Insurance Department Research Articles

Age Effect on Incidence, Physical, and Psychiatric Comorbidity for Sudden Cardiac Death in Schizophrenia: Effet de l’âge sur l’incidence, la comorbidité physique et psychiatrique de la mort cardiaque subite dans la schizophrénie

The pathogenesis of sudden cardiac death may differ between younger and older adults in schizophrenia, but evidence remains scant. This study investigated the age effect on the incidence and risk of the physical and psychiatric comorbidity for sudden cardiac death. Using 2000 to 2016 data from the Taiwan National Health Insurance Research Database and Department of Health Death Certification System, we identified a national cohort of 170,322 patients with schizophrenia, 1,836 of whom had a sudden cardiac death. Standardized mortality ratios (SMRs) were estimated. Hazard ratios and population attributable fractions of distinctive comorbidities for sudden cardiac death were assessed. The SMRs of sudden cardiac death were all >1.00 across each age group for both sexes, with the highest SMR in male patients aged <35 years (30.88, 95% CI: 26.18-36.18). The fractions of sudden cardiac death attributable to hypertension and congestive heart failure noticeably increased with age. By contrast, the fraction attributable to drug-induced mental disorder decreased with age. Additionally, chronic hepatic disease and sleep disorder increased the risk of sudden cardiac death in patients aged <35 years. Dementia and organic mental disorder elevated the risk in patients aged between 35-54 years. Ischemic heart disease raised the risk in patients aged ≥55 years. The risk is increased across the lifespan in schizophrenia, particularly for younger male patients. Furthermore, physical and psychiatric comorbidities have age-dependent risks. The findings suggest that prevention strategies targeted toward sudden cardiac death in patients with schizophrenia must consider the age effect.

Ambulatory care, insurance, and avoidable emergency department utilization in North Carolina

To examine whether and how avoidable emergency department (ED) utilization is associated with ambulatory or primary care (APC) utilization, insurance, and interaction effects. A cross-sectional analysis of electronic health records from 70,870 adults residing in Mecklenburg County, North Carolina, who visited an ED within a large integrated healthcare system in 2017. APC utilization was measured as total visits, categorized as: 0, 1, and>1. Insurance was defined as the method of payment for the ED visit as: Medicaid, Medicare, private, or uninsured. Avoidable ED utilization was quantified as a score (aED), calculated as the sum of New York University Algorithm probabilities multiplied by 100. Quantile regression models were used to predict the 25th, 50th, 75th, 95th, and 99th percentiles of avoidable ED scores with APC visits and insurance as predictors (Model 1) and with an interaction term (Model 2). Having >1 APC visit was negatively associated with aED at the lower percentiles and positively associated at higher percentiles. A higher aED was associated with having Medicaid insurance and a lower aED was associated with having private insurance, compared to being uninsured. In stratified models, having >1 APC visit was negatively associated with aED at the 25th percentile for the uninsured and privately insured, but positively associated with aED at higher percentiles among the uninsured, Medicaid-insured, and privately insured. The association between APC utilization and avoidable ED utilization varied based on segments of the distribution of ED score and differed significantly by insurance type.

Analysis of medical expenses of inpatients with diabetes: China's Eastern, Central, and Western regions (2013–2015)

ObjectiveWith the continuing rise in the global incidence of diabetes, the prevention of diabetes and control of associated medical expenses has become a public health issue worldwide. This study aims to identify the medical expenses of patients with diabetes in different regions of China and examine the differences in inpatient medical expenses and the impacts of them on these patients. Study designThis study is a longitudinal analysis of medical expenses for inpatients with diabetes for different years; horizontal analysis of medical expenses among different regions; and literature review. MethodsData were derived from China's Medical Insurance Department database. We selected inpatients with diabetes in the eastern, central, and western regions of China for the period 2013–2015 and randomly selected data through systematic sampling. ResultsAmong the 4150 patients with diabetes considered in this study, the patients' medical expenses were found to differ significantly across regions, years, ages, medical insurance types, medical institution levels, total medical expenses, medical insurance fund payments, and out-of-pocket (OOP) expenses. In addition, there were significant differences in total medical expenses for male and female patients. Furthermore, medical insurance type, patients' age, medical institution level, and year significantly influenced total medical expenses. ConclusionsInpatients with diabetes in different regions exhibited significant differences in total medical expenses, medical insurance fund payments, and OOP expenses. China should invest more in chronic disease treatment in its central and western regions, narrow the regional differences in medical expenses, and endeavor to ensure equity in the availability and cost of medical services. Moreover, patients with diabetes must be encouraged to access primary care to reduce their medical expenses.

