Benefit Coverage Research Articles

System pomocy społecznej a starzenie się populacji – wyzwania i bariery w zakresie opieki długoterminowej

Starzenie się populacji Polski stawia przed społeczeństwem wyzwania związane z koniecznością zabezpieczenia zróżnicowanych potrzeb rosnącej grupy osób starszych. Pomimo postępu cywilizacyjnego (m.in. w zakresie technologii medycznych) nie każda osoba starsza będzie się cieszyła dobrym zdrowiem i zachowa zdolność do samoopieki do ostatnich dni życia. Część seniorów będzie mogła w przypadku wystąpienia różnego typu ryzyka, m.in. socjalnego lub zdrowotnego, liczyć na wsparcie ze strony rodziny. Natomiast według prognoz demograficznych i ekonomicznych zwiększać się będzie liczba seniorów, których zabezpieczenie potrzeb będzie uzależnione od wsparcia ze strony sektora pomocy społecznej. Celem artykułu jest przedstawienie, przed jakimi wyzwaniami staje sektor pomocy społecznej w związku z procesem starzenia się populacji. W szczególności, jakie są zakres, formy i rodzaje świadczeń z pomocy społecznej dla osób starszych oraz jakie są główne ograniczenia i bariery w ich realizacji. Zaprezentowane dane wskazują, że rządzącym w Polsce trudno będzie w najbliższym czasie sprostać zapotrzebowaniu na usługi opiekuńcze, szczególnie w wymiarze długoterminowym z uwagi na niedostatek zasobów, w tym ludzkich, finansowych itp. Dodatkowo w agendzie politycznej nie widać nacisku na tę sferę polityki publicznej.

The High Coverage of Dental, Vision, and Hearing Benefits Among Medicare Advantage Enrollees.

While the traditional Medicare program does not cover dental, vision, and hearing services, Medicare Advantage (MA) plans have been given the flexibility to do so. However, it is not known how many MA enrollees are in plans that cover these services. The 2016 Medicare Current Beneficiary Survey linked to MA plan benefit data is used to examine enrollment levels in plans that cover dental, vision, and/or hearing services in MA. Medicaid beneficiaries are excluded from this analysis as coverage of supplemental benefits is largely determined by the state. The highest coverage of supplemental services is vision, followed by hearing and dental (71%, 56%, and 41%, respectively). Across all supplemental services, coverage for supplemental benefits is highest among low-income beneficiaries and those who have not completed high school. Hispanic Medicare beneficiaries had the highest enrollment in plans that offered a supplemental benefit, and white Medicare beneficiaries tended to have the lowest enrollment in these plans. Unlike in traditional Medicare, MA enrollees have access to health plans that offer supplemental benefits, including dental, vision, and/or hearing services. This analysis shows that enrollment in these plans is highest among low-income MA enrollees who may not have the means to purchase stand-alone insurance for these services in traditional Medicare. More analysis is warranted to examine the generosity of the coverage of these services in MA plans. However, for federal policy makers to consider offering supplemental coverage in traditional Medicare, the MA experience suggests this type of benefit would be valuable.

Managed Care Experiences of Medicaid Enrollees with Disabilities: A Qualitative Analysis of Consumer Survey Responses.

This qualitative analysis of survey data explores service and care experiences reported by Medicaid enrollees with disabilities newly transitioned to managed care. Consumer surveys were distributed to a random sample of adult program enrollees with disabilities in an independent evaluation of one state's Medicaid managed care (MMC) rollout. Researchers performed conventional content analysis to code comments submitted by enrollee participants (N=402) in response to two open-ended survey items. Six key themes were observed in the data: (1) unmet medical, long-term services and supports (LTSS), and informational needs; (2) ineffective care coordination; (3) barriers in accessing providers; (4) limitations in benefit coverage; (5) unreliable transportation; and (6) variable provider care experiences. The results revealed salient managed care performance issues for the disabled Medicaid population. Enrollee experiences can inform recommendations for service access, provision capacity, and the integrated care of people with disabilities in the state MMC program.

