Paid sick leave may reduce financial burden for cancer patients

As well as the enormous physical and emotional burdens cancer holds, the disease often takes its toll financially, causing many patients to leave employment. But a new study suggests the financial burden of cancer could be alleviated if patients receive paid sick leave.
[A woman with her hand on dollars]
Researchers say paid sick leave could increase the likelihood of job retention for cancer patients and lessen the financial burden.

Published in JAMA, the study found that cancer patients who received paid sick leave from their jobs were much more likely to retain employment following treatment and have less financial worry than those without paid sick leave.

At present, around 40% of employees in America do not receive paid sick leave; it is not mandated under the Family and Medical Leave Act and Affordable Care Act, and paid sick leave does not form a part of health insurance coverage.

However, study coauthor Dr. Christine Veenstra, clinical lecturer at the University of Michigan Medical School in Ann Arbor, notes paid sick leave could help ease financial problems experienced by many cancer patients.

“Paid sick leave allows patients to take the time they need for cancer treatment but still keep getting a paycheck,” notes Dr. Veenstra.

For their study, the team set out to assess the job retention and personal financial burden of 1,300 patients who had been diagnosed with stage 3 colorectal cancer.

Through surveys that were mailed to the patients and follow-up telephone calls, the researchers gathered information on their employment, access to paid sick leave and the personal financial circumstances 4 months before cancer treatment and 12 months after.

Patients with paid sick leave nearly twice as likely to retain job

Among 567 of the respondents who were employed, 56% had access to paid sick leave.

The researchers found that only 55% of patients who were employed at the time of cancer diagnosis retained their jobs after cancer treatment; those who received paid sick leave, however, were almost twice as likely to have kept their jobs as those without paid sick leave.

After adjusting for influential factors, such as income, health insurance and education, the team found only 33% of patients without paid sick leave retained their jobs, compared with 59% of those who received paid sick leave.

As well as having access to paid sick leave, patients who kept their jobs were also more likely to be male, white, married, more highly educated, have a higher income, have private health insurance and be free of other illness.

What is more, compared with patients who had access to paid sick leave, those who did not receive paid sick leave had a much higher financial burden; they were more likely to have difficulties making credit card payments, for example, and were more likely to have reduced spending on food and clothing and recreational activities.

The team believes their findings indicate paid sick leave may be of significant benefit to employees diagnosed with serious health problems. Dr. Veenstra says:

“Paid sick leave can really support working Americans who have cancer or other issues as they go through their treatment. It may help patients retain their jobs and alleviate the financial strain associated with cancer treatment.”

Medical News Today recently reported on a study suggesting most cancer cases are caused by lifestyle behaviors and environmental factors, opposing previous research that claimed most cases are caused by “bad luck.”

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Premium-based financial incentives did not motivate obese employees to lose weight

Results shed light on potential challenges of health insurance premium adjustments in wellness programs.

Employers around the nation are increasingly searching for ways to help their employees make healthy lifestyle choices including encouraging obese employees to lose weight, often by offering financial incentives in the form of reduced health insurance premiums to help encourage success. But these programs are likely to fail, according to new research from the Perelman School of Medicine at the University of Pennsylvania published in the January issue of Health Affairs.

The team’s findings revealed that tree different types of incentive programs using either health insurance premium adjustments or lottery-based financial incentives were in effective for promoting weight loss in a randomized trial using weight scales in the workplace. The researchers say the apparent failure of the incentives to promote weight loss suggests that employers encouraging weight reduction and other healthy lifestyle choices through workplace wellness programs should test incentive designs different from the typical premium-based financial incentives.

“More than 80 percent of large employers use financial incentives for health promotion. Many use health insurance premium adjustments, but these incentives are often delayed and, even when they aren’t, they are typically hidden in paychecks along with other deductions and payments. That makes them less noticeable,” said Mitesh Patel, MD, an assistant professor of Medicine and Health Care Management at in Penn’s Perelman School of Medicine and The Wharton School, and a staff physician at the Crescenz VA Medical Center in Philadelphia. “Our findings suggest that employers should consider testing designs alternative to the $550 premium-based incentives used in this study.”

