Should fee-for-service be for all guideline-advocated acute coronary syndrome (ACS) care? Observations from the Snapshot ACS study

2015 ◽  
Vol 39 (4) ◽  
pp. 379 ◽  
Author(s):  
Thomas G. Briffa ◽  
Christopher J. Hammett ◽  
David B. Cross ◽  
Andrew I. Macisaac ◽  
James M. Rankin ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Private Insurance ◽  
Insurance Coverage ◽  
Evidence Base ◽  
Insurance Status ◽  
Fee For Service ◽  
Health Insurance Status ◽  
Coronary Syndrome ◽  
Coronary Events ◽  
Privately Insured

Objective The aim of the present study was to explore the association of health insurance status on the provision of guideline-advocated acute coronary syndrome (ACS) care in Australia. Methods Consecutive hospitalisations of suspected ACS from 14 to 27 May 2012 enrolled in the Snapshot study of Australian and New Zealand patients were evaluated. Descriptive and logistic regression analysis was performed to evaluate the association of patient risk and insurance status with the receipt of care. Results In all, 3391 patients with suspected ACS from 247 hospitals (23 private) were enrolled in the present study. One-third of patients declared private insurance coverage; of these, 27.9% (304/1088) presented to private facilities. Compared with public patients, privately insured patients were more likely to undergo in-patient echocardiography and receive early angiography; furthermore, in those with a discharge diagnosis of ACS, there was a higher rate of revascularisation (P < 0.001). Each of these attracts potential fee-for-service. In contrast, proportionately fewer privately insured ACS patients were discharged on selected guideline therapies and were referred to a secondary prevention program (P = 0.056), neither of which directly attracts a fee. Typically, as GRACE (the Global Registry of Acute Coronary Events) risk score rose, so did the level of ACS care; however, propensity-adjusted analyses showed lower in-hospital adverse events among the insured group (odds ratio 0.68; 95% confidence interval 0.52–0.88; P = 0.004). Conclusion Fee-for-service reimbursement may explain differences in the provision of selected guideline-advocated components of ACS care between privately insured and public patients. What is known about this topic? There is variation in the pattern of acute coronary syndrome care across Australia. What does this paper add? Clear differences in the provision of selected proven therapies for acute coronary syndrome apply independent of whether a fee is charged or not. What are the implications for practitioners? Consideration should be given to the remuneration for proven therapies for acute coronary syndrome care in preference to those not supported by the evidence base.

scholarly journals The effect of insurance status on overall survival among children and adolescents with cancer

2020 ◽  
Vol 49 (4) ◽  
pp. 1366-1377 ◽  
Author(s):  
Xiaoyan Wang ◽  
Rohit P Ojha ◽  
Sonia Partap ◽  
Kimberly J Johnson
Keyword(s):  
Children And Adolescents ◽  
Cancer Survival ◽  
Proportional Hazards ◽  
Private Insurance ◽  
Insurance Coverage ◽  
Cox Proportional Hazards ◽  
Insurance Status ◽  
Risk Of Death ◽  
Adolescent Cancer ◽  
Privately Insured

Abstract Background Differences in access, delivery and utilisation of health care may impact childhood and adolescent cancer survival. We evaluated whether insurance coverage impacts survival among US children and adolescents with cancer diagnoses, overall and by age group, and explored potential mechanisms. Methods Data from 58 421 children (aged ≤14 years) and adolescents (15–19 years), diagnosed with cancer from 2004 to 2010, were obtained from the National Cancer Database. We examined associations between insurance status at initial diagnosis or treatment and diagnosis stage; any treatment received; and mortality using logistic regression, Cox proportional hazards (PH) regression, restricted mean survival time (RMST) and mediation analyses. Results Relative to privately insured individuals, the hazard of death (all-cause) was increased and survival months were decreased in those with Medicaid [hazard ratio (HR) = 1.27, 95% confidence interval (CI): 1.22 to 1.33; and −1.73 months, 95% CI: −2.07 to −1.38] and no insurance (HR = 1.32, 95% CI: 1.20 to 1.46; and −2.13 months, 95% CI: −2.91 to −1.34). The HR for Medicaid vs. private insurance was larger (pinteraction &lt;0.001) in adolescents (HR = 1.52, 95% CI: 1.41 to 1.64) than children (HR = 1.16, 95% CI: 1.10 to 1.23). Despite statistical evidence violation of the PH assumption, RMST results supported all interpretations. Earlier diagnosis for staged cancers in the Medicaid and uninsured populations accounted for an estimated 13% and 19% of the survival deficit, respectively, vs. the privately insured population. Any treatment received did not account for insurance-associated survival differences in children and adolescents with cancer. Conclusions Children and adolescents without private insurance had a higher risk of death and shorter survival within 5 years following cancer diagnosis. Additional research is needed to understand underlying mechanisms.