Knowledge Management using Ontology Based Tantra Framework for Good Governance

This paper proposes ontology-based Tantra Framework that accommodates Societal Information in an orderly, compact and unified manner to achieve Good Governance . In this work, Zachman Framework for Enterprise Architecture is used as reference and it is extended to address information operating at societal scale. The complexity of social information gets accentuated due to myriad possibilities of relationships, say compared to information pertaining to an Enterprise. In light of that, two additional columns namely relationships and relators have been added to Zachman Framework in Tantra Framework. The existing six columns of Zachman Framework namely who, what, how, when, where and why are interpreted as People, Assets/Attributes, Process, Event, Location and Objectives respectively. In addition to the six interrogatives of Zachman Framework that are ontology based, the concept of relationships and relators has been derived from The Unified Foundational Ontology . Even though Zachman considered his framework as Ontology, some researchers regarded it as taxonomy. Tantra Framework has addressed that perceived gap by extending the Zachman Framework by adding two additional columns. Application Scenarios The utility of Tantra Framework is analyzed by applying it to a set of Application Scenarios pertaining to People and Locations information, Revenue Capture, Social Benefit Coverage Analysis, Financial Inclusion and Metrics analysis. Tanta Framework interoperates with Balanced Score Card approach to set objectives, Theory of Change to lay out a process of change and Bartels’ theory of Market Separations to assess the access barriers within Society. This research study is focused on Indian context. Tantra Framework relies on eliciting the inherent order in social information to make it complete, correct and current. For example, in Chemistry, discovery of periodic table by Mendeleev led to a unifying scheme which not only captured the present but allowed for place-holders for future discoveries. A similar focus on eliciting inherent order in social information, can potentially reveal latent ‘facts’, ‘truths’ and ‘relationships.

Moon Care: strategies and challenges

Improving financial risk protection in National Health Insurance (NHI) is essential to ensure people's access to health care services and protect them from medical bankruptcy. The previous government 's initiatives to enhance the benefit coverage of the NHI and improve financial risk protection have not been successful due to the balloon effect of non-covered services. MoonCare’s two key strategies for preventing the balloon effect were to introduce the preliminary benefit scheme (PBS) which converts all the medically essential non-covered services to be covered in a short period of time and to raise the fee of covered services to compensate financial loss of hospitals and clinics resulting from the benefit expansion. In order for MoonCare to be successful, the PBS should be systematically designed and implemented considering that it has two components such as the coverage with evidence development (CED) and value-based insurance design (VBID). Also, the fee should be increased in a selective manner to reduce the reimbursement imbalance across clinical areas and to strengthen the delivery system. Furthermore, the health policies closely aligned with the implementation of MoonCare should be reformed simultaneously. The existing claims review system should be transformed to peer review system based on the medical record review. Also, the delivery system should be strengthened so as to prevent the large hospitals from seeing more non-serious patients. To prevent the balloon effect, the use of non-covered services should be monitored and controlled and also, the new medical technology appraisal system should be also improved to systematically manage the PBS scheme. Keywords: MoonCare, strategy, challenge

Knowledge of local leaders members of user associations of exchange covered Kafr EL-Sheikh District, In Kafr EL-Sheikh Governorate

The main aim of this research was to determine the level of knowledge of the local leaders of the associations members of the drainage collectors who covered the importance and benefits of drainage and the importance of preserving the watercourses from pollution in Kafr El Sheikh Kafr El-Sheikh governorate on a sample of 175 subjects. The data needed to achieve the research objectives were met using a questionnaire interview The percentages were calculated using the percentages, the mean arithmetic, and the standard deviation. The main results were that about 64%, approximately 64%, about 60%, about 90%, About 96%, Of the research sample were enrolled in the low and medium knowledge level categories of the guiding recommendations on the importance and benefits of drainage and the importance of protecting the watercourses from pollution, respectively, and that the independent variables combined with the level of knowledge of local leaders members of the user associations of exchange pools covering the importance and benefits of drainage and the importance of Maintenance of watercourses from pollution with a multivariate correlation coefficient 0.577, a value determined at the probability level of 0.01 based on the value of (P), which reached 6.199. The results also indicate that the independent variables combined explain 33.6% In addition to the level of knowledge of the local leaders, members of the user associations of exchange pools covering the importance and benefits of drainage coverage and the importance of preserving watercourses from pollution based on the value of R2.

