Paid Community Research Articles

Examining Consequences Related to Unmet Care Needs Across the Long-Term Care Continuum

At some point in our lives, approximately 70% of us will need support to help with daily care. Without adequate assistance we may experience unmet care need consequences (UCNC) – such as skipping meals, going without clean clothes, or taking the wrong medication. This study examines the likelihood of experiencing UCNC related to gaps in assistance with activities of daily living (ADL) and instrumental activities of daily living (IADL) across long-term care arrangements: informal community care, paid community care, residential care, and nursing homes. We examine a sample of older adults receiving assistance in a care arrangement (N=2,499) from the nationally representative 2015 National Health and Aging Trends Study. Cross-sectional and longitudinal regression models, adjusting for differences in demographic and health/functioning characteristics, examine if type of care arrangement in 2015 is associated with UCNC in 2015 and change in UCNC by 2017. Holding all else constant, there were no significant differences in UCNC related to ADLs in 2015 across care arrangements. However, those receiving paid community care were more likely to experience UCNC related to IADLs (going without clean clothes, groceries, or a hot meal and making medication errors) compared to those receiving only informal care (OR=1.64, p<.05) or residential care (OR=2.19, p<.01). By 2017, paid care was also significantly associated with continued UCNC, but older adults in informal care arrangements were most likely to experience a new UCNC. Results suggest improving/expanding assistance with IADLs among community-dwelling older adults, and promoting equitable access to residential care, to reduce UCNC.

Genetic Variant Reinterpretation: Economic and Population Health Management Challenges.

Genetic Variant Reinterpretation: Economic and Population Health Management Challenges.

The impact of paid community health worker deployment on child survival: the connect randomized cluster trial in rural Tanzania

BackgroundThis paper reports on a rigorously designed non-masked randomized cluster trial of the childhood survival impact of deploying paid community health workers to provide doorstep preventive, promotional, and curative antenatal, newborn, child, and reproductive health care in three rural Tanzanian districts.MethodsFrom August, 2011 to June 2015 ongoing demographic surveillance on 380,000 individuals permitted monitoring of neonatal, infant and under-5 mortality rates for 50 randomly selected intervention and 51 comparison villages. Over the initial 2 years of the project, logistics and supply support systems were managed by the Ifakara Health Institute. In 2013, the experiment transitioned its operational design to logistical support managed by the Ministry of Health and Social Welfare with the goal of enhancing government operational ownership and utilization of results for policy.ResultsThe baseline under 5 mortality rate was 81.3 deaths per 1000 live births with a 95% confidence interval (CI) of 77.2–85.6 in the intervention group and 82.7/1000 (95% CI 78.5–87.1) in the comparison group yielding an adjusted hazard ratio (HR) of 0.99 (95% CI 0.88–1.11, p = 0.867). After 4 years of implementation, the under 5 mortality rate was 73.2/1000 (95% CI 69.3–77.3) in the intervention group and 77.4/1000 (95% CI 73.8–81.1) in the comparison group (adjusted HR 0.95 [95% CI 0.86–1.07], p = 0.443). The intervention had no impact on neonatal mortality in either the first 2 years (HR 1.10 [95% CI 0.89–1.36], p = .392) or last 2 years of implementation (HR 0.98 [95% CI 0.74–1.30], p = .902). Although community health worker deployment significantly reduced mortality among children aged 1–59 months during the first 2 years of implementation (HR 0.85 [95% CI 0.76–0.96], p = 0.008), mortality among post neonates was the same in both groups in years three and four (HR 1.03 [95% CI 0.85–1.24], p = 0.772). Results adjusted for stock-out effects show that diminishing impact was associated with logistics system lapses that constrained worker access to essential drugs and increased post-neonatal mortality risk in the final two project years (HR 1.42 [95% CI 1·07–1·88], p = 0·015).ConclusionsCommunity health worker home-visit deployment had a null effect among neonates, and 2 years of initial impact among children over 1 month of age, but a null effect when tests were based on over 1 month of age data merged for all four project years. The atrophy of under age five effects arose because workers were not continuously equipped with essential medicines in years three and four. Analyses that controlled for stock-out effects suggest that adequately supplied workers had survival effects on children aged 1 to 59 months.Trial registrationRegistration for trial number ISRCTN96819844 was retrospectively completed on June 21, 2012.

