Changes in Healthcare Spending Attributable to High Deductible Health Plan Offer Among Enrollees with Comorbid Substance Use Disorder and Cardiovascular Disease.

BACKGROUND: The rise in prevalence of high deductible health plans (HDHPs) in the United States may raise concerns for high-need, high-utilization populations such as those with comorbid chronic conditions. In this study, we examine changes in total and out-of-pocket (OOP) spending attributable to HDHPs for enrollees with comorbid substance use disorder (SUD) and cardiovascular disease (CVD). METHODS: We used de-identified administrative claims data from 2007 to 2017. SUD and CVD were defined using algorithms of ICD 9 and 10 codes and HEDIS guidelines. The main outcome measures of interest were spending measure for all non-SUD/CVD-related services, SUD-specific services, and CVD-specific services, for all services and medications specifically. We assessed both total and OOP spending. We used an intent-to-treat two-part model approach to model spending and computed the marginal effect of HDHP offer as both the dollar change and percent change in spending attributable to HDHP offer. RESULTS: Our sample included 33,684 enrollee-years and was predominantly white and male with a mean age of 53 years. The sample had high demonstrated substantial healthcare utilization with 94% using any non-SUD/CVD services, and 84% and 78% using SUD and CVD services, respectively. HDHP offer was associated with a 17.0% (95% CI = [0.07, 0.27] increase in OOP spending for all non-SUD/CVD services, a 21.1% (95% CI = [0.11, 0.31]) increase in OOP spending for all SUD-specific services, and a 13.1% (95% CI = [0.04, 0.23]) increase in OOP spending for all CVD-specific services. HDHP offer was also associated with a significant increase in OOP spending on non-SUD/CVD-specific medications and SUD-specific medications, but not CVD-specific medications. CONCLUSIONS: This study suggests that while HDHPs do not change overall levels of annual spending among enrollees with comorbid CVD and SUD, they may increase the financial burden of healthcare services by raising OOP costs, which could negatively impact this high-need and high-utilization population.

The December Effect in Pediatric Elective Surgery Utilization: Differences Between Privately and Publicly Insured Children.

OBJECTIVES: The objective of this study was to identify differences in December elective surgery utilization between privately and publicly insured children, given that increases in the prevalence and size of annual deductibles may be driving more families with commercial health insurance to delay elective pediatric surgical procedures until later in the calendar year. STUDY DESIGN: We identified patients aged <18 years who underwent myringotomy, tonsillectomy ± adenoidectomy, tympanoplasty, hydrocelectomy, orchidopexy, distal hypospadias repair, or repair of inguinal, umbilical, or epigastric hernia using the 2012-2019 state inpatient and ambulatory surgery and services databases of 9 states. Log-binomial regression models were used to compare relative probabilities of procedures being performed each month. Linear regression models were used to evaluate temporal trends in the proportions of procedures performed in December. RESULTS: Our study cohort (n = 1 001 728) consisted of 56.7% privately insured and 41.8% publicly insured children. Peak procedure utilization among privately and publicly insured children was in December (10.1%) and June (9.6%), respectively. Privately insured children were 24% (95% CI 22%-26%) more likely to undergo surgery in December (P < .001), with a significant increase seen for 8 of 9 procedures. There was no trend over time in the percentage of procedures performed in December, except for hydrocelectomies, which increased by 0.4 percentage points/year among privately insured children (P = .02). CONCLUSIONS: Privately insured children are >20% more likely than publicly insured children to undergo elective surgery in December. However, despite increases in the prevalence of high deductibles, the proportion of procedures performed in December has not increased over recent years.

Secret Shopper Analysis Shows Getting Psychiatry Appointment in New York City is Well Kept Secret.

OBJECTIVE: The Mental Health Parity and Addiction Equity Act prevents payors from imposing more stringent limitations on mental health and substance disorder benefits than medical and surgical benefits. In this study, we assess a New York City insurer's parity compliance based on the accuracy and validity of network-provided information and a consider legal framework to address this. METHODS: A "secret shopper" analysis was performed, in which researchers attempted to contact the 192 psychiatrist providers listed in the 2019 online directory of United Healthcare psychiatry providers. RESULTS: Only 3.1% of calls resulted in researchers booking an appointment. 50.5% of calls resulted in "no response", 18.75% connected to psychiatrists not accepting new patients, and 8.8% of listed providers stated they were not in the United Healthcare network. CONCLUSIONS: Erroneous directory information exacerbates the issue of access to mental health treatment. Enforcement policy should hold insurers accountable for the reliability of their online directories.