In the study, 197 obese participants were enrolled in a workplace wellness program and given a weight loss goal equivalent to five percent of their weight at enrollment. Participants were randomly assigned to a control arm with no financial incentive for achieving the goal, or one of three intervention arms, each offering an incentive valued at $550. Two of these arms used health insurance premium adjustments, either delayed until the beginning the following year, or taking effect in the first pay period after achieving the goal. Participants in the third intervention group were entered into a daily lottery incentive. Twelve months after enrollment results of the study showed no significant changes in average weight loss for participants in any of the four groups.

“Though participants in our study didn’t experience significant weight loss, that doesn’t mean that all incentive programs are ineffective, only that we need to move to more creative designs that might better leverage predictable barriers to behavior change,” said David Asch, MD, MBA, a professor of Medicine and Health Care Management and director of the Penn Center for Health Care Innovation.

The Affordable Care Act contains a provision allowing employers to use up to 30 percent of health insurance premiums as penalties or rewards, which would total roughly $1,800 for the average employee. But, the authors emphasize that the incentive amount alone may not be enough to encourage the adoption of healthy behaviors. Rather, effectiveness of incentive programs typically depends in part on how the incentive is deployed and in what context.

“There is often a presumption that the size of the reward is all that matters. In reality, incentive systems vary in effectiveness according to how well they are designed,” said Kevin Volpp, MD, PhD, a professor of Medicine and Health Care Management and director of the Penn Center for Health Incentives and Behavioral Economics. “In this case, premium adjustments had little impact on weight and the lottery incentives we used were constrained by having to do weigh-ins in workplace settings. That made sustained engagement and behavior change more challenging.”

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Fast & sharp: Medicaid expansion gives hospitals immediate relief from uninsured care

50 percent drop in uninsured hospital stays seen in expansion states, compared with no change in non-expansion states.

Just six months after opening up health insurance to more low-income people, states saw a huge drop in the amount of care their hospitals provided to uninsured patients, and a rise in care for people with coverage, a new study finds.

The fast, sharp effect suggests one of the key parts of the Affordable Care Act works as intended, giving hospitals a chance to recoup more of the cost of care they provide instead of having to absorb it when a low-income patient can’t pay.

The study looked at hospital discharges in a sample of states that expanded Medicaid, using data from a new national source. In all, hospital stays by uninsured patients went down 50 percent, and stays by people with Medicaid went up 20 percent, between the end of 2013 and the middle of 2014.

But the same study also shows the flip side of the situation, in a sample of states that didn’t expand Medicaid after a Supreme Court decision made expansion optional.

There, hospitals continued to experience the same or even higher demand for care from people without insurance. The effect persisted even when the researchers, from the University of Michigan Institute for Healthcare Policy and Innovation, took into account other differences between the two types of states.

“In expansion states, we see exactly what we would expect to happen after Medicaid became available to more people,” says Sayeh Nikpay, Ph.D., MPH, lead author of the new study published in the January issue of Health Affairs. “Even in these early months, the shift from uninsured to Medicaid contrasts sharply with the steady demand for uninsured care in non-expansion states. This has implications for the financial status of hospitals.”

Fuel for ongoing debate

The findings have immediate relevance for the four states that are now considering expanding Medicaid, the 16 others that have not done so, and those that are evaluating whether to continue offering their recently expanded program.

The stakes for hospitals in those states will soon get higher. A year from now, another provision of the Affordable Care Act is scheduled to ratchet back the federal funds that some hospitals get to make up for some of the cost of caring for the uninsured.

Nikpay and her colleagues, U-M health economists Thomas Buchmueller and Helen Levy, performed the study using freshly available hospital discharge payment source data from a timely new source: the Agency for Healthcare Research and Quality’s HCUP Fast Stats program.

