Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study.

OBJECTIVE:To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17). DESIGN:Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions. SETTING:United States. PARTICIPANTS:A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey. MAIN OUTCOMES AND MEASURES:Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons. RESULTS:37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change -28.0% (95% confidence interval -38.4% to -15.8%); adjusted absolute change -122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (-29.0% (-40.5% to -15.3%); -442; adjusted P&lt;0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change -4.7 (-7.9 to -1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions. CONCLUSION:Medicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act's implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults

On the Cusp of Change: Health Information Technology in the United States, 2009

Examines the state of electronic health records (EHR) adoption in U.S. hospitals generally and in safety-net hospitals, changes in state and federal policies, links between EHR adoption and quality metrics, and implications for healthcare disparities

The quality of malaria care in 25 low-income and middle-income countries

Introduction Even with accessible and effective diagnostic tests and treatment, malaria remains a leading cause of death among children under five. Malaria case management requires prompt diagnosis and correct treatment but the degree to which this happens in low-income and middle-income countries (LMICs) remains largely unknown. Methods Cross-sectional study of 132 566 children under five, of which 25% reported fever in the last 2 weeks from 2006 to 2017 using the latest Malaria Indicators Survey data across 25 malaria-endemic countries. We calculated the per cent of patient encounters of febrile children under five that received poor quality of care (no blood testing, less or more than two antimalarial drugs and delayed treatment provision) across each treatment cascade and region. Results Across the study countries, 48 316 (58%) of patient encounters of febrile children under five received poor quality of care for suspected malaria. When comparing by treatment cascade, 62% of cases were not blood tested despite reporting fever in the last 2 weeks, 82% did not receive any antimalarial drug, 17% received one drug and 72% received treatment more than 24 hours after onset of fever. Of the four countries where we had more detailed malaria testing data, we found that 35% of patients were incorrectly managed (26% were undertreated, while 9% were overtreated). Poor malaria care quality varies widely within and between countries. Conclusion Quality of malaria care remains poor and varies widely in endemic LMICs. Treatments are often prescribed regardless of malaria test results, suggesting that presumptive diagnosis is still commonly practiced among cases of suspected malaria, rather than the WHO recommendation of test and treat'. To reach the 2030 global malaria goal of reducing mortality rates by at least 90%, focussing on improving the quality of malaria care is needed

Learning Task Specifications from Demonstrations

Real world applications often naturally decompose into several sub-tasks. In many settings (e.g., robotics) demonstrations provide a natural way to specify the sub-tasks. However, most methods for learning from demonstrations either do not provide guarantees that the artifacts learned for the sub-tasks can be safely recombined or limit the types of composition available. Motivated by this deficit, we consider the problem of inferring Boolean non-Markovian rewards (also known as logical trace properties or specifications) from demonstrations provided by an agent operating in an uncertain, stochastic environment. Crucially, specifications admit well-defined composition rules that are typically easy to interpret. In this paper, we formulate the specification inference task as a maximum a posteriori (MAP) probability inference problem, apply the principle of maximum entropy to derive an analytic demonstration likelihood model and give an efficient approach to search for the most likely specification in a large candidate pool of specifications. In our experiments, we demonstrate how learning specifications can help avoid common problems that often arise due to ad-hoc reward composition.Comment: NIPS 201

Health care spending in the United States and other high-income countries

Health care spending in the United States is a major concern and is higher than in other high-income countries, but there is little evidence that efforts to reform US health care delivery have had a meaningful influence on controlling health care spending and costs

Hospitalist Staffing and Patient Satisfaction in the National Medicare Population

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/96722/1/jhm2001.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/96722/2/jhm2001-sup-0001-suppinfo.pd

Health Information Technology in the United States: On the Cusp of Change, 2009

In this report we use the data collected for ONCHIT to focus on EHR adoption in the inpatient setting. We report on several important policy issues. These include the rate of adoption of EHRs among U.S. hospitals generally and among safety-net hospitals, changes in both state and federal policy, and the potential of EHRs to change the quality measurement enterprise