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.

The Project Appropriate Birth and a reduction in caesarean section rates: an analysis using the Robson classification system.

OBJECTIVE: The objective of this study was to assess caesarean section (CS) rates before and after the implementation of the Project Appropriate Birth (PPA), based on the Robson ten group classification system. DESIGN: A before-and-after study. SETTING: Maternity hospital in South Brazil. POPULATION: All pregnant women attending from April 2016 to April 2017 (period 1, pre-implementation of PPA) and from June 2017 to June 2018 (period 2, post-implementation of PPA). METHODS: Maternal and obstetric characteristics were evaluated, including Robson's classification, based on the characteristics of pregnancy and childbirth. A chi-square test and crude and adjusted relative rates were used to analyse the study variables. The significance level was set at 5%. MAIN OUTCOME MEASURES: The CS rate for each group, their contribution to the overall CS rate and the differences in these contributions before and after PPA implementation. RESULTS: The CS rates decreased from 62.4 to 55.6%, which represented a 10.9% reduction after the implementation of the PPA. Pregnant women in Robson classification groups 1-4 had a 21.4% reduction in CS rates, ranging from 49.1 to 38.6%. The greatest contributors to the overall CS rates were group 5 and group 2, accounting for more than 60% of the CS deliveries. CONCLUSION: The study results suggest that Project Appropriate Birth had an impact on the reduction of CS rates, especially in Robson classification groups 1 through 4, which indicates that providing mothers with evidence-based interventions for labour and childbirth assistance contributed to reduce CS rates. TWEETABLE ABSTRACT: The Project Appropriate Birth is an innovative project that has demonstrated promising results, suggesting that interventions based on scientific evidence can lead to real changes in childbirth care, contributing to reduce CS rates. The aim of the PPA is to promote activities to improve childbirth care and encourage vaginal delivery. In this study, 6238 pregnant women admitted to the hospital for delivery were included and classified into one of the Robson 10-group classification. Findings revealed a 10.9% reduction in the overall CS rate and a 21.4% reduction for pregnant women in Robson classification groups 1 through 4, after the implementation of the PPA.

[Health insurance scheme: main contributor to inequalities in COVID-19 mortality in ColombiaTipo de cobertura de assistência à saúde: o principal fator contribuinte para as desigualdades em mortalidade por COVID-19 na Colômbia]. / Plan de seguro de salud: factor que más contribuye a las desigualdades en la mortalidad por COVID-19 en Colombia.

Objectives: To quantify socioeconomic inequalities in COVID-19 mortality in Colombia and to assess the extent to which type of health insurance, comorbidity burden, area of residence, and ethnicity account for such inequalities. Methods: We analyzed data from a retrospective cohort of COVID-19 cases. We estimated the relative and slope indices of inequality (RII and SII) using survival models for all participants and stratified them by age and gender. We calculated the percentage reduction in RII and SII after adjustment for potentially relevant factors. Results: We identified significant inequalities for the whole cohort and by subgroups (age and gender). Inequalities were higher among younger adults and gradually decreased with age, going from RII of 5.65 (95% confidence interval [CI] = 3.25, 9.82) in participants younger than 25 years to RII of 1.49 (95% CI = 1.41, 1.58) in those aged 65 years and older. Type of health insurance was the most important factor, accounting for 20% and 59% of the relative and absolute inequalities, respectively. Conclusions: Significant socioeconomic inequalities exist in COVID-19 mortality in Colombia. Health insurance appears to be the main contributor to those inequalities, posing challenges for the design of public health strategies.

Objetivos: Quantificar as desigualdades socioeconômicas na mortalidade por COVID-19 na Colômbia e avaliar até que ponto o tipo de cobertura de assistência à saúde, a carga de comorbidades, o local de residência e a etnia contribuíram para tais desigualdades. Métodos: Analisamos dados de uma coorte retrospectiva de casos de COVID-19. Calculamos os índices relativo e angular de desigualdade (RII e SII, respectivamente) utilizando modelos de sobrevivência em todos os participantes, estratificando-os por idade e gênero. Calculamos o percentual de redução no RII e no SII após ajuste para fatores possivelmente relevantes. Resultados: Identificamos desigualdades significativas na coorte como um todo e por subgrupos (idade e gênero). As desigualdades foram maiores para adultos mais jovens e decaíram gradualmente com a idade, indo de um RII de 5,65 (intervalo de confiança [IC] de 95% = 3,25; 9,82] nos participantes com idade inferior a 25 anos a um RII de 1,49 [IC 95% = 1,41; 1,58] nas pessoas com 65 anos ou mais. O tipo de cobertura de assistência à saúde foi o fator mais importante, representando 20% e 59% das desigualdades relativa e absoluta, respectivamente. Conclusões: Desigualdades socioeconômicas significativas afetaram a mortalidade por COVID-19 na Colômbia. O tipo de cobertura de saúde parece ser o principal fator contribuinte para essas desigualdades, impondo desafios à elaboração de estratégias de saúde pública.