Surprise Billing in Surgical Care Episodes - Overview, Ethical Concerns, and Policy Solutions in Light of COVID-19.

Surprise Billing in Surgical Care Episodes - Overview, Ethical Concerns, and Policy Solutions in Light of COVID-19.

Arizona Passes Sweeping Legislation on MH Parity, Access to Care

Arizona Passes Sweeping Legislation on MH Parity, Access to Care

Incidence and risk factors of sudden cardiac death in bipolar disorder across the lifespan

ObjectiveData on the incidence and risk factors of sudden cardiac death in patients with bipolar disorder are lacking in the literature. MethodsBy using data from the Taiwan National Health Insurance Research Database and Department of Health Death Certification System between 2000 and 2016, we conducted a prospective national cohort study to determine the incidence and risk factors of sudden cardiac death in bipolar disorder patients. The study cohort included 46,490 patients with bipolar disorder, 467 of whom experienced sudden cardiac death. ResultsStratified analyses showed that the standardized mortality ratios (SMRs) of sudden cardiac death were all above 1.00 across each age interval, with the highest SMR in patients aged <30 years (31.96, 95% CI: 20.47–47.55). Notably, hypertension raised the risk of sudden cardiac death in both patients aged <50 years (1.85, 95% CI: 1.23–2.79) and aged ≥50 years (1.44, 95% CI: 1.14–1.83). In addition, venous and lymphatic disorders (1.97, 95% CI: 1.23–3.16), and alcohol use-related disorder (2.34, 95% CI: 1.62–3.38) elevated the risk of sudden cardiac death in patients aged <50 years. Congestive heart failure (1.59, 95% CI: 1.13–2.23) and dementia (1.75, 95% CI: 1.30–2.35) increased the risk of sudden cardiac death in patients aged ≥50 years. ConclusionsThe risk of sudden cardiac death is remarkably high in bipolar disorder patients across the lifespan. Prevention strategies specific to individuals with bipolar disorder are urgently required.

Availability of essential medicines in primary care in Vietnam

ABSTRACT Background: The constant availability of essential medicines at primary care is important for credibility and equity of healthcare services, especially for disadvantageous population. Methods: This study used the existing data to evaluate the availability of 30 essential medicines in 78 district health centers (DHCs) and 246 commune health stations (CHSs), located in 6 ecological regions in Vietnam. Descriptive statistics were used to describe the number of medicines, level, and percentage of availability. Analytical statistics were used to determine the differences between commune and district level. Results: On average, DHCs had 15.5 (SD = 4.5), and CHSs had 10.5 (SD = 5.3) of 30 medicines. 56.4% DHCs had fairly high or high level of availability. Meanwhile, the rate at commune level was only 24.8%. None of the surveyed health facilities had enough 30 selected medicines. The study findings showed considerable variation in the availability of medicines across ecological regions, therapeutic groups; as well as among medicines for chronic and acute diseases, or over-the-counter and prescription ones. Conclusions: The study demonstrated a poor availability of essential medicines across all levels of primary healthcare in Vietnam. Policymakers of the Drug administration and Health insurance department should soon work together to develop and regulate such a list of essential medicines.

Perception of Healthy Lifestyle Among Students of Medical Schools

Abstract Introduction/Aim: The aim of the present study was to evaluate ideas and motivational attitudes of medical school students towards a healthy lifestyle and its components. Methods: The study was conducted from March until August 2017, at the Department of Medical Sociology, Healthcare Economics and Health Insurance and at N.A. Semashko Public Health and Healthcare Department, I.M. Sechenov First Moscow State Medical University. We ran a medical and sociological survey in 984 randomly selected students from eight Russian medical universities. Results: The article presents the results of the medical and sociological study aimed at assessing the ideas and motivational attitudes of medical students towards healthy lifestyle and its elements. Our research showed that students of medical schools, while recognizing the importance of preserving their own health, are still largely committed to an unhealthy lifestyle, secondly, they refuse sports activities even more often, and, thirdly, they prove not to be active enough when it comes to disease prevention and health preservation. Conclusion: Taking into consideration the obtained results, healthy lifestyle among students of medical schools is an exception rather than common practice.

