Nora Verlaine Becker

Women Saw Large Decrease In Out-Of-Pocket Spending For Contraceptives After ACA Mandate Removed Cost Sharing

The Affordable Care Act mandates that private health insurance plans cover prescription contraceptives with no consumer cost sharing. The positive financial impact of this new provision on consumers who purchase contraceptives could be substantial, but it has not yet been estimated. Using a large administrative claims data set from a national insurer, we estimated out-of-pocket spending before and after the mandate. We found that mean and median per prescription out-of-pocket expenses have decreased for almost all reversible contraceptive methods on the market. The average percentages of out-of-pocket spending for oral contraceptive pill prescriptions and intrauterine device insertions by women using those methods both dropped by 20 percentage points after implementation of the ACA mandate. We estimated average out-of-pocket savings per contraceptive user to be

Where are lifesaving automated external defibrillators located and how hard is it to find them in a large urban city

248 for the intrauterine device and

ED, heal thyself

255 annually for the oral contraceptive pill. Our results suggest that the mandate has led to large reductions in total out-of-pocket spending on contraceptives and that these price changes are likely to be salient for women with private health insurance.

Costs of Contraceptive Coverage Under the Affordable Care Act.

OBJECTIVES Automated external defibrillators (AEDs) are lifesaving, but little is known about where they are located or how to find them. We sought to locate AEDs in high employment areas of Philadelphia and characterize the process of door-to-door surveying to identify these devices. METHODS Block groups representing approximately the top 3rd of total primary jobs in Philadelphia were identified using the US Census Local Employment Dynamics database. All buildings within these block groups were surveyed during regular working hours over six weeks during July-August 2011. Buildings were characterized as publically accessible or inaccessible. For accessible buildings, address, location type, and AED presence were collected. Total devices, location description and prior use were gathered in locations with AEDs. Process information (total people contacted, survey duration) was collected for all buildings. RESULTS Of 1420 buildings in 17 block groups, 949 (67%) were accessible, but most 834 (88%) did not have an AED. 283 AEDs were reported in 115 buildings (12%). 81 (29%) were validated through visualization and 68 (24%) through photo because employees often refused access. In buildings with AEDs, several employees (median 2; range 1-8) were contacted to ascertain information, which required several minutes (mean 4; range 1-55). CONCLUSIONS Door-to-door surveying is a feasible, but time-consuming method for identifying AEDs in high employment areas. Few buildings reported having AEDs and few permitted visualization, which raises concerns about AED access. To improve cardiac arrest outcomes, efforts are needed to improve the availability of AEDs, awareness of their location and access to them.

Stages of change and patient activation measure scores in the context of incentive-based health interventions.

Emergency department (ED) wait times have continued to worsen despite receiving considerable attention for more than 2 decades and despite the availability of a variety of methods to restructure care in a more streamlined fashion. This article offers an economic framework that abstracts away from the details of operations research to understand the fundamental disincentives to improving wait times. Hospitals that reduce wait times are financially penalized if they must provide more uncompensated care as a result. Pending changes under the Patient Protection and Affordable Care Act are considered. We find that the likely effect of the Patient Protection and Affordable Care Acts insurance expansion is to reduce this penalty for improving ED wait times. Consequently, mandating adoption of solutions to ED crowding may be unnecessary and counterproductive. If the insurance expansion is insufficient to fully solve the problem, the hospital value-based purchasing initiative should adopt wait times as a goal in its next iteration.