Incentivizing Excellent Care to At-Risk Groups with a Health Equity Summary Score.

BACKGROUND: Social risk factors (SRFs) such as minority race-and-ethnicity or low income are associated with quality-of-care, health, and healthcare outcomes. Organizations might prioritize improving care for easier-to-treat groups over those with SRFs, but measuring, reporting, and further incentivizing quality-of-care for SRF groups may improve their care. OBJECTIVE: To develop, as a proof-of-concept, a Health Equity Summary Score (HESS): a succinct, easy-to-understand score that could be used to promote high-quality care to those with SRFs in Medicare Advantage (MA) health plans, which provide care for almost twenty million older and disabled Americans and collect extensive quality measure and SRF data. DESIGN: We estimated, standardized, and combined performance scores for two sets of quality measures for enrollees in 2013-2016 MA health plans, considering both current levels of care, within-plan improvement, and nationally benchmarked improvement for those with SRFs (specifically, racial-and-ethnic minority status and dual-eligibility for Medicare and Medicaid). PARTICIPANTS: All MA plans with publicly reported quality scores and 500 or more 2016 enrollees. MAIN MEASURES: Publicly reported clinical quality and patient experience measures. KEY RESULTS: Almost 90% of plans measured for MA Star Ratings received a HESS; plans serving few patients with SRFs were excluded. The summary score was moderately positively correlated with publicly reported overall Star Ratings (r = 0.66-0.67). High-scoring plans typically had sizable enrollment of both racial-and-ethnic minorities (38-42%) and dually eligible beneficiaries (29-38%). CONCLUSIONS: We demonstrated the feasibility of developing and estimating a HESS that is intended to promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible MA enrollees. The HESS measures SRF-specific performance and does not simply duplicate overall plan Star Ratings. It also identifies plans that provide excellent care to large numbers of those with SRFs. Our methodology could be extended to other SRFs, quality measures, and settings.

Direct-to-member mailed colorectal cancer screening outreach for Medicaid and Medicare enrollees: Implementation and effectiveness outcomes from the BeneFIT study.

BACKGROUND: Colorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. To the authors' knowledge, little is known regarding the effectiveness of direct-to-member outreach by Medicaid health insurance plans to raise colorectal cancer screening use, nor how best to deliver such outreach. METHODS: BeneFIT is a hybrid implementation-effectiveness study of 2 program models that health plans developed for a mailed fecal immunochemical test (FIT) intervention. The programs differed with regard to whether they used a centralized approach (Health Plan Washington) or collaborated with health centers (Health Plan Oregon). The primary implementation outcome of the current study was the percentage of eligible enrollees to whom the plans delivered each intervention component. The primary effectiveness outcome was the rate of FIT completion within 6 months of mailing of the introductory letter. RESULTS: The health plans identified 12,000 eligible enrollees (8551 in Health Plan Washington and 3449 in Health Plan Oregon). Health Plan Washington mailed an introductory letter and FIT kit to 8551 enrollees (100%) and delivered a reminder call to 839 (10.3% of the 8132 attempted). Health Plan Oregon mailed an introductory letter, and a letter and FIT kit plus a reminder postcard to 2812 enrollees (81.5%) and 2650 enrollees (76.8%), respectively. FIT completion rates were 18.2% (1557 of 8551 enrollees) in Health Plan Washington. In Health Plan Oregon, completion rates were 17.4% (488 of 2812 enrollees) among enrollees who were mailed an introductory letter and 18.3% (484 of 2650 enrollees) among enrollees who also were mailed a FIT kit plus reminder postcard. CONCLUSIONS: The implementation of mailed FIT outreach by health plans may be effective and could reach many individuals at risk of developing colorectal cancer.

Emergency department encounters for opioid abuse, adverse events, poisoning, and dependence among members of a community-based health insurance plan-Central Texas, 2016-2018.

