Plan Choice Research Articles

Out-Of-Network Utilization and Plan Selection Among Medicare Advantage Cost Plan Enrollees.

To understand how Medicare Advantage (MA) networks impact utilization patterns and plan choices, using the 2019 discontinuation of MA 1876 Cost plans as a natural experiment. We study 1876 Cost plans, MA plans for which out-of-network care is covered through traditional Medicare (TM) and many of which CMS discontinued in 2019. We characterize the proportion of Cost plan enrollees who utilized out-of-network care in 2018 from different types of medical specialties. We then study how enrollees in discontinued plans selected into new plans in 2019. We use regression analysis to characterize whether higher risk enrollees selected into TM at higher rates. We identify discontinued plans using public MA plan data. We employ administrative Medicare enrollment and TM claims data to identify 2018 enrollees of discontinued plans, their 2018 out-of-network utilization, and their subsequent 2019 enrollment decisions. Among Cost plan enrollees, 69% utilized non-emergency room related care out of network in 2018. Out-of-network utilization was distributed across several types of specialties: 43% of Cost plan enrollees had at least one out-of-network claim with a primary care physician and over 20% had a claim with a medical specialist, surgical specialist, or nurse practitioner. We find evidence of adverse selection among enrollees of discontinued Cost plans in 2019. Conditional on one's 2018 Cost plan and county of residence, a standard deviation increase in risk score was on average associated with a 26.35% (95% CI, 25.57%-27.12%) increased likelihood of enrolling in TM. The high rate of out-of-network utilization suggests that MA enrollees value access to care outside of standard MA networks. Subsequent selection patterns indicate that preferences for broader networks and subsequent enrollment in TM is highest among higher risk enrollees, suggesting limited networks may induce extensive margin selection.

Four or five years: An examination of the motivations for selecting undergraduate engineering program length and impacts on student wellness.

The University of Prince Edward Island’s (UPEI) Faculty of Sustainable Design Engineering (FSDE) is unique in offering the undergraduate curriculum in both Four- and Five-Year degree plan lengths. The purpose of this study is to examine 1) the motivations for selecting and 2) impacts of degree plan length on UPEI FSDE student wellness. An anonymous, voluntary survey (REB approved) was developed and administered to approximately 200 undergraduate students during the Fall 2023 semester. Preliminary analysis found approximately 75% of undergraduate FSDE students follow the Five-Year degree plan option. Further, approximately 50% of respondents selected academic workload as the primary driver for their degree plan choice. The Five-Year degree plan length was the option of choice for UPEI FSDE students, with workload being the primary motivation for the selection. These findings help provide insight into how to better serve students and provide meaningful evidence to support curriculum design for fostering student wellness.

Combined electron and proton radiation effects on solar cells for earth orbit

Abstract We present a computational approach for accurate calculations of the combined effects of electron and proton radiation in space, tailored to a specific orbit and accounting for the full range of particle energies. The radiation-induced defect formation is shown to depend on the NIEL (Non-Ionizing Energy Loss), which reflects the small fraction of particle energy (from electrons, protons or other ions) lost through the ionisation of the material. The model developed by the Naval Research Laboratory (NRL) for predicting solar cell degradation based on NIEL aligns closely with the results from the Jet Propulsion Laboratory (JPL). However, the JPL model involves a more comprehensive methodology, incorporating experimental validation. To determine the energy dependence of NIEL, S(E), for both electrons and protons, we use the ESA NIEL calculation tool. This computational process involves assessing the radiation environment and its effects with an assistance from SPENVIS — a simulation platform developed by ESA/NASA for generating spacecraft trajectories in LEO, MEO or GEO. Proton and electron fluxes are simulated using the International Radiation Environment Near Earth (IRENE) model within SPENVIS. This model offers various calculation options — such as mean, percentile, perturbed or Monte Carlo simulations — based on the mission duration and launch date. The resulting proton and electron fluences, both integral and differential, are used to calculate the Displacement Damage Dose (DDD). This is achieved by integrating the product of NIEL with the differential fluences over the relevant particles energy range. To enhance efficiency, specialized software tools have been developed to extract particle fluxes and fluences from SPENVIS, interpolate them and perform the necessary integration to obtain DDD values for protons, electrons and the combined DDD. Equivalent fluences for defined energy ranges are also provided, enabling detailed, mission-specific radiation analyses. These tools streamline the evaluation of the radiation environment and its impact on solar cells, determining the design and material choices for mission planning and providing the data to predict space power generation throughout the mission’s duration.