The Measurement Plan

In their article Addressing Challenges to Implementation of the Contraceptive Coverage Guarantee of the Affordable Care Act Dr Politi and colleagues provided an overview of the current challenges in implementing insurance coverage of contraceptives with no out-of-pocket costs to patients as mandated by the Affordable Care Act (ACA). This law has already been shown to have substantially reduced out-of-pocket expenditures by privately insured women who take contraceptives. However the authors contended that “[i]nsurance companies benefit from the contraceptive coverage provision because all methods are cost saving after accounting for the costs of unintended pregnancies and births.” This oversimplifies a complex issue. Although it seems counter intuitive providing insurance coverage for a cost-effective preventive service does not guarantee that total insurer spending will decrease. The authors correctly stated that contraceptive use produces cost savings for insurers. However when the effect of the new law on insurers is considered the effect on their total spending doesn’t only depend on the cost savings of contraception. It also depends on whether the drop in out-of-pocket price induces more women to use contraception than were using it before the law. Consider the insurer’s perspective. Before the law some women enrolled in their plans were already using contraception and these women were paying the out-of-pocket costs themselves. Once the mandate went into effect the insurer began covering those costs. If the number of women using birth control doesn’t change after the law these new costs represent a net loss. Now imagine that because of the drop in the out-of-pocket price more women begin using contraception. The insurer is likely to reap savings from this new use relative to before the law. If rates of use of contraception increase enough these savings could potentially outweigh the costs of paying for birth control for both the new and old users. The more price-sensitive women are -- that is the more women who begin using contraception after the law because of the drop in out-of-pocket price -- the more likely it is that the law will produce cost savings for insurers. Cost savings are possible but not guaranteed. This concept has been well described in the health economics literature. How price sensitive are privately insured women for birth control? This is an empirical question and there are surprisingly little data available to answer it. It is also an important question because if insurer spending increases so will health insurance premiums -- and vice versa. Until more data are available stating without qualification that the ACA’s contraceptive coverage mandate will benefit insurers is premature. (full text)

Dissemination to Stakeholders

Purpose. To determine if two widely used behavioral change measures—Stages of Change (SoC) and Patient Activation Measure (PAM)—correlate with each other, are affected by financial incentives, or predict positive outcomes in the context of incentive-based health interventions. Design. Secondary analysis of two randomized controlled trials of incentives for weight loss and for improved diabetes self-monitoring. Setting. Philadelphia, Pennsylvania; Newark, New Jersey. Subjects. A total of 132 obese and 75 diabetic adults enrolled in one of two trials. Measures. SoC and PAM scores; weight loss and usage rate of diabetes self-monitoring equipment. Analysis. Multiple regression; Kruskal-Wallis test. Results. We found no association between baseline SoC and PAM scores in either study (p = .30 and p = .89). Regression models showed no association between baseline PAM score and SoC and subsequent outcomes for either study (weight loss study: PAM: p = .14, SoC: p = .1; diabetes study: PAM: p = .45, SoC: p = .61). Change in PAM score and SoC among participants in the intervention groups did not differ by study arm or among participants with better outcomes. Conclusion. PAM score and SoC may not effectively predict success or monitor progress among individuals enrolled in incentive-based interventions.

Understanding the Individual Mandate's SCOTUS Pivot Points

In epidemiological research measurements are carried out most importantly to document data on outcomes, exposures, and third factors, but measurements related to procedural or methodological considerations should not be ignored. At the planning stage, it is crucial to conduct a step-by-step critical analysis of the measurement processes that will be employed in the study and to consider how errors at each step can be avoided. By carefully documenting this process for each planned measurement, one assembles a measurement and standardization protocol that conforms with general epidemiological principles by respecting participants and by enhancing reproducibility, completeness, unbiasedness, and precision. We briefly review planning and standardization issues according to type of attribute. Finally, special sections are devoted to quality of life and cost measurements in order to highlight the increasing importance of these in practice.

Geographic variation in postpartum prescription opioid use: Opportunities to improve maternal safety

Dissemination of scientific work to others is an essential component of the research process. The most common form of dissemination is to publish articles in academic journals (See: Chaps. 28 and 31); however, a researcher may wish to disseminate work directly to the public, policymakers, or other non-academic stakeholders to achieve desirablwe effects on public health and to enhance the profile of the research team. A general discussion around engaging with stakeholders is found in Chap. 8. The current chapter extends our discussion of engaging with stakeholders from the perspective of disseminating scientific work in forms other than academic journal articles. First, we will introduce principles of dissemination and diffusion of information. We will then provide practical advice on developing dissemination strategies and on communicating with selected types of stakeholders, such as news media reporters. Finally, we discuss some ethical aspects of influencing public health policy and summarize practical advice in this respect.