Public Insurance Plan Research Articles

Will prior health insurance authorization for medications continue to hinder hepatitis C treatment delivery in the United States? Perspectives from hepatitis C treatment providers in a large urban healthcare system.

BackgroundThe recent introduction of direct acting antivirals for the treatment of hepatitis C virus (HCV) has dramatically improved treatment options for HCV infected patients. However, in the United States (US) treatment uptake has been low and time to initiation of therapy has been long. We sought to examine provider perspectives of facilitators and barriers to HCV treatment delivery.MethodsFrom June to August 2019, we conducted in-depth, semi-structured interviews with medical staff providing HCV care as part of a university medical center in Los Angeles, CA. In order to understand the HCV treatment process, we interviewed key staff members providing care to the majority of HCV patients seeking care at the university medical center, including hepatologists and infectious disease specialists as well as key nursing and pharmacy staff. The interviews focused on workload and activities required for HCV treatment initiation for non-cirrhotic, treatment naïve patients.ResultsProviders noted that successful HCV treatment delivery was reliant on a care model involving close collaboration between a team of providers, in particular requiring a highly coordinated effort between dedicated nursing and pharmacy staff. The HCV care team overwhelmingly reported that the process of insurance authorization was the greatest obstacle delaying treatment initiation and noted that very few patient level factors served as a barrier to treatment uptake.ConclusionsIn the US, prior authorization for HCV treatment is a requirement for most public and private insurance plans. In an era with access to therapies that allow for a cure—and until revocation of prior authorization for HCV treatment is a reality—implementing strategies that can expedite authorization to accelerate treatment access are critical. Not only will this benefit patients, but it has the potential to help expand treatment to settings that are otherwise too resource strained to successfully deliver HCV care.

Global Dialysis Perspective: Japan.

Hemodialysis therapy was first performed in Japan at United States military base hospitals during the Korean War (1950–1953) to treat injured American soldiers with crush syndrome transferred from the combat zone. Encouraged by such experiences, several university hospitals started to offer acute hemodialysis treatment in 1955 and chronic hemodialysis treatment in the early 1960s. The health insurance program started to cover chronic hemodialysis treatment in 1967. Initially, the costs were not fully covered by the program: a 30% to even 50% copayment was required for patients who were not beneficiaries of the public insurance plan. In 1972, the national government started a program that also covered copayment on the basis of the Basic Act for Persons with Disabilities as a result of lobbying activities by patient groups and academic societies. Since then, hemodialysis treatment has become almost free of charge, except for high-income patients (up to 20,000 Japanese Yen [JPY] or approximately United States $200 per month). Typically, the total monthly cost for a patient on maintenance dialysis is approximately 320,000 JPY or approximately United States $3000, excluding any additional fees or medications. The cost consists of the medical management fee, including routine laboratory tests (22,500 JPY per month), and technical fees (21,400 JPY × approximately 14/mo). The reimbursement system is updated every 2 years. In April 2006, the costs for erythropoiesis-stimulating agents were bundled with the technical fees of hemodialysis and with anticoagulant and normal saline for rinsing. Roxadustat has recently been approved and bundled. According to the recent annual report of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) (1), a total of 334,505 patients (2640.0 per million people in the general population) are receiving dialysis treatment in Japan as of 2017. In 40,959 incident patients (323 per million people in the general population), the average …

Moral hazard and subsidized crop insurance

AbstractAlong with adverse selection, moral hazard is one of the major hurdles that private and public insurance plans must contend with. Moral hazard occurs if risks are endogenous to a producer's behavior and if the insurer is unable to properly monitor the insured. We review the role of moral hazard in the US crop insurance program. We conduct an empirical analysis of one important aspect of the US crop insurance program—prevented planting. This provision provides indemnity payments if conditions are not suitable for planting. The program has been the subject of considerable controversy, especially during 2019, when the rate of claims is expected to be especially high. Because loss adjustors may encounter difficulties in assessing the weather conditions associated with prevented planting claims, the program is susceptible to moral hazard. We consider the extent to which prevented planting claims may be endogenous to prices. We find significant evidence of moral hazard. The likelihood of prevented planting claims increases as the expected market price decreases or as fertilizer costs increase for corn and soybeans in the Prairie Pothole Region and for grain sorghum and cotton in all states.