Pennsylvania launches statewide mental health initiative

Leaders from various state agencies joined Pennsylvania Gov. Tom Wolf Jan. 2 to launch a new statewide mental health initiative called “Reach Out PA: Your Mental Health Matters,” WENY News reported. The goal is to improve mental health care for residents. The initiative has four components: strengthening mental health care access, combating mental health stigma, increasing support and resources for children and young adults, and preparing state agencies and workers to help and reach out. Mental health advocates say it's important all parties involved work as a cohesive unit. “I want every Pennsylvanian to feel comfortable reaching out to someone if they're struggling,” says Wolf. “I want every Pennsylvanian to feel comfortable reaching out if they know someone else is struggling. I want to end the silence, because I want to end the stigma.” The Pennsylvania Insurance Department will make sure health insurance coverage provides access to affordable mental health care, the Departments of Labor &amp; Industry and State will work to address the lack of mental health workers in Pennsylvania and the Department of Education will work to increase the number of social workers inside schools across the state. Wolf is getting to work on this mental health initiative right away. He held the first roundtable discussion on Jan. 3.

Annuities are not securities: the regulatory Island in Illinois

PurposeDiscusses the significance of the Illinois Supreme Court ruling in Van Dyke v. White, which clarified that annuities are not securities in the state of Illinois, with a particular focus on the ramifications to insurance, brokerage and investment advisory standards of care as well as causes of action for breaches thereof.Design/methodology/approachDescribes the Court’s ruling as it relates to the industry going forward. Does not discuss the specifics of the plaintiff’s case or history.FindingsThe statutory language of Illinois’ securities laws specifically excludes annuities from the definition of securities. For this reason, the Illinois Department of Insurance has sole authority over regulating annuities, giving the Illinois Department of Securities no authority, except to the extent there is an investment advisor breach pursuant to §12(J) of the Illinois Securities Law of 1953. The industry has yet to react or adjust to the Court’s ruling, so there may be a future wave of reactions.Originality/valueAssists the reader in understanding the unique regulatory environment of annuities in Illinois, the relevant standards of care related to annuity advice and transactions, and remedies for grievances after the Illinois Supreme Court ruling in Van Dyke v. White.

Developing a team performance framework utilising Neethling’s thinking style preference instrument

Orientation: This article focuses on the employees and managers’ experience of the effects of Neethling’s thinking style preference instrument on team performance.Research purpose: The purpose of this study was to compile a framework to apply Neethling’s thinking style preferences to team performance.Motivation for the study: Organisations today are aware that they need to increase quality, decrease costs, advance customer service, increase their adaptability to an increasingly competitive environment and decrease the time spent on creating new products. To realise these goals, organisations must convert their work teams into more cohesive and dedicated teams. No or limited research has been conducted on how the application of Neethling’s thinking style preferences may influence team performance.Research approach/design and method: A qualitative exploratory study was conducted with 19 participants working in the Financial and Insurance Department of a sales-driven organisation in Gauteng, South Africa. The data were collected by means of focus group and individual interviews.Main findings: The positive effects of the Neethling’s thinking style preferences on the team were that the participants understood people better, their conflict management skills increased, their self-awareness improved, the communication in the team increased and they experienced an increase in team cohesion. The negative experiences were task avoidance, labelling and wrong assessments of people, but the positive experiences exceeded the negative experiences. Due to the positive experiences, the organisation also benefitted in terms of improved customer service and increased productivity, which could lead to organisational success and a competitive advantage.Practical/managerial implications: When used in teamwork, the Neethling’s thinking style preference instrument shows positive outcomes regarding team performance.Contribution/value-add: The findings of this study contribute new knowledge regarding the application of Neethling’s thinking style preferences in team performance.

In Case You Haven't Heard…

Failing to pay for needed mental health and addiction treatment has resulted in a $1 million fine for United Healthcare by Pennsylvania officials, The Philadelphia Inquirer reported Nov. 4. The company violated the federal Mental Health and Addiction Equity Act. “While we have already made changes, we will continue to make improvements to help individuals get care under their plans,” the company said in a statement. “We will collaborate with the Insurance Department to help more Pennsylvanians meet their mental health needs by providing additional resources and education to help them understand and access their benefits.”

