Prioritizing solutions to incorporate Prosthetics and Orthotics services into Iranian health benefits package: Using an analytic hierarchy process

INTRODUCTION

Health benefits package (HBP) is regarded as one of the main dimensions of health financing strategy. Even with increasing demands for prosthetics and orthotics (P&O) services to approximately 0.5% of the world's population, only 15% of vulnerable groups have the chance to make use of such benefits. Inadequate coverage of P&O services in the HBP is accordingly one of the leading reasons for this situation in many countries, including Iran.

AIMS

The main objective of this study was to find and prioritize solutions in order to facilitate and promote P&O services in the Iranian HBP.

STUDY DESIGN

A mixed-methods (qualitative-quantitative) research design was employed in this study.

METHODS

This study was conducted in two phases. First, semi-structured interviews were undertaken to retrieve potential solutions. Then an analytic hierarchy process (AHP) reflecting on seven criteria of acceptability, effectiveness, time, cost, feasibility, burden of disease, and fairness was performed to prioritize them.

RESULTS

In total, 26 individuals participated in semi-structured interviews and several policy solutions were proposed. Following the AHP, preventive interventions, infant-specific interventions, inpatient interventions, interventions until 6 years of age, and emergency interventions gained the highest priority to incorporate in the Iranian HBP.

CONCLUSION

A number of policy solutions were explored and prioritized for P&O services in the Iranian HBP. Our findings provide a framework for decision- and policy-makers in Iran and other countries aiming to curb the financial burdens of P&O users, especially in vulnerable groups.

The $74,973 Question: Are Medicare Beneficiaries Informed Users of Private Medical Care Contracts?

Health-care providers are allowed to opt-out of Medicare, privately contract with beneficiaries, and require that beneficiaries pay the full cost of services. Responses from a nationally representative sample of Medicare beneficiaries reveal that they lack the knowledge necessary to make informed decisions regarding such contracts. For example, only 4.6% of participants knew the correct answer to a real-life $74,973 question, leaving a full 95.4% vulnerable to paying a large bill, even a $74,973 bill, they should not pay. In addition to advocating that Medicare effectively monitor private medical care contracts, social workers should educate beneficiaries and/or their caregivers on the implications of entering into such contracts or refer them to their State Health Insurance Assistance Program or Senior Medicare Patrol program for expert guidance.

Association among change in medical costs, level of comorbidity, and change in adherence behavior

OBJECTIVES

Interventions to improve medication adherence are effective, but resource intensive. Interventions must be targeted to those who will potentially benefit most. We examined what heterogeneity exists in the value of adherence based on levels of comorbidity, and the changes in spending on medical services that followed changes in adherence behavior.

STUDY DESIGN

Retrospective cohort study examining medical spending for 2 years (April 1, 2011, to March 31, 2013) in commercial insurance beneficiaries.

METHODS

Multivariable linear modeling was used to adjust for differences in patient characteristics. Analyses were performed at the patient/condition level in 2 cohorts: adherent at baseline and nonadherent at baseline.

RESULTS

We evaluated 857,041 patients, representing 1,264,797 patient therapies consisting of 40% high cholesterol, 48% hypertension, and 12% diabetes. Among those with 3 or more conditions, annual savings associated with becoming adherent were $5341, $4423, and $2081 for patients with at least diabetes, hypertension, and high cholesterol, respectively. The increased costs for patients in this group who became nonadherent were $4653, $7946, and $4008, respectively. Depending on the condition and the direction of behavior change, savings were 2 to 7 times greater than the value for individuals with fewer than 3 conditions. In most cases, the value of preventing nonadherence (ie, persistence) was greater than the value of moving people who are nonadherent to an adherent state.

CONCLUSIONS

There is important heterogeneity in the impact of medication adherence on medical spending. Clinicians and policy makers should consider this when promoting the change of adherence behavior.

