Healthcare utilization of individuals with substance use disorders following Affordable Care Act implementation in a California healthcare system
Open accessAbstract
Background: Practitioners expected the Affordable Care Act (ACA) to increase availability of health services and access to treatment for Americans with substance use disorders (SUDs). Yet research has not examined the associations among ACA enrollment mechanisms, deductibles, and the use of SUD treatment and other healthcare services. Understanding these relationships can inform future healthcare policy. Methods: We conducted a longitudinal analysis of patients with SUDs newly enrolled in the Kaiser Permanente Northern California health system in 2014 (N = 6957). Analyses examined the likelihood of service utilization (primary care, specialty SUD treatment, psychiatry, inpatient, and emergency department [ED]) over three years after SUD diagnosis, and associations with enrollment mechanisms (ACA Exchange vs. other), deductibles (none, $1–$999 [low] and ≥$1000 [high]), membership duration, psychiatric comorbidity, and demographic characteristics. We also evaluated whether the enrollment mechanism moderated the associations between deductible limits and utilization likelihood. Results: Service utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2–3. Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees. Among non-Exchange enrollees, patients with deductibles were more likely than those without deductibles to receive SUD treatment. Exchange enrollment compared to other mechanisms was associated with less ED use. Psychiatric comorbidity was associated with greater use of all services. Nonwhite patients were less likely to initiate SUD and psychiatry treatment. Conclusions: Higher deductibles generally were associated with use of fewer health services, especially in combination with enrollment through the Exchange. The role of insurance factors, psychiatric comorbidity and race/ethnicity in health services for people with SUDs are important to consider as health policy evolves. © 2020 Elsevier Inc.
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Registry
Cites
Statistics
Claims the paper makes
9 of 27 cited sources checked · 4 supported · 0 flagged · accuracy not yet measured
- Premisecitation
The ACA appears to have improved coverage for SUD and psychiatry care.
“Evidence suggests a positive impact of the ACA on both SUD and psychiatry coverage (Cowell, Prakash, Jones, Barnosky, & Wedehase, 2018; Novak, Anderson, & Chen, 2018; Shover, Abraham, D’Aunno, Friedmann, & Humphreys, 2019), including an increase in insurance choices (Abraham et al., 2017; Andrews et al., 2018; Feder et al., 2017).”
Quote in the paperNot a substantial claim2 of 3 sources checked- cites Cowell, Prakash, Jones, Barnosky, & Wedehase, 2018 source
- cites Novak, Anderson, & Chen, 2018 source
The Discussion reports that adults with serious psychological distress were more likely to have health insurance after 2014 and faced fewer barriers to mental health care. It does not establish improved coverage specifically for substance use disorder treatment or psychiatry services; its finding concerns overall insurance coverage in a mental-health population. (LLM, conf=0.86)
Experimental — accuracy not yet measured - cites Shover, Abraham, D’Aunno, Friedmann, & Humphreys, 2019 source
- Premisecitation
Access to services is still a major problem.
“But access to services remains a major concern (Feder et al., 2017; Saloner et al., 2017), and much is still unknown regarding how ACA-associated enrollment through insurance exchanges and cost-sharing structures (especially deductibles) are associated with access to and use of SUD treatment and other health services in this complex patient population.”
Quote in the paperSubstantial claim1 of 2 sources checked - Study design and conductown data
The study could not examine Medicaid expansion's relationship to services due to collinearity with deductible limits.
“Medicaid expansion has the potential to improve access to SUD treatment (Andrews et al., 2019), but we were also not able to examine its relationship to services in the current analysis due to collinearity with deductible limits (Medicaid patients in our cohort did not have a deductible).”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites Andrews et al., 2019 source
The citation is attached to the claim that Medicaid expansion could improve access to SUD treatment, not to the citing authors’ explanation of collinearity in their own analysis. Table 1 (METHODS; page unavailable) includes Medicaid expansion status and shows higher unadjusted buprenorphine availability in expansion states, but its adjusted estimate is not statistically significant; it does not establish improved access to SUD treatment generally. (LLM, conf=0.76)
Experimental — accuracy not yet measured
- Findingown data
Nonwhite patients had lower odds of initiating psychiatry treatment.
“Controlling for all other characteristics, nonwhite patients had lower odds of initiating specialty SUD and psychiatry treatment (Table 2).”
Quote in the paperSubstantial claim - Findingown data
The difference between ACA Exchange and non-ACA enrollees in the association between high deductibles and psychiatry use was significant (ORR=0.68, 95% CI 0.51-0.91; 32% lower).
“The corresponding ORs among patients who enrolled via other non-ACA mechanisms were 0.83 (95% CI=0.74–0.92) for primary care and 0.85 (95% CI=0.73–0.98) for psychiatry; these represent a significantly lower difference of 22% (ratio of odds ratios [ORR]=0.78, 95% CI=0.63–0.96) and 32% (ORR=0.68, 95% CI=0.51–0.91), respectively.”
Quote in the paperSubstantial claim
- Findingown data
Among ACA Exchange enrollees, high deductibles were associated with lower odds of primary care use compared with no deductible (OR=0.64, 95% CI 0.54-0.77).
“Among patients who enrolled via the ACA exchange, those with high deductibles were less likely than those without deductibles to utilize primary care (odds ratio [OR]=0.64, 95% confidence interval [CI]=0.54–0.77) and psychiatry treatment (OR=0.58, 95% CI=0.45–0.74).”
Quote in the paperSubstantial claim - Findingown data
Black patients were less likely to utilize ED services compared to white patients.
“Hispanic patients were also more likely to utilize ED services, but Black patients were less likely, compared to white patients.”
Quote in the paperNot a substantial claim - Findingown data
Service use was stable during the second and third years after diagnosis.
“Service utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2–3.”
Quote in the paperNot a substantial claim - Findingown data
Service use declined between six and twelve months after the SUD diagnosis.
“Service utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2–3.”
Quote in the paperNot a substantial claim - Findingown data
In the cohort, the likelihood of using services peaked during the first six months after an SUD diagnosis.
“Service utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2–3.”
Quote in the paperNot a substantial claim - Findingown data
Exchange enrollment was associated with greater likelihood of remaining a KPNC member.
“In our sample, Exchange enrollment was associated with greater likelihood of remaining a member of KPNC, did not demonstrate an adverse association with routine care, and was associated with lower ED use.”
Quote in the paperSubstantial claim - Findingown data
In sensitivity analysis, censored patients were slightly more likely to visit the ED (64% vs 60%, p=0.009) than noncensored patients.
“The censored group used less primary care (59% vs. 77%, p<.001) and psychiatry services (20% vs. 29%, p<.001) in the first 6 months but were slightly more likely to visit the ED (64% vs. 60%, p=0.009; Table S6).”
Quote in the paperNot a substantial claim - Findingown data
Among patients enrolled via non-ACA mechanisms, high deductibles were associated with lower odds of psychiatry use compared with no deductible (OR=0.85, 95% CI 0.73-0.98).
