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Geng F, McGarry BE, Rosenthal MB, Zubizarreta JR, Resch SC, Grabowski DC. Preferences for Postacute Care at Home vs Facilities. JAMA HEALTH FORUM 2024; 5:e240678. [PMID: 38669031 PMCID: PMC11065156 DOI: 10.1001/jamahealthforum.2024.0678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/28/2024] [Indexed: 05/04/2024] Open
Abstract
Importance Two in 5 US hospital stays result in rehabilitative postacute care, typically through skilled nursing facilities (SNFs) or home health agencies (HHAs). However, a lack of clear guidelines and understanding of patient and caregiver preferences make it challenging to promote high-value patient-centered care. Objective To assess preferences and willingness to pay for facility-based vs home-based postacute care among patients and caregivers, considering demographic variations. Design, Setting, and Participants In September 2022, a nationally representative survey was conducted with participants 45 years or older. Using a discrete choice experiment, participants acting as patients or caregivers chose between facility-based and home-based postacute care that best met their preferences, needs, and family conditions. Survey weights were applied to generate nationally representative estimates. Main Outcomes and Measures Preferences and willingness to pay for various attributes of postacute care settings were assessed, examining variation based on demographic factors, socioeconomic status, job security, and previous care experiences. Results A total of 2077 adults were invited to participate in the survey; 1555 (74.9%) completed the survey. In the weighted sample, 52.9% of participants were women, 6.5% were Asian or Pacific Islander, 1.7% were American Indian or Alaska Native, 11.2% were Black or African American, 78.4% were White; the mean (SD) age was 62.6 (9.6) years; and there was a survey completion rate of 74.9%. Patients and caregivers showed a substantial willingness to pay for home-based and high-quality care. Patients and caregivers were willing to pay an additional $58.08 per day (95% CI, 45.32-70.83) and $45.54 per day (95% CI, 31.09-59.99) for HHA care compared with a shared SNF room, respectively. However, increased demands on caregiver time within an HHA scenario and socioeconomic challenges, such as insecure employment, shifted caregivers' preferences toward facility-based care. There was a strong aversion to below average quality. To avoid below average SNF care, patients and caregivers were willing to pay $75.21 per day (95% CI, 61.68-88.75) and $79.10 per day (95% CI, 63.29-94.91) compared with average-quality care, respectively. Additionally, prior awareness and experience with postacute care was associated with willingness to pay for home-based care. No differences in preferences among patients and caregivers based on race, educational background, urban or rural residence, general health status, or housing type were observed. Conclusions and Relevance The findings of this survey study underscore a prevailing preference for home-based postacute care, aligning with current policy trends. However, attention is warranted for disadvantaged groups who are potentially overlooked during the shift toward home-based care, particularly those facing caregiver constraints and socioeconomic hardships. Ensuring equitable support and improved quality measure tools are crucial for promoting patient-centric postacute care, with emphasis on addressing the needs of marginalized groups.
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Affiliation(s)
- Fangli Geng
- Harvard University Graduate School of Arts and Sciences, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Brian E. McGarry
- Department of Medicine, University of Rochester, Rochester, New York
| | - Meredith B. Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jose R. Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Stephen C. Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Faugno E, Gilkey MB, Cripps LA, Sinaiko A, Peltz A, Kingsdale J, Galbraith AA. "Pick a Plan and Roll the Dice": A qualitative study of consumer experiences selecting a health plan in the non-group market. HEALTH POLICY OPEN 2023; 5:100112. [PMID: 38170067 PMCID: PMC10758861 DOI: 10.1016/j.hpopen.2023.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
Background For consumers without access to employer-sponsored or public insurance, health plan choices in the non-group (individual) insurance market that do not meet consumer needs have the potential for negative downstream implications for health and financial well-being. Objective This qualitative interview study sought to understand consumers' experiences and challenges with choosing a non-group health plan, among those who later had negative experiences with the plan they chose. Methods We conducted semi-structured telephone interviews with a purposive sample of 36 participants from a large regional health insurance carrier in three states who enrolled in non-group plans in 2017 (21 in Affordable Care Act (ACA) Marketplace plans and 15 enrolled off-Marketplace). Participants were included if they reported negative experiences using their plan after enrollment, such as higher-than-expected medical costs. Interviews explored challenges choosing a plan; information needed for choosing; usefulness of available tools; and preferred format for interventions to improve plan choice experiences. We analyzed interview transcripts using thematic content analysis. Results Study participants reported experiencing substantial challenges to choosing an insurance plan. Key barriers included understanding insurance terms, finding relevant information, and making comparisons across plans. Participants valued the ability to make comparisons across carriers when using the Marketplace websites but were less satisfied with customer service. Suggestions for improvement included greater standardization of plans and language and availability of customized one-on-one assistance. Conclusion Findings from this study suggest that health plan selection in the non-group market presents challenges to consumers that may be addressed through enrollment assistance and improved presentation of information. Personalized assistance to find and choose coverage may lead to plan choices that better meet consumer needs and increase confidence choosing a plan in subsequent enrollment periods.