scholarly journals Health Insurance Status Impacts Rates of Overall Survival in Philadelphia-Positive Acute Lymphoblastic Leukemia

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 2581-2581
Author(s):  
Jeremy Chang ◽  
Sherry Zhang ◽  
Mojtaba Akhtari
Keyword(s):  
Overall Survival ◽  
Health Insurance ◽  
Acute Lymphoblastic Leukemia ◽  
Lymphoblastic Leukemia ◽  
Private Insurance ◽  
Insurance Coverage ◽  
Comprehensive Cancer Center ◽  
Insurance Status ◽  
Allogeneic Hsct ◽  
Health Insurance Status

Introduction: The Philadelphia chromosome is associated with a poor prognosis in patients with acute lymphoblastic leukemia (ALL). Prior to the use of hematopoietic stem cell transplantation (HSCT) and tyrosine kinase inhibitors (TKIs), Philadelphia-positive (Ph+) ALL patients were found to have an overall survival (OS) rate of less than 20% over the course of 3 years (Thomas et al., Blood 2004). While modern day therapies including allogeneic HSCT and newer-generation TKIs such as dasatinib have led to significant improvements in OS for this population, these treatments have variable accessibility due to costs for patients with limited to no health insurance. Methods: We performed a retrospective study at the Norris Comprehensive Cancer Center and Los Angeles County Hospital, both associated with the University of Southern California, to investigate outcomes in Ph+ ALL adults with different types of health insurance. Individuals included in the study were diagnosed with Ph+ ALL between 2004-2019. Health insurance options included private insurance, Medicare, Medicaid, or no insurance. Treatment modalities included allogeneic HSCT followed by maintenance TKI therapy or combination chemotherapy plus a TKI. The former was preferred if patients met the key transplant eligibility criteria of insurance coverage and caregiver availability at home. Patient OS was defined as the time from diagnosis of Ph+ ALL until patient death. Statistical analysis was performed using the Fisher's exact probability test with two-tailed p-values <0.05 deemed significant. Results: A total of 81 patients with Ph+ ALL were included in this study. Forty-seven patients (58%) were male and the median age at the time of diagnosis was 45 years (range 20-70). Two groups of patients were compared: those with either Medicare or private insurance (M/P) versus those with Medicaid or no insurance (M/N). Thirty-three patients (40.7%) were included in the M/P group and 48 patients (59.2%) in the M/N group. In comparing rates of OS, the 1-year OS was 100% vs. 85.1% (p = 0.038), 2-year OS was 96.2% vs. 75.8% (p = 0.033), and 3-year OS was 88.2% vs. 59.2% (p = 0.049) for M/P patients compared to M/N patients, respectively (Figure 1). In terms of treatment, there was a significant difference in the number of patients eligible to undergo allogeneic HSCT as 20 patients (60.6%) in the M/P group were able to be transplanted in contrast to 15 patients (31.3%) in the M/N group (p = 0.012). There were similar rates of caregiver availability to support HSCT between both groups; 24 M/P patients (72.7%) lived with a caregiver versus 33 M/N patients (68.8%) in comparison (p = 0.806). Furthermore, there were significantly more patients in the M/P group who were able to be treated with the newer-generation TKI dasatinib instead of the older agent imatinib compared to M/N patients (100% vs. 85.4%, p = 0.038). Conclusion: With the emergence of allogeneic HSCT and newer-generation TKIs, the rates of OS in the Ph+ ALL population improved dramatically from the prior era (Fielding et al., Blood 2009). However, barriers still exist to receiving these modern therapies, one of the most formidable being sufficient insurance coverage of costs. This study demonstrated that the Ph+ ALL population in the M/P group had significantly higher rates of OS at the 1-year, 2-year, and 3-year marks compared to those in the M/N group. Furthermore, there were also a greater percentage of patients in the former group who were able to undergo allogeneic HSCT during the study period. While eligibility for allogeneic HSCT depended on caregiver availability in addition to insurance status, there were similar rates of caregivers between the two groups, thus implying that this factor had no major impact on the differing rates of HSCT. Dasatinib was previously shown to have increased potency in inhibiting the in vitro growth of cells with wild-type BCR-ABL compared to imatinib, making it a preferred choice for TKI therapy (Li, Leukemia & Lymphoma 2008). There were again significantly more M/P patients than M/N patients who were able to be treated with dasatinib rather than imatinib. Given that health insurance status was found to be correlated with rates of OS, allogeneic HSCT, and the availability of newer-generation TKIs, it remains a critical point of discussion in the treatment of Ph+ ALL patients from all socioeconomic backgrounds. Disclosures No relevant conflicts of interest to declare.

