Browsing by Subject "Insurance coverage"

Now showing 1 - 7 of 7
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    Assessment of Racial Disparity in Survival Outcomes for Early Hormone Receptor–Positive Breast Cancer After Adjusting for Insurance Status and Neighborhood Deprivation
    (American Medical Association, 2022) Sadigh, Gelareh; Gray, Robert J.; Sparano, Joseph A.; Yanez, Betina; Garcoa, Sofia F.; Timsina, Lava R.; Obeng-Gyasi, Samilia; Gareen, Ilana; Sledge, George W.; Whelan, Timothy J.; Cella, David; Wagner, Lynne I.; Carlos, Ruth C.; Surgery, School of Medicine
    Importance: Racial disparities in survival outcomes among Black women with hormone receptor-positive breast cancer have been reported. However, the association between individual-level and neighborhood-level social determinants of health on such disparities has not been well studied. Objective: To evaluate the association between race and clinical outcomes (ie, relapse-free interval and overall survival) adjusting for individual insurance coverage and neighborhood deprivation index (NDI), measured using zip code of residence, in women with breast cancer. Design, setting, and participants: This was a post hoc analysis of 9719 women with breast cancer in the Trial Assigning Individualized Options for Treatment, a randomized clinical trial conducted from April 7, 2006, to October 6, 2010. All participants received a diagnosis of hormone receptor-positive, ERBB2-negative, axillary node-negative breast cancer. The present data analysis was conducted from April 1 to October 22, 2021. Main outcomes and measures: A multivariate model was developed to evaluate the association between race and relapse-free interval and overall survival adjusting for insurance and NDI level at study entry, early discontinuation of endocrine therapy 4 years after initiation, and clinicopathologic characteristics of cancer. Median follow-up for clinical outcomes was 96 months. Results: A total of 9719 women (4.2% [n = 405] Asian; 7.1% [n = 693] Black; 84.3% [n = 8189] White; 4.4% [n = 403] others/not specified) were included; 9.1% of included women [n = 889] were Hispanic or Latino. Median (SD) age was 56 (9.2) years. In multivariate models, Black race compared with White race was associated with statistically significant shorter relapse-free interval (hazard ratio [HR], 1.39; 95% CI, 1.05-1.84; P = .02) and overall survival (HR, 1.49; 95% CI, 1.10-2.99; P = .009), adjusting for insurance and NDI level at study entry and other factors. Although uninsured status was not associated with clinical outcomes, patients with Medicare (HR, 1.30; 95% CI, 1.01-1.68; P = .04) and Medicaid (HR, 1.44; 95% CI, 1.01-2.05; P = .05) had shorter overall survival compared with those with private insurance. Participants living in neighborhoods in the highest NDI quartile experienced shorter overall survival compared with those in the lowest quartile (HR, 1.34; 95% CI, 1.01-1.77; P = .04), regardless of self-identified race. Conclusions and relevance: The findings of this post hoc analysis of a randomized clinical trial suggest that Black women with breast cancer have significantly shorter relapse-free interval and overall survival compared with White women. Early discontinuation of endocrine therapy, clinicopathologic characteristics, insurance coverage, and NDI do not fully explain the observed disparity.