BACKGROUND: The United States appears to be in the midst of an opioid epidemic. National data indicate a rise in emergency department visits for opioid-related causes over the past decade. This data, while important in helping to explain the magnitude of the epidemic nationally offers only a glimpse of what can be expected to occur locally. The objective of this secondary data analysis was to describe the impact that opioid abuse, adverse events, poisoning, and dependence have on emergency department utilization for individuals who purchased health insurance under the Affordable Care Act in Central Texas from a community-based health maintenance organization. METHODS: Individuals who purchased health insurance from Sendero Health Plans in calendar years 2016, 2017, and 2018 were eligible for participation if they had both an emergency department encounter and an opioid-related ICD-10-CM diagnosis. Eligible individuals were assessed to determine if they were dispensed an opioid agonist or opioid antagonist prescription during the year of their emergency department encounter. Sendero medical claims data for calendar years 2016, 2017, and 2018 were used to calculate both the incidence and ratio of emergency department visits per 100,000-person Sendero member population. Sendero data were compared to available national data estimates. RESULTS: A total of 55 individuals had an emergency department encounter with a primary or secondary opioid-related diagnosis from January 1, 2016 through December 31, 2018. These 55 individuals had 69 unique emergency department encounters during this time period. The incidence of new claims per 100,000-member Sendero population was 67.1, 64.5, and 62.6 in 2016, 2017, and 2018 respectively. The ratio of unique emergency department encounters per 100,000-member Sendero population was 95.9, 82.6, and 66.5 in 2016, 2017, and 2018 respectively. CONCLUSION: Health insurance claims data from a community-based health plan can be used as a source of local information by policy makers and officials as they seek to address the impact of opioid abuse, adverse events, poisoning, and dependence in Central Texas as national data may not represent the local impact of this epidemic.

Total and out-of-pocket expenditures among women with metastatic breast cancer in low-deductible versus high-deductible health plans.

PURPOSE: High-deductible health plan (HDHP) enrollment is expanding rapidly and might substantially increase out-of-pocket (OOP) payment burden. We examined trends in total and OOP health service expenditures overall and by insurance coverage type among women with metastatic breast cancer. METHODS: We used a longitudinal time series design to examine measures among 5364 women with metastatic breast cancer insured by a large US health insurer from 2004 to 2011. We measured outcomes during the 12 months after a first identified metastatic breast cancer diagnosis and required women to have at least 6 months of prior enrollment. We plotted enrollment measures and adjusted total and OOP spending. We fit trend lines using linear autoregressive models. RESULTS: Between 2004 and 2011, the percentage of women with metastatic breast cancer enrolled in employer-mandated HDHPs increased from 8 to 23% while the percentage enrolled in employer-mandated low-deductible plans (LDHPs) decreased from 69 to 37%. Over the same time period, estimated annual inflation-adjusted total health service spending among women with metastatic breast cancer whose employers only offered HDHPs or LDHPS increased from $96,899 to $104,688 (increase of $1197 per year; 95% confidence interval [CI]: $47,$2,348). Corresponding OOP spending values among these women with employer-mandated deductible levels were $4,496 and $5,151 ($91 per year trend; 95% CI -$13,$195). From 2004-2011, women in HDHPs and LDHPs had unchanged annual OOP spending, estimated at of $6642 (95% CI $6,268,$7016) and $4,247 (95% CI $3956,$4538), respectively. Thus, women in HDHPs experienced 55% (44%, 66%) more OOP spending than women in LDHP. CONCLUSIONS: OOP spending among women with metastatic breast cancer and employer-mandated deductible levels was 55% higher among HDHP than LDHP members, and employer-mandated HDHP enrollment increased substantially from 2004 to 2011. Stakeholders and policymakers should design health plans that protect financially vulnerable cancer patients from high OOP costs.

Benefit requirements for substance use disorder treatment in state health insurance exchanges.

BACKGROUND: Established in 2014, state health insurance exchanges have greatly expanded substance use disorder (SUD) treatment coverage in the United States as qualified health plans (QHPs) within the exchanges are required to conform to parity provisions laid out by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act (MHPAEA). Coverage improvements, however, have not been even as states have wide discretion over how they meet these regulations. OBJECTIVE: How states regulate SUD treatment benefits offered by QHPs has implications for the accessibility and quality of care. In this study, we assessed the extent to which state insurance departments regulate the types of SUD services and medications plans must provide, as well as their use of utilization controls. METHODS: Data were collected as part of the National Drug Abuse Treatment System Survey, a nationally-representative, longitudinal study of substance use disorder treatment. Data were obtained from state Departments of Insurance via a 15-minute internet-based survey. RESULTS: States varied widely in regulations on QHPs' administration of SUD treatment benefits. Some states required plans to cover all 11 SUD treatment services and medications we assessed in the study, whereas others did not require plans to cover anything at all. Nearly all states allowed the plans to employ utilization controls, but reported little guidance regarding how they should be used. CONCLUSION: Although some states have taken full advantage of the health insurance exchanges to increase access to SUD treatment, others seem to have done the bare minimum required by the ACA. By not requiring coverage for the entire SUD continuum of care, states are hindering client access to appropriate types of care necessary for recovery.