scholarly journals Impact of Insurance Coverage on Outcomes in Primary Breast Sarcoma

Sarcoma ◽  
2018 ◽  
Vol 2018 ◽  
pp. 1-11 ◽  
Author(s):  
Julie L. Koenig ◽  
C. Jillian Tsai ◽  
Katherine Sborov ◽  
Kathleen C. Horst ◽  
Erqi L. Pollom
Keyword(s):  
Overall Survival ◽  
Private Insurance ◽  
Insurance Coverage ◽  
Disease Stage ◽  
Insurance Status ◽  
Rare Cancer ◽  
Breast Sarcoma ◽  
Specialized Care ◽  
Insured Patients ◽  
Privately Insured

Private insurance is associated with better outcomes in multiple common cancers. We hypothesized that insurance status would significantly impact outcomes in primary breast sarcoma (PBS) due to the additional challenges of diagnosing and coordinating specialized care for a rare cancer. Using the National Cancer Database, we identified adult females diagnosed with PBS between 2004 and 2013. The influence of insurance status on overall survival (OS) was evaluated using the Kaplan–Meier estimator with log-rank tests and Cox proportional hazard models. Among a cohort of 607 patients, 67 (11.0%) had Medicaid, 217 (35.7%) had Medicare, and 323 (53.2%) had private insurance. Compared to privately insured patients, Medicaid patients were more likely to present with larger tumors and have their first surgical procedure further after diagnosis. Treatment was similar between patients with comparable disease stage. In multivariate analysis, Medicaid (hazard ratio (HR), 2.47; 95% confidence interval (CI), 1.62–3.77; p<0.001) and Medicare (HR, 1.68; 95% CI, 1.10–2.57; p=0.017) were independently associated with worse OS. Medicaid insurance coverage negatively impacted survival compared to private insurance more in breast sarcoma than in breast carcinoma (interaction p<0.001). In conclusion, patients with Medicaid insurance present with later stage disease and have worse overall survival than privately insured patients with PBS. Worse outcomes for Medicaid patients are exacerbated in this rare cancer.