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Affiliation(s)
- Elena Faugno
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Melissa B. Gilkey
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC, USA
| | - Lauren A. Cripps
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Anna Sinaiko
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alon Peltz
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Jon Kingsdale
- Boston University, School of Public Health, Boston, MA, USA
- Brown University, Providence, RI, USA
| | - Alison A. Galbraith
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
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Pockros B, Shabet C, Stensland K, Herrel L. Out-of-Pocket Costs for Prostate Cancer Medications Substantially Vary by Medicare Part D Plan: An Online Tool Presents an Opportunity to Mitigate Financial Toxicity. UROLOGY PRACTICE 2023; 10:467-475. [PMID: 37347766 PMCID: PMC10597673 DOI: 10.1097/upj.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/25/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Patients with advanced prostate cancer are frequently prescribed enzalutamide or abiraterone, often requiring high out-of-pocket costs. Many of these patients are insured through Medicare and have an option to select among 54 different Part D drug plans. However, less than 30% of patients report comparing costs before selecting a plan. An online Part D plan navigator is publicly available and allows patients to compare estimated out-of-pocket prescriptions costs. In this study, we examine the variability of out-of-pocket costs based on available Part D drug plans for patients with prostate cancer and demonstrate how an online tool could save patients thousands of dollars. METHODS We identified drug plans available for selection in 2023 using the online Medicare Part D Plan Finder. We sampled plan options for 12 different zip codes within the United States. A university-sponsored specialty cancer pharmacy and online mail-order pharmacy were included for comparison. We identified out-of-pocket costs for enzalutamide and abiraterone based on all Part D plans available for selection. RESULTS On average, 24 Part D drug plans were available for each zip code. Median annual out-of-pocket costs were $11,626 for enzalutamide and $9,275 for abiraterone. The range of annual out-of-pocket costs were $9,854 to $13,061 for enzalutamide and $1,379 to $13,274 for abiraterone. Within certain zip codes, potential out-of-pocket cost savings were $2,512 for enzalutamide and $9,321 for abiraterone. Median difference of out-of-pocket cost between enzalutamide and abiraterone was $8,758. CONCLUSIONS Out-of-pocket costs vary considerably across Part D drug plans. The Medicare Part D Plan Finder is a simple and effective tool to identify affordable drug plans. Guidance on plan selection could save patients thousands of dollars and help mitigate the financial toxicity of treatment. Comprehensive cancer centers could include plan navigators as an essential component of treatment.
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Affiliation(s)
| | | | | | - Lindsey Herrel
- Department of Urology, University of Michigan, Ann Arbor, MI
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van den Broek-Altenburg E, Atherly A. Using discrete choice experiments to measure preferences for hard to observe choice attributes to inform health policy decisions. HEALTH ECONOMICS REVIEW 2020; 10:18. [PMID: 32529586 PMCID: PMC7291477 DOI: 10.1186/s13561-020-00276-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/29/2020] [Indexed: 05/16/2023]
Abstract
BACKGROUND Models of preferences in health services research (HSR) and Health Economics are often defined by readily available information, such as that captured in claims data and electronic health records. Yet many important questions about patient choices cannot be easily studied because of a lack of critical data elements. The objective of this review is to outline the advantages of using stated preferences (SP) data in health services research, and to outline how these methods can be used to evaluate choices that have not yet been offered or studied. MAIN BODY This article focuses on the application of DCE's to relevant policy and health system delivery questions currently relevant, particularly in the United States. DCE's may be helpful to collect data from patient or consumer data that we currently do not have. The article provides examples of research questions that have been answered using SP data collected with a DCE. It outlines how to construct a DCE and how to analyze the data. It also discusses the methodological challenges and emphasizes important considerations regarding the design and estimation methods. SP data can be adopted in situations where we would like to have consumer choice data, but we currently do not. These are often hypothetical situations to analyze the decision-making process of individuals. With SP data it is possible to analyze trade-offs patients make when choosing between treatment options where these hard to measure attributes are important. CONCLUSION This paper emphasizes that a carefully designed DCE and appropriate estimation methods can open up a new world of data regarding trade-offs patients and providers in healthcare are willing to make. It updates previous "how to" guide for DCE's for health services researchers and health economists who are not familiar with these methods or have been unwilling to use them and updates previous description of these methods with timely examples.