Exploring the Etiology and Clinical Diagnosis and Treatment of Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding refers to bleeding caused by the digestive tract above the flexor ligament, including diseases of the esophagus, stomach, duodenum, pancreas, biliary tract, and lesions after gastrojejunostomy. It is a common and critical condition in internal medicine. In recent years, with the continuous development of medical technology and the improvement of treatment methods, the diagnosis and treatment level of this disease has been greatly improved. However, this disease has the characteristics of fast onset, complex condition, and certain mortality rate. Therefore, exploring and analyzing the etiology, causes, and treatment plans of this disease is of great significance for improving the cure rate and prognosis of patients with this disease. Due to inflammation, mechanical injury, vascular disease, or adjacent organ lesions, the choice of treatment plan varies depending on the cause. Based on the above situation, this article, The etiology and diagnosis and treatment plan of upper gastrointestinal bleeding have been explored, which can provide reference for improving the treatment level of this disease

Intratumoral and peritumoral radiomics combined with computed tomography features for predicting the invasiveness of lung adenocarcinoma presenting as a subpleural ground-glass nodule with a consolidation-to-tumor ratio ≤50.

Preoperative accurate judgment of the degree of invasiveness in subpleural ground-glass lung adenocarcinoma (LUAD) with a consolidation-to-tumor ratio (CTR) ≤50% is very important for the choice of surgical timing and planning. This study aims to investigate the performance of intratumoral and peritumoral radiomics combined with computed tomography (CT) features for predicting the invasiveness of LUAD presenting as a subpleural ground-glass nodule (GGN) with a CTR ≤50%. A total of 247 patients with LUAD from our hospital were randomly divided into two groups, i.e., the training cohort (n=173) and the internal validation cohort (n=74) (7:3 ratio). Furthermore, 47 patients from three other hospitals were collected as the external validation cohort. In the training cohort, the differences in clinical-radiological features were compared using univariate and multivariate analyses. The gross tumor volume (GTV) and gross peritumoral tumor volume (GPTV5, GPTV10, and GPTV15) radiomics models were constructed based on intratumoral and peritumoral (5, 10, and 15 mm) radiomics features. Additionally, the radscore of the best radiomics model and clinical risk factors were used to construct a combined model and the predictive efficacy of the model was evaluated in the validation cohorts. Finally, the receiver operating characteristics (ROC) curve and area under the curve (AUC) value were used to evaluate the discriminative ability of the model. Tumor size and CTR were independent risk factors for predicting the invasiveness of LUAD. The GPTV10 model outperformed the other radiomics models, with AUC values of 0.910, 0.870, and 0.887 in the three cohorts. The AUC values of the combined model were 0.912, 0.874, and 0.892. A nomogram based on GPTV10-radscore, tumor size, and CTR exhibited high predictive efficiency for predicting the invasiveness of LUAD.

"No One Needs to be Forced": Qualitative Insights on Competing Priorities between Antiretroviral Therapy and Reproductive Health Planning during the Dolutegravir Rollout.

Potential associations between periconception dolutegravir (DTG) exposure and neural tube defects (NTDs) reported in 2018 caused shifting international and national antiretroviral treatment (ART) guidelines. They sometimes required women to use contraception prior to initiating DTG. To better understand the tensions between ART and family planning (FP) choices, and explore the decision-making processes of women living with HIV (WLHIV) and their healthcare providers (HCPs) employed, we conducted interviews with WLHIV exposed to DTG and their providers in western Kenya from July 2019 to August 2020. For the interviews with WLHIV, we sampled women at varying ages who either continued using DTG, switched to a different ART, or became pregnant while using DTG. We utilized inductive coding and thematic analysis. We conducted 44 interviews with WLHIV and 10 with providers. We found four dominant themes: (1) a range of attitudes about birth defects, (2) nuanced knowledge of DTG and its potential risk of birth defects, (3) significant tensions at the intersection of DTG and FP use with varying priorities amongst WLHIV and their providers for navigating the tensions, and (4) WLHIV desiring autonomy, and provider support for this, in such decision-making. Variations in beliefs were noted between WLHIV and HCPs. WLHIV highlighted the impact of community and social beliefs when discussing their attitudes while HCPs generally reported more medicalized views towards DTG utilization, potential adverse outcomes, and FP selection. Decisions pertaining to ART and FP selection are complex, and HIV treatment guidelines need to better support women's agency and reproductive health justice.