“The corresponding ORs among patients who enrolled via other non-ACA mechanisms were 0.83 (95% CI=0.74–0.92) for primary care and 0.85 (95% CI=0.73–0.98) for psychiatry; these represent a significantly lower difference of 22% (ratio of odds ratios [ORR]=0.78, 95% CI=0.63–0.96) and 32% (ORR=0.68, 95% CI=0.51–0.91), respectively.”
Quote in the paperSubstantial claim - Findingown data
Patients with a comorbid psychiatric disorder had significantly higher odds of using all health services studied, controlling for all other characteristics.
“Patients with a comorbid psychiatric disorder had significantly higher odds of using all health services studied, controlling for all other characteristics. Specifically, they had 1.4 to 2.1 times the odds of using primary care, specialty SUD, inpatient, and ED services; and 14 times the odds of using psychiatry treatment (Tables 2–3).”
Quote in the paperSubstantial claim - Findingown data
High and low deductibles were associated with lower odds of ED utilization.
“Similarly, high and low deductibles were associated with lower odds of ED utilization.”
Quote in the paperSubstantial claim - Findingown data
ACA Exchange enrollees had similar odds of inpatient service use compared with patients enrolled through other mechanisms (OR=0.88, 95% CI 0.73-1.06).
“Patients enrolled via the ACA Exchange had significantly lower odds of visiting the ED (OR=0.67, 95% CI=0.59–0.77), but had similar odds of using inpatient services as patients who enrolled through other mechanisms (OR=0.88, 95% CI=0.73–1.06).”
Quote in the paperSubstantial claim - Findingown data
Exchange enrollment, relative to other enrollment mechanisms, was associated with less emergency department use.
“Exchange enrollment compared to other mechanisms was associated with less ED use.”
Quote in the paperSubstantial claim - Findingown data
After adjusting for all other patient characteristics, enrollment mechanism moderated the association between deductibles and likelihood of specialty SUD treatment utilization.
“There was also evidence that the enrollment mechanism moderated the associations between deductibles and the likelihood of utilizing specialty SUD treatment after adjusting for all other patient characteristics in the multivariable models.”
Quote in the paperSubstantial claim - Findingown data
Primary care and psychiatric services use were similar across enrollment types, even within low and high deductible limits.
“However, primary care and psychiatric services use were similar across enrollment types, even within low and high deductible limits.”
Quote in the paperSubstantial claim - Findingown data
Nonwhite patients had a lower likelihood of starting SUD treatment.
“Nonwhite patients were less likely to initiate SUD and psychiatry treatment.”
Quote in the paperSubstantial claim - Findingown data
Compared with having no deductible, having a high deductible was linked to lower odds of using every health service studied except SUD treatment.
“Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees.”
Quote in the paperSubstantial claim - Findingown data
Hispanic patients were more likely to utilize ED services compared to white patients.
“Hispanic patients were also more likely to utilize ED services, but Black patients were less likely, compared to white patients.”
Quote in the paperNot a substantial claim - Findingown data
Nonwhite patients had a lower likelihood of starting psychiatry treatment.
“Nonwhite patients were less likely to initiate SUD and psychiatry treatment.”
Quote in the paperSubstantial claim - Findingown data
Among patients enrolled via non-ACA mechanisms, high deductibles were associated with higher odds of specialty SUD treatment utilization compared with no deductible (OR=1.22, 95% CI 1.04-1.42).
“Among patients who enrolled via the ACA exchange, there were no significant differences in the likelihood of utilizing specialty SUD treatment between patients with deductibles and those without; however, among patients who enrolled via other mechanisms, patients with high (OR=1.22, 95% CI=1.04–1.42) or low deductibles (OR=1.50, 95% CI=1.22–1.85) were more likely than those without deductibles to”
Quote in the paperSubstantial claim - Findingown data
For people enrolled through the Exchange, a high deductible had a strong negative association with psychiatry use.
“Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees.”
Quote in the paperSubstantial claim - Findingown data
Exchange enrollment was associated with lower ED use.
“In our sample, Exchange enrollment was associated with greater likelihood of remaining a member of KPNC, did not demonstrate an adverse association with routine care, and was associated with lower ED use.”
Quote in the paperSubstantial claim - Findingown data
The difference between ACA Exchange and non-ACA enrollees in the association between high deductibles and primary care use was significant (ORR=0.78, 95% CI 0.63-0.96; 22% lower).
“The corresponding ORs among patients who enrolled via other non-ACA mechanisms were 0.83 (95% CI=0.74–0.92) for primary care and 0.85 (95% CI=0.73–0.98) for psychiatry; these represent a significantly lower difference of 22% (ratio of odds ratios [ORR]=0.78, 95% CI=0.63–0.96) and 32% (ORR=0.68, 95% CI=0.51–0.91), respectively.”
Quote in the paperSubstantial claim - Findingown data
Patients with membership duration ≥6 months before SUD diagnosis were less likely to utilize primary care than those with <6 months (OR=0.89, 95% CI 0.83-0.96).
“Patients with a longer membership duration before receiving an SUD diagnosis (≥6 months) were less likely to utilize primary care (OR=0.89, 95% CI=0.83–0.96) and specialty SUD treatment (OR=0.78, 95% CI=0.69–0.87) than those with a shorter duration (<6 months); there were no differences for psychiatry treatment, inpatient hospitalizations, or ED visits (Tables 2–3).”
Quote in the paperNot a substantial claim - Findingown data
Among patients enrolled via non-ACA mechanisms, low deductibles were associated with higher odds of specialty SUD treatment utilization compared with no deductible (OR=1.50, 95% CI 1.22-1.85).
“Among patients who enrolled via the ACA exchange, there were no significant differences in the likelihood of utilizing specialty SUD treatment between patients with deductibles and those without; however, among patients who enrolled via other mechanisms, patients with high (OR=1.22, 95% CI=1.04–1.42) or low deductibles (OR=1.50, 95% CI=1.22–1.85) were more likely than those without deductibles to”
Quote in the paperSubstantial claim - Findingown data
In sensitivity analysis, there was no difference between censored and noncensored groups in specialty SUD and inpatient utilization.
“There was no difference between the censored and the noncensored group in specialty SUD and inpatient utilization.”
Quote in the paperNot a substantial claim - Findingown data
Compared with no deductible, high deductibles were associated with lower odds of hospitalization (OR=0.80, 95% CI 0.69-0.94).
“Compared to patients without a deductible, patients with high (OR=0.80, 95% CI=0.69–0.94) and low (OR=0.79, 95% CI=0.64–0.99) deductibles had lower odds of having a hospitalization (Table 3; Figure 2).”
Quote in the paperSubstantial claim - Findingown data
Among patients enrolled via non-ACA mechanisms, high deductibles were associated with lower odds of primary care use compared with no deductible (OR=0.83, 95% CI 0.74-0.92).
“The corresponding ORs among patients who enrolled via other non-ACA mechanisms were 0.83 (95% CI=0.74–0.92) for primary care and 0.85 (95% CI=0.73–0.98) for psychiatry; these represent a significantly lower difference of 22% (ratio of odds ratios [ORR]=0.78, 95% CI=0.63–0.96) and 32% (ORR=0.68, 95% CI=0.51–0.91), respectively.”