Optimising Contribution Rate for SOCSO’s Invalidity Pension Scheme: Actuarial Present Value (APV)

This study proposes the optimization of the contribution rate for Social Security Organization (SOCSO)’s Invalidity Pension Scheme (IPS). This study aims to statistically analyses the current situation of the contribution fund collection and the claim benefits payment under SOCSO’s IPS. It seeks to develop an actuarial formulation based on the benefits coverage from SOCSO’s IPS. It attempts to determine an optimal contribution rate to support the benefits provided under SOCSO’s IPS using an actuarial approach. It proposes an appropriate contribution rate to be implemented by SOCSO. Currently, the contribution rate for SOCSO’s IPS is 1%, which is shared equally between employer and employee. This contribution rate is directly deducted from the employee’s monthly gross salary. This contribution rate needs to be adjusted upwards by SOCSO soon to ensure that all payments of claims are sufficiently covered. Based on the 9th Actuarial Valuation Report issued by the International Labour Organization (ILO), recent statistics show that immediate revision of contribution rate is necessary to achieve the minimum loss ratio (max 20%) in SOCSO’s IPS funding systems. In this study, the Actuarial Present Value Approach is applied to all benefits under SOCSO’s IPS. SOCSO data from 1985 until 2014 are used in this study. Seven assumptions are made in this study namely mortality rate, salary ceiling, interest rate, retirement age, increment salary rate, age entry, and salary entry. By optimizing the worst-case scenario (single simulation), this study has found that the optimal contribution rate is 2.2% rather than the current 1%. This can be attributed to the fact that since 1969, many changes have occurred in the workplace, working conditions are different and many new jobs have been created. Therefore, an Actuarial Present Value Approach with regards to actuarial modeling was conducted to optimize SOCSO’s IPS contribution rate. In conclusion, an optimal contribution rate of 2.2% should be introduced and implemented in the future as part of the efforts to reduce society’s burden whilst ensuring that adequate protection is provided to the nation’s workforce.

Facial Feminization Surgery: The Ethics of Gatekeeping in Transgender Health

The lack of access to gender-affirming surgery represents a significant unmet health care need within the transgender community, frequently resulting in depression and self-destructive behavior. While some transgender people may have access to gender reassignment surgery (GRS), an overwhelming majority cannot afford facial feminization surgery (FFS). The former may be covered as a “medical necessity,” but FFS is considered “cosmetic” and excluded from insurance coverage. This demarcation between “necessity” and “cosmetic” in transgender health care based on specific body parts is in direct opposition to the scientific community’s understanding of gender dysphoria and professional guidelines for transgender health. GRS affects one’s ability to function in an intimate relationship, while FFS has the same impact on social interactions an, therefore may have a far greater implication for one’s quality of life. FFS is a cost-effective intervention that needs to be covered by insurance policies. The benefits of such coverage far exceed the insignificant costs.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study

BackgroundSmall private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers’ ability to serve poorer patient populations with quality health services?MethodsIn-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials’ experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically.ResultsPrivate providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers’ abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.ConclusionsOur data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.

Targeted Reforms in Health Care Financing to Improve the Care of Adolescents and Young Adults

Significant changes have occurred in the commercial and government insurance marketplace after the passage of 2 federal legislation acts, the Patient Protection and Affordable Care Act of 2010 and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Despite the potential these 2 acts held to improve the health care of adolescents and young adults (AYAs), including the financing of care, there are barriers to achieving this goal. In the first quarter of 2016, 13.7% of individuals 18 to 24 years of age still lacked health insurance. Limitations in the scope of benefits coverage and inadequate provider payment can curtail access to health care for AYAs, particularly care related to sexual and reproductive health and mental and behavioral health. Some health plans impose financial barriers to access because they require families to absorb high cost-sharing expenses (eg, deductibles, copayments, and coinsurance). Finally, challenges of confidentiality inherent in the billing and insurance claim practices of some health insurance plans can discourage access to health care in the absence of other obstacles and interfere with provision of confidential care. This policy statement summarizes the current state of impediments that AYA, including those with special health care needs, face in accessing timely and appropriate health care and that providers face in serving these patients. These impediments include limited scope of benefits, high cost sharing, inadequate provider payment, and insufficient confidentiality protections. With this statement, we aim to improve both access to health care by AYAs and providers' delivery of developmentally appropriate health care for these patients through the presentation of an overview of the issues, specific recommendations for reform of health care financing for AYAs, and practical actions that pediatricians and other providers can take to advocate for appropriate payments for providing health care to AYAs.

