Opinion Editorial
REFERENCES 1. Wang LY, Vernon-Smiley M, Gapinski MA, Desisto M, Maughan E, Sheetz A. Cost-benefit study of school nursing services [published online May 19, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2013.5441. 2. Johannesson M, Jönsson B, Karlsson G. Outcome measurement in economic evaluation. Health Econ. 1996;5(4):279-296. 3. Shannon RA, Kubelka S. Reducing the risks of delegation: use of procedure skills checklists for unlicensed assistive personnel in schools, part 2. NASN Sch Nurse. 2013;28(5):222-226. 4. O’Dell C, O’Hara K. School nurses’ experience with administration of rectal diazepam gel for seizures. J Sch Nurs. 2007;23(3):166-169. 5. Supreme Court of California. American Nurses Association v Tom Torlakson (Superintendent), American Diabetes Association (S184583), Sacramento, CA. August 12, 2013. http://www.cde.ca.gov/ls/he/hn/documents /anavtorlakson2013.pdf. Accessed February 25, 2014. 6. Maughan E, Adams R. Educators’ and parents’ perception of what school nurses do: the influence of school nurse/student ratios. J Sch Nurs. 2011;27 (5):355-363. 7. Funari M. Detecting symptoms, early intervention, and preventative education: eating
disorders & the school-age child. NASN Sch Nurse. 2013;28(3):162-166. 8. Schoessler S, White MV. Recognition and treatment of anaphylaxis in the school setting: the essential role of the school nurse. J Sch Nurs. 2013; 29(6):407-415. 9. Zacharski S, DeSisto M, Pontius D, Sheets J, Richesin C. For your information: management in the school setting: position statement. NASN Sch Nurse. 2013;28(5):263-265. 10. Pryjmachuk S, Graham T, Haddad M, Tylee A. School nurses’ perspectives on managing mental health problems in children and young people. J Clin Nurs. 2012;21(5-6):850-859. 11. Ramos MM, Greenberg C, Sapien R, Bauer-Creegan J, Hine B, Geary C. Behavioral health emergencies managed by school nurses working with adolescents. J Sch Health. 2013;83(10):712-717. 12. Rodriguez E, Rivera DA, Perlroth D, Becker E, Wang NE, Landau M. School nurses’ role in asthma management, school absenteeism, and cost savings: a demonstration project. J Sch Health. 2013;83(12):842-850.
orientation and gender identity/expression (sexual minority students): school nurse practice. NASN Sch Nurse. 2013;28(2):112-113. 15. Boudreaux S, Broussard L. Sudden cardiac arrest in schools: the role of the school nurse in AED program implementation. Issues Compr Pediatr Nurs. 2012;35(3-4):143-152. 16. Gleeson C. School nurses’ workloads: how should they be prioritised? Community Pract. 2009; 82(1):23-26. 17. Chabot G, Gagnon MP, Godin G. Redefining the school nurse role: an organizational perspective. J Health Organ Manag. 2012;26(4-5):444-466. 18. Guttu M, Engelke MK, Swanson M. Does the school nurse-to-student ratio make a difference? J Sch Health. 2004;74(1):6-9. 19. Cotton L, Brazier J, Hall DMB, et al. School nursing: costs and potential benefits. J Adv Nurs. 2000;31(5):1063-1071. 20. Durant BV, Gibbons LJ, Poole C, Suessmanm M, Wyckoff L. NASN position statement: caseload assignments. NASN Sch Nurse. 2011;26(1):49-51.
