To complete a scoping review of US health insurers\' use of health-related quality of life (HRQOL) patient-reported outcome measures (PROMs).
Literature review.
A literature search was constructed for articles that contained an insurer-related term and an HRQOL-related term between 1999 and 2019 using the MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, EconLit, and Business Source Complete databases.
The search identified 14,253 unduplicated records, of which 2340 passed abstract screening and 350 were included in the review. The populations addressed in these studies included both populations with specific health conditions (eg, diabetes) and an entire member population. The most common purpose of the article was to evaluate a policy or program (n = 255; 72.9%); the range of interventions evaluated included federal policy, subgroup management strategies, and identification of individual patients. The most common insurance mechanism was Medicare (n = 205; 58.6%). The most common source of data was collected specifically for a research project (n = 172; 49.1%), and the least common source of data was collected by providers at the point of care (n = 34; 9.7%). The most commonly addressed age group was 65 years and older (n = 262; 74.9%), and the least commonly addressed was younger than 18 years (n = 36; 10.3%). The most commonly used PROMs were single-item self-rated health (n = 138; 47.1%) and activities of daily living (n = 88; 30.0%), with validated depression questionnaires (n = 56; 19.1%) being the most common disease-focused questionnaire.
This review found a wide variety of articles across insurance providers, health conditions, and uses of PROMs. There is a noted paucity of data in pediatric populations and little information about the use of data collected within health care settings that is transmitted to health insurers.

BACKGROUND: Chronic diseases contribute to a significant proportion (71%) of all deaths each year worldwide. Governments and other stakeholders worldwide have taken various actions to tackle the key risk factors contributing to the prevalence and impact of chronic diseases. Private health insurers (PHI) are one key stakeholders, particularly in Australian health system, and their engagement in chronic disease prevention is growing. Therefore, we investigated the impacts of chronic disease prevention interventions implemented by PHI both in Australia and internationally.
METHODS: We searched multiple databases (Business Source Complete, CINAHL, Global Health, Health Business Elite, Medline, PsycINFO, and Scopus) and grey literature for studies/reports published in English until September 2020 using search terms on the impacts of chronic disease prevention interventions delivered by PHIs. Two reviewers assessed the risk of bias using a quality assessment tool developed by Effective Public Healthcare Panacea Project. After data extraction, the literature was synthesised thematically based on the types of the interventions reported across studies. The study protocol was registered in PROSPERO, CRD42020145644.
RESULTS: Of 7789 records, 29 studies were eligible for inclusion. There were predominantly four types of interventions implemented by PHIs: Financial incentives, health coaching, wellness programs, and group medical appointments. Outcome measures across studies were varied, making it challenging to compare the difference between the effectiveness of different intervention types. Most studies reported that the impacts of interventions, such as increase in healthy eating, physical activity, and lower hospital admissions, last for a shorter term if the length of the intervention is shorter.
CONCLUSIONS: Although it is challenging to conclude which intervention type was the most effective, it appeared that, regardless of the intervention types, PHI interventions of longer duration (at least 2 years) were more beneficial and outcomes were more sustained than those PHI interventions that lasted for a shorter period.
BACKGROUND: Primary source of funding was Geelong Medical and Hospital Benefits Association (GMHBA), an Australian private health insurer.

This article aims to introduce the inception and operation of the COVID-19 International Collaborative Research Project, the world\'s first coronavirus disease 2019 (COVID-19) open data project for research, along with its dataset and research method, and to discuss relevant considerations for collaborative research using nationwide real-world data (RWD). COVID-19 has spread across the world since early 2020, becoming a serious global health threat to life, safety, and social and economic activities. However, insufficient RWD from patients was available to help clinicians efficiently diagnose and treat patients with COVID-19, or to provide necessary information to the government for policy-making. Countries that saw a rapid surge of infections had to focus on leveraging medical professionals to treat patients, and the circumstances made it even more difficult to promptly use COVID-19 RWD. Against this backdrop, the Health Insurance Review and Assessment Service (HIRA) of Korea decided to open its COVID-19 RWD collected through Korea\'s universal health insurance program, under the title of the COVID-19 International Collaborative Research Project. The dataset, consisting of 476 508 claim statements from 234 427 patients (7590 confirmed cases) and 18 691 318 claim statements of the same patients for the previous 3 years, was established and hosted on HIRA\'s in-house server. Researchers who applied to participate in the project uploaded analysis code on the platform prepared by HIRA, and HIRA conducted the analysis and provided outcome values. As of November 2020, analyses have been completed for 129 research projects, which have been published or are in the process of being published in prestigious journals.

Patient-reported data are widely used for many purposes by different actors within a health system. However, little is known about the use of such data by health insurers. Our study aims to map the evidence on the use of patient-reported data by health insurers; to explore how collected patient-reported data are utilized; and to elucidate the motives of why patient-reported data are collected by health insurers.
The study design is that of a scoping review. In total, 11 databases were searched on. Relevant grey literature was identified through online searches, reference mining and recommendations from experts. Forty-two documents were included. We synthesized the evidence on the uses of patient-reported data by insurers following a structure-process-outcome approach; we also mapped the use and function of those data by a health insurer.
Health insurers use patient-reported data for assurance and improvement of quality of care and value-based health care. The patient-reported data most often collected are those of outcomes, experiences and satisfaction measures; structure indicators are used to a lesser extent and often combined with process indicators. These data are mainly used for the purposes of procurement and purchasing of services, quality assurance, improvement and reporting, and strengthening the involvement of insured people.
The breadth to which insurers use patient-reported data in their business models varies greatly. Some hindering factors to the uptake of such data are the varying and overlapping terminology in use in the field and the limited involvement of insured people in a health insurer\'s business. Health insurers are advised to be more explicit in regard to the role they want to play within the health system and society at large, and accommodate implications for the use of patient-reported data accordingly.