Transfusion Requirements and Hospitalization during First Line Treatment Among Newly Diagnosed Acute Myeloid Leukemia Patients Who Were Ineligible for Intensive Chemotherapy

Background: Newly diagnosed acute myeloid leukemia (ND AML) patients (pts) ineligible for intensive chemotherapy have limited treatment options. Most commonly used low intensity regimens are azacitidine (AZA), decitabine (DEC), or low-dose cytarabine (LDAC). These patients often have low blood counts that may contribute to poor quality of life (QoL) due to high risk for infections and may require transfusion of blood products. The objective of this study was to describe the patient characteristics, treatment patterns, and quantify the clinical outcomes (i.e., transfusion requirements infections and hospitalizations (hosp) among ND AML pts ineligible for intensive chemotherapy who received currently available therapies as first-line (1L) treatment in a real-world cohort.Methods: Eligible pts were found in the de-identified Optum© Clinformatics® Data Mart between 1/1/2010 and 6/30/2017 and had the following: AML at ≥2 encounters (ICD-9/10 codes) at least 30 days apart, ≥ 60 yrs. at diagnosis (dx), and ≥6 months (mo) benefit coverage before and ≥ 3 mo post dx. 1L treatment date (tx-index) was the date of first monotherapy (AZA, DEC, or LDAC) after AML diagnosis. 1L treatment duration was from tx-index to the end of study (EOS) defined as either end of 1L treatment, end of benefit coverage, relapse, or 12/31/2017. Transfusion independence (TI) during 1L treatment was defined as having neither platelets nor red blood cells (RBC) for ≥56 consecutive days (56-day TI). Patients with < 56 days of observation time from tx-index were not classified as achieving ≥56-day TI. During 1L treatment, transfusion support was defined as patients receiving either platelets and/or RBC regardless whether or not patients achieved ≥56-day TI. Sample selection and creation of analytic variables were performed using the Instant Health Data (IHD) platform (BHE, Boston, MA). Statistical analyses were undertaken with SAS software version 9.4 (SAS Institute Inc., Cary, NC, USA).Results: Among 785 eligible pts, 82.0% had Medicare Advantage, 59.2% were male, and the mean (median; range) age was 74.7 (75.0; range 60.0-89.0) yrs. The mean (median; range) baseline comorbidity score (measured by Quan Charlson Comorbidity Index, CCI) was 1.5 (1.0; 0-11), with an available follow-up period of 13.6 (10.6; 3.0-88.5) mo.As1L treatment, majority of pts received AZA (n=422, 53.8%) followed by DEC (n=337, 43.0%) and LDAC (n=26, 3.3%) and the mean (median; range) duration of treatment was 5.6 (3.7; 0.03-52.0) mo. A total of 4.5% (35) patients had major or minor GI hemorrhage, 1.9% (15) brain hemorrhage, and 48.7% (382) had infections of all grades (AZA: 202/422, 47.9%; DEC: 170/337, 50.5%; LDAC: 10/26, 38.5%).Prior to receiving 1L treatment, 48.0% (377/785) of patients required transfusion of either platelets and/or RBC (Table 1). During 1L treatment, 73.3% (575) of pts received transfusion support with a mean (median; range) of 8.5 (5.0; 1-181) transfusions of either platelets and/or RBC. Among 377 patients with transfusion support prior to 1L treatment, 33.7% (127/377) of patients achieved ≥ 56-day TI during 1L treatment (Table 1).Multivariate logistic regression showed pts with baseline transfusion requirement were less likely to achieve ≥56 consecutive day TI during 1L treatment vs. pts without baseline transfusion requirements (33.7% vs. 58.6%; OR = 0.37; 95% CI = 0.27 - 0.50; P < 0.001) with the current treatments.Among 785 patients during 1L treatment, the mean (median; range) number of hospitalizations was 0.91 (1.0; 0-8). A total of 53.1% (417) had ≥ 1 hospitalization; the mean (median; range) length of an inpatient stay was 10.9 (7.0; 1-97) days for these patients; and 49.4% (206), 75.1% (313), and 87.3% (364) of patients were admitted within 30, 60, 90 days of tx-index, respectively.Conclusions: This real-world study in ND AML patients showed transfusion burden on patients with the currently available non-intensive treatment with AZA and DEC being the most commonly used agents. Most (61.5%-80.1%) of the pts required transfusions for platelets and /or RBC and less than 40% (0%-38.6%) of the patients with baseline transfusion requirement achieved ≥56 consecutive days of transfusion independence anytime while receiving their 1L treatment. Additional research is warranted to understand the correlation between response to treatment and transfusion independence and subsequent impact on hospitalization and infections. DisclosuresBui:AbbVie: Employment. Marshall:AbbVie: Employment, Equity Ownership. Kamalakar:AbbVie: Employment. Posadas:AbbVie: Employment. Potluri:AbbVie: Employment, Equity Ownership.