Designed to give researchers and policymakers relatively rapid access to data from most states, it allowed the U-M team to study what happened in 15 states where full data from 2009 through mid-2014 were available. The expansion states were Arizona, California, Colorado, Hawaii, Iowa, Kentucky, Minnesota, New Jersey, and New York, while the non-expansion states were Florida, Georgia, Indiana, Missouri, Virginia, and Wisconsin.

They zeroed in on the period from fall 2013, when enrollment began for expanded Medicaid in most states that opted to expand the program, to the end of June 2014. As more data become available, including from individual hospital Medicare cost reports, they’ll continue to analyze the trend.

The researchers did not include data from Michigan, a state that expanded Medicaid but didn’t begin enrolling and covering residents until April 2014. But they and their colleagues at IHPI are conducting an even more in-depth evaluation of Michigan’s experience, under a state contract.

The findings also confirm what the three authors found in Connecticut, which expanded Medicaid in 2010. They reported those findings earlier this year in Health Affairs.

Other interesting findings

While the study found major changes in expansion states in uninsured and Medicaid hospital stays, it did not show significant changes in stays paid for by private insurance in early to mid-2014. That’s also when the first private plans sold on the ACA’s federal and state insurance marketplaces took effect, covering millions of people nationwide.

This is likely, they say, because those who were uninsured before 2014 and became sick enough to need hospital care in the first half of that year were likely to have been lower-income people who qualified for Medicaid under the new expanded criteria.

They also noticed some interesting effects in certain states in the study. For instance, Wisconsin hospitals experienced a jump in Medicaid discharges in the first half of 2014 – even though the state did not expand Medicaid to cover more residents under the ACA. The authors attribute this to a “welcome mat” effect, in which adults making less than the poverty level discovered that they were eligible for the state’s program, which had already expanded beyond previous federal requirements.

Kentucky, where Medicaid enrollment has nearly doubled since expansion, showed a 13.5 percentage point drop in uninsured hospital stays in just the first six months after expansion. Meanwhile, Georgia, a non-expansion state, saw a seven-point rise in uninsured hospital stays in early 2014.

Hospital Discharges in Medicaid Expansion/Non-Expansion States
Within months of the start of Medicaid expansion under the Affordable Care Act, hospitals in a sample of states that expanded eligibility for the program experienced a sharp decline in discharges of uninsured patients, and a less-steep rise in discharges of patients covered by any form of Medicaid. In a sample of states where Medicaid did not expand, no significant change occurred.


Health Affairs/University of Michigan

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Traditional Medicaid expansion and 'private option' both improve access to health care

Two different approaches used by states to expand Medicaid coverage for low-income adults — traditional expansion and the ‘private option’ — appear to be similarly successful in reducing numbers of the uninsured and in expanding access to and affordability of health care, according to a new study by researchers at Harvard T.H. Chan School of Public Health.

The study will be published in the January 2016 issue of Health Affairs.

“Under the Affordable Care Act (ACA), many states are dramatically expanding Medicaid, while others are taking alternative approaches to extending coverage to low-income adults, and roughly 20 states have not expanded at all,” said Benjamin Sommers, assistant professor of health policy and economics, and the study’s lead author. “Our findings suggest that deciding whether or not to expand matters much more than whether a state does so using public or private insurance.”

The 2012 Supreme Court decision on the ACA gave states the option of whether to expand Medicaid. So far, 30 states and the District of Columbia have chosen to expand coverage. Sommers and colleagues looked at three states with different policies: Kentucky, which expanded traditional Medicaid coverage; Arkansas, which used federal Medicaid funds to subsidize private insurance (the so-called ‘private option’); and Texas, which chose not to expand at all. They compared the preliminary effects of traditional and private Medicaid expansion versus non-expansion using a telephone survey of nearly 5,700 low-income adults in Kentucky, Arkansas, and Texas both before and after the first year of the ACA’s coverage expansions.