Innovations in Payer-Community Partnerships: The EmblemHealth Neighborhood Care Program.

Comprehensive and innovative strategies are needed to address and manage chronic diseases and conditions and to reduce health disparities. EmblemHealth Neighborhood Care (EHNC) sites provide community-based linkages across payers, health providers, and delivery systems and underserved communities using culturally sensitive methods tailored to meet the needs of the community. This article describes this novel initiative and early indicators of its feasibility. Three EHNC sites were established in New York City: Harlem, Cambria Heights, and Chinatown. Each site provides core health and customer services to members and the community. In addition, sites provide tailored services to meet the unique needs of each community. Preliminary data suggest that program and community members are utilizing the sites and returning for follow-up visits. Sites also demonstrate success in cross referral between EHNC teams. The EHNC program is both feasible from the payer's perspective and acceptable to diverse patient populations and settings.

Ethical considerations in dental plan claims adjudication

Ethical considerations in dental plan claims adjudication

Preparing for the Future of Rare Diseases.

Members of the rare disease community have devoted significant financial and personnel resources to address the numerous issues surrounding rare diseases. The past has been devoted to developing an emphasis on rare diseases including an emphasis on research studies or locating information on rare diseases and the requirements and limitations of conducting clinical trials with small patient populations. The expanded role of patient advocacy organizations and patient engagement in all aspects of clinical research continues to gain acceptance within the research community. The future will require a greater understanding and interpretation of available information from multiple sources including electronic health records and big data sources. The pipeline of potential orphan products continues to grow significantly and holds great promise for novel interventions due to advances in clinical trial design and data analyses. Expanding diagnostic procedures with improved sequencing methods will speed up the diagnosis or rare diseases. Accepting agreed upon nomenclature and codification of rare diseases will assist in differentiating diseases and identifying selected sub-populations of rare diseases. Improvements in patient recruitment and increased flexibility in the product review and approval procedures by regulatory agencies will facilitate product approvals. Children particularly will need help and assistance dealing with feelings of isolation from their peers due to their rare disease. During the transition from childhood to adolescence to adult, difficulties of fitting in with peers and not wanting to be different are a major concern. In response to increasing costs of treatments, Value-Based Care is gaining greater acceptance by the reimbursement and the payer community as a basis for payment for interventions. Mobile Health (M-health) Technologies have the potential to revolutionize how clinical research is conducted in the future. Wearable devices, remote sensors, and the development of mobile device applications (apps) will all assist in constant monitoring of patients for safety and efficacy of approved and investigational compounds. Tele Health and Tele Medicine may provide the necessary access to expert clinicians with a better understanding of individual rare diseases. The future promises great advances and even greater personalized treatments with the introduction of novel treatments and approaches to care.

The Medical Imaging &amp; Technology Alliance Conference on Research Endpoints Appropriate for Medicare Coverage of New PET Radiopharmaceuticals

The outcomes of a 2011 Medical Imaging & Technology Alliance (MITA) conference helped shape considerations about what might be the most appropriate pathways for the regulatory and payment considerations of new PET radiopharmaceuticals. As follow-up to that conference, MITA convened a second conference of stakeholders to advise payers on what might be acceptable endpoints for clinical trials to support the coverage of novel PET agents. The conference involved experts on imaging and clinical research, providers of PET services, as well as representatives of interested medical societies, the PET industry, and the regulatory and payer communities. The principal outcome of their deliberations was that it was unrealistic to expect trials of new PET radiopharmaceuticals to directly demonstrate a health benefit. Rather, intermediate outcomes, such as a positive change in patient management, would be more efficient and appropriate.