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Affiliation(s)
| | - Adam Atherly
- The Larner College of Medicine, University of Vermont, 89 Beaumont Ave, Burlington, VT, 05405, USA
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Politi MC, Grant RL, George NP, Barker AR, James AS, Kuroki LM, McBride TD, Liu J, Goodwin CM. Improving Cancer Patients' Insurance Choices (I Can PIC): A Randomized Trial of a Personalized Health Insurance Decision Aid. Oncologist 2020; 25:609-619. [PMID: 32108976 DOI: 10.1634/theoncologist.2019-0703] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/17/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Many cancer survivors struggle to choose a health insurance plan that meets their needs because of high costs, limited health insurance literacy, and lack of decision support. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. MATERIALS AND METHODS Eligible individuals (18-64 years, diagnosed with cancer for ≤5 years, English-speaking, not Medicaid or Medicare eligible) were randomized to I Can PIC or an attention control health insurance worksheet. Primary outcomes included health insurance knowledge, decisional conflict, and decision self-efficacy after completing I Can PIC or the control. Secondary outcomes included knowledge, decisional conflict, decision self-efficacy, health insurance literacy, financial toxicity, and delayed care at a 3-6-month follow-up. RESULTS A total of 263 of 335 eligible participants (79%) consented and were randomized; 206 (73%) completed the initial survey (106 in I Can PIC; 100 in the control), and 180 (87%) completed a 3-6 month follow-up. After viewing I Can PIC or the control, health insurance knowledge and a health insurance literacy item assessing confidence understanding health insurance were higher in the I Can PIC group. At follow-up, the I Can PIC group retained higher knowledge than the control; confidence understanding health insurance was not reassessed. There were no significant differences between groups in other outcomes. Results did not change when controlling for health literacy and employment. Both groups reported having limited health insurance options. CONCLUSION I Can PIC can improve cancer survivors' health insurance knowledge and confidence using health insurance. System-level interventions are needed to lower financial toxicity and help patients manage care costs. IMPLICATIONS FOR PRACTICE Inadequate health insurance compromises cancer treatment and impacts overall and cancer-specific mortality. Uninsured or underinsured survivors report fewer recommended cancer screenings and may delay or avoid needed follow-up cancer care because of costs. Even those with adequate insurance report difficulty managing care costs. Health insurance decision support and resources to help manage care costs are thus paramount to cancer survivors' health and care management. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. I Can PIC provides health insurance information, supports patients through managing care costs, offers a list of financial and emotional support resources, and provides a personalized cost estimate of annual health care expenses across plan types.
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Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Rachel L Grant
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Nerissa P George
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Abigail R Barker
- Brown School and Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Aimee S James
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Lindsay M Kuroki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Timothy D McBride
- Brown School and Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Courtney M Goodwin
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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Gray C, Cooke CE, Brandt N. Evolution of the Medicare Part D Medication Therapy Management Program from Inception in 2006 to the Present. AMERICAN HEALTH & DRUG BENEFITS 2019; 12:243-251. [PMID: 32015791 PMCID: PMC6979045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 06/08/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND In 2006, the Centers for Medicare & Medicaid Services (CMS) implemented the newly established Medicare Part D program that required plan sponsors to offer a medication therapy management (MTM) program. The MTM program requirements have become more prescriptive over the past decade in the attempt to address low beneficiary enrollment rates, improve the quality of services provided, and address gaps in meeting the needs of enrollees. OBJECTIVE To describe changes to the requirements for the Medicare Part D MTM program since its inception in 2006 and the impact of these changes to inform future program enhancements. METHODS We obtained publicly available information extracted from the Medicare Part D MTM program fact sheets for the years 2008 through 2018, in addition to searching indexed literature through PubMed and additional literature through Internet searches. We then categorized the program's requirement changes annually, and described the Part D MTM program characteristics and reported statistics. DISCUSSION Significant changes to the Part D MTM program requirements occurred in 2010, 2013, and 2016 regarding eligibility criteria, MTM services, and reporting requirements. Thresholds to determine beneficiary eligibility have been lowered. Specific MTM services now include an annual comprehensive medication review, followed by a written summary using the Standardized Format. Quarterly targeted medication reviews are also required. Reporting requirements now include comprehensive medication review completion rates and the number of prescriber interventions, among others. Despite more prescriptive MTM program requirements, the low utilization of the MTM program continues. CONCLUSION Low beneficiary enrollment rates in the Medicare Part D MTM program led CMS to lower thresholds required for eligibility to expand the beneficiary pool. More prescriptive MTM service requirements enhanced service standardization. Despite these changes, MTM enrollment and comprehensive medication review rates remain low, likely, in part, from a lack of financial incentives. The Enhanced MTM program is a 5-year test model that is providing participating Part D plans regulatory flexibility and financial incentives to design their own MTM programs, to evaluate the impact of different program designs on beneficiary engagement and outcomes.