The Role of Physician Recommendations and Public Policy in Human Papillomavirus Vaccinations

BACKGROUND

Immunization rates for human papillomavirus (HPV) infections remain low among teenagers despite strong evidence of the effectiveness of vaccines. Physician recommendations of the vaccine are far from universal. Several states have enacted policies that mandate HPV vaccination or distribute educational materials.

OBJECTIVES

To provide policy makers, physicians, and researchers information on the relative importance of physician recommendations and early state-level policies to promote HPV vaccinations among targeted age groups.

METHODS

We first use probit models to determine the strongest correlates of immunization in a nationally representative US sample of teenagers. We then use instrumental variable probit models to determine the direct role that physician recommendations play in vaccination using plausibly exogenous physician encounters that are likely not the result of more health-conscious parents seeking out information on the vaccine.

RESULTS

We show that children in the targeted age range who are more likely to encounter physicians for reasons other than seeking out the vaccine, such as through mandatory wellness exams or previous asthma diagnoses, are significantly more likely to get the vaccine. There is no consistent evidence that the state policies we analyze have been effective.

CONCLUSION

Encouraging recommendations by physicians may be the most effective path toward increasing HPV vaccination. State-level mandates and policies are yet to exhibit effectiveness.

Coverage for hepatitis C drugs in Medicare Part D

OBJECTIVES

The recent arrival of new hepatitis C virus (HCV) drugs has brought fiscal pressures onto Medicare Part D; spending on HCV drugs in Part D jumped from $283 million in 2013 to $4.5 billion in 2014. We examined the current benefit designs for HCV drugs in Part D plans and analyzed patients' financial burden for those drugs.

STUDY DESIGN

A cross-sectional analysis of CMS' July 2015 Part D Plan Formulary File and the Wolters Kluwer Health Medi-Span Electronic Drug File v.2.

METHODS

We analyzed the type and amount of cost sharing for HCV drugs and the extent to which plans apply utilization management tools. We then estimated total out-of-pocket spending for beneficiaries to complete a course of treatment.

RESULTS

All Part D plans covered at least 1 recently introduced HCV drug, as of July 2015. Nearly all plans charged relatively high coinsurance and required prior authorization for new HCV drugs. For enrollees with no subsidy, the mean out-of-pocket spending needed to complete a course of treatment is substantial, ranging from $6297 to $10,889. For enrollees with a low-income subsidy, out-of-pocket spending varies between $10.80 and $1191.

CONCLUSIONS

Under the current Part D benefits, HCV drug users with no subsidy face sizable financial burdens, even with catastrophic coverage and the recent in-gap discount for brand name drugs. As baby boomers-the group most likely to have HCV-join Medicare, efforts should be made to ensure patient access to these needed drugs.

Medicaid reimbursement, prenatal care and infant health

This paper evaluates the impact of state-level Medicaid reimbursement rates for obstetric care on prenatal care utilization across demographic groups. It also uses these rates as an instrumental variable to assess the importance of prenatal care on birth weight. The analysis is conducted using a unique dataset of Medicaid reimbursement rates and 2001-2010 Vital Statistics Natality data. Conditional on county fixed effects, the study finds a modest, but statistically significant positive relationship between Medicaid reimbursement rates and the number of prenatal visits obtained by pregnant women. Additionally, higher rates are associated with an increase in the probability of obtaining adequate care, as well as a reduction in the incidence of going without any prenatal care. However, the effect of an additional prenatal visit on birth weight is virtually zero for black disadvantaged mothers, while an additional visit yields a substantial increase in birth weight of over 20 g for white disadvantaged mothers.

Accuracy of pharmacy benefit manager medication formularies in an electronic health record system and the Epocrates mobile application

BACKGROUND

Physicians commonly use formulary medication coverage information generated by electronic heath records (EHRs) and the Epocrates mobile drug database application when making medication selection decisions. Nonformulary selections may lead to higher out-of-pocket patient costs and nonadherence with prescribed regimens. Nonformulary selections also contribute to higher overall health plan spending. However, the accuracy of these systems compared with actual insurance coverage is not known. 