The Medical Imaging & Technology Alliance Conference on Research Endpoints Appropriate for Medicare Coverage of New PET Radiopharmaceuticals

The outcomes of a 2011 Medical Imaging & Technology Alliance (MITA) conference helped shape considerations about what might be the most appropriate pathways for the regulatory and payment considerations of new PET radiopharmaceuticals. As follow-up to that conference, MITA convened a second conference of stakeholders to advise payers on what might be acceptable endpoints for clinical trials to support the coverage of novel PET agents. The conference involved experts on imaging and clinical research, providers of PET services, as well as representatives of interested medical societies, the PET industry, and the regulatory and payer communities. The principal outcome of their deliberations was that it was unrealistic to expect trials of new PET radiopharmaceuticals to directly demonstrate a health benefit. Rather, intermediate outcomes, such as a positive change in patient management, would be more efficient and appropriate.

Utilization Management in Radiology, Part 1: Rationale, History, and Current Status

Previous growth in the utilization of medical imaging has led to numerous efforts to reduce associated spending. Although these have historically been directed toward unit cost reductions, recent interest has emerged by various stakeholders in curbing inappropriate utilization. Radiology benefits managers have widespread market penetration and have been promoted largely by the payer community as effective mechanisms to curb increases in imaging volume. The provider community has tended to favor real-time order entry decision support systems. These have demonstrated comparable effectiveness to radiology benefits managers in early projects but currently have only limited market penetration. In this first of a two-part series, the rationale for the development of utilization management programs will be discussed and their history and current status reviewed.

Letter from the President.

Personalized MedicineVol. 7, No. 5 News & ViewsFree AccessLetter from the PresidentEdward AbrahamsEdward Abrahams1225 New York Avenue, NW, Suite 450, Washington, DC 20005, USA. Search for more papers by this authorEmail the corresponding author at eabrahams@personalizedmedicinecoalition.orgPublished Online:29 Sep 2010https://doi.org/10.2217/pme.10.59AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail In 2005 the Partners Healthcare Center for Personalized Genetic Medicine (PCPGM) convened the first of what has become the pre-eminent annual conference on personalized medicine. That first conference sought to explore the promise and prospects of targeted therapeutics’ ability to transform modern medicine. Its vision and impetus came from Raju Kucherlapati, then Scientific Director of the Center. His organizing premise was that a broad array of stakeholders from different sectors should discuss and develop a common agenda, based on the assumption that one-size-fits-all, trial-and-error medicine represents a broken paradigm, good for neither patients nor society. Believing that the pharmaceutical, diagnostic, device, information technology, payer, provider, government, legal and academic communities each have a role to play and that interaction among and between them is essential for development and adoption of personalized medicine, he created a place where its issues could be explored and addressed at the Harvard Medical School in Boston (MA, USA).The Personalized Medicine Coalition (PMC), then newly formed and sharing the governing assumption that changes were and are required in the legal, regulatory, and educational arenas if patients are going to benefit from the exciting new developments in science, began a collaboration with PCPGM that has become a vital partnership. The conference, which serves as an annual meeting for the coalition, informs our continuing efforts to stimulate investment in personalized medicine from both the private and public sectors, based on the assumption that personalized medicine offers a new platform for achieving individual and societal goals, namely better medical outcomes and lower costs in healthcare.The PMC also launched its annual Leadership Award in Personalized Medicine at that meeting, and will bestow its sixth award at the next conference on 17 November 2010 to an individual whose contributions in science, business, and/or policy have helped advance this new medical frontier.Since that first conference there have been significant, and even dramatic changes in the landscape of personalized medicine, which the conference carefully tracks and helps promote. There has been an explosion in the knowledge of how genes are implicated in common and rare diseases and this knowledge continues to increase at a rapid pace. The development and availability of new technologies that enable rapid and low-cost DNA sequencing has rapidly accelerated. The molecular diagnostics industry is developing apace led by the increased demand for what Harvard Business School’s Clayton Christensen calls ‘precision medicine’. Many major pharmaceutical and biotechnology companies are using the principles of personalized medicine as a cornerstone of their drug development efforts. The NIH and the US FDA are working closely to help guide the implementation of personalized medicine in the USA. Led by pharmacy benefit managers, the payer community also is increasingly interested in how personalized medicine can improve outcomes and decrease costs. What only a few years ago was considered to be a view of the future of healthcare is now regarded as a present reality with aspects already implemented and others soon to come.The conference, which the PMC is pleased and honored to sponsor, has become the premier event in the field, widely recognized because of the mix of participants and the depth, quality and distinction of its topics and content. Chaired by Kucherlapati, it brings together all of the stakeholders with an interest in personalized medicine for a day and half of thoughtful conversation. Four successive annual meetings have been held since the first one, each surpassing its predecessors in numbers of registrants. In 2006 Harvard Business School became a co-host of the annual conference, adding a distinctive perspective to the planning of the meetings. It also offers highly popular sessions at the conference featuring Harvard Business School professors who use interactive case studies to illustrate strategic problems and opportunities in personalized medicine.The sixth annual Personalized Medicine Conference will be held 17–18 November 2010, again at the Joseph B Martin Conference Center of Harvard Medical School. As Kucherlapati has noted, ‘The 2010 conference promises to be another engaging meeting highlighting the current impact of personalized medicine as it enters the healthcare delivery system and explores how recent experiences may guide and inform policies, plans and actions of key stakeholders.’FiguresReferencesRelatedDetails Vol. 7, No. 5 Follow us on social media for the latest updates Metrics History Published online 29 September 2010 Published in print September 2010 Information© Future Medicine LtdPDF download