13. Brewin D, Koren A, Morgan B, Shipley S, Hardy RL. Behind closed doors: school nurses and sexual education. J Sch Nurs. 2014;30(1):31-41. 14. Bradley B, Kelts S, Robarge D, Davis C, Delger S, Compton L. NASN position statement: sexual
The Downside of Increased Cost Sharing Aaron E. Carroll, MD, MS
From 1971 through 1982, the RAND Corporation conducted the most comprehensive randomized clinical trial of health insurance ever performed.1 The investigators randomized more than 2700 families and 7700 individuals to 1 of 5 health insurRelated article page 649 ance plans with different levels of cost sharing. The major finding of the study was that increased cost sharing, or making people pay more out-ofpocket for their care, led people to spend less on health care. They also found that increased cost sharing did not, in general, lead to worse health outcomes.1 Since publication of the RAND Health Insurance Experiment findings, reduced health care spending as a result of increased cost sharing has become an accepted fact. Namely, people are more reluctant to spend their own money than someone else’s. However, one of the major limitations of the RAND study was that it contained mostly healthy people. Some investigators argue that the sickest people dropped out of the experiment voluntarily, thus skewing the population.2 Furthermore, healthy people almost by definition are going to be fine in the short term with less health care. Finding ways to get them to spend less is a good thing. What about people who are unhealthy? A less reported, but still important, finding of the RAND study was that poorer people with hypertension had significantly increased mortality. They likely avoided necessary care, which led to worse health outcomes.3 Cost sharing has very 606
different implications for people with chronic conditions. They need care, and if we incentivize them to avoid it, then outcomes can get worse. Cost sharing is the subject of a study by Fung et al,4 who conducted a telephone survey of 769 parents of children with asthma who were aged 4 to 11 years. They asked the parents about how they sought care for their child’s condition. Specifically, they gathered data on how financial stress and costs changed how they sought care. Their findings are not surprising, given our prior knowledge about cost sharing. Families with higher levels of cost sharing were more likely to avoid or delay office and emergency department visits. They were more likely to forgo care. They were also more likely to borrow money or cut back on necessities to afford the care they could give to their children. This finding should give all of us pause. These are children with asthma. The care they are avoiding, delaying, or forgoing is necessary care. We all know that when it comes to asthma, preventing exacerbations is better than treating them. Most surprising was who was most affected by cost sharing. The literature is replete with studies that show that Medicaid is associated with worse outcomes than private insurance. 5 In this case, however, Medicaid was not the underperformer. For the most part, Medicaid and the State Children’s Health Insurance Program have little, if any, cost sharing, which removes the financial burden for people to obtain care. Com-
JAMA Pediatrics July 2014 Volume 168, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Nanyang Technological University User on 05/25/2015
jamapediatrics.com
Editorial Opinion
prehensive insurance, like that had by many people earning more than 400% of the federal poverty line (FPL), also has lower levels of cost sharing. However, cheaper commercial insurance, like that which lower-income Americans might purchase, has higher out-of-pocket expenses. Commercially insured children in families who earned less than 250% of the FPL and who had higher levels of cost sharing were more likely to avoid or delay care than those who had better commercial insurance and those with Medicaid.4 Medicaid also provided more financial protection than commercial insurance from higher levels of cost sharing. These findings have specific implications for health care reform. Although some people will find it easier to get insurance in the state exchanges than they might on the individual market before this year, many of the less expensive plans have particularly high levels of cost sharing. Silver level plans, or those that are required for many to obtain subsidies to help defray the costs of premiums, have an actuarial value of 70%, meaning that 30% of care will be paid for by individuals themselves.
Conflict of Interest Disclosures: None reported.
ARTICLE INFORMATION Author Affiliations: Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis; Center for Health Policy and Professionalism Research, Indiana University School of Medicine, Indianapolis. Corresponding Author: Aaron E. Carroll, MD, MS, Indiana University School of Medicine, 410 W 10th St, Health Information and Translational Sciences Bldg 4099C, Indianapolis, IN 46202 (aaecarro @iupui.edu). Published Online: May 19, 2014. doi:10.1001/jamapediatrics.2014.449.
In many areas, including California, where this study took place, the cost-sharing copayments, coinsurance, deductibles, and out-of-pocket maximums will likely be higher than the threshold set in this study. In other words, we have good reason to believe that families making less than 250% of the FPL who obtain insurance in the exchanges will avoid or delay more care and face greater financial stress than those in this study. In addition, states that forgo the Medicaid expansion or even amend it to move the poorest among us into commercial insurance with high levels of cost sharing will leave those families at increased risk for difficulty getting care or higher levels of financial stress. The Affordable Care Act will do a great deal to reduce the numbers of the uninsured in the United States. However, having insurance is just the first step toward improved access.6 Health care is still expensive, and obtaining it is still difficult for many in the United States. As Fung and colleagues4 have shown us, we cannot ignore cost sharing, especially with respect to lower-income individuals obtaining commercial insurance through the exchanges.
REFERENCES 1. Brook RH, Ware JE Jr, Rogers WH, et al. Does free care improve adults’ health? results from a randomized controlled trial. N Engl J Med. 1983;309 (23):1426-1434. 2. Nyman JA. American health policy: cracks in the foundation. J Health Polit Policy Law. 2007;32(5): 759-783. 3. Chernew ME, Newhouse JP. What does the RAND Health Insurance Experiment tell us about the impact of patient cost sharing on health outcomes? Am J Manag Care. 2008;14(7):412-414.