OBJECTIVE

To assess the accuracy of formulary status icons generated by an EHR system and the Epocrates mobile application for patients with Alabama Medicaid and Blue Cross Blue Shield of Alabama (BCBS), the primary insurance providers in the state of Alabama.

METHODS

Patients of all ages who had a chart review performed at the outpatient family medicine or pediatric clinics at the University of Alabama at Birmingham Huntsville Medical Regional Campus from May to October 2013 were included in this retrospective analysis. Patients who were not insured by either Alabama Medicaid or BCBS were excluded. Patients who did not have new medications added at the time of the visit were also excluded. For each medication prescribed, the formulary status provided in the EHR system and Epocrates was compared with the actual Medicaid and BCBS formularies published online, and the accuracy of the 2 databases was determined. 

RESULTS

A total of 1,529 medication records were analyzed. The EHR and Epocrates provided accurate formulary information for 93.1% and 89.4% of medications, respectively. Formulary information generated by the EHR was 96.3% accurate for Medicaid patients and 80.1% accurate for BCBS patients. Epocrates was 88.2% accurate for Medicaid patients and 94.4% accurate for BCBS patients. A total of 936 medication records from the pediatric clinic were analyzed, and the majority of these patients (88.4%) had Medicaid insurance. In this population, the EHR was more accurate (96.9%) than Epocrates (86.6%). Of the small number of pediatric medication records (n = 109) associated with patients who had BCBS, Epocrates was more accurate (92.7%) than the EHR (83.5%). In family medicine, 593 medication records were analyzed. Again, for Medicaid patients, the EHR was more accurate (95.3%) than Epocrates (91.5%). For those with BCBS, Epocrates was more accurate (95.3%) than the EHR (78.2%). When over-the-counter (OTC) medications (n = 232) were analyzed separately from prescription medications, it was found that overall the EHR was 90.5% accurate, and Epocrates was 41.4% accurate. It is important to note that when only prescription medications were analyzed, the accuracy rates were high (93.6% for the EHR and 98.0% for Epocrates).

CONCLUSIONS

Formulary information generated by the EHR system and the Epocrates mobile application is a useful tool for physicians when prescribing medications, but neither source is completely accurate. Prescribers should be particularly cautious when making OTC formulary decisions using the Epocrates mobile application, since the formulary information provided for these medications was found to be the least accurate.

Gender, race, and variation in the evaluation of microscopic hematuria among Medicare beneficiaries

BACKGROUND

Female gender and black race are associated with delayed diagnosis and inferior survival in patients with bladder cancer.

OBJECTIVE

We aimed to determine the association between gender, race, and evaluation of microscopic hematuria (an early sign of bladder cancer).

DESIGN AND PARTICIPANTS

This was a cohort study using a 5 % random sample of fee-for-service Medicare beneficiaries diagnosed with incident hematuria (International Classification of Diseases, Ninth Revision [ICD-9] code 599.7x) between January 2009 and June 2010 in a primary care setting. Beneficiaries with pre-existing explanatory diagnoses or genitourinary procedures were excluded.

MAIN MEASURES

The main endpoint was completeness of the hematuria evaluation in the 180 days after diagnosis. Evaluations were categorized as complete, incomplete, or absent based on receipt of relevant diagnostic procedures and imaging studies.

KEY RESULTS

In all, 9,211 beneficiaries met the study criteria. Hematuria evaluations were complete in 14 %, incomplete in 21 %, and absent in 65 % of subjects. Compared to males, females were less likely to have a procedure (26 vs. 12 %), imaging (41 vs. 30 %), and a complete evaluation (22 vs. 10 %) (p < 0.001 for each comparison). Receipt of a complete evaluation did not differ by race. Controlling for baseline characteristics, a complete evaluation was less likely in white women (OR, 0.40 [95 % CI, 0.35-0.46]) and black women (OR, 0.46 [95 % CI, 0.29-0.70]) compared to white men; no difference was found between black and white men.