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    Association of Insurance Expansion With Surgical Management of Thyroid Cancer
    (American Medical Association, 2017-08-01) Loehrer, Andrew P.; Murthy, Shilpa S.; Song, Zirui; Lubitz, Carrie C.; James, Benjamin C.; Surgery, School of Medicine
    Importance: To our knowledge, thyroid cancer incidence is increasing faster than any other cancer type and is currently the fifth most common cancer among women. While this rise is likely multifactorial, there has been scarce consideration of the effect of insurance statuses on the treatment of thyroid cancer. Objective: We evaluate the association of insurance expansion with thyroid cancer treatment using the 2006 Massachusetts health reform, which serves as a unique natural experiment. Design, Setting, and Participants: We used the Agency for Healthcare Research and Quality State Inpatient Databases to identify patients with government-subsidized or self-pay insurance or private insurance who were admitted to a hospital with thyroid cancer and underwent a thyroidectomy between 2001 and 2011 in Massachusetts (n = 8534) and 3 control states (n = 48 047). Difference-in-differences models were used to evaluate an association between the 2006 Massachusetts health care reform and thyroid cancer treatment, and participants were controlled for age, sex, comorbidities, and secular trends. Main Outcomes and Measures: Change in the thyroidectomy rate for thyroid cancer treatment was the primary outcome evaluated. Results: The Massachusetts cohort consisted of 6443 women (75.5%) and 2091 men (24.5%), of whom 6388 (79.6%) were white, 391 (4.9%) were black, 527 (6.6%) were Hispanic, 424 (5.3%) were Asian/Pacific Islander, 63 (0.8%) were Native American, and 228 (2.8%) were other. The participants from control states included 36 818 women (76.6%) and 11 229 men (23.4%), of whom 30 432 (65.5%) were white, 3818 (8.2%) were black, 6462 (13.9%) were Hispanic, 2591 (5.6%) were Asian/Pacific Islander, 211 (0.5%) were Native American, and 2947 (6.3%) were other. Before the 2006 Massachusetts insurance expansion, patients with government-subsidized or self-pay insurance had lower thyroidectomy rates for thyroid cancer in Massachusetts and the control states compared with patients with private insurance. The Massachusetts insurance expansion was associated with a 26% increased rate of undergoing a thyroidectomy (incident rate ratio, 1.26; 95% CI, 1.04-1.52; P = .02) and a 22% increased rate of neck dissection (incident rate ratio, 1.22; 95% CI, 1.07-1.37; P = .002) for treating cancer compared with control states. Conclusions and Relevance: The 2006 Massachusetts health reform, which is a model for the Affordable Care Act, was associated with a 26% increased rate of thyroidectomy for treating thyroid cancer. Our study suggests that insurance expansion may be associated with increased access to the surgical management of thyroid cancer. Further studies need to be conducted to evaluate the effect of healthcare expansion at a national level.
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    Evidence-based methodology for obtaining commercial insurance coverage of stereotactic radiosurgery for intractable epilepsy
    (Elsevier, 2020) McClelland, Shearwood, III.; Verma, Vivek; Radiation Oncology, School of Medicine
    Objectives: The coverage policies of many commercial insurers in the United States do not include coverage of stereotactic radiosurgery (SRS) for intractable epilepsy despite recent Level I evidence supporting its efficacy. We sought to assess the efficacy of an evidence-based methodology in obtaining coverage approval of SRS for intractable epilepsy. Patients and methods: The clinical policy guidelines from five of the largest United States commercial insurers were reviewed for their language regarding coverage of SRS for epilepsy. An evidence-based questionnaire was created for temporal lobe epilepsy and extratemporal lobe epilepsy based on recent evidence. Telephone interviewers of Insurers assessed the likelihood of SRS coverage for an epilepsy patient meeting the clinical inclusion criteria in the questionnaire. This likelihood was assessed numerically based on interviewee response (2 = yes, 1 = dependent on peer-to-peer, 0 = no). Results: Of the five policy guidelines, none included literature more recent than 2017. For TLE, 3/5 insurance companies indicated likely SRS coverage; 2/5 indicated peer-to-peer discussion dependence for patients meeting questionnaire criteria for a score of 8/10. For extratemporal TLE, 2/5 companies indicated likely SRS coverage and 3/5 indicated peer-to-peer discussion dependence for a total score of 7/10. Conclusion: Creation of an evidence-based methodology in approaching commercial insurers greatly increased the likelihood of SRS coverage for an indication (intractable epilepsy) widely perceived as investigational. These results should pave the way for epilepsy patients to receive coverage should they be appropriate SRS candidates.
