RAND Corporation, Santa Monica, California.
Center for Economic and Social Research at the University of Southern California, Los Angeles.
JAMA Netw Open. 2023 Nov 1;6(11):e2343087. doi: 10.1001/jamanetworkopen.2023.43087.
Fluoride varnish reduces children's tooth decay, yet few clinicians provide it. Most state Medicaid programs have covered this service during medical visits for children aged 1 to 5 years, but private insurers began covering it only in 2015 due to the Patient Protection and Affordable Care Act (ACA) mandate that they cover a set of recommended preventive services without cost-sharing. Evidence on clinicians' behavior change postmandate is limited.
To examine monthly changes in fluoride varnish applications among pediatric clinicians following the ACA mandate.
DESIGN, SETTING, AND PARTICIPANTS: Using all-payer claims data from Massachusetts, this cohort study applied an interrupted time-series approach with linear regression models comparing changes in monthly clinician-level outcomes before and after the mandate. Participants included clinicians who billed at least 5 well-child visits for patients aged 1 to 5 years and were observed at least once premandate. Adjusted for clinician fixed effects, models were assessed overall and separately for clinicians categorized by their monthly share of well-child visits paid by private insurers before the mandate: mostly private (>66% of visits paid by private insurers), mostly public (<33% of visits paid by private insurers), or mixed (33%-66% of visits paid by private insurers) insurance types. Analysis was performed from June 1, 2022, to July 31, 2023.
Preenactment and postenactment of the ACA mandate for private insurers to cover fluoride varnish applications without cost-sharing.
Clinician-month measures of whether fluoride varnish was provided during at least 1 well-child visit and the share of such visits, analyzed separately for clinicians who did and did not apply fluoride varnish premandate.
The sample included 2405 clinicians, with 107 841 clinician-months. Premandate, 10.48% of the visits included fluoride varnish applications. Two years postmandate, the likelihood of ever applying fluoride varnish was 13.64 (95% CI, 10.97-16.32) percentage points higher. For clinicians providing fluoride varnish premandate, the share of visits with fluoride varnish increased by 9.22 (95% CI, 5.41-13.02) percentage points. This increase was observed in clinicians who treated children with insurance that was mostly mixed and mostly private; no substantial change was observed among those treating children with mostly public insurance.
In this cohort study of pediatric primary care clinicians, an association between the ACA mandate and an increase in fluoride varnish application was observed, especially among clinicians primarily treating privately insured patients and those applying it premandate. However, application remains infrequent, suggesting persistent barriers.
氟化物涂料可减少儿童龋齿，但很少有临床医生提供这种服务。大多数州的医疗补助计划已经涵盖了为 1 至 5 岁儿童提供的医疗服务，但由于《患者保护与平价医疗法案》（ACA）要求私人保险公司不承担任何费用而涵盖了这一服务，因此私人保险公司从 2015 年才开始涵盖这一服务。关于临床医生在授权后行为变化的证据有限。
检查 ACA 授权后儿科临床医生中氟化物涂料应用的每月变化情况。
设计、设置和参与者：本队列研究使用来自马萨诸塞州的所有支付者索赔数据，采用中断时间序列方法，使用线性回归模型比较授权前后每月临床医生水平结果的变化。参与者包括至少为 1 至 5 岁患者提供 5 次常规儿童保健就诊并至少在授权前观察过一次的临床医生。在调整了临床医生固定效应后，根据他们在授权前每月私人保险公司支付的常规儿童保健就诊份额，对模型进行了总体评估，并分别对以下临床医生进行了评估：主要由私人保险公司（私人保险公司支付的就诊份额>66%）、主要由公共保险公司（私人保险公司支付的就诊份额<33%）或混合（私人保险公司支付的就诊份额 33%-66%）保险类型。分析于 2022 年 6 月 1 日至 2023 年 7 月 31 日进行。
私人保险公司在 ACA 授权前承保氟化物涂料应用，无需共付额。
在至少 1 次常规儿童保健就诊中提供氟化物涂料的临床医生月指标，以及分别为授权前和授权后应用氟化物涂料的临床医生的此类就诊比例。
该样本包括 2405 名临床医生，共有 107841 名临床医生月。授权前，10.48%的就诊包括氟化物涂料应用。授权后两年，氟化物涂料应用的可能性增加了 13.64（95%CI，10.97-16.32）个百分点。对于在授权前提供氟化物涂料的临床医生，应用氟化物涂料的就诊比例增加了 9.22（95%CI，5.41-13.02）个百分点。这种增加发生在治疗主要由混合保险和私人保险支付的儿童的临床医生中；在主要治疗公共保险支付的儿童的临床医生中，没有观察到实质性变化。
在这项针对儿科初级保健临床医生的队列研究中，观察到 ACA 授权与氟化物涂料应用增加之间存在关联，尤其是在主要治疗私人保险患者的临床医生和授权前应用氟化物涂料的临床医生中。然而，应用仍然很少，表明仍然存在持续的障碍。
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