CONCLUSIONS

Women are less likely than men to undergo a complete and timely hematuria evaluation, a finding likely relevant to women's more advanced stage at bladder cancer diagnosis. System-level process improvement between providers of urologic and primary care in the evaluation of hematuria may benefit women harboring malignancy.

Willingness to pay for health insurance among HIV-positive patients in India

BACKGROUND

Standard health insurance products in India currently exclude conditions related to HIV. Although antiretroviral (ARV) drugs are now publicly funded, the burden of treatment due to hospitalization on people living with HIV and AIDS (PLHIV) continues to be high. Unlike many countries, India is yet to eliminate the exclusion clause in standard health insurance products.

OBJECTIVE

The overall aim of this study was to understand if PLHIV would be willing to participate in and purchase commercial health insurance, if it were offered to them.

METHODS

This study uses primary survey data to analyse the burden of treatment due to hospitalization and estimates the willingness to pay (WTP) for health insurance based on the contingent valuation approach.

RESULTS

The average WTP per year was in the range of Indian rupee (R) 1,145-1,355 or $US20-24, with hospitalization and economic status significantly affecting the WTP.

CONCLUSION

The findings of the study can serve as evidence for possible changes to policy on health insurance that would allow PLHIV to purchase health insurance.

Plan choice, health insurance cost and premium sharing

We develop a model of premium sharing for firms that offer multiple insurance plans. We assume that firms offer one low quality plan and one high quality plan. Under the assumption of wage rigidities we found that the employee's contribution to each plan is an increasing function of that plan's premium. The effect of the other plan's premium is ambiguous. We test our hypothesis using data from the Employer Health Benefit Survey. Restricting the analysis to firms that offer both HMO and PPO plans, we measure the amount of the premium passed on to employees in response to a change in both premiums. We find evidence of large and positive effects of the increase in the plan's premium on the amount of the premium passed on to employees. The effect of the alternative plan's premium is negative but statistically significant only for the PPO plans.

How are state insurance marketplaces shaping health plan design?

Part of states' roles in administering the new health insurance marketplaces is to certify the health plans available for purchase. This analysis focuses on how state-based and state partnership marketplaces are using their flexibility in setting certification standards to shape plan design in the individual market. It focuses on three aspects of certification: provider networks; inclusion of essential community providers; and benefit substitution, which allows plans to offer benefits that differ from a state's benchmark plan. A review of documents collected from 18 states and the District of Columbia finds that 13 states go beyond the minimum federal requirements with respect to provider network standards, four states specify additional standards for including essential community providers, and five states and Washington, D.C., bar benefit substitution. These interstate variations in plan design reflect the challenges policymakers face in balancing health care affordability, benefit coverage, and access to care through the marketplace plans.

Patient Protection and Affordable Care Act; program integrity: exchange, premium stabilization programs, and market standards; amendments to the HHS notice of benefit and payment parameters for 2014. Final rule

This final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act). Specifically, this final rule outlines financial integrity and oversight standards with respect to Affordable Insurance Exchanges, qualified health plan (QHP) issuers in Federally-facilitated Exchanges (FFEs), and States with regard to the operation of risk adjustment and reinsurance programs. It also establishes additional standards for special enrollment periods, survey vendors that may conduct enrollee satisfaction surveys on behalf of QHP issuers, and issuer participation in an FFE, and makes certain amendments to definitions and standards related to the market reform rules. These standards, which include financial integrity provisions and protections against fraud and abuse, are consistent with Title I of the Affordable Care Act. This final rule also amends and adopts as final interim provisions set forth in the Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 interim final rule, published in the Federal Register on March 11, 2013, related to risk corridors and cost-sharing reduction reconciliation.

Department of Health and Human Services. Patient Protection and Affordable Care Act; standards related to essential health benefits, actuarial value and accreditation. Final rule

This final rule sets forth standards for health insurance issuers consistent with title I of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, referred to collectively as the Affordable Care Act. Specifically, this final rule outlines Exchange and issuer standards related to coverage of essential health benefits and actuarial value. This rule also finalizes a timeline for qualified health plans to be accredited in Federally-facilitated Exchanges and amends regulations providing an application process for the recognition of additional accrediting entities for purposes of certification of qualified health plans.

