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Scholarly Works (15 results)

  • Thesis
  • Peer Reviewed
UCLA Electronic Theses and Dissertations (2017)

Research Objective: Improving mental health insurance generosity has been a goal of policy-makers concerned that high cost-sharing reduces access to specialty mental health care for those needing services. Using 2009-11 data, this study examines this concern by measuring the extent to which specialty mental health use and expenditures change in response to changes in three kinds of benefit design features: 1. Financial requirements (copayments, coinsurance, and deductible levels), 2. Quantitative treatment limits (whether or not the plan limits the number of annual visits or days covered), and 3. Non-quantitative treatment limits (additional penalty copayment and coinsurance charged if patients are required to obtain prior authorization but do not). This study first examines whether each of the benefit design features is negatively associated with use and expenditures. Then, using interaction terms, it examines whether each of the benefit design features negatively modifies the effects of the others on the outcomes.

Study Design: Linked claims, enrollment, and benefit design data from a large national managed behavioral health organization represent a year before (2009) and a year after (2011) the Mental Health Parity and Addiction Equity Act (MHPAEA) mandated that, when provided, mental health and substance use disorder benefits must be at parity with medical benefits. A first-differences study design is implemented using change scores. Outcomes measure changes in annual in-network (INN) and out-of- network (OON) use, total (plan and patient) expenditures, and patient out-of-pocket expenditures for individual psychotherapy visits and inpatient days. Predictors are change scores of individual benefit design features (2011-2009 value), with separate measures for INN and OON benefits, as well as change scores of the interaction terms to examine modifying effects. Effects are estimated using linear regression, adjusting standard errors for employer-level clustering. Separate regressions are run for plans that only cover in-network services and plans that cover in- and out-of-network (INN/OON) services.

Population Studied: The study sample consists of commercially-insured adults (18 to 64 years old), residing in the U.S., without a substance use disorder diagnosis, who are enrolled in a plan subject to MHPAEA in both 2009 and 2011.

Principal Findings: Among the 85% of total sample enrollees (1,058,474 enrollees) enrolled in INN/OON plans, increases in copayment are associated with small increases in patient expenditures (β=$0.11/year), while elimination of treatment limits is associated with small increases in use (β=0.10 visits/year) and total expenditures (β=$7.65/year) for INN individual psychotherapy. For INN inpatient care, increases in deductibles are associated with small increases in patient expenditures (β=$0.0004/year) and increases in coinsurance are associated with small increases in days of care (β=0.0007 days). Similar results were observed among INN-only plans, with the addition of positive effects of coinsurance on patient expenditures for inpatient care (β=0.14 days/year) and of negative significant effects of additional penalty copayment on individual psychotherapy (β=-0.0006 visits/year; β=-$0.04/year) and inpatient care (β=-0.01 days/year). Interaction terms were not consistently significant enough to lend support to the hypothesis about modifying effects. None of the benefit design features were statistically significant predictors of OON use.

Conclusions: Elimination of limits was the benefit design feature with the largest impact. It was associated with an additional $7.65 increase in total expenditure/year for individual psychotherapy (a 50% increase over 2009 total expenditures). Increases in INN patient expenditures associated with increases financial requirements were small in magnitude, but statistically significant. As hypothesized, non-quantitative limits were negatively associated with use and total expenditures, but only among INN-only plans.

Implications for Policy or Practice: The findings suggest that, in a population of adults with employer-sponsored insurance, increases in cost-sharing through financial requirements results, on average, in greater financial burden for patients who use services, rather than decreases in use. Average income may be high enough in this sample that, on average, use is not sensitive to relatively small changes in cost-sharing. On the other hand, eliminating limits may be associated with improved access to care for those with the greatest need.

    Cover page: The Effects of Three Types of Insurance Benefit Design Features on Specialty Mental Health Utilization
    • Article
    • Peer Reviewed
    UCLA Previously Published Works (2022)

    Background

    Collection of patient-reported data has been demonstrated to improve asthma outcomes. One method to collect information is through the electronic patient portal. In practice, patient portal use in pediatrics and, specifically for asthma management, has had low uptake.

    Objective

    To understand parental/caregiver experience of pediatric asthma care management, and perceptions of the use of patient portal questionnaires before the clinic visit.