The 2018 decision to establish an Advisory Council on adding pharmaceuticals to universal health coverage in Canada

Canada is the only Universal Health Insurance country in the OECD without universal insurance for outpatient prescription drugs, a situation generally perceived as unfair and inefficient. In June 2018, the federal government launched an Advisory Council on the Implementation of National Pharmacare, to report in 2019 on the best strategy to implement a national Pharmacare program that would provide all Canadians access to affordable outpatient prescription drugs. The Council was asked to consider three options: a universal public plan for all Canadians; a public catastrophic insurance plan that would kick off once spending on prescription drugs reaches a given threshold; and a more modest patching of existing gaps, providing coverage to those who are not eligible to any form of insurance. Beyond the relative consensus around the ideas that gaps in coverage should be filled to make drugs affordable to all, and that the costs of drugs are too high in Canada, the Council faces the challenge of addressing three underlying issues: 1) what amount of income redistribution will result from each of the three options; 2) how much savings would the implementation of a single payer generate? 3) what role restricting a national formulary would play in achieving those savings, and what would be the political consequences of narrowing the formulary?

Women's Preventive Services Initiative's Well-Woman Chart

The Well-Woman Chart summarizes current recommendations for preventive health services for women from adolescence and continuing across the lifespan. It was developed by the Women's Preventive Services Initiative, a national collaborative of women's health professional organizations and patient representatives. The Well-Woman Chart includes current clinical guidelines from the U.S. Preventive Services Task Force, Bright Futures from the American Academy of Pediatrics, and the Women's Preventive Services Initiative that are covered with no cost-sharing for public and most private insurance plans under the prevention service mandate of the Affordable Care Act. The structure of the Well-Woman Chart is based on age intervals and pregnancy status categories that align with existing recommendations. The target audience for the Well-Woman Chart is all clinicians providing preventive health care for women, particularly in primary care settings, and patients affected by the recommendations. The preventive services recommendations apply to females 13 years of age and older and pregnant females of any age. The Well-Woman Chart provides clinical guidance for screening, counseling, and other recommended preventive services for women during health care visits based on age, pregnancy status, and risk factors.

Variable access to antiviral treatment of chronic hepatitis B in Canada: a descriptive study.

Antiviral treatment for chronic hepatitis B is costly, which presents challenges for universal drug coverage for the estimated 480 000 people with the disease in Canada. We appraised criteria for reimbursement of chronic hepatitis B antivirals by public drug plans in Canada. In this descriptive study, we reviewed the reimbursement criteria for lamivudine, adefovir, tenofovir, entecavir, telbivudine, pegylated or standard interferon, and emtricitabine-tenofovir in the 10 provinces and the Yukon Territory as well as 3 federal programs: Correctional Services Canada, Veterans' Affairs and the Non-Insured Health Benefits Program. We extracted data from publicly available formularies. The primary outcomes extracted were prescriber details, reimbursement regulations and published list price. All public drug insurance plans limit access to antiviral treatment in patients with chronic hepatitis B based on viral characteristics, fibrosis stage and/or specialist approval. Lamivudine use is restricted only in British Columbia and Ontario. Six plans (43%) cover entecavir or tenofovir with no restriction, and 8 plans (57%) cover these agents if patients have advanced fibrosis/cirrhosis. Nine plans (64%) provide coverage of interferon, although 4 of these programs reimburse only nonpegylated interferon, which is not currently recommended for chronic hepatitis B treatment. We found substantial variability among jurisdictions in reimbursement criteria for the treatment of chronic hepatitis B in Canada. The findings can inform health policy and support the development and adoption of a national chronic hepatitis B strategy to ensure equitable and timely access to treatment no matter where patients reside in Canada.

Filling the Cavities: Improving the Efficiency and Equity of Canadaas Dental Care System

Ensuring that all members of the community, including the poor, have access to urgently needed healthcare is a central objective of Canadian social policy. Yet, in the current system, there are many population groups in which individuals have difficulty accessing even urgently needed dental care. Moreover, the number of Canadians unable to access dental care is likely to grow rapidly in the next decade as the baby-boom generation retires and loses insurance coverage, and the number of Canadians working in the gig economy, where benefits such as employer sponsored health insurance are rare, rises. Lack of access to dental care may lead to substantial reductions in quality of life due to both the discomfort of oral pain, and the embarrassment associated with having bad breath or bad teeth. Furthermore, there is research to suggest that poor oral health may be a disadvantage in the labour market and also that there may be a link between oral health on the one hand, and heart disease, strokes, and certain forms of cancer, on the other. Untreated oral health problems also are responsible for a not insignificant amount of visits to primary-care physicians and hospital emergency rooms. We believe provincial governments should take inspiration from other countries and start moving toward some form of universal dental insurance coverage; in doing so they should also consider ways in which the dental services sector could become more competitive and efficient. Policy initiatives along those lines could yield major payoffs, in terms of both equity and efficiency. A straightforward way of creating universality would be to gradually expand existing public plans until they covered everyone in the population. However, universality does not necessarily mean that everyone must be insured through the same plan. As an alternative, we explore a mixed model with competition between private and public insurance. In our proposals to improve public dental coverage in Canada, we further scope out possible stumbling blocks in developing a broader public insurance plan, for example, controversies over what should be covered, and how public payment models and regulation could encourage more efficient service delivery.