Health Insurance, Health Savings Accounts and Healthcare Utilization.

Assuming symmetric information, we show that a high-deductible health plan (HDHP) combined with a tax-favored health savings account (HSA) induces more savings and less treatment compared with a full coverage plan under reasonable risk preferences. Furthermore, a higher tax subsidy increases savings in any case but decreases medical utilization if and only if treatment expenses are above the deductible. A larger deductible increases savings but does not necessarily decrease healthcare utilization. Whether an HDHP/HSA combination is preferred over a full coverage contract depends on absolute risk aversion. A higher tax advantage increases the attractiveness of an HDHP/HSA combination, whereas the effects of changes in the deductible are ambiguous. The paper shows that a potential regulator needs to carefully set the size of the deductible as only in a certain corridor of the probability of sickness, its effect on aggregate healthcare costs are unambiguously favorable.

How much segmentation is needed in the health care marketplace? An exploratory study of HMO and non-HMO customers.

The health care landscape has changed dramatically. Consumers now seek plans whose benefits better fit their health care needs and desires for access to providers. This exploratory survey of more than 1,000 HMO and non-HMO customers found significant differences with respect to their selection processes for health plans and providers, and their expectations regarding access to and communication with health care providers. While there are some similarities in factors affecting choice, segmentation strategies are necessary to maximize the appeal of a plan, satisfy customers in the selection of physicians, and meet their expectations regarding access to those physicians.

Value of the Pharmacist in the Medication Reconciliation Process.

Involving pharmacists in the process of comparing the medications that should be ordered for a patient with the new medications that are currently ordered and resolving differences improves accuracy, decreases mortality, and improves transitions of care.

High deductible health plans: does cost sharing stimulate increased consumer sophistication?

OBJECTIVE: To determine whether increased cost sharing in health insurance plans induces higher levels of consumer sophistication in a non-elderly population. STUDY DESIGN: This analysis is based on the collection of survey and demographic data collected from enrollees in the RAND health insurance experiment (HIE). During the RAND HIE, enrollees were randomly assigned to different levels of cost sharing (0, 25, 50 and 95%). METHODS: The study population compromises about 2000 people enrolled in the RAND HIE, between the years 1974 and 1982. Effects on health-care decision making were measured using the results of a standardized questionnaire, administered at the beginning and end of the experiment. Points of enquiry included whether or not enrollees' (i) recognized the need for second opinions (ii) questioned the effectiveness of certain therapies and (iii) researched the background/skill of their medical providers. Consumer sophistication was also measured for regular health-care consumers, as indicated by the presence of a chronic disease. PRINCIPAL FINDINGS: We found no statically significant changes (P < 0.05) in the health-care decision-making strategies between individuals randomized to high cost sharing plans and low cost sharing plans. Furthermore, we did not find a stronger effect for patients with a chronic disease. CONCLUSIONS: The evidence from the RAND HIE does not support the hypothesis that a higher level of cost sharing incentivizes the development of consumer sophistication. As a result, cost sharing alone will not promote individuals to become more selective in their health-care decision-making.

The impact of telehealth cost-sharing on healthcare utilization: Evidence from high-deductible health plans.