Escalating levels of healthcare spending and price variation in the healthcare market have driven government and insurer interest in price transparency tools that are intended to help consumers shop for services and reduce overall healthcare spending. However, it is unclear whether the objectives of price transparency are being achieved. We conducted a scoping review to synthesize the impact of price transparency on consumer, provider, and purchaser behaviours and outcomes. Price transparency tools had weak impact overall on consumers due to low uptake, and mixed effects on providers. Price-aware patients chose less costly services that led to out-of-pocket cost savings and savings for health insurers; however, these savings did not translate into reductions in aggregate healthcare spending. Disclosure of list prices had no effect, however disclosure of negotiated prices prompted supply-side competition which led to decreases in prices for shoppable services.

BACKGROUND: Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population.
METHODS: The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage.
RESULTS: Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415).
CONCLUSIONS: For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.

The lack of knowledge regarding the roles and actions of return to work (RTW) stakeholders create confusion and uncertainty about how and when to RTW after experiencing a common mental disorder (CMD). Purpose The purpose of this scoping review is to disentangle the various stakeholders\' role and actions in the RTW process of workers on sick-leave due to CMDs. The research question is: What is documented in the existing literature regarding the roles and actions of the identified stakeholders involved in the RTW process of workers on sick-leave due to CMDs? Methods In conducting this scoping review, we followed Arksey and O\'Malley\'s (Int J Soc Res Methodol 8:19-32, 2005) methodology, consisting of different stages (e.g., charting the data by categorizing key results). Results 3709 articles were screened for inclusion, 243 of which were included for qualitative synthesis. Several RTW stakeholders (n=11) were identified (e.g., workers on sick leave due to CMDs, managers, union representatives, rehabilitation professionals, insurers, return to work coordinators). RTW stakeholders\' roles and actions inter- and intra-system were recommended, either general (e.g., know and understand the perspectives of all RTW stakeholders) or specific to an actor (e.g., the return to work coordinator needs to create and maintain a working alliance between all RTW stakeholders). Furthermore, close to 200 stakeholders\' actions, spread out on different RTW phases, were recommended for facilitating the RTW process. Conclusions Eleven RTW stakeholders from the work, heath and insurance systems have been identified, as well as their respective roles and actions. Thanks to these results, RTW stakeholders and policy makers will be able to build practical relationships and collaboration regarding the RTW of workers on sick leave due to CMDs.

OBJECTIVE: Health plan coverage policies can influence utilization of genetic tests. Our goal was to characterize the current state of test-related policies from US private payers.
METHODS: We searched the public websites of 206 insurers for coverage policies. We documented the number of policies, tests mentioned, coverage determination and policy effective dates.
RESULTS: Approximately one-third of insurers had at least one genetic testing policy. Moderate consistency was seen between payers. Tests in oncology and personalized medicine were most frequently addressed. Half of the policies specifically excluded coverage of a particular genetic service. Nearly half of insurers had at least one out-of-date policy.
CONCLUSIONS: Genetic services are addressed by many large health plans. Challenges remain in ensuring consistency and currency of payer policy for genetic tests.

Curbing the obesity epidemic is likely to require a suite of interventions targeting the obesogenic environment as well as individual behaviour. Evidence suggests that the effectiveness of behaviour modification programmes can be enhanced by financial incentives that immediately reward weight loss behaviour. This systematic review investigated the effectiveness of incentives with a focus on assessing the relative effectiveness of incentives that target different behaviours as well as factors of importance when implementing these programmes in real-world settings (health insurer settings). A narrative review of the academic and grey literature including a variety of study designs was undertaken. Twenty studies met inclusion criteria and were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results suggest that incentivizing weight loss is effective in the short term while the incentives are in place. There are various incentive designs, and although the relative effectiveness of each of these on weight loss is not clear, it appears that positive incentives increase the uptake into programmes and may reduce dropouts. As with other weight loss initiatives, there is a need to explore ways to maintain weight loss in the longer term - incentives for weight maintenance could play a role.

Selective contracting by health insurers and channelling patients to contracted providers is crucial in a health care system based on managed competition, as this should lead to better value for money delivery of healthcare. However, an important consequence for enrolees is that health insurers interfere with their choice of care provider. This scoping review aims to find out what is known about selective contracting from the enrolee\'s perspective. Is it being done and how do enrolees feel about the role of their health insurer in their care provider choice? A literature search was conducted, and, in addition, experts were consulted for extra information and documents. Results show that selective contracting and channelling are practised in several countries. This is mostly through negative financial incentives, which are also found to be the most effective strategy. However, enrolees are very negative about restrictions on provider choice introduced by their insurer. This results in enrolees feeling less satisfaction with, and trust in, care providers and health insurers. Choice is crucial in this respect since enrolees are more satisfied with their health plans and care providers when they have chosen them themselves. Future research should focus on the role of trust and how people weigh different attributes of health plans if selective contracting and channelling is to be implemented in a manner acceptable to enrolees.