    Methods

    We conducted semi-structured interviews with caregivers of children 5-11 years old with asthma in the University of California, Los Angeles (UCLA) Health System. We included patient portal "users" (n = 20) and "non-users" (n = 5). Interview questions were developed based on clinic visit workflow with a focus on perceived usefulness and ease of use to complete pediatric asthma questionnaires in the patient portal before the visit. Interviews were audio-recorded, transcribed, and codes were generated from themes using constant comparative analysis.

    Results

    We identified eight themes related to caregiver-physician communication, perception of portal questionnaires, facilitators, and barriers to portal questionnaire use. A salient finding was that caregivers considered the portal questionnaire as a tool to be integrated into the visit to facilitate a conversation about their child's asthma. Caregiver portal-based questionnaire use was more likely if the ongoing data entered was accessible to caregivers to track and update, and if caregivers were reassured the clinicians would use questionnaire responses during the visit.

    Conclusion

    Caregivers of children with asthma are more likely to complete a patient portal intake questionnaire before the visit if they trust their responses will be used during the visit to inform care.
      Cover page: Partnered decision support: Parental perspectives of completing a pre‐visit pediatric asthma questionnaire via the patient portal
      • Article
      • Peer Reviewed
      UC Davis Previously Published Works (2021)
      Teleost fishes vary in their reliance on median and paired fins (MPF) or undulation of the body (BCF) to generate thrust during straight-line, steady swimming. Previous work indicates that swimming mode is associated with different body shapes, though this has never been empirically demonstrated across the diversity of fishes. As the body does not play as active a mechanical role in steady swimming by MPF swimmers, this may relax constraints and spur higher rates of body shape diversification. We test these predictions by measuring the impact of the dominant steady swimming mode on the evolution of body shape across 2295 marine teleost fishes. Aligning with historical expectations, BCF swimmers exhibit a more elongate, slender body shape, while MPF propulsion is associated with deeper and wider body shapes. However, in contrast to expectations, we find that BCF propulsion is associated with higher morphological diversity and greater variance around trait optima. This surprising result is consistent with the interpretation that stronger functional trade-offs stimulate phenotypic evolution, rather than constrain it.
        Cover page: The Effect of Locomotion Mode on Body Shape Evolution in Teleost Fishes
        • Article
        • Peer Reviewed
        UCLA Previously Published Works (2017)

        Background

        The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between behavioral health and medical health insurance benefits among the commercially insured. This study determines whether MHPAEA was associated with increased BH expenditures and utilization among a population with substance use disorder (SUD) diagnoses.

        Methods

        Claims and eligibility data from 5,987,776 enrollees, 2008-2013, were obtained from a national, commercial, managed behavioral health organization. An interrupted time series study design with segmented regression analysis estimated time trends of per-member-per-month (PMPM) spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance. The study sample contained individuals with drug or alcohol use disorder diagnosis during study period (N=2,716,473 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits; medication management; individual, group and family psychotherapy, and structured outpatient care); intermediate care utilization (day treatment; recovery home and residential); and inpatient utilization.

        Results

        Starting at the beginning of the post-parity period, MHPAEA was associated with increased levels of PMPM total and plan spending ($25.80 [p=0.01]; $28.33 [p=0.00], respectively), as well as the number of PMPM assessment/evaluation, individual psychotherapy, and group psychotherapy visits, and inpatient days (0.01 visits [p=0.01]; 0.02 visits [p=0.01]; 0.01 visits [p=0.03]; 0.01days [p=0.01], respectively). Following these initial level changes, MHPAEA was also associated with monthly increases in PMPM total, plan, and patent out-of-pocket spending ($2.56/month [p=0.00]; $2.25/month [p=0.00]; $0.27 [p=0.03], respectively), as well as structured outpatient visits and inpatient days (0.0012 visits/month [p=0.01]; 0.0012days/month [p=0.00]).