Prevalence and Predictors of Renal Impairment Among Patients with Multiple Myeloma (MM): An Analysis of Oncology Clinic Electronic Health Records Linked to Commercial Claims in the United States

BackgroundAlthough incurable, MM is responsive to treatment, and the prognosis of MM patients has improved dramatically over the past two decades. This has led to increased recognition of the importance of effective long-term management of the classic clinicopathological features of MM. Renal impairment (RI) is a defining hallmark of active myeloma. While it is known that RI is associated with poor survival and can complicate drug dosing and limit treatment options, patterns of renal function and risk factors of RI in MM are poorly characterized. This study seeks to characterize the natural history and risk factors of RI in MM using a unique real-world dataset that links patient-level electronic health records (EHR) to healthcare insurance claims.MethodsThe Oncology Services Comprehensive Electronic Records (OSCER) database contains EHR data from community and hospital-affiliated oncology clinics in the U.S. The MarketScan (MS) database contains healthcare claims information from large employers, managed care organizations, Medicare, and Medicaid programs. This study used a subset of MM patients with overlapping data from OSCER and MS, allowing the analysis of EHR-based serum creatinine and claims-based comorbidity data in the same patient.Patients ≥ 18 with a MM diagnosis between 2011 and February 28, 2016 in an OSCER clinic; had at least 6 months of continuous MS benefits coverage; no MM diagnosis in MS in the 3 months prior to OSCER MM diagnosis; and no evidence of another malignancy prior to MM diagnosis were included in the study. Index date was the date of OSCER MM diagnosis and patients were followed up until February 28, 2017. Baseline (BL) patient characteristics and potential risk factors of RI, including demographics, BMI, ECOG, ISS stage, and comorbidities (e.g., hypertension, diabetes, hypercalcemia, etc.) were assessed in the 6 months prior to index. Intravenous bisphosphonate (IV BP) use was assessed during follow-up. Renal function was assessed using the MDRD eGFR method or CKD stage diagnosis codes, with RI defined in this study as eGFR < 60 or stage 3+ CKD. BL eGFR was assessed using the serum creatinine measurement closest to the index in the interval 1 month before and 1 month after index.The prevalence of RI in the year following diagnosis was calculated based on the average number of at-risk patients during this period. Change in renal function for up to 4 years post-diagnosis was assessed by BL renal function and was characterized based on the worst recorded estimate of renal function during this period. A multivariate Cox model was used to assess the impact of BL risk factors and IV BP use during follow-up on progression to RI in patients without RI at BL (eGFR ≥ 60 and CKD diagnosis). Follow-up IV BP use (dose count) was treated as a time-dependent variable.ResultsThe median number of eGFR values recorded per patient during follow-up was 18 (range: 7-36). Among newly diagnosed MM patients (n = 625), 69% (95% CI: 65-73%) experienced ≥ 1 episodes of eGFR < 60 ml/min or stage 3+ CKD diagnosis (RI) within 1 year of diagnosis, with 16% (13-20%) experiencing an episode of eGFR 15-29 or stage 4 CKD and 15% (11-18%) experiencing an episode of eGFR < 15 or stage 5 CKD.Among patients without RI at diagnosis (n = 281), 37% (31-43%) subsequently experienced at least one episode of RI during follow-up (Figure 1). In addition, 26% (20-32%) of patients with BL eGFR 30-59 or stage 3 CKD experienced progression to an episode of eGFR < 30 or stage 4+ CKD, and 31% (20-42%) of patients with BL eGFR 15-29 or stage 4 CKD progressed to an episode of eGFR < 15 or stage 5 CKD.In our multivariate Cox model, use of the IV BP zoledronic acid (ZA) during follow-up; ECOG; baseline eGFR; known predisposing conditions, including autoimmune diseases, vascular conditions, and infections of the kidney were found to be associated with higher risk for experiencing an episode of RI in patients with high BL renal function (Figure 2). In our sample, 12 doses of ZA was associated with a 2.4-fold (1.2-4.8) increase in risk of RI. A baseline ECOG of 1 vs. 0 was also associated with a 2.4-fold (1.1-5.2) increase in risk of RI.ConclusionsUsing a unique EHR-insurance claims linked data source, we found that two-thirds of patients experienced at least one episode of renal impairment within the first year of MM diagnosis. Repeated exposure to zoledronic acid and poor performance status may increase the risk of RI in patients without renal impairment at diagnosis. DisclosuresBlock:Amgen, Inc.: Consultancy. Fu:Amgen: Employment, Equity Ownership. Wade:Wade Outcomes Research and Consulting: Employment, Equity Ownership. Jaramillo:Amgen, Inc.: Consultancy; SimulStat: Employment. Bhatta:Amgen, Inc.: Employment, Equity Ownership. Raskin:Amgen, Inc.: Employment, Equity Ownership. Hernandez:Amgen, Inc.: Employment, Equity Ownership.