Indications and reimbursement of cardiac computed tomography angiography: History, present and future perspectives

To comment that cardiac computed tomography angiography (CCTA) is an exciting tool in the evaluation of coronary artery disease (CAD) is an understatement. As a new method, however, differing clinical and reimbursement guidelines exist to guide the use of the method, resulting in confusion among referring and interpreting physicians in whether CCTA is reasonably indicated and covered by an individual patient's payer. Such confusion has slowed the acceptance of CCTA within the medical community. Clinical and reimbursement guidelines related to CCTA indications, including those from public and private payers, are reviewed, summarized, and compared in text and table formats. The commonalities extant within medical society guidelines and gradually within the payer community allow the increasingly frequent use of CCTA for certain indications. Challenges to full-fledged acceptance of the technique based on guideline and payer policies are reviewed and are increasingly being overcome.

Author’s Response

Current Procedural Terminology® (CPT®) code–specific preauthorization is being promulgated within the payer community, much to the chagrin of radiologists and referring physicians. In short, a payer determines whether contrast should be administered for a specific examination. If the examination is performed differently (resulting in a different CPT® code), payment for the entire service is denied.

Interpreting Change Scores of Tests and Measures Used in Physical Therapy

Over the past decade, the methods and science used to describe changes in outcomes of physical therapy services have become more refined. Recently, emphasis has been placed not only on changes beyond expected measurement error, but also on the identification of changes that make a real difference in the lives of patients and families. This article will highlight a case example of how to determine and interpret "clinically significant change" from both of these perspectives. The authors also examine how to use item maps within an item response theory model to enhance the interpretation of change at a content level. Recommendations are provided for physical therapists who are interpreting changes in the context of clinical practice, case reports, and intervention research. These recommendations include a greater application of indexes that help interpret the meaning of clinically significant change to multiple clinical, research, consumer, and payer communities.

Corporate Executives Address Psychiatric Disability in Workers

Corporate Executives Address Psychiatric Disability in Workers

The Business of PET/CT

This chapter discusses how to market to and educate the referral community and third party payers about the benefits of the emerging PET/CT technology. Clearly, the fusion of PET and CT into one piece of equipment will present challenges for years to come. It is important for providers to be involved with all of the administrators, managers, referring and interpreting physicians, and the payer communities in their market to clearly understand individual payer business practices and to identify opportunities to educate and influence changes in payment and coverage policies.