        Conclusion

        MHPAEA was associated with modest increases in total, plan, and patient out-of-pocket spending and outpatient and inpatient utilization. These increases, while modest in magnitude, are larger in magnitude than increases detected among a sample of all enrollees (i.e. not only those with SUD diagnoses).
          • Article
          • Peer Reviewed
          UC Davis Previously Published Works (2022)
          The deep sea contains a surprising diversity of life, including iconic fish groups such as anglerfishes and lanternfishes. Still, >65% of marine teleost fish species are restricted to the photic zone <200 m, which comprises less than 10% of the ocean's total volume. From a macroevolutionary perspective, this paradox may be explained by three hypotheses: 1) shallow water lineages have had more time to diversify than deep-sea lineages, 2) shallow water lineages have faster rates of speciation than deep-sea lineages, or 3) shallow-to-deep sea transition rates limit deep-sea richness. Here we use phylogenetic comparative methods to test among these three non-mutually exclusive hypotheses. While we found support for all hypotheses, the disparity in species richness is better described as the uneven outcome of alternating phases that favored shallow or deep diversification over the past 200 million y. Shallow marine teleosts became incredibly diverse 100 million y ago during a period of warm temperatures and high sea level, suggesting the importance of reefs and epicontinental settings. Conversely, deep-sea colonization and speciation was favored during brief episodes when cooling temperatures increased the efficiency of the ocean's carbon pump. Finally, time-variable ecological filters limited shallow-to-deep colonization for much of teleost history, which helped maintain higher shallow richness. A pelagic lifestyle and large jaws were associated with early deep-sea colonists, while a demersal lifestyle and a tapered body plan were typical of later colonists. Therefore, we also suggest that some hallmark characteristics of deep-sea fishes evolved prior to colonizing the deep sea.
            Cover page: Alternating regimes of shallow and deep-sea diversification explain a species-richness paradox in marine fishes
            • Article
            • Peer Reviewed
            UCLA Previously Published Works (2017)

            Objective

            The Mental Health Parity and Addiction Equity Act (MHPAEA) significantly changed regulations governing behavioral health benefits for large, commercially insured employers. Pre-MHPAEA, many plans covered only a specific number of behavioral health treatment days or visits; post-MHPAEA, such quantitative treatment limits (QTLs) were allowed only if they were "at parity" with medical-surgical limits. This study assessed MHPAEA's effect on the prevalence of behavioral health QTLs.

            Methods

            Analyses used 2008-2013 specialty behavioral health benefit design data for Optum large-group plans, both carve-outs (N=2,257 plan-years, corresponding to 1,527 plans and 40 employers) and carve-ins (N=11,644 plan-years, 3,569 plans, and 340 employers). Descriptive statistics were calculated for limits existing at parity implementation, distinguished by accumulation period (annual or lifetime), level of care (inpatient, intermediate, or outpatient), unit (days, visits, or courses), condition, and network level. Proportions of plans using specific limits during the preparity (2008-2009), transition (2010), and postparity (2011-2013) periods were compared with Fisher's exact tests.

            Results

            Preparity, the most common QTLs were annual visit or day limits. Accounting for overlap in limit types, 89% of regular carve-out plans, 90% of in-network-only carve-outs, and 77% of carve-in plans limited outpatient visits; 66% of regular carve-out plans, 74% of in-network-only carve-outs, and 73% of carve-ins limited inpatient or intermediate days. Postparity, QTLs almost entirely disappeared (p<.001).