4. Fung V, Graetz I, Galbraith A, et al. Financial barriers to care among low-income children with asthma: health care reform implications [published online May 19, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2014.79. 5. Frakt A, Carroll AE, Pollack HA, Reinhardt U. Our flawed but beneficial Medicaid program. N Engl J Med. 2011;364(16):e31. doi:10.1056/NEJMp1103168. 6. Allen H, Wright BJ, Baicker K. New Medicaid enrollees in Oregon report health care successes and challenges. Health Aff (Millwood). 2014;33(2): 292-299.
The Tale of 2 Trials Disentangling Contradictory Evidence on Hypertonic Saline for Acute Bronchiolitis Sim Grewal, MD; Terry P. Klassen, MD
For pediatricians looking for answers on how best to provide treatment for their patients, nothing can be more frustrating than 2 randomized clinical trials (RCTs) with contradictory results. It may encourage nihilism and a throwing up of Related articles pages 657 one’s hands, thinking cliniand 664 cal researchers have no idea what they are doing by producing data and gaining publications but not shedding light on the tough management issues that pediatricians face day to day. These 2 RCTs1,2 on the use of nebulized hypertonic saline for the management of bronchiolitis could potentially lead practitioners to despair in this way. One RCT1 indicates that hyjamapediatrics.com
pertonic saline is very helpful, can improve a patient’s condition clinically, and can lead to reduced hospitalizations. The other RCT2 comes to the opposite conclusion. Yet ultimately, pediatricians need some guidance as to what to do with the next patient with bronchiolitis whom they will assess and provide with treatment. Fortunately, we have made great progress and gained much understanding as to how to develop and evaluate evidence for clinical decision making in the past 60 years, and these advances can help guide us in disentangling this confusion. In the 1950s, medicine imported the RCT from the agricultural field as a useful tool to evaluate the effectiveness of new therapies.3 Over time, this process became increasingly used JAMA Pediatrics July 2014 Volume 168, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Nanyang Technological University User on 05/25/2015
607
REFERENCES 1. Wang LY, Vernon-Smiley M, Gapinski MA, Desisto M, Maughan E, Sheetz A. Cost-benefit study of school nursing services [published online May 19, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2013.5441. 2. Johannesson M, Jönsson B, Karlsson G. Outcome measurement in economic evaluation. Health Econ. 1996;5(4):279-296. 3. Shannon RA, Kubelka S. Reducing the risks of delegation: use of procedure skills checklists for unlicensed assistive personnel in schools, part 2. NASN Sch Nurse. 2013;28(5):222-226. 4. O’Dell C, O’Hara K. School nurses’ experience with administration of rectal diazepam gel for seizures. J Sch Nurs. 2007;23(3):166-169. 5. Supreme Court of California. American Nurses Association v Tom Torlakson (Superintendent), American Diabetes Association (S184583), Sacramento, CA. August 12, 2013. http://www.cde.ca.gov/ls/he/hn/documents /anavtorlakson2013.pdf. Accessed February 25, 2014. 6. Maughan E, Adams R. Educators’ and parents’ perception of what school nurses do: the influence of school nurse/student ratios. J Sch Nurs. 2011;27 (5):355-363. 7. Funari M. Detecting symptoms, early intervention, and preventative education: eating
disorders & the school-age child. NASN Sch Nurse. 2013;28(3):162-166. 8. Schoessler S, White MV. Recognition and treatment of anaphylaxis in the school setting: the essential role of the school nurse. J Sch Nurs. 2013; 29(6):407-415. 9. Zacharski S, DeSisto M, Pontius D, Sheets J, Richesin C. For your information: management in the school setting: position statement. NASN Sch Nurse. 2013;28(5):263-265. 10. Pryjmachuk S, Graham T, Haddad M, Tylee A. School nurses’ perspectives on managing mental health problems in children and young people. J Clin Nurs. 2012;21(5-6):850-859. 11. Ramos MM, Greenberg C, Sapien R, Bauer-Creegan J, Hine B, Geary C. Behavioral health emergencies managed by school nurses working with adolescents. J Sch Health. 2013;83(10):712-717. 12. Rodriguez E, Rivera DA, Perlroth D, Becker E, Wang NE, Landau M. School nurses’ role in asthma management, school absenteeism, and cost savings: a demonstration project. J Sch Health. 2013;83(12):842-850.