Quote in the paperSubstantial claim - Findingown data
Compared with no deductible, low deductibles were associated with lower odds of hospitalization (OR=0.79, 95% CI 0.64-0.99).
“Compared to patients without a deductible, patients with high (OR=0.80, 95% CI=0.69–0.94) and low (OR=0.79, 95% CI=0.64–0.99) deductibles had lower odds of having a hospitalization (Table 3; Figure 2).”
Quote in the paperSubstantial claim - Findingown data
Patients with membership duration ≥6 months before SUD diagnosis were less likely to utilize specialty SUD treatment than those with <6 months (OR=0.78, 95% CI 0.69-0.87).
“Patients with a longer membership duration before receiving an SUD diagnosis (≥6 months) were less likely to utilize primary care (OR=0.89, 95% CI=0.83–0.96) and specialty SUD treatment (OR=0.78, 95% CI=0.69–0.87) than those with a shorter duration (<6 months); there were no differences for psychiatry treatment, inpatient hospitalizations, or ED visits (Tables 2–3).”
Quote in the paperSubstantial claim - Findingown data
Among ACA Exchange enrollees, high deductibles were associated with lower odds of psychiatry use compared with no deductible (OR=0.58, 95% CI 0.45-0.74).
“Among patients who enrolled via the ACA exchange, those with high deductibles were less likely than those without deductibles to utilize primary care (odds ratio [OR]=0.64, 95% confidence interval [CI]=0.54–0.77) and psychiatry treatment (OR=0.58, 95% CI=0.45–0.74).”
Quote in the paperSubstantial claim - Findingown data
Among ACA Exchange enrollees, there were no significant differences in specialty SUD treatment utilization between patients with deductibles and those without.
“Among patients who enrolled via the ACA exchange, there were no significant differences in the likelihood of utilizing specialty SUD treatment between patients with deductibles and those without; however, among patients who enrolled via other mechanisms, patients with high (OR=1.22, 95% CI=1.04–1.42) or low deductibles (OR=1.50, 95% CI=1.22–1.85) were more likely than those without deductibles to”
Quote in the paperSubstantial claim - Findingown data
Among people not enrolled through the Exchange, having a deductible was associated with a higher likelihood of receiving SUD treatment than having no deductible.
“Among non-Exchange enrollees, patients with deductibles were more likely than those without deductibles to receive SUD treatment.”
Quote in the paperSubstantial claim - Findingown data
Higher deductibles had a generally negative association with healthcare utilization in this SUD population.
“As anticipated, higher deductibles had a generally negative association with utilizing healthcare in this population.”
Quote in the paperSubstantial claim - Findingown data
Nonwhite patients had lower odds of initiating specialty SUD treatment.
“Controlling for all other characteristics, nonwhite patients had lower odds of initiating specialty SUD and psychiatry treatment (Table 2).”
Quote in the paperSubstantial claim - Findingown data
Psychiatric comorbidity was associated with greater service use of all types.
“Psychiatric comorbidity was associated with greater service use of all types.”
Quote in the paperSubstantial claim - Findingown data
Patients with a comorbid psychiatric disorder had 14 times the odds of using psychiatry treatment.
“Patients with a comorbid psychiatric disorder had significantly higher odds of using all health services studied, controlling for all other characteristics. Specifically, they had 1.4 to 2.1 times the odds of using primary care, specialty SUD, inpatient, and ED services; and 14 times the odds of using psychiatry treatment (Tables 2–3).”
Quote in the paperSubstantial claim - Findingown data
ACA Exchange enrollees had lower odds of ED visits compared with patients enrolled through other mechanisms (OR=0.67, 95% CI 0.59-0.77).
“Patients enrolled via the ACA Exchange had significantly lower odds of visiting the ED (OR=0.67, 95% CI=0.59–0.77), but had similar odds of using inpatient services as patients who enrolled through other mechanisms (OR=0.88, 95% CI=0.73–1.06).”
Quote in the paperSubstantial claim - Findingown data
Enrollment mechanism did not moderate the associations between deductible limits and likelihood of inpatient hospitalization or ED visit, after controlling for demographics and comorbidities.
“The enrollment mechanism did not moderate the associations between deductible limits and the likelihood of having an inpatient hospitalization or ED visit, controlling for demographics and comorbidities.”
Quote in the paperSubstantial claim - Findingown data
Asian, Native Hawaiian, or Pacific Islander patients had higher odds of utilizing inpatient and ED services compared to white patients.
“Asian, Native Hawaiian, or Pacific Islander patients had higher odds of utilizing inpatient and ED services compared to white patients (Table 3).”
Quote in the paperNot a substantial claim - Findingown data
After adjusting for demographics, chronic medical conditions, and psychiatric comorbidities, enrollment mechanism moderated the relationship between deductible limits and likelihood of primary care and psychiatry utilization.
“Controlling for demographic characteristics, chronic medical conditions, and psychiatric comorbidities, there was evidence that the enrollment mechanism moderated the associations between deductible limits and the likelihood of utilizing primary care and psychiatry treatment from the multivariable models (Table 2; Figure 2).”
Quote in the paperSubstantial claim - Findingown data
Having a psychiatric comorbidity was associated with greater use of every service category.
“Psychiatric comorbidity was associated with greater use of all services.”
Quote in the paperSubstantial claim - Findingown data
Patients with a comorbid psychiatric disorder had 1.4 to 2.1 times the odds of using primary care, specialty SUD, inpatient, and ED services.
“Patients with a comorbid psychiatric disorder had significantly higher odds of using all health services studied, controlling for all other characteristics. Specifically, they had 1.4 to 2.1 times the odds of using primary care, specialty SUD, inpatient, and ED services; and 14 times the odds of using psychiatry treatment (Tables 2–3).”
Quote in the paperSubstantial claim - Findingown data
For people enrolled through the Exchange, a high deductible had a strong negative association with primary care use.
“Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees.”
Quote in the paperSubstantial claim - Premisecitation
The number of people with identified SUDs who enrolled in health plans rose.
“The number of individuals with identified SUDs enrolled in health plans increased (Campbell, Parthasarathy, Altschuler, Young-Wolff, & Satre, 2018).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Campbell, Parthasarathy, Altschuler, Young-Wolff, & Satre, 2018 source
- Premisecitation
A prior study in the same California health system found that post-ACA patients with SUDs had more psychiatric and medical conditions than a pre-ACA SUD cohort.
“A previous evaluation of SUD patients enrolled in the same California healthcare system found that compared to a pre-ACA enrollment cohort with SUDs, post-ACA SUD patients had more psychiatric and medical conditions and greater enrollment in high-deductible plans.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Campbell et al., 2018 source
- Study design and conductreasoning
The study included chronic medical comorbidity as a covariate to control for confounding.
“so we included this covariate to control for confounding.”
Quote in the paperSubstantial claim - Premisecitation
A prior study in the same California health system found that post-ACA patients with SUDs were more often enrolled in high-deductible plans than a pre-ACA SUD cohort.
