee's monthly income. I find that patients exposed to higher coinsurance rates demand fewer services relative to patients facing lower cost sharing. This reduction holds for both discretionary and preventive services. Lower utilization translates into lower costs, despite evidence that patients facing higher prices do not substitute away from more expensive providers.

Impact of High Deductible Health Plans on Diabetes Care Quality and Outcomes: Systematic Review.

OBJECTIVE: To provide a review of the impact of high deductible health plans (HDHPs) on the utilizations of services required for optimal management of diabetes and subsequent health outcomes. METHODS: Systematic literature review of studies published between January 1, 2000, and May 7, 2021, was conducted that examined the impact of HDHP on diabetes monitoring (eg, recommended laboratory and surveillance testing), routine care (eg, ambulatory appointments), medication management (eg, medication initiation, adherence), and acute health care utilization (eg, emergency department visits, hospitalizations, incident complications). RESULTS: Of the 303 reviewed articles, 8 were relevant. These studies demonstrated that HDHPs lower spending at the expense of reduced high-value diabetes monitoring, routine care, and medication adherence, potentially contributing to the observed increases in acute health care utilization. Additionally, patient out-of-pocket costs for recommended screenings doubled, and total health care expenditures increased by 49.4% for HDHP enrollees compared with enrollees in traditional health plans. Reductions in disease monitoring and routine care and increases in acute health care utilization were greatest in lower-income patients. None of the studies examined the impact of HDHPs on access to diabetes self-management education, technology use, or glycemic control. CONCLUSION: Although HDHPs reduce some health care utilization and costs, they appear to do so at the expense of limiting high-value care and medication adherence. Policymakers, providers, and payers should be more cognizant of the potential for negative consequences of HDHPs on patients' health.

Reduced Cost-sharing for Preventive Drugs Preferentially Benefits Low-income Patients With Diabetes in High Deductible Health Plans With Health Savings Accounts.

BACKGROUND: High deductible health plans linked to Health Savings Accounts (HSA-HDHPs) must include all care under the deductible except for select preventive services. Some employers and insurers have adopted Preventive Drug Lists (PDLs) that exempt specific classes of medications from deductibles. OBJECTIVE: The objective of this study was to examine the association between shifts to PDL coverage and medication utilization among patients with diabetes in HSA-HDHPs. RESEARCH DESIGN: A natural experiment comparing pre-post changes in monthly and annual outcomes in matched study groups. SUBJECTS: The intervention group included 1744 commercially-insured HSA-HDHP patients with diabetes age 12-64 years switched by employers to PDL coverage; the control group included 3349 propensity-matched HSA-HDHP patients whose employers offered no PDL. MEASURES: Outcomes were out-of-pocket (OOP) costs for medications and the number of pharmacy fills converted to 30-day equivalents. RESULTS: Transition to the PDL was associated with a relative pre-post decrease of $612 (-35%, P<0.001) per member OOP medication expenditures; OOP reductions were higher for key classes of antidiabetic and cardiovascular medicines listed on the PDL; the policy did not affect unlisted classes. The PDL group experienced relative increases in medication use of 6.0 30-day fills per person during the year (+11.2%, P<0.001); the increase was more than twice as large for lower-income (+6.6 fills, +12.6%, P<0.001) than higher-income (+3.0 fills, +5.1%, P=0.024) patients. CONCLUSION: Transition to a PDL which covers important classes of medication to manage diabetes and cardiovascular conditions is associated with substantial annual OOP cost savings for patients with diabetes and increased utilization of important classes of medications, especially for lower-income patients.

Is Insurance a Barrier to HIV Preexposure Prophylaxis? Clarifying the Issue.

Clinical trials have demonstrated that preexposure prophylaxis (PrEP) protects against HIV infection; yet, even with its approval by the Food and Drug Administration (FDA) in 2012, less than 10% of eligible users in the United States are currently taking PrEP.While there are multiple factors that influence PrEP uptake and pose barriers to PrEP implementation, here we focus on PrEP's cost in the United States, which, at the current list price of $2000 per month and with high levels of cost sharing, can leave insured users with more than $1000 in out-of-pocket costs every year. We discuss how patient deductibles, monthly premiums, copayments, and coinsurance vary widely and may increase the financial burden. Although drug payment-assistance programs have made PrEP more affordable to uninsured and underinsured users, lack of insurance is a barrier to PrEP accessibility. The FDA approved a generic version in 2017; however, that version has not been distributed to US consumers and may not be more affordable.As other countries begin implementing PrEP programs, the extent of PrEP's availability as a tool in the global fight against HIV remains to be seen.