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    Health care–related transportation insecurity is associated with adverse health outcomes among adults with chronic liver disease
    (Wolters Kluwer, 2024-01-11) Ufere, Nneka N.; Lago-Hernandez, Carlos; Alejandro-Soto, Alysa; Walker, Tiana; Li, Lucinda; Schoener, Kimberly; Keegan, Eileen; Gonzalez, Carolina; Bethea, Emily; Singh, Siddharth; El-Jawahri, Areej; Nephew, Lauren; Jones, Patricia; Serper, Marina; Medicine, School of Medicine
    Background: Health care-related transportation insecurity (delayed or forgone medical care due to transportation barriers) is being increasingly recognized as a social risk factor affecting health outcomes. We estimated the national burden and adverse outcomes of health care-related transportation insecurity among US adults with chronic liver disease (CLD). Methods: Using the U.S. National Health Interview Survey from 2014 to 2018, we identified adults with self-reported CLD. We used complex weighted survey analysis to obtain national estimates of health care-related transportation insecurity. We examined the associations between health care-related transportation insecurity and health care-related financial insecurity, food insecurity, self-reported health status, work productivity, health care use, and mortality. Results: Of the 3643 (representing 5.2 million) US adults with CLD, 267 [representing 307,628 (6%; 95% CI: 5%-7%)] reported health care-related transportation insecurity. Adults with CLD experiencing health care-related transportation insecurity had 3.5 times higher odds of cost-related medication nonadherence [aOR, 3.5; (2.4-5.0)], 3.5 times higher odds of food insecurity [aOR, 3.5; (2.4-5.3)], 2.5 times higher odds of worsening self-reported health status over the past year [aOR, 2.5; (1.7-3.7)], 3.1 times higher odds of being unable to work due to poor health over the past year [aOR, 3.1; (2.0-4.9)], and 1.7 times higher odds of being in a higher-risk category group for number of hospitalizations annually [aOR, 1.7; (1.2-2.5)]. Health care-related transportation insecurity was independently associated with mortality after controlling for age, income, insurance status, comorbidity burden, financial insecurity, and food insecurity [aHR, 1.7; (1.4-2.0)]. Conclusions: Health care-related transportation insecurity is a critical social risk factor that is associated with health care-related financial insecurity, food insecurity, poorer self-reported health status and work productivity, and increased health care use and mortality among US adults with CLD. Efforts to screen for and reduce health care-related transportation insecurity are warranted.
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    Insurance Denials of Care Amount to Unlicensed Medical Practice
    (Academy of Managed Care Pharmacy, 2020) Bennett, William E.; Pediatrics, School of Medicine
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    Segregation by Payer in Obstetrics and Gynecology Residency Ambulatory Care Sites
    (American Medical Association, 2024-09-03) Vinekar, Kavita; Qasba, Neena; Reiser, Hannah; Banks, Erika; Arora, Kavita S.; Tucker Edmonds, Brownsyne; George, Karen; Obstetrics and Gynecology, School of Medicine
    Importance: Many teaching hospitals in the US segregate patients by insurance status, with resident clinics primarily composed of publicly insured or uninsured patients and faculty practices seeing privately insured patients. The prevalence of this model in obstetrics and gynecology residencies is unknown. Objectives: To examine the prevalence of payer-based segregation in obstetrics and gynecology residency ambulatory care sites nationally and to compare residents' and program directors' perceptions of differences in quality of care between payer-segregated and integrated sites. Design, setting, and participants: This national survey study included all 6060 obstetrics and gynecology residents and 293 obstetrics and gynecology residency program directors in the US as of January 2023. The proportion of program directors reporting payer segregation was calculated to characterize the national prevalence of this model in obstetrics and gynecology. Perceived differences in care quality were compared between residents and program directors at payer-segregated sites. Main outcome and measures: The primary measure was prevalence of payer-based segregation in obstetrics and gynecology residency programs in the US as reported by residency program directors. The secondary measure was resident and program director perceptions of care quality in these ambulatory