CMS Offers “Global Approach” as Alternative to Therapy Caps

CMS Offers “Global Approach” as Alternative to Therapy Caps

2002 Pauline Cerasoli Lecture: Advancing Contemporary Practice—A Role for Educators

INTRODUCTION September 11, 2001, is a day to forever be remembered. That the tragedy of the magnitude of that day and everything that followed could become the powerful force it has by creating such a positive bond among many people around the world is remarkable. I pray that we have learned from 9-11. I, we, pray that we can find more effective methods of communicating our vast differences and our close similarities to one another. The tragic event that changed Pauline Cerasoli's life forever is another reminder of humankind's inability to successfully respect the dignity of another's life. Yet, once again tragedy transformed us. We were able to create something positive out of tragedy by celebrating Polly's life and her legacy. The symbol for this is, of course, the annual Pauline Cerasoli Lecture. Polly's deep dedication to physical therapy and to serving others is a part of that legacy. Another part is the leadership she modeled for us. She challenged the status quo within our profession both in clinical practice and in academia. She helped advance practice by creating and facilitating collaboration between practice and education. Her commitment to bring us, educators and clinicians, together has always made a strong impression on me. And it is with this orientation that I offer the following remarks. THE CHALLENGE Physical therapist clinicians are challenged today to defend physical therapy interventions; to identify the relevance of these interventions in the lives of consumers; to provide evidence that supports intervention decisions; and to demonstrate the costs, the risks, and the benefits of our decisions. Physical therapist educators focus on establishing and delivering curricula that prepare graduates to provide excellent and contemporary services. They also focus on delivering curricula that meet the needs of today's practice and that also anticipate future demands on practice. These are major challenges, and they are occurring in a health care environment undergoing tremendous change. With change come threats. Threats are from but not limited to patients, management, the payer community, providers, policy makers, the vendor community, and the higher education community. We are also sensitive to not a threat but a serious concern that exists within our own professional community, that being how we ensure that all professional students being educated beyond the baccalaureate degree will receive appropriate clinical supervision in their clinical course work. Within this context, we-physical therapist clinicians and educators-are challenged to maintain a meaningful and viable presence. We are challenged to better define who a physical therapist is and what a physical therapist does and to defend how one is educated to become a physical therapist-both didactically and clinically. We are challenged to respond to those disciplines claiming they are more appropriate to provide our services than we. And we are challenged to provide evidence that demonstrates our effectiveness. Despite these serious challenges, I submit that we, physical therapist clinicians and physical therapist educators, have a unique opportunity. I believe we must abandon our laissez-faire approach of interacting with one another and instead forge a close, synergistic partnership. In so doing, we would be able to achieve an effective collaboration that would allow us, through the partnering of our significant resources, to advance the goals of our profession in a more timely, efficient, and effective manner. And we must! We, physical therapist educators, are in the most favorable position for facilitating this partnership. As educators, we have considerable advantages that most clinicians lack. To develop, plan, and implement curricula for the future clinicians and leaders of our profession, we are responsible for teaching the use of contemporary methods. We are also responsible for identifying levels of evidence that support our theories and techniques. …

Building social relationships through valued roles: three older adults and the community membership project.

The experiences of three older adults with developmental disabilities highlight ways in which social relationships can be nourished through the establishment of community roles. Members of the Community Membership Project of the Center on Aging and Community used paid community builders working individually with older persons who had developmental disabilities in order to help them obtain positive, valued social roles and relationships with nondisabled community members. As a means to this end, participants were supported to engage in community activities corresponding to the interests and talents discovered in an initial period of exploration. Stories of these community builders' work illustrate the intentional strategies and concerted effort necessary to create community connections and meaningful relationships.