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Overuse and insurance plan type in a privately insured population.

ABSTRACT: OBJECTIVES:A substantial portion of healthcare spending is wasted on services that do not directly improve patient health and that cause harm in some cases. Features of health insurance coverage, including enrollment in high-deductible health plans (HDHPs) or health maintenance organizations (HMOs), may provide financial and nonfinancial mechanisms to potentially reduce overuse of low-value healthcare services. STUDY DESIGN:Using 2009 to 2013 administrative data from 3 large commercial insurers, we examined patient characteristics and health insurance plan types associated with overuse of 6 healthcare services identified by the Choosing Wisely campaign. METHODS:We explored associations between overuse and patient characteristics using multivariate logistic regression models, including patient age, gender, enrollment in an HMO, enrollment in an HDHP, an indicator of primary care fragmentation, and number of outpatient visits as explanatory variables. RESULTS:Measurement of services highlighted as potential overuse by the Choosing Wisely recommendations revealed low to moderate prevalence, depending on the service. HMO coverage and enrollment in HDHPs were significantly associated with differences in prevalence of all 6 services, albeit differently in terms of the direction of the effects. Primary care fragmentation was significantly associated with higher rates of overuse. CONCLUSIONS:Neither HDHPs nor HMO plans, with their closed networks and referral requirements, consistently reduced overuse, although HMO plans were never associated with higher rates of overuse. As policy makers seek levers for reducing low-value healthcare utilization, health insurance plan features may prove a valuable target, although the effect may be complicated by other factors.

SUBMITTER: Rosenthal MB

PROVIDER: S-EPMC5985657 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Overuse and insurance plan type in a privately insured population.

Rosenthal Meredith B MB Colla Carrie H CH Morden Nancy E NE Sequist Thomas D TD Mainor Alexander J AJ Li Zhonghe Z Nguyen Kevin H KH

The American journal of managed care 20180301 3

<h4>Objectives</h4>A substantial portion of healthcare spending is wasted on services that do not directly improve patient health and that cause harm in some cases. Features of health insurance coverage, including enrollment in high-deductible health plans (HDHPs) or health maintenance organizations (HMOs), may provide financial and nonfinancial mechanisms to potentially reduce overuse of low-value healthcare services.<h4>Study design</h4>Using 2009 to 2013 administrative data from 3 large comme ...[more]

PMID: 29553277

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Project description:ImportanceHealth care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking.ObjectiveTo compare the outcomes of nonoperatively managed appendicitis against appendectomy.Design, setting, and participantsThis national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018.ExposuresAppendectomy (control arm) or nonoperative management (treatment arm).Main outcomes and measuresShort-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index.ResultsOf 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P < .001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P = .02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P < .001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P < .001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P = .003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days.Conclusions and relevanceAccording to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.

Project description:IntroductionBenzodiazepines are commonly prescribed in the U.S. but entail safety concerns, including dependency. In pediatrics, many indications lack trial data. Authors aimed to describe youth initiating prescription benzodiazepine treatment, identify potential indications and prescribing concerns, estimate the duration of treatment by potential indication, and identify factors that predict long-term use.MethodsThe study cohort included children (aged 3-12 years) and adolescents (aged 13-17 years) initiating prescription benzodiazepine treatment (≥3 days' supply) from January 2010 to September 2015 in a U.S. commercial claims database. Potential indications included selected ICD-9-CM diagnoses (≤30 days prior). Long-term (≥6 months) benzodiazepine treatment was estimated with Kaplan-Meier estimation and modified Poisson regression identified independent predictors of long-term benzodiazepine treatment (analysis completed in 2018).ResultsOf 24,504 children and 61,046 adolescents initiating benzodiazepines, 62% of the children and 68% of the adolescents had a potential indication. Anxiety disorders were the most common indication, with mental health indications more common among adolescents (45%) than children (23%) and epilepsy and movement disorders higher in children. Recent opioid prescriptions were common before benzodiazepine initiation (children, 22%; adolescents, 21%). Six percent of the initiators became long-term benzodiazepine users. Potential indication, provider contact, psychotropic medication, and chronic conditions independently predicted long-term benzodiazepine treatment in adolescents and children.ConclusionsU.S. children and adolescents are prescribed benzodiazepines for various mental health and other medical conditions, many lacking evidence of pediatric efficacy. Long-term benzodiazepine treatment, concurrent opioid prescriptions, psychotropic use, and prior substance use disorder diagnoses suggest safety risks among some youth prescribed benzodiazepines.

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Overuse and insurance plan type in a privately insured population.

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Overuse and insurance plan type in a privately insured population.

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