Total per-visit medical expenses incurred by outpatients with diabetes-Evidence from six provinces in eastern China.

Chronic diseases associated with diabetes threaten the health of Chinese people and contribute to poverty. Medical service utilization records of 78 124 visits by outpatients with diabetes to medical institutions in China's eastern region between 2013 and 2015 were randomly selected from the Medical Insurance Department (MID) database. One-way analysis of variance (ANOVA) was used to compare the average total per-visit, out-of-pocket (OOP), and medical insurance (MI) fund expenses between variables. Multiple linear regression analysis was performed to identify possible risk factors affecting total per-visit medical expenses. Average total per-visit medical expenses were 244.59, 285.56, and 435.33 yuan in primary, secondary, and tertiary medical institutions, respectively. Significant differences were found for average total per-visit medical expenses by year of visit, age, type of medical insurance, and levels of medical institutions. No significant differences were found for average total per-visit medical expenses by gender. The functions of medical networks at all levels should be clarified and the Urban Resident Basic Medical Insurance (URBMI) reimbursement ratio improved to ensure equal access to medical services irrespective of medical insurance type. Patients with chronic diseases should be encouraged to visit primary medical institutions to reduce medical expenses.

BUDGETARY REVENUE BREAKDOWN AT THE LOCAL LEVEL OF PUBLIC ADMINISTRATION IN FEDERAL COUNTRIES

Ensuring the financial autonomy of local government bodies is an important component for creating conditions on accelerating the development of individual territories of the country and increasing the efficiency of their use. Creation of mechanisms for providing sufficient amounts of financial resources, activities of the above-mentioned authorities require thorough research in this area, especially within the study of foreign experience by building budget systems and organizing redistribution of financial resources between their individual components at different levels. Experience of federative countries is particularly significant in this area. The outlined confirms the relevance of the chosen topic of the article. Accordingly, the following goal of the research was set – to identify structural features and trends in the transformation of budget revenues at the local level of public administration in federative countries from 2000 to 2015. To achieve this goal, the following tasks were set: to determine the revenues structure of local government in federative countries; to analyse main tendencies of the change of the specified structure during 2000–2015; to apply cluster analysis in order to identify groups of countries that are similar to the processes of revenue generation of local government budgets in federative countries. Methodology. Statistics for assessment of budgetary revenue’s breakdown in several federative countries by the IMF data was processed, assessment of breakdown transformation with the use of the Ryabtsev index was done, and similarity and distinctions of revenue’s breakdown in different countries with the use of the hierarchical cluster analysis was investigated. Outcomes. It was found that among the analysed federative countries, the own tax revenue has a significant share (higher than 30% in a breakdown of all revenue) only in Belgium, Germany, Australia, Canada, and also in Bosnia and Herzegovina; the inter-budgetary transfers take the main position in financing of local budgets in Austria, Belgium, Canada, Russia, and Brazil; own non-tax revenues in local budgets are significant only in Australia and Bosnia and Herzegovina. It was proved that in fifteen years only in Russia, the opposite type of revenues breakdown sources was created and it demonstrates shifting to the centralization of public finance. It was also revealed that in 2000, the countries’ cluster structure by breakdown sign had obviously expressed group character, but further it evolved from a group structure to the step structure displaying specifics in the formation of local budgets’ revenues in each country. Practical implications. Practical outcomes of the study are analytical information on the structure of revenues of local government in federative countries, which may be useful by introducing new mechanisms for increasing the financial autonomy of local self-government. In addition, the obtained data may be useful for other not federative countries in terms of studying peculiarities of the formation of budget revenues of local government and analysis of the impact of such revenues on the socio-economic development of separate territories. Value/originality. The conducted study is relevant given the importance of developing local government in federative countries and providing it with the necessary financial resources for independent self-functioning. The data obtained during the research implementation are of practical value and can be used in the process of implementing measures to increase the financial independence of budget revenues at the level of local self-government in federative countries. This research was carried out within the framework of the scientific work performing of the Department of Finance, Banking and Insurance of the Chernihiv National University of Technology on the following topics: “Financial stability of economic systems in crisis management” (No. 0115U001149) and “Theoretical and applied aspects on financial provision of the national economy” (State Registration No. 0113U002741).