Asymptomatic canine vector-borne diseases and diagnostic performance: Comparison between blood smears vs. conventional PCR

Across the globe, vector-borne diseases (VBD) are causes of health and economic concern, particularly for companion animals such as dogs and cats. The common clinical presentation ranges from subclinical to acute infection even a proportion with symptomatic manifestation. The diagnosis of asymptomatic animals with VBDs is quite challenging since veterinary practitioners do rely on presenting clinical signs to inform the choice of diagnostic plan. In Malaysia, blood smears (thin and thick) are employed in the diagnosis of VBDs such as babesiosis, anaplasmosis, theileriosis and trypanosomiasis. This method is readily available and inexpensive; however, the sensitivity and specificity are low as the diagnosis is strongly dependent on the experience of the examiner. Conventional polymerase chain reaction (PCR) on the other hand is used in larger veterinary clinics and hospitals in Malaysia and is only utilised when there is a suspicion of VBDs. This study attempts to compare the thin blood smear method and conventional PCR in the diagnosis of of Anaplasma phagocytophilum, A. platys, Babesia canis, B. gibsoni, Ehrlichia canis in dogs in Malaysia. Thirty clinically healthy dogs (17 males and 13 females) averaging 2 years of age were randomly selected from clinic walk-ins to screen for VBDs with both blood smear and conventional PCR. In general, the conventional PCR was 2.5 times more sensitive and specific than the blood smear in the detection of VBDs including Babesia canis, Babesia gibsoni and Ehrlichia canis in the asymptomatic sampled dogs. The detection rate for blood smears was 20% (6/30) in comparison with 50% (15/30). Therefore, it is imperative to conduct screenings for VBDs in dogs, even when they present as asymptomatic, in order to avert the oversight of potential health emergencies. Conventional PCR emerges as the recommended methodology for screening asymptomatic dogs for VBDs.

Why educators endorse a neuromyth: relationships among educational priorities, beliefs about learning styles, and instructional decisions.

Despite evidence to the contrary, many people believe in learning styles (LS)-the idea that students learn best in their preferred modality, such as visual, auditory, or kinesthetic. However, the impact of this belief on instructional decisions remains unclear. Therefore, this study investigated how belief in the neuromyth impacts instructional choices and why educators choose an LS lesson plan or an alternative. We found that educators' beliefs about LS indeed predicted their instructional choice, but that other factors influenced their decisions as well. Three themes encapsulate educators' justifications for their lesson plan choices: beliefs about LS, practical considerations, and student learning and motivation. These findings suggest that for many educators, implementing an LS lesson provides an opportunity to integrate diverse teaching strategies that address multiple educational priorities. Although many prior studies have replicated the prevalence of the myth, this is one of the first to explore the reasons that LS is attractive to educators. Attempts to dispel the LS neuromyth could leverage the reasons educators find LS appealing to provide alternative research-backed approaches to meet their goals. Future research should examine the extent to which beliefs in the LS neuromyth are translated into instructional practices within classroom lessons and explore potential differences across grade levels.

Motivational Factors Influencing the Choice of Medical Studies and Future Career Plans among Montenegrin Students.