“A previous evaluation of SUD patients enrolled in the same California healthcare system found that compared to a pre-ACA enrollment cohort with SUDs, post-ACA SUD patients had more psychiatric and medical conditions and greater enrollment in high-deductible plans.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Campbell et al., 2018 source
- Interpretationown data
Future healthcare reforms that expand insurance coverage for people with SUDs might lead to short-term increases in utilization for a range of health services.
“This suggests that future healthcare reforms that expand insurance coverage for people with SUDs might also lead to short-term increases in utilization for a range of health services.”
Quote in the paperSubstantial claim - Interpretationown data
For this health system, the concern about narrow behavioral health networks in ACA Exchange plans appears unfounded.
“For this health system, that concern appears unfounded.”
Quote in the paperSubstantial claim - Interpretationown data
The decrease in service use over time was not due to high utilizers leaving KPNC.
“Our sensitivity analysis suggested that this result was not due to high utilizers leaving the KPNC healthcare system.”
Quote in the paperSubstantial claim - Interpretationown data
Higher deductibles were generally associated with using fewer health services, particularly when combined with Exchange enrollment.
“Higher deductibles generally were associated with use of fewer health services, especially in combination with enrollment through the Exchange.”
Quote in the paperSubstantial claim - Interpretationown data
The initial high utilization may be temporary.
“This suggests that the initial high utilization may be temporary.”
Quote in the paperSubstantial claim - Interpretationown data
The investigation confirms the ongoing importance post-ACA of psychiatric comorbidity.
“Our investigation confirms the ongoing importance post-ACA of psychiatric comorbidity and suggests that future efforts in behavioral health reform must anticipate high demand for healthcare in this vulnerable clinical population.”
Quote in the paperSubstantial claim
- Classified as probably not a substantial claim. 14
- May combine two claims. 16
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe ACA increased the number of insurance choices available.
“including an increase in insurance choices (Abraham et al., 2017; Andrews et al., 2018; Feder et al., 2017).”
Quote in the paperNot a substantial claim2 of 3 sources checked- cites Abraham et al., 2017 source
- cites Andrews et al., 2018 source
The Study Results (Alternative Benefit Coverage; page unavailable) report an increase in the number of states offering an alternative Medicaid benefit plan. The paper does not establish that individuals had more insurance plans to choose from; its finding concerns plan availability across states and addiction-treatment benefits. (LLM, conf=0.73)
Experimental — accuracy not yet measured - cites Feder et al., 2017 source
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationChronic medical conditions may affect whether patients choose a plan with a lower or no deductible when such a choice is available.
“Patients with chronic medical conditions utilize more health services than patients without such conditions (Gulley, Rasch, & Chan, 2011), which may influence their decision to choose a plan with a lower (or no) deductible if given an option (Gulley et al., 2011), so we included this covariate to control for confounding.”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites Gulley et al., 2011 source
The Results report greater health-service use among people with chronic conditions, but the cited claim concerns whether that affects their choice of deductible. The Methods discuss insurance coverage as a control variable, not plan selection; searches for deductible and plan choice found no passage addressing that decision. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Classified as probably not a substantial claim.
PremisecitationPatients with chronic medical conditions use more health services than patients without them.
“Patients with chronic medical conditions utilize more health services than patients without such conditions (Gulley, Rasch, & Chan, 2011), which may influence their decision to choose a plan with a lower (or no) deductible if given an option (Gulley et al., 2011), so we included this covariate to control for confounding.”
Quote in the paperSubstantial claim1 of 1 sources checked- cites Gulley, Rasch, & Chan, 2011 source
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationAfter the ACA was implemented in 2014, the number of people without insurance in the United States fell.
“Following ACA implementation in 2014, the overall number of individuals living without insurance dropped (Maclean & Saloner, 2019; Thomas, Shartzer, Kurth, & Hall, 2018).”
Quote in the paperNot a substantial claim1 of 2 sources checked- cites Maclean & Saloner, 2019 source
The Discussion (p. 29) reports a reduction in the uninsured among people receiving substance use disorder treatment after ACA-related Medicaid expansions. Section 2.3 also reports a post-expansion decline in uninsurance among low-income U.S. adults. Neither passage establishes that the overall number of uninsured people in the United States fell. (LLM, conf=0.84)
Experimental — accuracy not yet measured - cites Thomas, Shartzer, Kurth, & Hall, 2018 source
May combine two claims.
Findingown dataIn sensitivity analysis, the censored group had a larger proportion of patients with high deductibles (28% vs 19%, p<.001) and a smaller proportion who enrolled via the ACA exchange (13% vs 18%, p<.001) compared to the noncensored group.
“The censored group had a larger proportion of patients with high deductibles (28% vs. 19%, p<.001) and a smaller proportion of patients who enrolled via the ACA exchange (13% vs 18%, p<.001) compared to the noncensored group (Table S6).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThere were no differences in psychiatry treatment, inpatient hospitalization, or ED visits between patients with membership duration ≥6 months and those with <6 months.
“Patients with a longer membership duration before receiving an SUD diagnosis (≥6 months) were less likely to utilize primary care (OR=0.89, 95% CI=0.83–0.96) and specialty SUD treatment (OR=0.78, 95% CI=0.69–0.87) than those with a shorter duration (<6 months); there were no differences for psychiatry treatment, inpatient hospitalizations, or ED visits (Tables 2–3).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataUtilization of primary care, specialty SUD treatment, psychiatry, inpatient hospitalization, and ED was highest in the first 6 months after index and declined in the next 6 months, then remained stable.
“Utilization of any primary care, specialty SUD treatment, psychiatry, inpatient hospitalizations, and ED was highest in the 0–6 months after index and decreased in the subsequent (6–12 months) time window; utilization remained stable thereafter (Figure 1, Table S3).”
- Also stated in: § Conclusion · plain
“This study found that in newly enrolled patients with SUDs, health service utilization peaked in the 6 months following an SUD diagnosis and then decreased to a stable level in years 2–3.”
Quote in the paperSubstantial claim- Also stated in: § Conclusion · plain
May combine two claims.
Findingown dataCompared to patients aged 18-34, patients aged 50-64 had higher odds of utilizing primary care and inpatient services, but lower odds of utilizing psychiatry and ED services.
“Compared to younger patients (18–34 years), older patients (50–64 years) had higher odds of utilizing primary care and inpatient services, but lower odds of utilizing psychiatry and ED services (Tables 2–3).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe trends in utilization did not differ by deductible limit or SUD diagnosis type.
“These trends did not vary by deductible limit (Figure S1) or type of SUD diagnosis (Figure S2).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataCompared to patients aged 18-34, patients aged 35-49 had higher odds of utilizing primary care and specialty SUD services, but lower odds of utilizing inpatient and ED services.
“Patients aged 35–49 years had higher odds of utilizing primary care and specialty SUD services, but lower odds of utilizing inpatient and ED services, compared to patients aged 18–34 years (Tables 2–3).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataIn sensitivity analysis, patients censored due to disenrollment at 6-12 months used less primary care (59% vs 77%, p<.001) and psychiatry services (20% vs 29%, p<.001) in the first 6 months than noncensored patients.