2472. The Impact of State Medicaid Policies on Adult Vaccination Post Affordable Care Act Implementation

BackgroundMedicaid rules permit each state to determine which adult vaccines will be covered, the cost-sharing policy for adult vaccination services, provider reimbursement policy, and the settings where vaccines may be administered. Aside from coverage and cost-sharing policy variability across the country, provider reimbursement remains a large challenge to adult immunization services. Evidence shows that pregnant women with Medicaid insurance have lower rates of Tdap vaccination than those women who are privately insured. This study investigates the differences in policies in both fee for service and managed care arrangements post ACA implementation.Methods(1) Statutory and regulatory codes of all 50 states and DC were collected and relevant laws were analyzed and coded based on characteristics of the provisions. (2) Attorney identified and reviewed all publicly available material relating to benefit coverage, cost-sharing, and payment for adult vaccination under Medicaid from all 50 states and DC. (3) PHLP attorney conducted interviews of state Medicaid Directors. Questions addressed coverage, cost-sharing, and reimbursement policies in FFS and MCO arrangements and examined what factors influence policy design in and how immunizations are promoted thru Medicaid.ResultsDue to ACA, 32 states and D.C. implemented an expansion and 19 haven’t. Those adults who now receive insurance via expansion have access to all ACIP adult vaccinations with no cost-sharing. 14 of these states and one non expansion state cover all Medicaid enrollees. There are 35 states and DC that have traditionally enrolled Medicaid adults where coverage may not exist or cost-sharing does exist. Payment also varies and in many cases reimbursement falls below the private sector payment resulting in providers who are unwilling to take a financial loss on providing vaccinations and facilities not receiving payment for vaccination services.ConclusionMany factors may impact adult immunizations some occur before a patient has the opportunity to choose to vaccinate. Sometimes providers are taking financial losses by vaccinating. Coverage and cost-sharing barriers still exist for non-expansion adults. Results from this study can help inform Medicaid polices and provide Medicaid programs insight into other policies around the country.Disclosures All authors: No reported disclosures.