There is a concerning trend of emigration among highly educated individuals in Montenegro. This includes medical professionals who seek better job opportunities abroad. The aim of the present study was to identify the primary motivational factors driving Montenegrin medical students to pursue a career in medicine, and whether these factors undergo changes over the course of their studies. A cross-sectional study included 210 medical students in Montenegro, 27.62% were males, and 72.38% were females. The mean age of the students was 21.90 years (SD=3.05) (range 19-39). Their academic motivation was analysed using the Academic Motivation Scale, previously validated in various cultural contexts. The results showed that autonomous motivation levels were higher than controlled motivation levels (p<0.001) among students in Montenegro, which has been previously associated with better learning outcomes. Students with medical doctors among their family members had higher extrinsic motivation related to rewards and punishments (extrinsic motivation with external regulation p=0.018). Amotivation showed a trend of increasing as the students got closer to graduation (p=0.057). Only 8.1% of students planned a career in primary healthcare, and 1% wished to specialize in family medicine. This study's findings, which indicate high levels of autonomous motivation among medical students, are of significant importance. They contribute to a comprehensive understanding of the motivation factors among medical students and young healthcare professionals in Montenegro. Moreover, they provide a basis for the implementation of strategic interventions to retain highly skilled medical professionals within the country's workforce, thereby addressing the concerning trend of emigration among this group.

Factors influencing young patient arrival date at the orthodontic office: a study of 456 cases

The arrival date young patient's first orthodontic consultation is unrestricted but may influence the choice of treatment plan as well as its modalities. The objective of this study was to determine the factors that influence the date of the first consultation at the orthodontic office: advice from a third party or a health professional, the patient's gender, the socioeconomic level, the actual need for orthodontic treatment, and the vertical and anteroposterior skeletal dysmorphia. Young patient's file younger than 16 years were systematically included. A Wilcoxon and Kruskal-Wallis test was performed in univariate and multivariate analysis. The threshold was 5%. 456 young patients were included. Anteroposterior skeletal discrepancy, referral by an acquaintance, and socioeconomic level appeared to be factors influencing patient arrival date. Gender, actual need for orthodontic treatment, referral from a health professional, and vertical skeletal discrepancy did not influence the arrival date at the office. The date of consultation is not related to the actual orthodontic treatment need. Word-of-mouth seems to play an important role. Patients seem to relate an anteroposterior discrepancy to the need to consult an orthodontist, but do not relate it to vertical discrepancy, although ventilation may be related to severe dysmorphia. This study encourages more communication about orthodontic treatment indications with patients and caregivers.

Grading of skull base meningiomas by combined perfusion: arterial spin labeling and T2* dynamic susceptibility perfusion

BackgroundConventional MRI has no distinction between high- and low-grade meningiomas, which has a crucial for choice of therapeutic plan, especially skull base meningiomas which need more meticulous endoscopy-approached surgery. The aim of our study was to evaluate role of perfusion by arterial spin labeling and dynamic susceptibility perfusion in grading of skull base meningiomas.ResultsThe relative arterial spin labeling (ASL), tumor blood flow (TBF), and tumor blood volume (TBV) ratios showed significant differences between low- and high-grade meningiomas.ConclusionsMRI perfusion is a useful in differentiation between low- and high-grade meningiomas. There is significant correlation between ASL and DSC perfusion supporting possibility of using ASL in clinical practice as an alternative technique to DSC perfusion, particularly for patients with renal impairment where no contrast injection needed.

Access to insurance navigation support through the State Health Insurance Assistance Program (SHIP).

Medicare enrollment is complex, particularly for low-income individuals who are dually eligible for Medicare and Medicaid, and the wrong plan choice can adversely impact beneficiaries' out-of-pocket costs and access to providers and medications. The State Health Insurance Assistance Program (SHIP) is a federal program that provides counseling on Medicare coverage, but the degree to which SHIP services are accessible to low-income beneficiaries is unknown. We interviewed SHIP counselors and coordinators to characterize factors affecting access to and quality of SHIP services for low-income beneficiaries. Availability of volunteers was cited as the primary barrier to SHIP services. Topics related to dual eligibility for Medicare and Medicaid were frequently covered in counseling sessions, and staff expressed a desire for more training related to Medicaid and integrated-care programs. Our results suggest that additional counselors and increased training on topics relevant to dually eligible individuals may improve SHIP's ability to provide health insurance-related information to low-income Medicare beneficiaries.