orientation and gender identity/expression (sexual minority students): school nurse practice. NASN Sch Nurse. 2013;28(2):112-113. 15. Boudreaux S, Broussard L. Sudden cardiac arrest in schools: the role of the school nurse in AED program implementation. Issues Compr Pediatr Nurs. 2012;35(3-4):143-152. 16. Gleeson C. School nurses’ workloads: how should they be prioritised? Community Pract. 2009; 82(1):23-26. 17. Chabot G, Gagnon MP, Godin G. Redefining the school nurse role: an organizational perspective. J Health Organ Manag. 2012;26(4-5):444-466. 18. Guttu M, Engelke MK, Swanson M. Does the school nurse-to-student ratio make a difference? J Sch Health. 2004;74(1):6-9. 19. Cotton L, Brazier J, Hall DMB, et al. School nursing: costs and potential benefits. J Adv Nurs. 2000;31(5):1063-1071. 20. Durant BV, Gibbons LJ, Poole C, Suessmanm M, Wyckoff L. NASN position statement: caseload assignments. NASN Sch Nurse. 2011;26(1):49-51.
13. Brewin D, Koren A, Morgan B, Shipley S, Hardy RL. Behind closed doors: school nurses and sexual education. J Sch Nurs. 2014;30(1):31-41. 14. Bradley B, Kelts S, Robarge D, Davis C, Delger S, Compton L. NASN position statement: sexual
The Downside of Increased Cost Sharing Aaron E. Carroll, MD, MS
From 1971 through 1982, the RAND Corporation conducted the most comprehensive randomized clinical trial of health insurance ever performed.1 The investigators randomized more than 2700 families and 7700 individuals to 1 of 5 health insurRelated article page 649 ance plans with different levels of cost sharing. The major finding of the study was that increased cost sharing, or making people pay more out-ofpocket for their care, led people to spend less on health care. They also found that increased cost sharing did not, in general, lead to worse health outcomes.1 Since publication of the RAND Health Insurance Experiment findings, reduced health care spending as a result of increased cost sharing has become an accepted fact. Namely, people are more reluctant to spend their own money than someone else’s. However, one of the major limitations of the RAND study was that it contained mostly healthy people. Some investigators argue that the sickest people dropped out of the experiment voluntarily, thus skewing the population.2 Furthermore, healthy people almost by definition are going to be fine in the short term with less health care. Finding ways to get them to spend less is a good thing. What about people who are unhealthy? A less reported, but still important, finding of the RAND study was that poorer people with hypertension had significantly increased mortality. They likely avoided necessary care, which led to worse health outcomes.3 Cost sharing has very 606
different implications for people with chronic conditions. They need care, and if we incentivize them to avoid it, then outcomes can get worse. Cost sharing is the subject of a study by Fung et al,4 who conducted a telephone survey of 769 parents of children with asthma who were aged 4 to 11 years. They asked the parents about how they sought care for their child’s condition. Specifically, they gathered data on how financial stress and costs changed how they sought care. Their findings are not surprising, given our prior knowledge about cost sharing. Families with higher levels of cost sharing were more likely to avoid or delay office and emergency department visits. They were more likely to forgo care. They were also more likely to borrow money or cut back on necessities to afford the care they could give to their children. This finding should give all of us pause. These are children with asthma. The care they are avoiding, delaying, or forgoing is necessary care. We all know that when it comes to asthma, preventing exacerbations is better than treating them. Most surprising was who was most affected by cost sharing. The literature is replete with studies that show that Medicaid is associated with worse outcomes than private insurance. 5 In this case, however, Medicaid was not the underperformer. For the most part, Medicaid and the State Children’s Health Insurance Program have little, if any, cost sharing, which removes the financial burden for people to obtain care. Com-
JAMA Pediatrics July 2014 Volume 168, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Nanyang Technological University User on 05/25/2015
jamapediatrics.com
Editorial Opinion
prehensive insurance, like that had by many people earning more than 400% of the federal poverty line (FPL), also has lower levels of cost sharing. However, cheaper commercial insurance, like that which lower-income Americans might purchase, has higher out-of-pocket expenses. Commercially insured children in families who earned less than 250% of the FPL and who had higher levels of cost sharing were more likely to avoid or delay care than those who had better commercial insurance and those with Medicaid.4 Medicaid also provided more financial protection than commercial insurance from higher levels of cost sharing. These findings have specific implications for health care reform. Although some people will find it easier to get insurance in the state exchanges than they might on the individual market before this year, many of the less expensive plans have particularly high levels of cost sharing. Silver level plans, or those that are required for many to obtain subsidies to help defray the costs of premiums, have an actuarial value of 70%, meaning that 30% of care will be paid for by individuals themselves.