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Affiliation(s)
- Cori Gray
- Pharmacy student, University of Maryland School of Pharmacy, Baltimore
| | - Catherine E Cooke
- Research Associate Professor, Department of Pharmacy Practice & Science, University of Maryland School of Pharmacy
| | - Nicole Brandt
- Professor of Pharmacy Practice and Science, and Executive Director, Peter Lamy Center on Drug Therapy and Aging, University of Maryland School of Pharmacy
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Bundorf MK, Polyakova M, Stults C, Meehan A, Klimke R, Pun T, Chan AS, Tai-Seale M. Machine-Based Expert Recommendations And Insurance Choices Among Medicare Part D Enrollees. Health Aff (Millwood) 2019; 38:482-490. [PMID: 30830808 DOI: 10.1377/hlthaff.2018.05017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Choosing a health insurance plan is difficult for many people, and patient-centered decision support may help consumers make these choices. We tested whether providing a patient-centered decision-support tool-with or without machine-based, personalized expert recommendations-influenced decision outcomes for Medicare Part D enrollees. We found that providing an online patient-centered decision-support tool increased older adults' satisfaction with the process of choosing a prescription drug plan and the amount of time they spent choosing a plan. Providing personalized expert recommendations as well increased rates of plan switching. Many people who could have accessed the tool chose not to, and the characteristics of people who used the tool differed from those who did not. We conclude that a patient-centered decision-support tool providing personalized expert recommendations can help people choose a plan, but different approaches may be necessary to encourage more people to periodically reevaluate their options.
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Affiliation(s)
- M Kate Bundorf
- M. Kate Bundorf ( ) is an associate professor of health research and policy at the Stanford University School of Medicine, in California
| | - Maria Polyakova
- Maria Polyakova is an assistant professor of health research and policy at the Stanford University School of Medicine
| | - Cheryl Stults
- Cheryl Stults is a research sociologist at the Palo Alto Medical Foundation Research Institute, in California
| | - Amy Meehan
- Amy Meehan is a research associate at the Palo Alto Medical Foundation Research Institute
| | - Roman Klimke
- Roman Klimke is a graduate student at the John F. Kennedy School of Government, Harvard University, in Cambridge, Massachusetts
| | - Ting Pun
- Ting Pun is an independent consultant in Mountain View, California
| | - Albert Solomon Chan
- Albert Solomon Chan is chief of digital patient experience and an investigator at Sutter Health, in Palo Alto, and an adjunct professor at the Stanford Center for Biomedical Informatics Research, Stanford School of Medicine
| | - Ming Tai-Seale
- Ming Tai-Seale is a professor in the Department of Family Medicine and Public Health, University of California San Diego, director of outcomes analysis and scholarship at UC San Diego Health, and director of research at UCSD Health Sciences International, in La Jolla
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Wong CA, Ellsworth E, Madanay F, Chandrasekaran D, Moore M, Polsky D, Ubel PA. The Roles Of Assisters And Automated Decision Support Tools In Consumers' Marketplace Choices: Room For Improvement. Health Aff (Millwood) 2019; 38:473-481. [PMID: 30830825 DOI: 10.1377/hlthaff.2018.05021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Assisters provide in-person and phone-based support to help consumers narrow their plan options on the Affordable Care Act's health insurance Marketplaces. We elicited the perspectives of a national sample of thirty-two assisters from ten states on consumer plan selection and available Marketplace decision support tools (for example, total cost estimators and provider network look-up tools). Assisters identified several shortcomings that limited their use of decision support tools, such as nonspecific cost estimates and inaccurate provider network data. Assisters instead provided individualized cost estimates, called provider offices to verify network coverage, and found innovative strategies to help consumers access care affordably under their chosen plan. Two priorities emerged for optimizing consumers' Marketplace insurance selection process: improve the quality of data used in decision support tools and invest in assister programs. Assister strategies should be a benchmark for improving decision support tools, with lessons to be learned for future tool development.
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Affiliation(s)
- Charlene A Wong
- Charlene A. Wong ( ) is an assistant professor of pediatrics and public policy, and faculty in the Duke-Margolis Center for Health Policy, all at Duke University, in Durham, North Carolina
| | - Eric Ellsworth
- Eric Ellsworth is director of Health Data Strategy at Consumers' Checkbook/Center for the Study of Services, in Washington, D.C
| | - Farrah Madanay
- Farrah Madanay is a PhD student in the Sanford School of Public Policy at Duke University
| | - Dave Chandrasekaran
- Dave Chandrasekaran is an independent health policy consultant and Certified Application Counselor based in Washington, D.C
| | - Megan Moore
- Megan Moore was an intern in the Duke-Margolis Center for Health Policy at Duke University when this work was completed
| | - Daniel Polsky
- Daniel Polsky is the Robert D. Eilers Professor in Health Care Management and Policy and executive director of the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania, in Philadelphia
| | - Peter A Ubel
- Peter A. Ubel is the Madge and Dennis T. McLawhorn Professor of Business, Public Policy, and Medicine at Duke University
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