Correction: Comparison of Canadian public medication insurance plans and the impact on out-of-pocket costs

Correction: Comparison of Canadian public medication insurance plans and the impact on out-of-pocket costs

Comparison of Canadian public medication insurance plans and the impact on out-of-pocket costs.

Research from 2006 documented substantial variation in medication coverage for residents across Canada. Since then, some provinces have implemented major medication plan reforms. We aimed to update the information on publicly funded medication insurance plans available across Canada and to compare out-of-pocket costs across the country. We compared provincial medication insurance plans using data from public websites and other public source documents. Using 2 hypothetical clinical examples, we determined the amount and type of a patient's out-of-pocket costs for 5 different patient subtypes that varied based on medication burden, age and income. Each province offers a plan to all residents. Cost-sharing is employed across all provinces. Some residents must pay a premium to receive insurance or must pay 100% of their medication costs until they reach a deductible amount, above which government funding covers a portion of medication costs. With the scenario of low medication burden (medication cost about $500), out-of-pocket costs ranged from $250 to $2100 for higher-income residents and from $0 to $700 for lower-income residents. With the scenario of high medication burden (medication cost about $1800), the corresponding ranges were $250-$2500 and $0-$1100. The variation was due to province of residence, age and income. Variations in out-of-pocket payments continue to exist across the provinces, with some groups facing high expenses. Further work is required to understand the impact of different cost-sharing mechanisms, develop policies to limit out-of-pocket expenses and improve provincial drug plans.

Insurance-related Practices at Title X-funded Family Planning Centers under the Affordable Care Act: Survey and Interview Findings

IntroductionGiven the recent reforms in the United States health care system, including the passage and implementation of the Affordable Care Act, as well as anticipated upcoming changes to health care coverage, it is critical that publicly funded health care providers understand how to effectively work with their states' Medicaid programs and the private health insurance plans in their service areas to provide high-quality contraceptive care to the millions of women relying on services at these sites annually. MethodsWe collected survey data from a nationally representative sample of 535 clinics providing family planning services that received Title X funding and conducted semistructured interviews with 23 administrators at a subsample of surveyed clinics to explore provider-reported experiences working with health plans and to identify barriers to, and practices that lead to, adequate reimbursement for services provided. ResultsProviders report that knowledgeable staff are crucial to securing contracts with both public and private insurance plan issuers, and that the contracts they secure often include coverage restrictions on methods or services clinics offer their clients. Good staff relationships with issuers are key to obtaining adequate and consistent reimbursement for all covered services. ConclusionsProviders are trying to understand how insurance programs in their area knit together. Regardless of how U.S. health policies and delivery systems may change in the coming years, it is imperative that publicly funded family planning centers continue to work with health plans and maximize their third-party revenue to provide services to those in need.

Majority of Americans Say Mental Health Care Should Be Covered by Insurance

Among other findings, the APA-sponsored poll suggested that few Americans believe mental health is a high priority for policymakers or that the country is headed in the right direction with regard to addressing the opioid crisis.

Differences in utilization of dental procedures by children enrolled in Wisconsin Medicaid and Delta Dental insurance plans.