care settings. Before study initiation, the study hypothesis was that residents and program directors at ambulatory sites with payer-based segregation would report more disparity in perceived health care quality between resident and faculty practices compared with those from integrated sites. Results: A total of 251 residency program directors (response rate, 85.7%) and 3471 residents (response rate, 57.3%) were included in the study. Resident respondent demographics reflected demographics of obstetrics and gynecology residents nationally in terms of racial and ethnic distribution (6 [0.2%] American Indian or Alaska Native; 425 [13.0%] Asian; 239 [7.3%] Black or African American; 290 [8.9%] Hispanic, Latinx, or Spanish; 7 [0.2%] Native Hawaiian or Other Pacific Islander; 2052 [62.7%] non-Hispanic White; 49 [1.5%] multiracial; 56 [1.7%] other [any race not listed]; and 137 [4.2%] preferred not to say) and geographic distribution (regional prevalence of payer-based segregation: 36 of 53 [67.9%] in the Northeast, 35 of 44 [79.5%] in the Midwest, 43 of 67 [64.2%] in the South, and 13 of 22 [59.1%] in the West), with 2837 respondents (86.9%) identifying as female. Among program directors, 127 (68.3%) reported payer-based segregation in ambulatory care. University programs were more likely to report payer-based segregation compared with community, hybrid, and military programs (63 of 85 [74.1%] vs 31 of 46 [67.4%], 32 of 51 [62.7%], and 0, respectively; P = .04). Residents at payer-segregated programs were less likely than their counterparts at integrated programs to report equal or higher care quality from residents compared with faculty (1662 [68.7%] vs 692 [81.6%] at segregated and integrated programs, respectively; P < .001). Conclusions and relevance: In this survey study of residents and residency program directors, payer-based segregation was prevalent in obstetrics and gynecology residency programs, particularly at university programs. These findings reveal an opportunity for structural reform to promote more equitable care in residency training programs.
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    Trends in US Health Insurance Coverage During the COVID-19 Pandemic
    (American Medical Association, 2021-09-03) Bundorf, M. Kate; Gupta, Sumedha; Kim, Christine; Economics, School of Liberal Arts
    Importance: While most working-age adults in the US obtain health insurance through an employer, little is known about the implications of the massive pandemic-related job loss in March 2020 and subsequent rebound for rates of employer-sponsored coverage and uninsurance. Objective: To determine how health insurance coverage changed during the COVID-19 pandemic. Design setting and participants: Analysis of trends in insurance coverage based on repeated cross sections of the US Census Bureau's Household Pulse Survey data, using linear regression to adjust for respondent's demographic and socioeconomic characteristics and state of residence. More than 1.2 million US adults aged 18 to 64 years were surveyed from April 23 through December 21, 2020. Exposures: The COVID-19 pandemic, separated into spring and summer and fall and winter time periods during 2020, as well as state Medicaid expansion status. Main outcomes and measures: Regression-based estimates of the weekly percentage-point change in respondents' health insurance status, including having any health insurance, any employer-sponsored health insurance, or only nonemployer sponsored coverage. Nonemployer-sponsored coverage is categorized into private, Medicaid, and other public in some analyses. Results: The study population included 1 212 816 US adults (51% female; mean [SD] age, 42 [13] years) across all 50 US states and Washington DC. Among these respondents, rates of employer-sponsored coverage declined by 0.2 percentage points each week during the COVID-19 pandemic. Other types of coverage, particularly from public sources, increased by 0.1 and 0.2 percentage points in the spring and summer and fall and winter periods, respectively. Overall, health insurance coverage of any type declined, particularly during the spring and summer period, during which uninsurance increased by 1.4 percentage points, representing more than 2.7 million newly uninsured people, over a 12-week period. Conclusions and relevance: In this cross-sectional study of data from the US Census Bureau's Household Pulse Survey, results showed that while public programs played an important role in protecting US adults from pandemic-driven declines in employment-sponsored coverage, many people became uninsured during 2020.