Positive surgical margin after attempted radical surgery in patients with locally advanced urothelial carcinoma: literature review and case reports

Positive surgical margin is observed in approximately 10 % of specimens after radical surgery for locally advanced urothelial carcinoma, and is associated with an increased risk of locoregional recurrence, metastases, and death. R+ patients are a heterogeneous group of patients requiring individual treatment approaches. There is no standard of care for R+ patients; acceptable options include observation, removal of residual tumor, postoperative chemotherapy (CT), immunotherapy (IT), radiation therapy (RT), and chemoradiotherapy (CRT). The choice of treatment plan depends on the location and characteristics of the primary tumor, use of neoadjuvant chemotherapy (NACT) before surgery and the response to it, the pathological response, the presence of detectable residual tumor, as well as the potential tolerability of immediate postoperative treatment.

The impact of terminating cost-sharing reductions payments on health insurance plan choices.

The Trump administration terminated cost-sharing reductions (CSRs) payments to health insurers in 2017, while still required insurers to provide CSRs to eligible enrollees in the Marketplace. Marketplace administration data reveals that, in response to this termination, insurers raised premiums to compensate for their loss. Consequently, premium increases led to more advanced premium tax credits for enrollees in the Marketplace. To investigate the impact of CSRs payment termination on low-income consumer insurance plan choices, I leverage variations in state price regulations and employed a difference-in-differences design. In a robustness analysis, I utilized differences in county income distributions to examine the effects of the termination on insurance choices. The results indicate that after the termination, more low-income enrollees opted for cheaper bronze plans, and fewer chose silver plans. These results suggest that alterations in subsidy channels may inadvertently encourage low-income individuals to purchase less expensive health insurance plans, highlighting an unintended consequence of the termination of cost-sharing subsidies.

Lexicographic optimization-based planning for stereotactic radiosurgery of brain metastases

AimTo validate a fully-automated lexicographic optimization-planning system (mCycle, Elekta) for single-(SL) and multiple-(ML, up to 4 metastases) lesions in intracranial stereotactic radiosurgery (SRS, 21 Gy, single fraction). MethodsA pre-determined priority list, Wish-List (WL), represents a dialogue between planner and clinician, establishing strict constraints and pursuing objectives. In order to satisfy the clinical protocol without manual intervention, four patients were required to tweak and fine-tune each WL (SLp, MLp) for coplanar arcs. Thirty-five testing plans (20 SLp, 15 MLp) were automatically re-planned (mCP). Automatic and manual plans were compared including dose constraints, conformality, modulation complexity score (MCS), delivery time, and local gamma analysis (2%/2 mm). To ensure plan clinical acceptability, two radiation oncologists conducted an independent blind plan choice. ResultsEach WL-tuning took 3 days. Estimated median manual plans and mCP calculation time were 8 and 3 h, respectively. Significant increases in SLp and MLp target coverage and conformity were registered. mCP showed a not significant and clinically acceptable higher median brain V12Gy. SLp registered a −5.8% MU decrease with comparable median delivery time (MP 2.0 min, mCP 1.9 min) while MLp showed a +9.8% MU increase and longer delivery time (MP 3.5 min, mCP 4.4 min). mCP MCS resulted significantly higher without affecting gamma passing rates. At blind choice, mCP were preferred in the majority of cases. ConclusionsLexicographic optimization produced acceptable SRS plans with coplanar arcs significantly reducing the overall planning time in cases with up to 4 brain metastases. These planning improvements suggest further investigations by setting high-quality non-coplanar arc plans as a reference.

