Can Moral Framing Drive Insurance Enrollment in the US?

To encourage health insurance uptake, marketers and policymakers have focused on consumers’ economic self-interest, attempting to show that insurance is a good deal or to sweeten the deal, with subsidies or penalties. Still, some consumers see insurance as a bad deal, either because they rationally exploit private risk information (“adverse selection”), or irrationally misperceive the value due to cognitive biases (e.g., optimism). As a result, about 30 million Americans remain uninsured, including many who could afford it.At the same time, polling suggests that Americans view health insurance through a moral lens, seeking to protect those with pre-existing conditions especially. In other markets, “green halo” and “noble edge” frames have been shown effective. As part of a broader research agenda on private law solutions to healthcare policy, we test whether moral framing could support insurance uptake. We report four phases of research.First, to understand current health insurance marketing in America, we collected the universe of advertisements from the state and Federal exchanges and coded a 10% sample for themes of economic self-interest versus three moral themes: helping others, helping community, or responsibility. In the 199 ads in which any theme appeared, 191 ads (96%, CI: 92-98%) centered on economic self-interest.Second, we enrolled 344 uninsured Americans in an online, vignette experiment where we offered various insurance plans. Over a baseline where 43.6% were willing to purchase insurance, we found that framing an economically-identical plan around generosity yielded an 11.8% higher uptake.Third, we conducted five focus groups with 32 adults, including two groups in Spanish. We explored variations in the frames and probed for resistance, to prepare for the next phase of research.Fourth, using an online advertising platform (Google), we purchased 5.6 million advertising impressions in English and Spanish, targeting higher-income Americans nationwide during the 2021 open-enrollment period. Consumers saw advertisements from a control group (highlighting economic self-interest, with real ads collected from the field) versus three experimental groups (helping others, helping community, or responsibility). We measured whether consumers clicked to “shop now” on the healthcare.gov website (1.01% click-through rate (CTR) in English and 1.38% CTR in Spanish at baseline). “Helping community” ads increased CTR over the control by 14.5% in English and by 33.7% in Spanish. Ads emphasizing “responsibility” increased CTR by 30.3% in English, though reduced CTR by 14.7% in Spanish. “Helping others” ads increased CTR by 9.8% in English but decreased CTR by 13.9% in Spanish. All of these results were significant at the .01 level and were robust to demographic controls and subgroup analyses, using individual and county-level covariates.Although the optimal approach varies, the status quo self-oriented message of economic rationality was not the top-performing approach for either language group. Scaled up to real-world advertising budgets, back-of-the-envelope extrapolation suggests that under moral framing, millions of additional Americans could be driven to shop for health insurance

Comprehensive Genomic Profiling of Pancreatic Acinar Cell Carcinomas

significantly enriched for genomic alterations (GAs) causing inactivation of DNA repair genes (45%); these GAs have been associated with sensitivity to platinum-based therapies and PARP inhibitors. Collectively, these results identify potentially actionable GAs in the majority of PACCs, and provide a rationale for using personalized therapies in this disease. Statement of Significance PACC is genomically distinct from other pancreatic cancers. Fusions in RAF genes and mutually exclusive inactivation of DNA repair genes represent novel potential therapeutic targets that are altered in over two-thirds of these tumors

Correction to: Cluster identification, selection, and description in Cluster randomized crossover trials: the PREP-IT trials

An amendment to this paper has been published and can be accessed via the original article

Can Moral Framing Drive Insurance Enrollment in the US?

To encourage health insurance uptake, marketers and policymakers have focused on consumers’ economic self-interest, attempting to show that insurance is a good deal or to sweeten the deal, with subsidies or penalties. Still, some consumers see insurance as a bad deal, either because they rationally exploit private risk information (“adverse selection”), or irrationally misperceive the value due to cognitive biases (e.g., optimism). As a result, about 30 million Americans remain uninsured, including many who could afford it.At the same time, polling suggests that Americans view health insurance through a moral lens, seeking to protect those with pre-existing conditions especially. In other markets, “green halo” and “noble edge” frames have been shown effective. As part of a broader research agenda on private law solutions to healthcare policy, we test whether moral framing could support insurance uptake. We report four phases of research.First, to understand current health insurance marketing in America, we collected the universe of advertisements from the state and Federal exchanges and coded a 10% sample for themes of economic self-interest versus three moral themes: helping others, helping community, or responsibility. In the 199 ads in which any theme appeared, 191 ads (96%, CI: 92-98%) centered on economic self-interest.Second, we enrolled 344 uninsured Americans in an online, vignette experiment where we offered various insurance plans. Over a baseline where 43.6% were willing to purchase insurance, we found that framing an economically-identical plan around generosity yielded an 11.8% higher uptake.Third, we conducted five focus groups with 32 adults, including two groups in Spanish. We explored variations in the frames and probed for resistance, to prepare for the next phase of research.Fourth, using an online advertising platform (Google), we purchased 5.6 million advertising impressions in English and Spanish, targeting higher-income Americans nationwide during the 2021 open-enrollment period. Consumers saw advertisements from a control group (highlighting economic self-interest, with real ads collected from the field) versus three experimental groups (helping others, helping community, or responsibility). We measured whether consumers clicked to “shop now” on the healthcare.gov website (1.01% click-through rate (CTR) in English and 1.38% CTR in Spanish at baseline). “Helping community” ads increased CTR over the control by 14.5% in English and by 33.7% in Spanish. Ads emphasizing “responsibility” increased CTR by 30.3% in English, though reduced CTR by 14.7% in Spanish. “Helping others” ads increased CTR by 9.8% in English but decreased CTR by 13.9% in Spanish. All of these results were significant at the .01 level and were robust to demographic controls and subgroup analyses, using individual and county-level covariates.Although the optimal approach varies, the status quo self-oriented message of economic rationality was not the top-performing approach for either language group. Scaled up to real-world advertising budgets, back-of-the-envelope extrapolation suggests that under moral framing, millions of additional Americans could be driven to shop for health insurance