The researchers found that in Kentucky and Arkansas, the two states that expanded coverage, the uninsured rate declined dramatically — from roughly 40% in 2013 to 16% in 2014 — compared to a much smaller change in Texas (from 38% to 27%). In both Kentucky and Arkansas, compared to Texas, the number of people who reported skipping medications due to cost and who had trouble paying medical bills declined, and the share of individuals with chronic conditions obtaining regular care increased. The researchers did not find major changes in the amount of health care used or in participants’ self-reported health after the Medicaid expansion’s first year. The only significant difference found between the two expansion states was that, in Kentucky, people had less trouble paying medical bills than in Arkansas.

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New report shows fewer Texans have problems paying medical bills

Fewer Texans say they have problems paying their medical bills in 2015 compared with 2013, according to a new report released today by Rice University’s Baker Institute for Public Policy and the Episcopal Health Foundation (EHF).

The report found that since enrollment began in the Affordable Care Act (ACA) health insurance marketplace, the percentage of Texans who reported problems paying health care bills dropped almost 15 percent (25.8 percent in 2013 to 22 percent in 2015). The drop was consistent across income levels and health insurance status and corresponds with national data showing the percentage of adults reporting problems paying medical bills dropped across the U.S.

Data released this week in a nationwide Kaiser Family Foundation/New York Times survey show 26 percent of U.S. adults reported having problems paying medical bills in the past year.

“The fact that Texans had fewer problems paying their medical bills in 2015 is good news,” said Vivian Ho, the chair in health economics at Rice’s Baker Institute and director of the institute’s Center for Health and Biosciences, a professor of economics at Rice and a professor of medicine at Baylor College of Medicine. “One reason fewer Texans are having problems paying medical bills is because more Texans now have health insurance. However, one in five Texans still has problems affording health care. And it’s no surprise our data show the uninsured and those with lower incomes continue to struggle paying those bills more than anyone else.”

The report found that 30 percent of uninsured Texans reported problems paying their health care costs in 2015, down from 35 percent in 2013. Researchers found just 20 percent of those with health insurance said they had problems paying medical bills last year, down from 23 percent in 2013.

When it comes to skipping health care services because of cost, the report found uninsured Texans are more likely to skip all services (primary care, specialist care, prescription drugs, etc.) than those with insurance. However, researchers discovered fewer uninsured Texans said they skipped getting care in 2015 compared with 2013.

“On the whole, uninsured Texans reported fewer problems with affording health care in 2015,” said Elena Marks, EHF’s president and CEO, and a nonresident health policy fellow at the Baker Institute. “While our data doesn’t explain exactly why that is happening, the Texas economy improved during that time, which might have helped the uninsured pay for care.”

In addition, Marks said that because the number of insured patients across the state increased, more charitable care may have been available to the uninsured. New 1115 Medicaid waiver projects across Texas also may have enabled more uninsured adults to access affordable health services, Marks said.

Researchers found those with the lowest incomes were much more likely to say they skipped getting primary care, prescription drugs and dental care than those with higher incomes.

The report shows all groups reported dental care was the most likely health service they skipped because of cost.

“The connection between oral health and overall health is well-documented, yet we often regard dental care as ‘extra’ rather than essential,” Marks said. “Most plans, including in the ACA marketplace, offer dental care coverage as only an ‘add on.'”

The report is the 17th in a series on the implementation of the ACA in Texas co-authored by Marks and Ho.

The Health Reform Monitoring Survey (HRMS) is a quarterly survey of adults ages 18-64 that began in 2013. This report is a summary of data extracted from the HRMS surveys in Texas administered between September 2013 and September 2015.

The HRMS is designed to provide timely information on implementation issues under the ACA and to document changes in health-insurance coverage and related health outcomes. The Baker Institute and EHF are partnering to fund and report on key factors about Texans obtained from an expanded, representative sample of Texas residents (HRMS-Texas).

The HRMS was developed by the Urban Institute, conducted by GfK and jointly funded by the Robert Wood Johnson Foundation, the Ford Foundation and the Urban Institute. The analyses and conclusions based on HRMS-Texas are those of the authors and do not represent the view of the Urban Institute, the Robert Wood Johnson Foundation or the Ford Foundation.

Full survey report:

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