“The censored group used less primary care (59% vs. 77%, p<.001) and psychiatry services (20% vs. 29%, p<.001) in the first 6 months but were slightly more likely to visit the ED (64% vs. 60%, p=0.009; Table S6).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataPatients with a chronic medical comorbidity had significantly higher odds of utilizing all health services except specialty SUD treatment, which they were less likely to utilize.
“Patients with a chronic medical comorbidity had significantly higher odds of utilizing all health services, except for specialty SUD treatment, which they were less likely to utilize (Tables 2–3).”
Quote in the paperSubstantial claimMay combine two claims.
PremisecitationKPNC's membership is racially and socioeconomically diverse and matches the surrounding geographic area's demographics.
“The membership is racially and socioeconomically diverse and representative of the demographic of the geographic area (Gordon, 2015; Selby et al., 2005).”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Gordon, 2015
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites Selby et al., 2005
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenThe study received approval from the UCSF and KPNC institutional review boards, which also granted a waiver of informed consent.
“The University of California, San Francisco and Kaiser Permanente Northern California Institutional Review Boards approved the study and approved a waiver of informed consent.”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductown dataThis study used a large SUD patient cohort enrolled in health coverage post-ACA and included comprehensive data on diagnoses, insurance coverage, and use of care over three years.
“This study used a large SUD patient cohort enrolled in health coverage post-ACA and included comprehensive data on diagnoses, insurance coverage, and use of care over three years.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
Study design and conductreasoningThe study did not include insurance type as a covariate because it was collinear with deductible limits and Exchange enrollment.
“We did not include type of insurance (beyond deductible limits) as a covariate due to its collinearity with deductible limits and enrollment via the ACA exchange (Medicaid patients did not have a deductible and enrolled through another mechanism).”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S2 (checkable).
Study design and conductreasoningKPNC data are well-suited to examine ACA-related changes in health service utilization given the size and diversity of its membership.
“KPNC data are well-suited to examine ACA-related changes in health service utilization given the size and diversity of its membership.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationcitationHigh deductibles have the potential to dissuade SUD patients from accessing needed health services, and ACA Exchange enrollees may be more sensitive to them.
“Consistent with prior findings (Agarwal, Mazurenko, & Menachemi, 2017), our results suggest that high deductibles have the potential to dissuade SUD patients from accessing needed health services, and that those who enroll via the ACA exchange may be more sensitive to them.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Agarwal, Mazurenko, & Menachemi, 2017 source
May combine two claims.
Interpretationown dataRace/ethnic disparities in SUD and psychiatry treatment initiation exist in this cohort, where overall insurance coverage was not a barrier but specific mechanisms could be.
“The race/ethnic disparities in SUD and psychiatry treatment initiation in this cohort, in which overall insurance coverage was not a barrier but specific mechanisms could be, highlight the importance of addressing this complicated challenge to health equity.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
PremisecitationEarlier research indicates that an SUD diagnosis frequently follows a critical event, such as an ED visit.
“As with earlier studies (Holder, 1998; Parthasarathy, Weisner, Hu, & Moore, 2001), which indicate that SUD diagnosis is often precipitated by a critical event such as an ED visit, we expected that postdiagnosis utilization would be highest in the period immediately following diagnosis but would likely decrease over time, although trajectories would vary by type of utilization.”
Quote in the paperSubstantial claim0 of 2 sources checkedMay combine two claims.
PremisecitationThe ACA created state insurance exchanges and required SUD and psychiatric disorder treatment to be covered as essential benefits.
“The Affordable Care Act (ACA) (U.S. Congress, 2010) established state insurance exchanges to promote and offer health coverage, and mandated SUD and psychiatric disorder treatment as essential benefits.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites U.S. Congress, 2010
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Classified as probably not a substantial claim. May combine two claims.
Study design and conductreasoningThe study is observational and based on EHR data, so causal relationships cannot be attributed to the findings.
“However, we should note that is an observational study based on EHR data. As such, we cannot attribute causal relationships to our findings.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
PremisecitationThe Andersen model holds that healthcare utilization is shaped by predisposing factors, need, and enabling factors.
“We examined factors associated with utilization as conceptualized by the Andersen model of healthcare utilization (Andersen, 1995; Weisner, Matzger, Tam, & Schmidt, 2002), which proposes that utilization is determined by predisposing (e.g., race/ethnicity and other demographic factors) need (e.g., diagnoses) (Andersen, 1995) and enabling factors (e.g., benefit plan, Exchange enrollment) (Dhingra,”
Quote in the paperSubstantial claim0 of 3 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationMany chronic medical conditions are known to be associated with SUDs.
“We identified common chronic medical conditions (Ornstein, Nietert, Jenkins, & Litvin, 2013), many of which are known to be associated with SUDs (Mertens, Lu, Parthasarathy, Moore, & Weisner, 2003) using ICD-9/10 codes recorded within the first year after initial enrollment.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Mertens, Lu, Parthasarathy, Moore, & Weisner, 2003 source
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe study ran a sensitivity analysis to test whether high utilizers leaving the health system explained the observed drop in utilization between the first and second six-month periods.
“We conducted a sensitivity analysis to determine whether high utilizers leaving the health system influenced the observed pattern of decreased utilization from the 0–6 month to the 6–12 month follow-up periods.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductcitationThe analysis applied generalized estimating equations to handle correlation across repeated measures.
“To account for correlation between repeated measures, we used the generalized estimating equations methodology (Liang & Zeger, 1986).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Liang & Zeger, 1986 source
Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).
Interpretationown dataThe findings can inform future work on health reform and policy efforts to improve access to healthcare for similar clinically complex patients in other health systems.
“Nevertheless, our findings can inform future work on health reform and policy efforts to improve access to healthcare for similar clinically complex patients in other health systems.”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductown dataSensitivity analyses were conducted to examine the robustness of the findings in the absence of a randomized clinical trial, and these analyses supported the initial findings.
“However, we have conducted sensitivity analyses to examine the robustness of our findings in the absence of a randomized clinical trial. These analyses supported our initial findings; e.g., indicating that service use decrease over time was not due to high utilizers leaving KPNC.”
Quote in the paperSubstantial claim
The paper relies on this without support.
How ACA enrollment mechanisms and cost-sharing structures relate to SUD treatment and other health service use in this population is not yet known.
“Yet research has not examined the associations among ACA enrollment mechanisms, deductibles, and the use of SUD treatment and other healthcare services.”
“But access to services remains a major concern (Feder et al., 2017; Saloner et al., 2017), and much is still unknown regarding how ACA-associated enrollment through insurance exchanges and cost-sharing structures (especially deductibles) are associated with access to and use of SUD treatment and other health services in this complex patient population.”
The authors state this as an assumption.
ACA-related effects would be more visible among first-time enrollees than among the broader SUD-diagnosed membership.
“We focused on new enrollees based on the premise that ACA-related influence would be more apparent among first-time enrollees than in the overall SUD-diagnosed membership.”
The paper relies on this without support.
Deductibles are more common in ACA benefit plans than in other plans.