Role of Health Technology Assessment in Drug Policies: Korea

South Korea is the first Asian country to mandate the submission of pharmacoeconomic data for reimbursement decision making. For a new drug to be listed, it must demonstrate its value in terms of comparative effectiveness and cost effectiveness. The Health Insurance Review and Assessment Service (HIRA) judges the submitted drug’s value and decides whether its coverage is appropriate on the basis of the recommendation of the Pharmaceutical Benefit Coverage Assessment Committee. Once the drug has been accepted by HIRA, the National Health Insurance Service and the sponsoring company negotiate the price and expected sales volume. Even if HIRA acknowledges the value of the drug, it cannot be listed if the negotiation fails. In the off-patent market, generic and original branded drugs are treated equally in terms of pricing. Once generics enter the market, both drug prices should be lowered to 53.55% or less of the on-patent price. Since the current system was implemented, concerns have been raised about a decline in the accessibility of new drugs, especially for high-priced drugs used to treat serious diseases. In 2013, several measures had been introduced aimed at improving the accessibility of these drugs. A risk-sharing scheme and an increase in the maximum acceptable cost-effectiveness ratio were subsequently initiated. Although these schemes have been successful in improving access to high-priced drugs, they are often criticized for reducing transparency in pricing. Finding a balance between accessibility and efficiency is still a challenge in Korea.

A Day-to-day Invariant Macroscopic Fundamental Diagrams for Probe Vehicles

The macroscopic fundamental diagram (MFD) for an urban area provides a new thought on aggregate traffic management and control that are less affected by details. The MFD is conventionally constructed by using loop detector data, which may not widely exist due to the limited coverage of hardware installation. In contrast, the probe vehicle data have the benefits of low cost and wide coverage. To make use of the widely existing low cost data, we propose an MFD for probe vehicles (pMFD). Taking Beijing road network as an example, we empirically demonstrate that the pMFD is day-to-day invariant in shape. We then explicitly analyse the relation between the pMFD and the conventional MFD. This study relaxes the data constraint of the MFD construction and provides a new insight on macroscopic network condition monitoring.

Relative risk of all-cause mortality in patients with nontuberculous mycobacterial lung disease in a US managed care population.

The risk of all-cause mortality of nontuberculous mycobacterial lung disease (NTMLD) in the United States (US) population is not well established. This study aims to assess the public health burden of NTMLD in the US by comparing the relative risk of all-cause mortality in the NTMLD population with an age- and sex-matched cohort from the general population. Patients with physician claims for NTMLD (ICD-9 0.031; ICD-10 A31.0) were identified between 2007 and 2016 from a large US national managed care insurance plan covering approximately 15-18 million members annually. A control group with no NTMLD ICD-9 or 10 codes was randomly selected from the general population and matched 3:1 to the NTMLD sample according to birth year, gender, and insurance benefit coverage. The date of first NTMLD diagnosis of each patient was assigned to the matched controls as the index date. The Cox proportional hazard method compared survival between cohorts, adjusting for demographic factors and baseline comorbidities. A total of 2005 patients with NTMLD and 6014 controls were identified, with a mean follow-up duration of 3.4 years and 3.7 years, respectively. The NTMLD group had substantially higher proportions of patients with asthma (23.3% versus 3.5%), bronchiectasis (36.5% versus 0.1%), COPD (52.0% versus 5.9%), arrhythmia (22.6% versus 6.5%), coronary artery disease (18.5% versus 6.6%), heart failure (11.9% versus 4.1%), and cancer (18.5% versus 5.0%). The unadjusted rate of all-cause mortality from the index date was 20.7 per 1000 person-years in the NTMLD group vs 5.6 per 1000 person-years in the control group (rate ratio = 3.73; 95% CI: 2.93-4.75). Multivariable Cox regression, adjusted for the above variables as well as all other important baseline covariates, showed a doubling risk of all-cause mortality (hazard ratio [HR] = 2.06; CI: 1.52-2.79; P < 0.001) in the NTMLD vs control group. All-cause mortality, adjusted for other factors, more than doubled with NTMLD compared with an age-sex-matched control group in a large US national managed care insurance plan.