OBJECTIVE: Evaluate whether cost-sharing decreases led high-deductible health plans (HDHP) enrollees to increase their use of healthcare. DATA SOURCES, STUDY SETTING: National sample of chronically-ill patients age 18-64 from 2018 to 2020 (n = 1,318,178). STUDY DESIGN: Difference-in-differences analyses using entropy-balancing weights were used to evaluate the effect of a policy shift to $0 cost-sharing for telehealth on utilization for HDHP compared with non-HDHP enrollees. Due to this shock, HDHP enrollees experienced substantial declines in cost-sharing for telehealth, while non-HDHP enrollees experienced small declines. Event study models were also used to evaluate changes over time. DATA COLLECTION/EXTRACTION METHODS: Outcomes included use of any outpatient care; use of $0 telehealth; use of $0 telehealth as a proportion of all outpatient care; and use of any telehealth. To test whether any differences were due to preferences for care modality versus cost-sharing, we further evaluated use of non-$0 telehealth as a placebo test. PRINCIPAL FINDINGS: There was no difference in change in overall outpatient visits (p = 0.84), with chronicall-ill HDHP enrollees using less care both before and after the policy shift. However, compared with non-HDHP enrollees, HDHP enrollees increased their use of $0 telehealth by 0.08 visits over a 9-month period, a 27% increase (95% CI 0.07-0.09, p < 0.001) and shifted 1.2 percentage points more of their care to $0 telehealth, a 15% increase (ß = 0.01, 95% CI 0.01, 0.01, p < 0.001). However, HDHP enrollees had lower uptake of non-$0 telehealth than non-HDHP enrollees (ß = -0.01, 95%CI -0.02, 0.00, p = 0.04). CONCLUSIONS: Recent-but-expiring federal legislation exempts telehealth from HDHP deductibles for care provided in 2023 and 2024. Our results indicate that extending the protections provided by this legislation could help reduce the gap in access to care for chronically-ill persons enrolled in HDHPs.

Deductible imputation in administrative medical claims datasets.

OBJECTIVE: To validate imputation methods used to infer plan-level deductibles and determine which enrollees are in high-deductible health plans (HDHPs) in administrative claims datasets. DATA SOURCES AND STUDY SETTING: 2017 medical and pharmaceutical claims from OptumLabs Data Warehouse for US individuals <65 continuously enrolled in an employer-sponsored plan. Data include enrollee and plan characteristics, deductible spending, plan spending, and actual plan-level deductibles. STUDY DESIGN: We impute plan deductibles using four methods: (1) parametric prediction using individual-level spending; (2) parametric prediction with imputation and plan characteristics; (3) highest plan-specific mode of individual annual deductible spending; and (4) deductible spending at the 80th percentile among individuals meeting their deductible. We compare deductibles' levels and categories for imputed versus actual deductibles. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: All methods had a positive predictive value (PPV) for determining high- versus low-deductible plans of ≥87%; negative predictive values (NPV) were lower. The method imputing plan-specific deductible spending modes was most accurate and least computationally intensive (PPV: 95%; NPV: 91%). This method also best correlated with actual deductible levels; 69% of imputed deductibles were within $250 of the true deductible. CONCLUSIONS: In the absence of plan structure data, imputing plan-specific modes of individual annual deductible spending best correlates with true deductibles and best predicts enrollees in HDHPs.

The relationship between mental health reforms and general population suicide rates in Australia over the past three and a half decades: 1987-2021.

Nearly 3,000 Australians tragically end their lives by suicide each year, underscoring a major national public health challenge with substantial socio-economic ramifications. Australia's National Mental Health Plans (NMHPs) aim to improve mental health and reduce suicide rates. This study investigates their effectiveness by analyzing how age-standardized suicide rates across Australian jurisdictions have fluctuated alongside the implementation of five NMHPs from 1987 to 2021. Findings reveal mixed impacts, with some plans linked to decreases and others associated with increases in suicide rates across different periods and regions. Notably, the recent decline in 2020 requires careful consideration amidst COVID-19 pandemic influences. These insights not only provide valuable evidence for shaping future mental health policies and initiatives but also for future health services research.

The price of cost-effectiveness thresholds under therapeutic competition in pharmaceutical markets.

Health systems around world are increasingly adopting cost-effectiveness (CE) analysis to inform decisions about access and reimbursement. We study how CE thresholds imposed by a health plan for granting reimbursement affect drug producers' pricing incentives and patients' access to new drugs. Analysing a sequential pricing game between an incumbent drug producer and a potential entrant with a new drug, we show that CE thresholds may have adverse effects for payers and patients. A stricter CE threshold may induce the incumbent to switch pricing strategy from entry accommodation to entry deterrence, limiting patients' access to the new drug. Otherwise, irrespective of whether entry is deterred or accommodated, a stricter CE threshold is never pro-competitive and may in fact facilitate a collusive outcome with higher prices of both drugs. Compared to a laissez-faire policy, the use of CE thresholds when an incumbent monopolist is challenged by therapeutic substitutes can only increase the surplus of a health plan if it leads to entry deterrence. In this case the price reduction by the incumbent necessary to deter entry outweighs the health loss to patients who do not get access to the new drug.