“Deductibles are features across different benefit plans, including commercial plans, but are more common in ACA benefit plans.”
The paper relies on this without support.
The index date (first SUD diagnosis) is a valid starting point for measuring post-diagnosis utilization.
“Utilization of any primary care, specialty SUD treatment, psychiatry, inpatient hospitalizations, and ED was highest in the 0–6 months after index and decreased in the subsequent (6–12 months) time window; utilization remained stable thereafter (Figure 1, Table S3).”
The paper relies on this without support.
Deductible limits are a valid measure of patient cost-sharing that can affect healthcare utilization.
“As anticipated, higher deductibles had a generally negative association with utilizing healthcare in this population.”
The paper relies on this without support.
Enrollment mechanism (ACA Exchange vs other) is a valid proxy for coverage type and information environment.
“Controlling for demographic characteristics, chronic medical conditions, and psychiatric comorbidities, there was evidence that the enrollment mechanism moderated the associations between deductible limits and the likelihood of utilizing primary care and psychiatry treatment from the multivariable models (Table 2; Figure 2).”
The paper relies on this without support.
The multivariable models adequately control for confounding.
“Controlling for demographic characteristics, chronic medical conditions, and psychiatric comorbidities, there was evidence that the enrollment mechanism moderated the associations between deductible limits and the likelihood of utilizing primary care and psychiatry treatment from the multivariable models (Table 2; Figure 2).”
The paper relies on this without support.
The sensitivity analysis comparing censored and noncensored patients addresses the potential bias from disenrollment.
“Our sensitivity analysis suggested that this result was not due to high utilizers leaving the KPNC healthcare system.”
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Longitudinal data analysis using generalized linear models
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BackgroundMethodInfluentialNew Evidence Regarding Racial And Ethnic Disparities In Mental Health: Policy Implications
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BackgroundSaloner, B. K., & Cook, B. L. (2013) · Health Affairs · doi:10.1377/hlthaff.2011.0983 · Cited by 350 · see citing works
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Self-citationUrgent need for improved mental health care and a more collaborative model of care
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Self-citationThe Prevalence of Chronic Diseases and Multimorbidity in Primary Care Practice: A PPRNet Report
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Who goes to alcohol and drug treatment? Understanding utilization within the context of insurance
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“We examined factors associated with utilization as conceptualized by the Andersen model of healthcare utilization (Andersen, 1995; Weisner et al., 2002), which proposes that utilization is determined by predisposing (e.”
MethodSelf-citationDhingra, S. S., Zack, M., Strine, T., Pearson, W. S., & Balluz, L. (2010) · Psychiatric Services · doi:10.1176/ps.2010.61.5.524 · Cited by 144 · see citing works
Agarwal, R., Mazurenko, O., & Menachemi, N. (2017) · Health Affairs · doi:10.1377/hlthaff.2017.0610 · Cited by 135 · cited 1× · see citing works
“Consistent with prior findings (Agarwal et al., 2017), our results suggest that high deductibles have the potential to dissuade SUD patients from accessing needed health services, and that those who enroll via the ACA exchange may be more sensitive to them.”
ResultCurran, G. M., Sullivan, G., Williams, K., Han, X., Allee, E., & Kotrla, K. J. (2008) · BMC Emergency Medicine · doi:10.1186/1471-227x-8-17 · Cited by 120 · cited 1× · see citing works
“Several prior studies have also found that patients with psychiatric comorbidity use more health services than those with SUD alone (Curran et al., 2008; Graham et al., 2017; Painter et al., 2018).”
Health Care Reform and Care at the Behavioral Health--Primary Care Interface
Druss, B. G., & Mauer, B. J. (2010) · Psychiatric Services · doi:10.1176/ps.2010.61.11.1087 · Cited by 106 · see citing works
Parthasarathy, S., Weisner, C., Hu, T. W., & Moore, C. (2001) · Journal of Studies on Alcohol · doi:10.15288/jsa.2001.62.89 · Cited by 100 · cited 1× · see citing works
“Consistent with prior studies of SUD treatment samples that have found elevated levels of healthcare utilization either immediately before or after starting SUD treatment (Holder, 1998; Parthasarathy et al., 2001; Wickizer, Krupski, Stark, Mancuso, & Campbell, 2006), results of our longitudinal analysis showed that ut…”
ResultSelf-citationSaloner, B., Bandara, S., Bachhuber, M., & Barry, C. L. (2017) · Psychiatric Services · doi:10.1176/appi.ps.201600182 · Cited by 85 · cited 1× · see citing works
“But access to services remains a major concern (Feder et al., 2017; Saloner et al., 2017), and much is still unknown regarding how ACA-associated enrollment through insurance exchanges and cost-sharing structures (especially deductibles) are associated with access to and use of SUD treatment and other health services…”
BackgroundTreatment for substance use disorder: Opportunities and challenges under the affordable care act
Tai, B., & Volkow, N. D. (2013) · Social Work in Public Health · doi:10.1080/19371918.2013.758975 · Cited by 81 · see citing works
The complex web of health: Relationships among chronic conditions, disability, and health services
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“Patients with chronic medical conditions utilize more health services than patients without such conditions (Gulley et al., 2011), which may influence their decision to choose a plan with a lower (or no) deductible if given an option (Gulley et al.”
BackgroundThe affordable care act transformation of substance use disorder treatment
Abraham, A. J., Andrews, C. M., Grogan, C. M., D’Aunno, T., Humphreys, K. N., Pollack, H. A., & Friedmann, P. D. (2017) · American Journal of Public Health · doi:10.2105/ajph.2016.303558 · Cited by 79 · cited 1× · see citing works
“, 2019), including an increase in insurance choices (Abraham et al., 2017; Andrews et al., 2018; Feder et al., 2017).”
BackgroundImpact of ACA health reforms for people with mental health conditions
Thomas, K. C., Shartzer, A., Kurth, N. K., & Hall, J. P. (2018) · Psychiatric Services · doi:10.1176/appi.ps.201700044 · Cited by 77 · cited 1× · see citing works
“Following ACA implementation in 2014, the overall number of individuals living without insurance dropped (Maclean & Saloner, 2019; Thomas et al., 2018).”
BackgroundInfluentialCost-sharing: effects on spending and outcomes.
Swartz, K. (2010) · PubMed · Cited by 75 · see citing works
Galbraith, A. A., Ross‐Degnan, D., Soumerai, S. B., Rosenthal, M. B., Gay, C., & Lieu, T. A. (2011) · Health Affairs · doi:10.1377/hlthaff.2010.0584 · Cited by 74 · cited 1× · see citing works
“We categorized deductible limits into three levels (none, 1–$999 and ≥$1000), as in prior research (Parthasarathy & Campbell, 2016) and based on the definition of high deductibles (Galbraith et al., 2011) and benefit plans available at KPNC during this period.”
MethodNetworks In ACA Marketplaces Are Narrower For Mental Health Care Than For Primary Care
Zhu, J. M., Zhang, Y., & Polsky, D. E. (2017) · Health Affairs · doi:10.1377/hlthaff.2017.0325 · Cited by 62 · cited 1× · see citing works
“, 2018) and primary care networks (Zhu et al., 2017), which raises concerns about treatment access.”