Few studies have directly compared dental procedures provided in public and private insurance plans for enrollees living in dental health professional shortage areas (DHPSAs). We examined the rates for the different types of dental procedures received by 0-18-year-old children living in DHPSAs and non-DHPSAs who were enrolled in Medicaid and those enrolled under Delta Dental of Wisconsin (DDW) for years 2002 to 2008. Medicaid and DDW dental claims data for 2002 to 2008 was analyzed. Enrollees were divided into DDW-DHPSA and non-DHPSA and Medicaid-DHPSA and non-DHPSA groups. Descriptive and multivariable analyses using over-dispersed Poisson regression were performed to examine the effect of living in DHPSAs and insurance type in relation to the number of procedures received. Approximately 49 and 65 percent of children living in non-DHPSAs that were enrolled in Medicaid and DDW received at least one preventive dental procedure annually, respectively. Children in DDW non-DHPSA group had 1.79 times as many preventive, 0.27 times fewer complex restorative and 0.51 times fewer endodontic procedures respectively, compared to those in Medicaid non-DHPSA group. Children enrolled in DDW-DHPSA group had 1.53 times as many preventive and 0.25 times fewer complex restorative procedures, compared to children in Medicaid-DHPSA group. DDW enrollees had significantly higher utilization rates for preventive procedures than children in Medicaid. There were significant differences across Medicaid and DDW between non-DHPSA and DHPSA for most dental procedures received by enrollees.

Association of Healthy Home Environments and Use of Patient-Centered Medical Homes by Children of Low-Income Families

IntroductionMedicaid agencies have been promoting the patient-centered medical home (PCMH) model. Most caregivers choose physician practices for their children, and we hypothesized that those following healthier childrearing practices are more likely to seek care in a PCMH. MethodWe selected children with public insurance plans (n = 20,801) from the 2011–2012 National Survey of Children's Health. We used generalized ordinal logistic regression with state fixed effects to assess the association between home environments and children's use of PCMHs. ResultsChildren living in the healthiest homes were 1.33 times (p = .001) more likely to receive care from the highest level of PCMH. In states with early PCMH implementation, the odds increased to 2.11 times (p = .001). DiscussionOur results show a significant, sizeable relationship between healthier home environments and the use of PCMH by children from low-income families. They provide implications for assessing the effect of PCMH use on health outcomes and use patterns.

Farmer Participation, Entry and Exit Decisions in the Italian Crop Insurance Programme

AbstractThe factors affecting the demand for agricultural insurance in the USA have been extensively studied over the last two decades. However, the determinants of a farm's entry and exit decisions in the insurance market have received relatively little attention. Turnover in the insurance book of business is an important issue in most private and public crop insurance plans. Moreover, insurance markets in the EU are still largely under‐investigated. We investigate empirically the determinants of crop insurance participation in Italy. We show that the participation rate is high for large firms and that it is negatively correlated with crop diversification, which is itself a form of insurance. High premiums tend to inhibit both entry and exit from the insurance market. Larger and wealthier farms are more likely to adopt insurance and renew coverage over time. We discuss implications of our results for public intervention and the private industry. In particular, we demonstrate that the decision to drop coverage by an insured grower may differ significantly from the corresponding decision to enroll in an insurance programme by an uninsured farmer. To the extent that policymakers want to encourage participation in subsidized crop insurance programmes, education and outreach efforts toward uninsured farmers may differ substantially from those directed toward keeping insured farmers enrolled in the programme. We investigate these differences.

A Two-Tier Health Care System: The New Zealand Story

The Canadian health care system is at a crossroads. Litigation building on the Supreme Court of Canada’s decision in Chaoulli that could lead to the establishment of a parallel private tier is underway in several provinces. For example, in a challenge set to proceed to trial this fall, Dr. Brian Day and six patient plaintiffs are challenging several British Columbia laws that restrict parallel private care. Provincial governments across Canada employ various laws to protect public Medicare, including bans on private insurance for publicly insured services, limits on dual practice by physicians (i.e. prohibiting those who are paid through the public insurance plan from also being paid from the public purse), and bans on extra-billing for insured services (i.e. preventing physicians from topping up public payments by charging patients more). Plaintiffs in the upcoming cases allege that the combination of long wait times in the public system and limits on private care infringe their Charter rights to life and security of the person. As judges evaluate these claims, a key consideration will be whether restrictions on private care are essential to preserving quality, efficiency, and accessibility within Canada’s public health care system. In assessing the impact of liberalizing these laws, courts will rely on the comparative experience of countries that also have universal public health insurance, but that allow parallel private care. However, too often, the subtleties of foreign countries’ experiences with two-tier care and contextual differences between health care systems are downplayed or ignored, in favour of simplistic conclusions. For example, in Chaoulli, Chief Justice McLachlin accepted a “common sense” argument that prohibiting private health insurance was not related to the provision of quality public health care, given the experiences of several western democracies with “medical services that are superior to and more affordable than the services that are presently available in Canada,” without addressing the differences that exist between Canada and these countries. This paper draws lessons for Canada from New Zealand’s health care system, which permits two-tier health care. After briefly comparing the two systems, we address the claim that New Zealand’s shorter wait lists coupled with its permissive approach to a parallel private system suggest that Canada should loosen its own restrictions on privatization. We argue that not only are there concerns with the reliability of New Zealand’s wait list data, but that its method of organizing wait lists and its permissiveness of dual practice raise serious concerns with equitable access, quality of care, and physician conflicts of interest. We conclude by arguing that the uncertainty inherent in adapting comparative health policy literature to the Canadian context necessitates judicial deference to policy-makers in the upcoming constitutional challenges.