Integrating Fuzzy Prioritization Method and FMEA in the Operational Processes of an Automotive Company

This study includes a risk analysis application. In the article the authors analyzed insurance department's operational processes between October 2015 to April 2016 with a Failure Mode and Effect Analysis (FMEA) of an automotive firm. In the FMEA application, the article summarized engineers and managers opinions during process development and benefitted from these engineers and managers for analysis of these failures one by one. In application study is constructed on data transfer systems analysis among dealer, insurance departments and insurance companies for risk management. The purpose of this study is for the sample company revealing all failures, the reasons for these failures and making a risk analysis of these failures. In this study, for all determined failures was the calculated risk level with the occurrence, severity, and detection score, and preventive functions were organized according to these risk level scores. Using the fuzzy prioritization method for the evaluation of failures, more objective evaluations were attempted and suggestions for the prevention of failures have improved RPN values of 5 failures. In this way, the 5 failures RPN values are lower than 100.

IMPLEMENTASI KERAHASIAAN INFORMASI MEDIS DALAM REKAM MEDIS PASIEN ( Studi Kasus di Rumah Sakit Islam AT-TIN HUSADA Ngawi Jawa Timur)

The implementation of the confidentiality of medical record documents at RSI AT-Tin Husada Ngawi which is still not kept confidential, it can be seen from the patient's medical record documents in the insurance department and in the BPJS unit more than 24 hours for claims purposes, the medical records of inpatients should be 2x 24 hours must be returned to the medical record unit. This type of research is descriptive qualitative. The study was conducted at RSI AT-Tin Husada Ngawi in September 2018. The subjects were medical records officers, doctors and patients, using the Observation and Interview method, using a retrospective and the technique used was purposive sampling. The population here is the medical records of patients and doctors, data analysis with flow models. The results of research at RSI AT-Tin Husada Ngawi, there are 3 ownership of medical record documents in the Hospital, namely: Belonging to the hospital, public property or third party property, owned by the patient. The information the doctor gives the patient about the patient's illness is clear and before medical treatment the patient must complete the informed consent form. But to protect the rights of patients to the confidentiality of the contents of medical records at RSI AT-Tin Husada Ngawi, it is not yet in accordance with the Minister of Health Regulation No.269/Menkes/Per/III/2008. It is recommended that RSI AT-Tin Husada Ngawi need a clear and clear SOP about the return of medical record files.

MINDING THE PROTECTION GAP: RESOLVING UNINTENDED, PERVASIVE, PROFOUND HOMEOWNER UNDERINSURANCE

A significant majority of homeowners in the United States unwittingly have less insurance than necessary to rebuild their home in the event of a complete loss. This persistent, multibillion-dollar protection gap first emerged in the 1990s and has never resolved despite a desire by most homeowners to contract for full replacement coverage. While a great deal of academic and industry literature has addressed the issue of underinsurance, the work has been done without reference to two sources that unlock the conundrum. The first is the 1550 page administrative rulemaking file of the California Department of Insurance collected in the wake of wildfires in 2007. The second is a deep understanding of the software insurers use to determine the adequacy of coverage limits when a homeowner purchases full replacement coverage. In addition to these two sources, this Article documents the problem of underinsurance and its causes by synthesizing both prior scholarship and primary source documents, including SEC filings, patents, industry websites, and interviews with trade organization representatives. After establishing the existence of widespread underinsurance, this Article demonstrates how the law’s treatment of risk allocation in the wake of inadequate insurance coverage encourages inaccurate coverage limits by uncoupling the risk created by inaccurately calculated coverage limits from the responsibility for the consequences of error. This Article concludes with a proposed regulation that would recouple risk and responsibility while still providing the insurance industry and consumers with the freedom to contract for alternative coverage limits.