Male breast cancer in BRCA1 and BRCA2 mutation carriers: pathology data from the Consortium of Investigators of Modifiers of BRCA1/2

Abstract Background BRCA1 and, more commonly, BRCA2 mutations are associated with increased risk of male breast cancer (MBC). However, only a paucity of data exists on the pathology of breast cancers (BCs) in men with BRCA1/2 mutations. Using the largest available dataset, we determined whether MBCs arising in BRCA1/2 mutation carriers display specific pathologic features and whether these features differ from those of BRCA1/2 female BCs (FBCs). Methods We characterised the pathologic features of 419 BRCA1/2 MBCs and, using logistic regression analysis, contrasted those with data from 9675 BRCA1/2 FBCs and with population-based data from 6351 MBCs in the Surveillance, Epidemiology, and End Results (SEER) database. Results Among BRCA2 MBCs, grade significantly decreased with increasing age at diagnosis (P = 0.005). Compared with BRCA2 FBCs, BRCA2 MBCs were of significantly higher stage (P for trend = 2 × 10−5) and higher grade (P for trend = 0.005) and were more likely to be oestrogen receptor–positive [odds ratio (OR) 10.59; 95 % confidence interval (CI) 5.15–21.80] and progesterone receptor–positive (OR 5.04; 95 % CI 3.17–8.04). With the exception of grade, similar patterns of associations emerged when we compared BRCA1 MBCs and FBCs. BRCA2 MBCs also presented with higher grade than MBCs from the SEER database (P for trend = 4 × 10−12). Conclusions On the basis of the largest series analysed to date, our results show that BRCA1/2 MBCs display distinct pathologic characteristics compared with BRCA1/2 FBCs, and we identified a specific BRCA2-associated MBC phenotype characterised by a variable suggesting greater biological aggressiveness (i.e., high histologic grade). These findings could lead to the development of gender-specific risk prediction models and guide clinical strategies appropriate for MBC management

Male breast cancer in BRCA1 and BRCA2 mutation carriers: pathology data from the Consortium of Investigators of Modifiers of BRCA1/2

Abstract Background BRCA1 and, more commonly, BRCA2 mutations are associated with increased risk of male breast cancer (MBC). However, only a paucity of data exists on the pathology of breast cancers (BCs) in men with BRCA1/2 mutations. Using the largest available dataset, we determined whether MBCs arising in BRCA1/2 mutation carriers display specific pathologic features and whether these features differ from those of BRCA1/2 female BCs (FBCs). Methods We characterised the pathologic features of 419 BRCA1/2 MBCs and, using logistic regression analysis, contrasted those with data from 9675 BRCA1/2 FBCs and with population-based data from 6351 MBCs in the Surveillance, Epidemiology, and End Results (SEER) database. Results Among BRCA2 MBCs, grade significantly decreased with increasing age at diagnosis (P = 0.005). Compared with BRCA2 FBCs, BRCA2 MBCs were of significantly higher stage (P for trend = 2 × 10−5) and higher grade (P for trend = 0.005) and were more likely to be oestrogen receptor–positive [odds ratio (OR) 10.59; 95 % confidence interval (CI) 5.15–21.80] and progesterone receptor–positive (OR 5.04; 95 % CI 3.17–8.04). With the exception of grade, similar patterns of associations emerged when we compared BRCA1 MBCs and FBCs. BRCA2 MBCs also presented with higher grade than MBCs from the SEER database (P for trend = 4 × 10−12). Conclusions On the basis of the largest series analysed to date, our results show that BRCA1/2 MBCs display distinct pathologic characteristics compared with BRCA1/2 FBCs, and we identified a specific BRCA2-associated MBC phenotype characterised by a variable suggesting greater biological aggressiveness (i.e., high histologic grade). These findings could lead to the development of gender-specific risk prediction models and guide clinical strategies appropriate for MBC management

Implementing stakeholder engagement to explore alternative models of consent: An example from the PREP-IT trials

Introduction: Cluster randomized crossover trials are often faced with a dilemma when selecting an optimal model of consent, as the traditional model of obtaining informed consent from participant's before initiating any trial related activities may not be suitable. We describe our experience of engaging patient advisors to identify an optimal model of consent for the PREP-IT trials. This paper also examines surrogate measures of success for the selected model of consent. Methods: The PREP-IT program consists of two multi-center cluster randomized crossover trials that engaged patient advisors to determine an optimal model of consent. Patient advisors and stakeholders met regularly and reached consensus on decisions related to the trial design including the model for consent. Patient advisors provided valuable insight on how key decisions on trial design and conduct would be received by participants and the impact these decisions will have. Results: Patient advisors, together with stakeholders, reviewed the pros and cons and the requirements for the traditional model of consent, deferred consent, and waiver of consent. Collectively, they agreed upon a deferred consent model, in which patients may be approached for consent after their fracture surgery and prior to data collection. The consent rate in PREP-IT is 80.7%, and 0.67% of participants have withdrawn consent for participation. Discussion: Involvement of patient advisors in the development of an optimal model of consent has been successful. Engagement of patient advisors is recommended for other large trials where the traditional model of consent may not be optimal