Differential low uptake of free vitamin D supplements in preterm infants: the Quebec experience.

BackgroundVitamin D is essential for bone mineralization, particularly in premature infants. For nearly 20 years, Quebec has offered a program of free vitamin D supplements via its public medication insurance plan Régie de l’Assurance Maladie du Québec (RAMQ). The objective of this study is to evaluate the number of preterm infants that obtained at least one bottle (50 doses) of vitamin D supplement through this program and to determine if uptake varied by gestational age.MethodsThis was a retrospective cohort study of preterm infants covered by RAMQ and born from 1998 to 2008; all infants had 1 year of follow-up data regarding supplement use. Data were extracted from the Quebec Pregnancy Cohort, a linked administrative database and were stratified by early (<34 weeks) or late gestational age premature infants. The number of infants obtaining supplements was the primary outcome and their characteristics were compared across gestational age groups. Predictors for participation (obtaining at least 1 bottle) or adherence (2 or more bottles) were identified via logistic regression (GEE).Results10288 infants were eligible; the percentage exposed to vitamin D was 24.5% (37.4%- early; 20.7%-late preterm infants, p < 0.001). The median number of bottles obtained was 2 for early and 1 for late preterms. For all premature infants, there was an apparent geometric decline in the infants obtaining subsequent bottles of supplements over the 12 month period. Additionally, there was a significant decline in program participation over time (OR = 0.90/year, 95% CI: 0.89-0.90) regardless of gestational age. Older or more educated mothers were positive predictors for participation. A prescription from a pediatrician significantly increased the odds of obtaining the supplement.ConclusionEarly preterm infants were more likely to obtain the supplement post-discharge; uptake was low and decreased with time for both age categories. Specifically, targeting late preterm infants and young mothers with less education could improve vitamin D uptake.

Advocates Urge More Cooperation Among MH Organizations

Back to table of contents Previous article Professional NewsFull AccessAdvocates Urge More Cooperation Among MH OrganizationsVabren WattsVabren WattsSearch for more papers by this authorPublished Online:14 Apr 2014https://doi.org/10.1176/appi.pn.2014.4b7AbstractMultiple benefits accrue to patients with psychiatric disorders when the many organizations in the mental health field pool their advocacy efforts to improve care and insurance coverage.The African proverb “it takes a village to raise a child” may apply in the context of treating people with mental illness. Debbie Plotnick, M.S.S., M.L.S.P., discussed the importance of caring for those with mental illness outside of mental health care facilities.On February 28, Debbie Plotnick, M.S.S, M.L.S.P., senior director of state policy at the advocacy organization Mental Health America, spoke at the 2014 Intensive Winter Institute sponsored by the American Nurses Association (ANA) and the APA Minority Fellowship Program to discuss the importance of caring for those with mental illness in the community and collaboration among mental health care organizations.Mental health professionals are often located in the facilities in which people are being treated for their mental illness, Plotnick said, but “we should often go into the community to ensure that there are resources available concerning mental illness, so that people will know how to obtain help if they or a loved one is struggling with mental illness.”Plotnick emphasized that the community-based outreach concept can also be applied to help individuals recover from mental illness. “As we explore what we need [to improve] quality, we should consider more than clinical quality,” Plotnick said, explaining that mental health facilities often see patients when they are seriously ill and do not see those patients when they are well. “We need to know how they are doing . . . whether they’re back to a fulfilling life with a safe place to live and with meaningful work.”In an interview with Psychiatric News, Plotnick said that she has had personal experiences with the integration of mental health treatment and community outreach practices. “My daughter struggled with serious mental illness as an adolescent, and she was able to find community resources to keep her in school and help her take control of her illness. She is now a successful young woman who is a nurse.”In light of the multiple recent changes reshaping the health care system, Plotnick emphasized that it is especially important to advocate for both public and private insurance plans that will guarantee coverage of prevention efforts, peer-counseling services, and wellness programs, in addition to community inclusion services—that is, intervention services that guide those with psychiatric disabilities back into society to live a functional life. Plotnick said that this goal will be achieved only through a collaborative advocacy effort from all mental health organizations. She added that by making the needs of patients the primary focus of interdisciplinary meetings by organizations in the mental health field, mental health professionals will become more effective—benefitting patients in all stages of treatment and recovery.Annelle Primm, M.D., said that, “When mental health care organizations work collaboratively, it can only mean great things for the field of mental health.”Annelle Primm, M.D., M.P.H., APA deputy medical director and director of the Division of Diversity and Health Equity, agreed. “I think it is important for mental health care professionals to learn about the great benefits of team-based care, particularly in the context of the Affordable Care Act, which values interdisciplinary work,” she said.Primm noted that this is the first year that that APA and the ANA have co-sponsored the Intensive Winter Institute—usually it is hosted solely by the ANA. “Hopefully, there will be some sustained contact and opportunity for research and joint policy work,” said Primm. “When mental health care organizations work collaboratively, it can only mean great things for the field of mental health and for mental health care delivery. People are now equipped with the knowledge that they need to be on top of cutting-edge issues in today’s changing health care environment.” ■ ISSUES NewArchived