Conflict of Interest Disclosures: None reported.
ARTICLE INFORMATION Author Affiliations: Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis; Center for Health Policy and Professionalism Research, Indiana University School of Medicine, Indianapolis. Corresponding Author: Aaron E. Carroll, MD, MS, Indiana University School of Medicine, 410 W 10th St, Health Information and Translational Sciences Bldg 4099C, Indianapolis, IN 46202 (aaecarro @iupui.edu). Published Online: May 19, 2014. doi:10.1001/jamapediatrics.2014.449.
In many areas, including California, where this study took place, the cost-sharing copayments, coinsurance, deductibles, and out-of-pocket maximums will likely be higher than the threshold set in this study. In other words, we have good reason to believe that families making less than 250% of the FPL who obtain insurance in the exchanges will avoid or delay more care and face greater financial stress than those in this study. In addition, states that forgo the Medicaid expansion or even amend it to move the poorest among us into commercial insurance with high levels of cost sharing will leave those families at increased risk for difficulty getting care or higher levels of financial stress. The Affordable Care Act will do a great deal to reduce the numbers of the uninsured in the United States. However, having insurance is just the first step toward improved access.6 Health care is still expensive, and obtaining it is still difficult for many in the United States. As Fung and colleagues4 have shown us, we cannot ignore cost sharing, especially with respect to lower-income individuals obtaining commercial insurance through the exchanges.
REFERENCES 1. Brook RH, Ware JE Jr, Rogers WH, et al. Does free care improve adults’ health? results from a randomized controlled trial. N Engl J Med. 1983;309 (23):1426-1434. 2. Nyman JA. American health policy: cracks in the foundation. J Health Polit Policy Law. 2007;32(5): 759-783. 3. Chernew ME, Newhouse JP. What does the RAND Health Insurance Experiment tell us about the impact of patient cost sharing on health outcomes? Am J Manag Care. 2008;14(7):412-414.
4. Fung V, Graetz I, Galbraith A, et al. Financial barriers to care among low-income children with asthma: health care reform implications [published online May 19, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2014.79. 5. Frakt A, Carroll AE, Pollack HA, Reinhardt U. Our flawed but beneficial Medicaid program. N Engl J Med. 2011;364(16):e31. doi:10.1056/NEJMp1103168. 6. Allen H, Wright BJ, Baicker K. New Medicaid enrollees in Oregon report health care successes and challenges. Health Aff (Millwood). 2014;33(2): 292-299.
The Tale of 2 Trials Disentangling Contradictory Evidence on Hypertonic Saline for Acute Bronchiolitis Sim Grewal, MD; Terry P. Klassen, MD
For pediatricians looking for answers on how best to provide treatment for their patients, nothing can be more frustrating than 2 randomized clinical trials (RCTs) with contradictory results. It may encourage nihilism and a throwing up of Related articles pages 657 one’s hands, thinking cliniand 664 cal researchers have no idea what they are doing by producing data and gaining publications but not shedding light on the tough management issues that pediatricians face day to day. These 2 RCTs1,2 on the use of nebulized hypertonic saline for the management of bronchiolitis could potentially lead practitioners to despair in this way. One RCT1 indicates that hyjamapediatrics.com
pertonic saline is very helpful, can improve a patient’s condition clinically, and can lead to reduced hospitalizations. The other RCT2 comes to the opposite conclusion. Yet ultimately, pediatricians need some guidance as to what to do with the next patient with bronchiolitis whom they will assess and provide with treatment. Fortunately, we have made great progress and gained much understanding as to how to develop and evaluate evidence for clinical decision making in the past 60 years, and these advances can help guide us in disentangling this confusion. In the 1950s, medicine imported the RCT from the agricultural field as a useful tool to evaluate the effectiveness of new therapies.3 Over time, this process became increasingly used JAMA Pediatrics July 2014 Volume 168, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Nanyang Technological University User on 05/25/2015
607