Older adults navigating medicare: when benefits are denied

Guided by Bourdieu's theory of practice and symbolic violence, this qualitative study explored experiences and perceptions of elderly beneficiaries who had been denied rehabilitation services by Medicare. In semistructured interviews, 12 beneficiaries or family members told of the physical, psychological, and financial consequences of service denial/termination. The resulting perception of Medicare was as a cumbersome, difficult to negotiate system. Findings have implications for future research on service denial and indicate the need for better communication with, and support of, consumers by health care professionals when this occurs.

Impact of health care reform on reproductive service providers

The Affordable Care Act affects access to reproductive services in many ways. Beginning in 2014 many individuals will purchase health insurance through the State Insurance Exchanges being drawn to this market by the affordable coverage made even more so by premium subsidies available to lower income individuals. The plans being offered through these exchanges must provide coverage that meets the benefits as defined under the Essential Health Benefits. However, it still remains unclear how Essential Health Benefits will be described and specifically what, if any, reproductive services will be included. Beyond the exchanges low income individuals will have access to the expansion in Medicaid occurring in many states starting also in 2014. Each state Medicaid program is responsible for describing their extent of coverage for reproductive services. Already in place affecting many younger individuals in need of reproductive services is the Dependent 26 provision, which provides coverage to dependents up to the age of 26 under a guardian's insurance. These provisions of the Affordable Care Act may increase access to reproductive services for many individuals previously uninsured or underinsured.

Evolving strategies for optimal care management and plan benefit designs

As a prevalent, complex disease, diabetes presents a challenge to managed care. Strategies to optimize type 2 diabetes care management and treatment outcomes have been evolving over the past several years. Novel economic incentive programs (eg, those outlined in the Patient Protection and Affordable Care Act of 2010 that tie revenue from Medicare Advantage plans to the quality of healthcare delivered) are being implemented, as are evidence-based interventions designed to optimize treatment, reduce clinical complications, and lower the total financial burden of the disease. Another step that can improve outcomes is to align managed care diabetes treatment algorithms with national treatment guidelines. In addition, designing the pharmacy benefit to emphasize the overall value of treatment and minimize out-of-pocket expenses for patients can be an effective approach to reducing prescription abandonment. The implementation of emerging models of care that encourage collaboration between providers, support lifestyle changes, and engage patients to become partners in their own treatment also appears to be effective.

Department of Health and Human Services. Patient protection and Affordable Care Act; data collection to support standards related to essential health benefits; recognition of entities for the accreditation of qualified health plans. Final rule

This final rule establishes data collection standards necessary to implement aspects of section 1302 of the Patient Protection and Affordable Care Act (Affordable Care Act), which directs the Secretary of Health and Human Services to define essential health benefits. This final rule outlines the data on applicable plans to be collected from certain issuers to support the definition of essential health benefits. This final rule also establishes a process for the recognition of accrediting entities for purposes of certification of qualified health plans.

The bare essentials. Release of LOM report leaves HHS to determine what should be covered by health benefits packages

In the wake of an IOM report on the criteria HHS should use to determine what benefits will be "essential" under reform, various stakeholders are weighing in. The National Association of Public Hospitals and Health Systems would like "enabling" services--such as language, transportation and case-management services--included, because they help make medical care more effective, says Xiaoyi Huang, left, of the NAPH.

A profile of social security child beneficiaries and their families: sociodemographic and economic characteristics

Using a rich dataset that links the Census Bureau's Survey of Income and Program Participation calendar-year 2004 file with Social Security benefit records, this article provides a portrait of the sociodemographic and economic characteristics of Social Security child beneficiaries. We find that the incidence ofbenefit receipt in the child population differs substantially across individual and family-level characteristics. Average benefit amounts also vary across subgroups and benefit types. The findings provide a better understanding of the importance of Social Security to families with beneficiary children. Social Security is a major source of family income for many child beneficiaries, particularly among those with low income or family heads with lower education and labor earnings.

