Assessing the effect of virtual navigation interventions to improve health insurance literacy and decrease financial burden: A CCSS randomized trial

儿童癌症幸存者通常有复杂的健康需求，需要医疗监测，需要他们 以驾驭复杂的医疗保健系统。尽管《平价医疗法案》扩大了 在医疗保险方面，许多儿童癌症幸存者继续遭受保险不足和护理障碍的困扰。 充分的医疗保险知识是幸存者获得和利用医疗保险以及 防止高额自付费用或未得到满足的医疗保健需求。迫切需要干预措施来支持 儿童癌症幸存者解决保险问题，但到目前为止还没有制定任何干预措施 提高儿童幸存者的医疗保险素养。以安徒生和阿代的行为模型为指导 使用医疗服务，我们开发了一本患者导航干预和医疗保险小册子，目标是 幸存者。我们进行了一项试点随机试验，比较了干预、医疗保险导航工具 (提示-S)，通过Zoom同步交付，到增强的日常护理(EUC；数字医疗保险手册 仅在儿童癌症幸存者研究(CCSS)队列中的82名幸存者中。提示-S合并了一个 强大的心理教育成分，4个45分钟的课程旨在改善幸存者的概念 了解医疗保险和医疗费用。初步结果支持其可行性、可接受性和初步 功效。作为对RFA-CA-20-027的响应，我们提出了一种类型1混合有效性-实施试验来测试 提示-S VS EUC促进健康保险素养，以及改善下游经济困难和 医疗保健。我们将从CCSS队列中随机抽取520名幸存者到：提示-S，提示-A(4个预先录制的， 异步导航器会话，这有可能具有成本效益和可伸缩性)，以及EUC。全 研究活动，包括招聘、数据收集和导航，将通过CCSS虚拟进行 移动健康平台和患者门户。我们将调查提示-S是否提高了医疗保险素养 在6个月时超过EUC(主要结果)，并探索提示在效果大小和成本方面的相对差异-S 与提示-A相比。我们将探索主持人(例如，社会人口统计、保险状况、州医疗补助 扩展状况、癌症和健康史、基线识字)的干预效果。该协会 具有较长期结果的医疗保险素养，如财务困难(担心，未得到满足的医疗保健 需求和医疗费用的财务后果)，自付费用的减少，以及 将对18个月的医疗保健利用率进行调查。实施评估将评估干预措施的 覆盖范围、参与度、可接受性、忠诚度和可持续性(包括成本)。本研究对1)具有创新性 数字干预交付的比较，2)侧重于医疗保险素养，3)获得国家 长期的儿童癌症幸存者样本。解决医疗保险问题的数字化干预措施 识字可导致国家可持续改善儿童幸存者的保健费用和护理。

Childhood cancer survivors often have complex health needs that require medical surveillance, requiring them to navigate the complexities of the health care system. Despite the Affordable Care Act’s expansion of insurance, many childhood cancer survivors continue to experience underinsurance and barriers to care. Adequate health insurance literacy is a key skill for survivors to obtain and utilize health insurance and to prevent high out-of-pocket costs or unmet health care needs. Interventions are critically needed to support childhood cancer survivors in addressing issues of insurance, but to date no intervention has been developed to improve childhood survivors’ health insurance literacy. Guided by Andersen and Aday’s Behavioral Model of Health Services Use, we developed a patient navigation intervention and health insurance booklet, targeted for survivors. We conducted a pilot randomized trial comparing intervention, Health Insurance Navigation Tools (HINT-S), delivered synchronously via Zoom, to enhanced usual care (EUC; digital health insurance booklet only) among 82 survivors in the Childhood Cancer Survivor Study (CCSS) cohort. HINT-S incorporates a strong psychoeducational component, with 4 45-minute sessions designed to improve survivors’ conceptual knowledge of health insurance and cost. Preliminary results support its feasibility, acceptability, and preliminary efficacy. In response to RFA-CA-20-027, we propose a Type 1 hybrid effectiveness-implementation trial to test HINT-S vs. EUC to promote health insurance literacy, as well as improving downstream financial hardship and health care. We will randomize 520 survivors from the CCSS cohort to: HINT-S, HINT-A (4 prerecorded, asynchronous navigator sessions, which has the potential to be cost-effective and scalable), and EUC. All study activities, including recruitment, data collection, and navigation, will be conducted virtually, via the CCSS mHealth platform and patient portal. We will investigate whether HINT-S improves health insurance literacy over EUC at 6 months (primary outcome) and explore the relative difference in effect size and cost of HINT-S compared to HINT-A. We will explore moderators (e.g., sociodemographics, insurance status, state Medicaid expansion status, cancer and health history, and baseline literacy) of the intervention effects. The association of health insurance literacy with longer-term outcomes, such as financial hardship (worry, unmet healthcare needs, and financial consequences of medical costs), decreases in out-of-pocket-costs, and improvements in healthcare utilization at 18 months will be investigated. Implementation evaluation will assess the intervention’s reach, engagement, acceptability, fidelity, and sustainability (including cost). This study is innovative for the 1) comparison of digital intervention delivery, 2) focus on health insurance literacy, and 3) access to a national sample of long-term childhood cancer survivors. Digitally-delivered interventions that address health insurance literacy can lead to national sustainable improvements in childhood survivors’ health care costs and care.