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Self-citationHigh-Deductible Health Insurance Plans: Efforts To Sharpen A Blunt Instrument
Reed, M., Fung, V., Price, M., Brand, R., Benedetti, N., Derose, S. F., Newhouse, J. P., & Hsu, J. (2009) · Health Affairs · doi:10.1377/hlthaff.28.4.1145 · Cited by 58 · cited 1× · see citing works
“Although we found more consistent associations for higher deductibles and less healthcare initiation, it is possible that even a modest deductible could deter patients from seeking treatment (Brot-Goldberg, Chandra, Handel, & Kolstad, 2017; Reed et al., 2009).”
ResultMedicaid benefits for addiction treatment expanded after implementation of the Affordable Care Act
Andrews, C. M., Grogan, C. M., Smith, B. T., Abraham, A. J., Pollack, H. A., Humphreys, K., Westlake, M. A., & Friedmann, P. D. (2018) · Health Affairs · doi:10.1377/hlthaff.2018.0272 · Cited by 54 · cited 1× · see citing works
“, 2019), including an increase in insurance choices (Abraham et al., 2017; Andrews et al., 2018; Feder et al., 2017).”
BackgroundLipton, B. J., Decker, S. L., & Sommers, B. D. (2017) · Medical Care Research and Review · doi:10.1177/1077558717706575 · Cited by 54 · see citing works
Feder, K. A., Mojtabai, R., Krawczyk, N., Young, A. S., Kealhofer, M., Tormohlen, K. N., & Crum, R. M. (2017) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2017.07.015 · Cited by 51 · cited 3× · see citing works
“…of the ACA on both SUD and psychiatry coverage (Cowell, Prakash, Jones, Barnosky, & Wedehase, 2018; Novak, Anderson, & Chen, 2018; Shover, Abraham, D’Aunno, Friedmann, & Humphreys, 2019), including an increase in insurance choices (Abraham et al., 2017; Andrews et al., 2018; Feder et al., 2017).”
BackgroundInfluentialImpact of Medicaid restrictions on availability of buprenorphine in addiction treatment programs
Andrews, C. M., Abraham, A. J., Grogan, C. M., Westlake, M. A., Pollack, H. A., & Friedmann, P. D. (2019) · American Journal of Public Health · doi:10.2105/ajph.2018.304856 · Cited by 43 · cited 1× · see citing works
“Medicaid expansion has the potential to improve access to SUD treatment (Andrews et al., 2019), but we were also not able to examine its relationship to services in the current analysis due to collinearity with deductible limits (Medicaid patients in our cohort did not have a deductible).”
BackgroundStein, B. D., Orlando, M., & Sturm, R. (2000) · Psychiatric Services · doi:10.1176/appi.ps.51.2.195 · Cited by 42 · cited 1× · see citing works
“If SUD treatment and psychiatry services are viewed as discretionary and less essential than primary care, they may be especially vulnerable to cost-sharing mechanisms (Lo Sasso & Lyons, 2002, 2004; Stein et al., 2000).”
BackgroundHumphreys, K., & Frank, R. G. (2014) · Addiction · doi:10.1111/add.12606 · Cited by 40 · see citing works
Graham, K., Cheng, J. M., Bernards, S., Wells, S. L., Rehm, J. T., & Kurdyak, P. A. (2016) · The Canadian Journal of Psychiatry · doi:10.1177/0706743716664884 · Cited by 39 · cited 1× · see citing works
“Several prior studies have also found that patients with psychiatric comorbidity use more health services than those with SUD alone (Curran et al., 2008; Graham et al., 2017; Painter et al., 2018).”
BackgroundKaiser Permanente Medical Care Program
Selby, J. V., Smith, D. H., Johnson, E. S., Raebel, M. A., FRIEDMAN, G. D., & McFarland, B. H. (2006) · Pharmacoepidemiology · doi:10.1002/9780470059876.ch15 · Cited by 39 · see citing works
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Painter, J. M., Malte, C. A., Rubinsky, A. D., Campellone, T. R., Gilmore, A. K., Baer, J. S., & Hawkins, E. J. (2017) · The American Journal of Drug and Alcohol Abuse · doi:10.1080/00952990.2017.1381701 · Cited by 34 · cited 1× · see citing works
“Several prior studies have also found that patients with psychiatric comorbidity use more health services than those with SUD alone (Curran et al., 2008; Graham et al., 2017; Painter et al., 2018).”
BackgroundSatre, D. D., Campbell, C. I., Gordon, N. P., & Weisner, C. M. (2010) · The International Journal of Psychiatry in Medicine · doi:10.2190/pm.40.1.e · Cited by 28 · see citing works
Self-citationThe readiness of addiction treatment agencies for health care reform
Molfenter, T. D., Capoccia, V., Boyle, M. G., et al. (2012) · Substance Abuse Treatment Prevention and Policy · doi:10.1186/1747-597x-7-16 · Cited by 26 · see citing works
WICKIZER, T. M., KRUPSKI, A., STARK, K. D., MANCUSO, D., & CAMPBELL, K. (2006) · The Milbank Quarterly · doi:10.1111/j.1468-0009.2006.00458.x · Cited by 26 · cited 1× · see citing works
“Consistent with prior studies of SUD treatment samples that have found elevated levels of healthcare utilization either immediately before or after starting SUD treatment (Holder, 1998; Parthasarathy et al., 2001; Wickizer et al., 2006), results of our longitudinal analysis showed that utilization among people with SU…”
ResultGuerrero, E. G., Garner, B. R., Cook, B. L., Kong, Y., Vega, W. A., & Gelberg, L. (2017) · Substance Abuse Treatment Prevention and Policy · doi:10.1186/s13011-017-0113-6 · Cited by 26 · cited 1× · see citing works
“Some expected these disparities to be mitigated post-ACA (Guerrero et al., 2017).”
BackgroundMcConville, S., Raven, M. C., Sabbagh, S. H., & Hsia, R. Y.-J. (2018) · Health Affairs · doi:10.1377/hlthaff.2017.0784 · Cited by 22 · see citing works
Cost sharing for substance abuse and mental health services in managed care plans
Hodgkin, D., Horgan, C. M., Garnick, D. W., & Merrick, E. L. (2003) · Medical Care Research and Review · doi:10.1177/1077558702250248 · Cited by 21 · cited 1× · see citing works
“price-sensitive relative to other medical care (Hodgkin et al., 2003; Parthasarathy & Campbell, 2016; Swartz, 2010), or not being aware of the implications of deductibles.”
BackgroundPourat, N., Davis, A., Salce, E., et al. (2012) · Health Affairs · doi:10.1377/hlthaff.2012.0545 · Cited by 21 · cited 3× · see citing works
“KPNC's integrated model is becoming more common as other health plans and federally qualified health centers move toward providing integrated SUD treatment services and using EHRs (Pourat et al., 2012).”