Residential long-term care: public solutions to access and quality problems

Residential long-term care in Canada is characterized by unequal access and quality problems largely due to inadequate public funding and regulation, commercial involvement and its exclusion from medicare. Programs are patchwork, with variations across provinces in the availability of services, level of public funding, eligibility criteria and out-of-pocket costs borne by residents. Most provinces have cut long-term care bed capacity relative to the senior population in the past decade, without sufficiently expanding home and community care or adequately increasing staffing to reflect the higher acuity of the remaining residents. As a result, care is often rushed and underfunded, with poor working conditions leading to poor quality of care and quality of life for residents. This relationship between workers' and residents' well-being is well documented but poorly addressed. Also well researched but rarely reported are the negative impacts of privatization, at all levels: financing, ownership, management and delivery. This article describes the state of residential long-term care in Canada and proposes three policy directions: creating a pan-Canadian long-term care program, improving quality and reversing privatization.

Insurance data for research in companion animals: benefits and limitations

The primary aim of this article is to review the use of animal health insurance data in the scientific literature, especially in regard to morbidity or mortality in companion animals and horses. Methods and results were compared among studies on similar health conditions from different nations and years. A further objective was to critically evaluate benefits and limitations of such databases, to suggest ways to maximize their utility and to discuss the future use of animal insurance data for research purposes. Examples of studies on morbidity, mortality and survival estimates in dogs and horses, as well as neoplasia in dogs, are discussed.We conclude that insurance data can and should be used for research purposes in companion animals and horses. Insurance data have been successfully used, e.g. to quantify certain features that may have been hitherto assumed, but unmeasured. Validation of insurance databases is necessary if they are to be used in research. This must include the description of the insured population and an evaluation of the extent to which it represents the source population. Data content and accuracy must be determined over time, including the accuracy/consistency of diagnostic information. Readers must be cautioned as to limitations of the databases and, as always, critically appraise findings and synthesize information with other research. Similar findings from different study designs provide stronger evidence than a sole report. Insurance data can highlight common, expensive and severe conditions that may not be evident from teaching hospital case loads but may be significant burdens on the health of a population.

Cost minimization of medicare part D prescription drug plan expenditures

OBJECTIVE

To minimize out-of-pocket prescription drug plan (PDP) expenditures by Medicare beneficiaries.

STUDY DESIGN

Cost-minimization analysis.

METHODS

Trained student pharmacists from 6 California pharmacy schools provided expert guidance on Medicare Part D PDPs to beneficiaries through interventions at statewide outreach events. Demographic and insurance information for 2008 was collected via survey. Cost information for the beneficiary's current PDP for 2008 and for the least expensive PDP for 2008 was obtained using the Medicare Plan Finder tool (http://www.medicare.gov).

RESULTS

Data were collected from 250 beneficiaries at 22 outreach events. For the cost-minimization analysis, data were excluded from 72 beneficiaries who were not enrolled in a stand-alone PDP before the intervention and from another 23 beneficiaries for whom information regarding their current PDP or prescription drug profile was incomplete. Of the remaining 155 study participants, 39.4% were male, the mean (SD) age was 74.6 (8.7) years, and they were taking a mean (SD) of 5.3 (3.5) prescription drugs each month. In addition, 68 beneficiaries (43.9%) had limited or no English proficiency, and 85 beneficiaries (54.8%) were enrolled in both Medicare and Medicaid. In total, 89.7% of beneficiaries could have realized cost savings by switching to a different PDP. The median annual potential cost savings was $98 per beneficiary but this varied as a function of subsidy level.

CONCLUSION

Targeted community outreach services to Medicare Part D beneficiaries can help optimize patient selection of a PDP, thereby resulting in lower out-of-pocket expenditures.