Health Promotion Quality Regarding Post-Placental IUDs in Malang Regency

Introduction: Community welfare is confronted with a substantial challenge by Indonesia's burgeoning population, and the government's principal aim is the promotion of Long-acting reversible contraceptives (LARC). Post-placental IUD is an efficacious method that incorporates health promotion by means of midwife-delivered contraceptive counseling. Counseling promotes the development of positive relationships, knowledge, attitudes, and behaviors, thereby fostering responsible behavior and individual agency in decision-making. Nevertheless, the low utilization rate of postpartum IUD contraception can be attributed to the scarcity of information regarding the mother. The objective of this study is to examine the level of health promotion regarding post-placental IUD family planning in Malang Regency. Material and Methods: Descriptive methods will be employed, including verbal and written observations of behavior and descriptive data on individuals. The interview-based data collection process spanned the months of June to August 2023. Results: The research results suggest that inadequate efforts to promote postpartum IUD contraception are due to a dearth of understanding, motivation, resources, geographical proximity, and community customs. The objective is to improve the existing insufficiency of post-placental IUD family planning promotion in Malang Regency. Conclusion: From the beginning of pregnancy onwards, expectant women must be consistently motivated and educated about health promotion and family planning in order to develop an interest in and understanding of the choice of post-placental IUD family planning.

Strategy practitioners and the procedural legitimacy of strategic planning in nonprofit community sport

ABSTRACT This study examines how leaders of community sport organizations (CSOs) engage in a strategic planning process through the intersection of institutional work and the strategy-as-practice (SAP) approach. The SAP approach focuses on the micro-level social activities, processes, and practices that inform how organizational leaders engage in strategic planning. A multiple-case study of four CSOs with contrasting approaches to the practice of strategy provides insight into the role of strategy practitioners and their choice of strategy activities. The study also examines how these activities contribute to the procedural legitimacy of strategic planning. The findings highlight four roles that strategy practitioners hold within their clubs (i.e. consultant, board member, staff member, facilitator) and three general types of activities that indicate varying levels of stakeholder involvement in planning. The findings provide evidence of the need for a granular approach to the study of strategic planning and a focus on how organizational leaders’ roles and choice of activities shape strategic planning and its legitimacy.

Partner Plan Choices and Medicare Advantage Enrollment Decisions Among Older Adults

This study examines the association of partner Medicare Advantage plan status over 1 year with beneficiary and plan characteristics.

Environmental and economic multi-objective real options analysis: Electrification choices for field development investment planning

Hydrocarbons combustion is one of the primary sources of greenhouse gas emissions, causing climate change. As large volumes of gas are burned to power the energy-consuming oil and gas production on offshore platforms, the Norwegian petroleum industry contributes significantly to the country’s emissions, making it a target for environmental regulations. Hence, Norwegian petroleum companies are facing the challenge of finding solutions to comply with increasing environmental requirements while being economically feasible. Offshore platforms electrification helps to reduce carbon emissions, but relevant investment decisions are complicated by uncertainty related to market fluctuations and regulations. In this study, we analyze how considering environmental and economic objectives simultaneously affects optimal investment strategies under uncertainty. We develop a novel methodology for determining the project value and the best investment policy for field development, considering several objectives and uncertain factors. By introducing multi-objective optimization into a real options investment valuation model, economic and environmental objectives are combined using the weighted sum method. The optimization model allows to determine trade-offs between the objectives of the project along with a flexible investment policy. Such optimal solutions result in a significant decrease in carbon emissions at only a marginal reduction in economic value.

Comparative study on informed consent regulation in health care among Italy, France, United Kingdom, Nordic Countries, Germany, and Spain

The information and subsequent expression of will, so-called informed consent, have become the essential element of health right, understood as the right to autonomous choice in health, based on the fiduciary relationship between physician and patient. This gradually leads European Countries to adopt special legislations and to issue frequent judgments on the subject. However, new challenges in daily clinical practice call for further study of legal solutions. The authors analyse and compare the regulations on informed consent in health care of Italy, France, the United Kingdom, the Nordic Countries, Germany, and Spain. The health and legal contexts, existence of special regulations on informed consent and their characteristics are discussed. Informed consent resulted a mandatory requirement. Clear communication about treatment, therapeutic alternatives, and major risks, discussed in conversation, but preferably documented in writing, are agreed upon. The possibility of dissent and withdrawal of consent are also included. There is a growing interest in involving and regulating the entire health team in information and consent. Lowering the age of consent for minors or analysing the maturity of minors are attempts to increase their participation in health decisions. On another side, the protection of adult incapables persons requires greater involvement of family and fiduciaries to better adapt to changing health needs. Health policy must take responsibility for training health professionals and citizens about the value of health information and communication as a shared choice in care planning, to strengthen the bond of trust with the healthcare system and users.