Enough to Hang Your Hat On

Texas law is currently silent on the issue of whether insurance companies may sell insurance policies that require policyholders to bring coverage disputes to an arbitrator rather than the courts. As incentives increase for insurance companies to avoid costly litigation and for consumers to cut ever- increasing premiums, this creates a situation where a hasty, ill-considered proposal to allow such policy terms could shake the insurance market and public policy in the state for years to come. Rather than taking a reactive position, the Texas legislature should work with the Department of Insurance and stake- holders to affirmatively decide: (1) whether to allow such policies at all and, if so, (2) to create a robust legal framework that companies and consumers can both benefit from and rely upon. Other countries, such as the United Kingdom, have well-established frameworks in place that can be instructive, as University of Minnesota Law School professor Daniel Schwarcz has argued. Ultimately though, Texas must determine for itself what policy will suit such a vast and diverse state, particularly given its extreme weather. Texas should consider establishing an independent body to assist in insurance dispute resolution and to promote transparency. This Comment lays out the case for doing so: better outcomes, better insurance, and better access to justice.

DIRECTIONS OF DEVELOPMENT OF THE FINANCIAL SERVICES MARKET OF UKRAINE

Development of the financial services market is an important component of the national economy’s development. Within this market, credit and investment resources are formed, which are the basis of economic development of the real economy sector of the state. It is this that determines the importance of creating conditions for improving the efficiency of financial institutions, which become intermediaries between persons who have free funds and those economic entities that they need. The outlined justifies the relevance of the topic. Consequently, taking into consideration the objective of the study, the following aim of its implementation was set: to identify and substantiate the main determinants of the development of the financial services market in Ukraine. To achieve this goal, the following tasks were set and solved: to identify the main, most important, measures of transformation of the environment of financial institutions functioning; to substantiate the essence of such measures and the peculiarities of their implementation; to specify basic actions within the limits of separate determinants of the financial services market development, to describe their applied character. Method. In the course of the research, a range of different scientific methods was used. Among the general techniques, it is necessary to allocate methods of observation, comparison, abstraction. It is advisable to include the method of economic analysis, synthesis, system approach, content methods, and event analysis in specific research methods. Results. Universal priorities of financial services markets development in different countries are determined and systematized, the analysis of which made it possible to investigate perspective determinants of the development of such a market in Ukraine, peculiarities of their introduction into the functioning of the financial services sphere are described. Among these measures are the following: increase in the stability of financial institutions, increase the transparency of the functioning of producers and consumers of financial services, raising the level of financial literacy in society, reforming the state regulation system of the activities of financial intermediaries, the formation of the trust infrastructure system. Taking into consideration the received scientific outcomes, the justification of peculiarities on the implementation of these priorities in the system of the financial services market functioning in Ukraine is conducted. Practical implications. The research results obtained in the course of the research implementation regarding the possibilities of changing the financial services market for improving the efficiency of financial institutions work have an applied character, and their implementation will make it possible to form a new environment for the functioning of such economic actors. This will facilitate the transformation of financial resources to increase the formation of investment and loan funds. The results obtained can be used by public authorities that regulate the activities of financial institutions in the process of developing new strategic documents for the development of the financial services market in Ukraine. Value/originality. The conducted research is relevant, considering the significant impact of the financial services market on the development of the national economy, the proposed measures for the development of such a market are applied and can be used by public authorities in the regulation of the activities of financial institutions. This research has been conducted within the framework of the scientific work implementation Department of Finance, Banking and Insurance, Chernihiv National University of Technology, Ukraine on the following topics: “Financial stability of economic systems in crisis conditions of management” (No. 0115U001149) and “Development of financial intermediaries in the turbulent conditions of the national economy’s functioning” (No. 0115U001149).

The Effectiveness and Value of Lanadelumab and C1 Esterase Inhibitors for Prophylaxis of Hereditary Angioedema Attacks.

Funding for this summary was contributed by the Laura and John Arnold Foundation, Blue Shield of California, and California Health Care Foundation to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, AHIP Anthem, Blue Shield of California, CVS Caremark, Express Scripts, Harvard Pilgrim Health Care, Cambia Health Solutions, United Healthcare, Kaiser Permanente, Premera Blue Cross, AstraZeneca, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, National Pharmaceutical Council, Prime Therapeutics, Sanofi, Spark Therapeutics, Health Care Service Corporation, Editas, Alnylam, Regeneron, Mallinkrodt, Biogen, HealthPartners, and Novartis. Agboola, Dreitlein, and Pearson are ICER employees. Lin reports personal fees from ICER, during the conduct of this study, and grants from the National Institutes of Health and the California Department of Insurance, outside the submitted work. Carlson and Lubinga report grants from ICER, during the conduct of this study.