Health insurance literacy, status, and financial toxicity in women receiving treatment for metastatic breast cancer.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 96-96
Author(s):  
Courtney Williams ◽  
Stacey A. Ingram ◽  
Valerie Lawhon ◽  
Clara Wan ◽  
Kelly Kenzik ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Health Insurance ◽  
Private Insurance ◽  
Metastatic Breast ◽  
Insurance Status ◽  
Financial Toxicity ◽  
Health Insurance Status ◽  
Health Insurance Literacy ◽  
Insured Patients ◽  
Privately Insured

96 Background: Though uninsurance rates declined after the Affordable Care Act, the number of underinsured, or individuals who spend > 10% of their income on out-of-pocket (OOP) medical costs, continues to rise. In patients with metastatic breast cancer (MBC), underinsurance may lead to financial toxicity (FT), or patient-level financial burden and distress, since diagnosis and treatment is extremely costly. This study explores health insurance literacy and the association between FT and health insurance status in women receiving treatment for MBC. Methods: This cross-sectional study utilized survey data collected from 2017-2019 in women age ≥18 receiving treatment for MBC at two academic medical centers in Alabama. FT was measured by the Comprehensive Score for Financial Toxicity (COST) tool (11-item scale from 0-44, with lower scores indicating worse FT). Health insurance status and OOP costs were self-reported. Effect sizes were calculated using Cohen’s d or Cramer’s V. Mixed and generalized linear models clustered by site and treating medical oncologist estimated the association between FT and health insurance status. Results: In 81 women with MBC, median COST score was 24 (interquartile range [IQR] 17-30), 44% had private insurance, 40% Medicare, and 16% Medicaid. Though 25% and 33% of surveyed patients did not know their health insurance premium or deductible cost, respectively, privately insured patients more often knew the cost of their premiums (97%; V = 0.58) and deductibles (81%; V = 0.33) compared to publicly insured patients. In adjusted models, FT levels did not differ significantly based on health insurance type (private insurance COST 21, 95% confidence interval [CI] 18-25; Medicaid COST 23, 95% CI 17-29; Medicare COST 24, 95% CI 20-27). However, risk of severe FT (COST ≤13) was 147% higher for privately insured patients versus Medicare beneficiaries (risk ratio 2.47, 95% CI 1.44-4.21). Conclusions: Despite higher levels of health insurance literacy, privately insured patients receiving treatment for MBC may be at increased risk of severe FT. Further research is needed to understand causes of underinsurance in patients with MBC, which could lead to cancer-related FT.

scholarly journals High Dose Statins: Is it Beneficial over Conventional Dose of Statin in Acute Coronary Syndrome?

1970 ◽  
Vol 2 (2) ◽  
pp. 245-251
Author(s):  
AEM M Islam ◽  
AAS Mazumder
Keyword(s):  
Acute Coronary Syndrome ◽  
Heart Disease ◽  
Statin Therapy ◽  
Disease Risk ◽  
Cardiovascular Disease Risk ◽  
Surgical Care ◽  
High Dose ◽  
Coronary Syndrome ◽  
Conventional Dose ◽  
Coronary Events

Increasing burden of cardiovascular disease risk factors has led to increase in the incidence in the coronary artery disease (CAD). Advancements in medical and surgical care of patients with heart disease have led to a large number of people surviving acute coronary events. Patients with acute coronary syndrome (ACS) are at high risk for recurrent coronary events, sudden death, and all cause mortality. Conventional revascularization therapies reduce the risk of further ischaemia but do not affect the underlying atherosclerotic disease. Statins have a proven record in the secondary prevention of coronary heart disease. Furthermore, statins have been shown to exert various pleotropic effects, which may stabilize vulnerable atherosclerotic plaques. Therefore, initiating, statin therapy in patients with established CAD is both beneficial and more cost effective. Trials conducted in recent times have addressed the issue of whether higher dose statin therapy provides further reductions in the risks of cardiovascular events following an acute coronary syndrome diagnosis, over and above that provided by a conventional dose statin regimen. However, recent trials of high dose statin therapy in patients with acute coronary syndromes have yielded conflicting results. The aim of this article is to provide a critical and up-to-date summary of the findings of clinical trials of intensive statin therapy, including a brief overview of safety and efficacy of such treatments. Keywords: Statin; Acute coronary syndrome. DOI: 10.3329/cardio.v2i2.6648Cardiovasc. j. 2010; 2(2) : 245-251

scholarly journals Trends and predictors of rehospitalisation following an acute coronary syndrome: report from the Australian and New Zealand population of the Global Registry of Acute Coronary Events (GRACE)