The Political Economy of Unemployment Insurance based on Individual Savings Accounts: Lessons from Chile

ABSTRACTIn recent years, unemployment protection systems based on individual savings have been instituted in several developing countries. Chile was one of the first to establish such a system, which at the time was widely cited as a model for other countries. This article discusses the particular political context in which the Chilean system was created before examining how it works in terms of coverage and levels of benefits received by unemployed workers. The authors undertake a detailed analysis of the administrative data produced by the system and conclude that the insurance covers only a small proportion of the unemployed, as most workers generally had precarious jobs that did not allow them to contribute to the system consistently. The Chilean case illustrates how difficult it is to establish functioning unemployment insurance in developing countries with precarious labour markets. Based on the interaction between employment characteristics and the conditions imposed by the benefit system, the article assesses the efficacy of the Unemployment Insurance Savings Accounts (UISA) system and analyses whether it can indeed serve as a model for other developing countries.

Negotiations with Terrorist Organizations for the Release of Abductees: Between Declarations and Practice. The Israeli Case

For decades, democratic countries have dealt with terrorist attacks carried out for the purpose of negotiations, which is the preferred modus operandi for some terrorist organizations. To what extent can a democratic regime effectively combat this abominable act while preserving a liberal or democratic character? Furthermore, these cases have become one of the most complicated dilemmas in both domestic and foreign policy. The prevalent opinion is that it is not possible to avoid meeting some of the demands of these terrorists. A government may even consent to paying a heavy price, so as to end the situation sooner. Media coverage influences this price, as extensive coverage of the terrorist attacks benefits the terrorists and thus increases their bargaining power. In contrast to the declarations of Israeli leaders in negotiations in cases of abduction, Israel has adopted a very flexible approach and is not interested in adopting the rigid approach of refusal to negotiate. The position of the opponents to negotiations with terrorist organizations is that the very negotiations with terrorist organizations legitimize them and the terrorist attacks, thus devaluing claims that terrorism is not a legitimate means of achieving one’s aims, and prevents the use of force in these situations. When all the prisoner exchange deals by the State of Israel are examined, approximately 7,500 terrorists have been released in the framework of the different deals, including terrorists with blood on their hands, in return for 14 living soldiers and civilians and 6 bodies of soldiers. A total of 1,027 terrorists were released in the Shalit deal alone.

DVB-S2X based Non-Linear Distortion Cancellation using 64-APSK for Satellite Forward Link

Objective: This paper aims at designing DVB-S2X based satellite forward link with higher order modulation scheme for achieving large data transmission with less prone to distortion. Method: The 64-APSK modulation scheme is used to design this forward link with MATLAB Simulink version 17. Findings: The high quality end-to-end transmission with less design complexity is achieved with addition of phase noise at user terminal, satellite transponder with IMUX, OMUX filter response and TWTA characteristics. The analysis of channel performance can be done through constellation diagram. Application: It enables traffic demand and bandwidth-demand adaptation benefits for large area coverage. Keywords: Satellite Forward Link, DVB-S2X, 64-APSK, OMUX, TWTA

A paradigm shift: from doctor-patient to payer-patient relationship.

Before the Second World War most individuals had a physician who was responsible for their health from cradle to grave. I don’t want to idealise that situation but there is no doubt that the relationship was a private interaction based on trust. In the past, the payer used to be the patient and the relationship was clear; now we pay indirectly. The payer may be the government through a mixture of taxes, employer contributions, and national insurance, or they may be an insurance company or a health maintenance organisation. In the brave new world after the Second World War many countries developed models of universal health coverage. The benefits of universal health coverage for the citizens were explicit and defined in the Bismarck model;1 they were vague and implicit in the Beveridge model.2 However, this did not much matter because modern medicine was in its infancy, the populations were younger, and medical technologies relatively cheap. There was no mention or thought given to quality of care provided, the assumption being that the physicians would do their best. In most people’s minds health was simply the absence of illness. The increasing costs of new technologies3 and the ageing population have made the promises of full universal health care very challenging as the payers collect data in their effort …