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

儿童癌症幸存者往往有复杂的健康需求，需要医疗监督，要求他们 来驾驭复杂的医疗体系尽管《平价医疗法案》扩大了 尽管有保险，许多儿童癌症幸存者继续经历保险不足和护理障碍。 适当的健康保险知识是幸存者获得和利用健康保险的关键技能， 防止高额的自付费用或未满足的医疗保健需求。迫切需要采取干预措施， 儿童癌症幸存者在解决保险问题方面的作用，但迄今为止尚未制定任何干预措施 提高儿童幸存者的健康保险知识。本文以Andersen和Aday的行为模式为指导， 卫生服务使用，我们开发了一个患者导航干预和健康保险小册子，针对 幸存者我们进行了一项试点随机试验，比较干预，健康保险导航工具， （HINT-S），通过Zoom同步交付，以增强常规护理（EUC;数字健康保险手册 儿童癌症幸存者研究（CCSS）队列中的82名幸存者中。HINT-S采用了 强有力的心理教育组成部分，有4个45分钟的课程，旨在提高幸存者的概念 了解健康保险和费用。初步结果支持其可行性，可接受性，初步 功效作为对RFA-CA-20-027的回应，我们提出了1型混合有效性实施试验，以测试 HINT-S与EUC的比较，以促进健康保险知识的普及，并改善下游的财务困难， 保健我们将CCSS队列中的520名幸存者随机分为：HINT-S，HINT-A（4名预先记录， 异步导航会话，具有成本效益和可扩展性的潜力）和EUC。所有 研究活动，包括招募、数据收集和导航，将通过CCSS以虚拟方式进行 mHealth平台和患者门户网站。我们将调查HINT-S是否提高了健康保险知识 6个月时（主要结局），并探索HINT-S的效应量和成本的相对差异 与HINT-A相比。我们将探讨版主（例如，社会人口统计学，保险状况，州医疗补助 扩展状态、癌症和健康史以及基线识字率）。协会 健康保险知识的长期结果，如财务困难（担心，未满足的医疗保健 需求，以及医疗费用的财务后果），自付费用的减少，以及 将调查18个月时的医疗保健利用情况。实施评估将评估干预措施的效果 覆盖范围、参与度、可接受性、忠诚度和可持续性（包括成本）。本研究的创新之处在于：（1） 数字干预交付的比较，2）关注健康保险知识，3）获得国家 长期儿童癌症幸存者的样本。数字化交付的干预措施，解决健康保险问题 扫盲可以使国家在儿童幸存者的保健费用和护理方面取得可持续的改善。

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.