BackgroundInfluentialThe sensitivity of substance abuse treatment intensity to co-payment levels
Sasso, A. T. L., & Lyons, J. S. (2004) · The Journal of Behavioral Health Services & Research · doi:10.1007/bf02287338 · Cited by 17 · see citing works
Novak, P. J., Williams-Parry, K. F., & Chen, J. (2016) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-016-0264-6 · Cited by 17 · see citing works
Behavioral health coverage in the individual market increased after ACA parity requirements
Cowell, A. J., Prakash, S., Jones, E., Barnosky, A., & Wedehase, B. (2018) · Health Affairs · doi:10.1377/hlthaff.2017.1517 · Cited by 17 · cited 1× · see citing works
“Evidence suggests a positive impact of the ACA on both SUD and psychiatry coverage (Cowell et al., 2018; Novak et al., 2018; Shover et al., 2019), including an increase in insurance choices (Abraham et al.”
BackgroundThe Effects of Copayments on Substance Abuse Treatment Expenditures and Treatment Reoccurrence
Sasso, A. T. L., & Lyons, J. S. (2002) · Psychiatric Services · doi:10.1176/appi.ps.53.12.1605 · Cited by 16 · see citing works
Weisner, C. M., Lu, Y., Hinman, A., Monahan, J. T., Bonnie, R. J., Moore, C. D., Chi, F., & Appelbaum, P. S. (2009) · Psychiatric Services · doi:10.1176/ps.2009.60.5.646 · Cited by 15 · cited 1× · see citing works
“A contributing factor could also be that such patients were required to remain in treatment either by employer or court mandates, which are common and are associated with retention (Weisner et al., 2009).”
BackgroundSelf-citationShover, C. L., Abraham, A., D'Aunno, T., Friedmann, P. D., & Humphreys, K. (2019) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2019.07.012 · Cited by 10 · cited 1× · see citing works
“Evidence suggests a positive impact of the ACA on both SUD and psychiatry coverage (Cowell et al., 2018; Novak et al., 2018; Shover et al., 2019), including an increase in insurance choices (Abraham et al.”
BackgroundCharacteristics of patients with substance use disorder before and after the Affordable Care Act
Campbell, C. I., Parthasarathy, S., Altschuler, A., Young-Wolff, K. C., & Satre, D. D. (2018) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2018.08.028 · Cited by 7 · cited 1× · see citing works
“Although this prior work did not examine patterns of health service utilization, the findings suggest that newly enrolled patients post-ACA may have greater clinical needs as well as increased financial obstacles to accessing services (Campbell et al., 2018).”
BackgroundSelf-citationHigh‐Deductible Health Plans: Implications for Substance Use Treatment
Parthasarathy, S., & Campbell, C. I. (2016) · Health Services Research · doi:10.1111/1475-6773.12456 · Cited by 6 · see citing works
Self-citationStewart, M. T., Horgan, C. M., Hodgkin, D., et al. (2017) · Psychiatric Services · doi:10.1176/appi.ps.201700098 · Cited by 6 · cited 1× · see citing works
“Prior studies have found that health plans offered through the ACA Exchange are more likely to have narrow behavioral health networks compared to other non-Exchange plans (Stewart et al., 2018) and primary care networks (Zhu et al.”
BackgroundHolder (1998) · doi:10.1002/(sici)1099-176x(199803)1:1
Flagged first, then by citations
3 of the 59 references couldn’t be matched to a known paper.
Cited by
Sorted by citations
Lin, C., Cousins, S. J., Zhu, Y., Clingan, S. E., Mooney, L. J., Kan, E., Wu, F., & Hser, Y. (2024) · Journal of Substance Use and Addiction Treatment · doi:10.1016/j.josat.2024.209484 · Cited by 91 · see citing works
“However, enrollees from non-ACA mechanisms with deductibles were more likely to seek specialty SUD treatment than those without (Satre et al., 2020).”
BackgroundDickson‐Gómez, J., Weeks, M. R., Green, D., Boutouis, S., Galletly, C. L., & Christenson, E. A. (2022) · Drug and Alcohol Dependence Reports · doi:10.1016/j.dadr.2022.100051 · Cited by 48 · see citing works
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“Lack of insurance coverage and access to mental health services is a longstanding problem(1) that the Affordable Care Act has only partly addressed.(12) In the context of COVID-19, there has been a substantial shift to telehealth.”
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Self-citationSatre, D. D., Parthasarathy, S., Young‐Wolff, K. C., Meacham, M. C., Borsari, B. E., Hirschtritt, M. E., Dyke, L. V., & Sterling, S. (2022) · Journal of Studies on Alcohol and Drugs · doi:10.15288/jsad.21-00186 · Cited by 6 · see citing works
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Eddelbuettel, J. C. P., Kennedy‐Hendricks, A., Meiselbach, M. K., Stuart, E. A., Huskamp, H. A., Busch, A. B., Hollander, M. A. G., Schilling, C. J., Barry, C. L., & Eisenberg, M. D. (2024) · Journal of General Internal Medicine · doi:10.1007/s11606-024-08700-2 · Cited by 2 · see citing works
“12 Parallel research has also explored how HDHPs impact enrollees with SUD, 19–23 but no study to date has scrutinized the impact of HDHPs on healthcare spending among enrollees with a comorbid behavioral and physical health condition, such as SUD and CVD.”
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Technology-Assisted Interventions for SUDs with Racial/Ethnic Minorities in the United States
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“…with previous research that has shown that individuals who have improved access to health-care through insurance coverage (Hamersma and Maclean 2021) and low deductibles (Satre et al. 2020) are more likely to use those services, while those who are uninsured are less likely (Magrath et al. 2021).”
Doren, N. V., Hall, C., Iturralde, E., Sterling, S., & Satre, D. D. (2026) · doi:10.2196/preprints.112230
Self-citation
- Authors
- Satre, D. D., Palzes, V. A., Young-Wolff, K. C., Parthasarathy, S., Weisner, C., Guydish, J., & Campbell, C. I.
- Affiliations
- Kaiser Permanente (US)
- University of California, San Francisco (US)
- Corresponding author
- Satre, Derek D.
- ORCID
- Venue
- Journal of Substance Abuse Treatment
- Publisher
- Elsevier BV
- Published
- 2020-11
- Volume
- 118
- Pages
- 108097
- ISSN
- 0740-5472 (ISSN-L)
- PMC
- PMC7519171
- OpenAlex
- W3047345873
- Cited by
- 22
- References
- 59
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 7 · 2023: 4 · 2022: 3 · 2021: 2 · 2020: 2
- FWCI
- 2.34
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Substance Abuse Treatment (acceptedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Institute on Alcohol Abuse and Alcoholism
- Tobacco-Related Disease Research Program
- National Institute on Drug Abuse
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Keywords
- substance use disorders, Affordable Care Act, health care utilization, health insurance deductibles, psychiatric comorbidity, emergency department utilization, racial and ethnic disparities, Kaiser Permanente, health policy
- MeSH terms
- California, Delivery of Health Care, Humans, Patient Acceptance of Health Care, United States, Substance-Related Disorders, Patient Protection and Affordable Care Act
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-09-28.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.
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