Heart ◽  
2012 ◽  
Vol 98 (23) ◽  
pp. 1728-1731 ◽  
Author(s):  
Prashanthi V Sangu ◽  
Isuru Ranasinghe ◽  
Bernadette Aliprandi Costa ◽  
Gerard Devlin ◽  
John Elliot ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
New Zealand ◽  
Coronary Syndrome ◽  
Zealand Population ◽  
Coronary Events ◽  
Global Registry ◽  
Syndrome Report

Relationship between insurance status and diagnosis of cutaneous immune-related adverse events.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e18535-e18535
Author(s):  
Michael Chang ◽  
Nira A. Krasnow ◽  
Amy E. Blum ◽  
Vartan Pahalyants ◽  
William S. Murphy ◽  
...  
Keyword(s):  
Linear Regression ◽  
Adverse Events ◽  
Massachusetts General Hospital ◽  
Private Insurance ◽  
Insurance Coverage ◽  
Multivariable Analysis ◽  
Maculopapular Rash ◽  
Insurance Status ◽  
Billing Data ◽  
Delays In Diagnosis

e18535 Background: Cutaneous immune-related adverse events (cirAEs) are among the most common side effects of immune checkpoint inhibitor (ICI) therapy. While insurance status has been shown to influence outcomes in patients treated with ICIs, its impact on cirAE management remains underexplored. We therefore evaluated insurance status in patients with cirAEs, examining its effect on rate of and time to cirAE diagnosis. Methods: Using billing data, we retrospectively identified patients who initiated anti-PD-1/PDL-1 and/or anti-CTLA-4 therapy at Massachusetts General Hospital between January 1, 2016 and March 8, 2019 (n = 2,459) for possible cirAE. Eligible cirAEs included reactions attributed to ICI by the clinician, consistent with established morphologic categories. For each patient with confirmed cirAE (n = 358), we abstracted oncologic history, cirAE features, and insurance status. Associations between insurance and cirAE diagnosis outcomes were assessed via logistic and linear regression, and adjusted for age, sex, race, ICI type, cancer diagnosis, cirAE type, and significant covariates ( P< 0.05). Results: Of the 2,459 patients who received ICIs, 2,419 (98.4%) had documented insurance status. Most ICI recipients had Medicare (n = 1,119; 46.3%) or private insurance (n = 1,156; 47.8%) relative to Medicaid (n = 104; 4.3%) or other government insurance (e.g. Tricare) (n = 40; 1.7%). We found that 358 (median age 64 years, 40.5% female) developed a cirAE. Among cirAE patients, 175 had Medicare (48.9%), 174 had private insurance (48.6%), 6 had Medicaid (1.7%), and 3 had other government insurance (0.8%). The most common cirAEs across insurance types were maculopapular rash, pruritus, and eczematous and lichenoid eruptions. In the multivariable analysis, ICI patients with Medicare insurance had a higher rate of cirAE diagnosis (adjusted odds ratio: 2.41, 95% CI: 1.00, 5.90, P= 0.05) relative to Medicaid patients. In addition, in terms of time to cirAE diagnosis at dermatology visit, Medicare insurance was associated with longer delays, with a linear regression coefficient of 132.2 (95% CI: 4.78, 259.6; P= 0.04). No significant associations were found between other insurance types and cirAE diagnosis outcomes. Conclusions: Our study shows that patients with Medicaid are less likely to be diagnosed with cirAE relative to those with Medicare, despite delays in diagnosis, when controlling for all other demographic/oncologic factors. Ultimately, these findings are reassuring that despite insurance differences, patients with cirAEs are receiving suitable care and appropriately seen by dermatologists. As insurance coverage for specialists can vary widely, these initial findings are a promising indicator that patients with cirAEs are well-connected within healthcare systems.

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