            Conclusions

            Before MHPAEA, QTLs were common. Postimplementation, virtually all plans dropped such limits, suggesting that MHPAEA was effective at eliminating QTLs. However, increasing access to behavioral health care will mean going beyond such QTL changes and looking at other areas of benefit management.
              Cover page: The Mental Health Parity and Addiction Equity Act (MHPAEA) Evaluation Study: Impact on Quantitative Treatment Limits
              • Article
              • Peer Reviewed
              UC Davis Previously Published Works (2024)
              A decline in diversity from the equator to the poles is a common feature of Earths biodiversity. Here, we examine body shape diversity in marine fishes across latitudes and explore the role of time and evolutionary rate in explaining the diversity gradient. Marine fishes occupation of upper latitude environments has increased substantially over the last 80 million years. Fishes in the highest latitudes exhibit twice the rate of body shape evolution and one and a third times the disparity compared to equatorial latitudes. The faster evolution of body shape may be a response to increased ecological opportunity in polar and subpolar oceans due to (1) the evolution of antifreeze proteins allowing certain lineages to invade regions of cold water, (2) environmental disturbances driven by cyclical warming and cooling in high latitudes, and (3) rapid transitions across depth gradients. Our results add to growing evidence that evolutionary rates are often faster at temperate, not tropical, latitudes.
                Cover page: High-latitude ocean habitats are a crucible of fish body shape diversification.
                • Article
                • Peer Reviewed
                UC Davis Previously Published Works (2020)
                Key innovations may allow lineages access to new resources and facilitate the invasion of new adaptive zones, potentially influencing diversification patterns. Many studies have focused on the impact of key innovations on speciation rates, but far less is known about how they influence phenotypic rates and patterns of ecomorphological diversification. We use the repeated evolution of pharyngognathy within acanthomorph fishes, a commonly cited key innovation, as a case study to explore the predictions of key innovation theory. Specifically, we investigate whether transitions to pharyngognathy led to shifts in the rate of phenotypic evolution, as well as shifts and/or expansion in the occupation of morphological and dietary space, using a dataset of 8 morphological traits measured across 3,853 species of Acanthomorpha. Analyzing the 6 evolutionarily independent pharyngognathous clades together, we found no evidence to support pharyngognathy as a key innovation; however, comparisons between individual pharyngognathous lineages and their sister clades did reveal some consistent patterns. In morphospace, most pharyngognathous clades cluster in areas that correspond to deeper-bodied morphologies relative to their sister clades, whereas occupying greater areas in dietary space that reflects a more diversified diet. Additionally, both Cichlidae and Labridae exhibited higher univariate rates of phenotypic evolution compared with their closest relatives. However, few of these results were exceptional relative to our null models. Our results suggest that transitions to pharyngognathy may only be advantageous when combined with additional ecological or intrinsic factors, illustrating the importance of accounting for lineage-specific effects when testing key innovation hypotheses. Moreover, the challenges we experienced formulating informative comparisons, despite the ideal evolutionary scenario of multiple independent evolutionary origins of pharyngognathous clades, illustrates the complexities involved in quantifying the impact of key innovations. Given the issues of lineage specific effects and rate heterogeneity at macroevolutionary scales we observed, we suggest a reassessment of the expected impacts of key innovations may be warranted.
                  Cover page: Do key innovations unlock diversification? A case-study on the morphological and ecological impact of pharyngognathy in acanthomorph fishes.
                  • Article
                  • Peer Reviewed
                  UC Berkeley Previously Published Works (2019)

                  Background

                  Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment.

                  Aims of the study

                  Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level.

                  Methods

                  A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted.

                  Results

                  For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services.

                  Discussion

                  Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.
                    Cover page: The Effects of Three Kinds of Insurance Benefit Design Features on Specialty Mental Health Care Use in Managed Care.
                    • Article
                    • Peer Reviewed
                    UC Davis Previously Published Works (2022)
                    Diversity of feeding mechanisms is a hallmark of reef fishes, but the history of this variation is not fully understood. Here, we explore the emergence and proliferation of a biting mode of feeding, which enables fishes to feed on attached benthic prey. We find that feeding modes other than suction, including biting, ram biting, and an intermediate group that uses both biting and suction, were nearly absent among the lineages of teleost fishes inhabiting reefs prior to the end-Cretaceous mass extinction, but benthic biting has rapidly increased in frequency since then, accounting for about 40% of reef species today. Further, we measured the impact of feeding mode on body shape diversification in reef fishes. We fit a model of multivariate character evolution to a dataset comprising three-dimensional body shape of 1,530 species of teleost reef fishes across 111 families. Dedicated biters have accumulated over half of the body shape variation that suction feeders have in just 18% of the evolutionary time by evolving body shape ∼1.7 times faster than suction feeders. As a possible response to the ecological and functional diversity of attached prey, biters have dynamically evolved both into shapes that resemble suction feeders as well as novel body forms characterized by lateral compression and small jaws. The ascendance of species that use biting mechanisms to feed on attached prey reshaped modern reef fish assemblages and has been a major contributor to their ecological and phenotypic diversification.
                      Cover page: The rise of biting during the Cenozoic fueled reef fish body shape diversification
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