HIV, Tobacco Use, and Poverty: A Potential Cause of Disparities in Health Status by Race and Socioeconomic Status

Tobacco use in the U.S. has declined significantly since the 1960s, but differentially by socioeconomic status. Current HIV (human immunodeficiency virus) infection rates in the United States are higher in minorities and underprivileged individuals. Effective highly active anti-retroviral therapy (HAART) has changed HIV into a chronic infection. Mortality among HIV patients is now as likely to be due to heart disease and cancers as HIV-related infections. In the current situation, one would expect public insurance plans to focus on interventions targeting lifestyle-associated behaviors such as tobacco use that have been found to be associated with increased risk for heart disease and cancers. Review of the AIDS Drug Assistance Program formularies and the Medicaid Programs of 50 states and the District of Columbia, however, revealed that coverage for smoking cessation is inadequate in most instances. To reduce health disparities, publicly funded programs that serve the nation's most vulnerable should provide coverage for effective tobacco cessation.

Evaluation of medication therapy management services for patients with cardiovascular disease in a self-insured employer health plan.

Cardiovascular disease (CVD) is a major cause of mortality in the United States, representing the highest total expenditures among major diseases. To improve CVD-associated outcomes, medication therapy management (MTM) services have been included in essential health benefit packages offered by various health plans. Nevertheless, the impact of such MTM services on outcomes is still unclear, especially from the perspective of the self-insured employer. To (a) compare economic outcomes between patients who received and those who did not receive MTM services from the self-insured employer's perspective and (b) compare clinical outcomes before and after receiving MTM services. This study consisted of 2 pre- and post-retrospective designs: (1) a cohort study with comparison groups and (2) a cohort study within group comparison. Patients were beneficiaries aged 19 years or older who were diagnosed with CVD conditions according to ICD-9-CM codes and continuously enrolled in a public university-sponsored insurance plan between 2008-2010. Patients were divided into MTM and non-MTM groups. The first MTM encounter was assigned as the index date for the MTM group. Match-paired patients who did not receive MTM services were randomly assigned the index date based on age category, gender, and comorbidity. Measures for pharmacy, medical, and total expenditures were obtained from medical and pharmacy claims. Paired t-tests and independent t-tests using data generated from 1000 bootstraps compared mean cost difference within and between groups. The return on investment (ROI) was calculated by dividing the average net benefit from MTM services by the average cost of MTM services. Clinical parameters, including blood pressure (BP) and body mass index (BMI), were retrieved from electronic medical records from a pharmacist-provided clinic where MTM services took place. Paired-t tests were used to compare the mean difference between baseline and endpoint values. Further, this study examined changes in the proportion of patients who achieved an individualized treatment goal for BP and BMI. The study also quantified the improvement in disease stages after the index date using the McNemar's test. Statistical analyses were performed by using SAS software version 9.2 with statistical significance level of 0.05. A total of 63 patients and 62 match-paired patients were included in the MTM group and the non-MTM group, respectively. The mean cost (SD) per patient in the MTM group during the 6 months post-index period for CVD-related pharmacy, all-cause medical, and total expenditures was lower than the 6 months pre-index period by $22.0 (19.1), $79.2 (99.6), and $75.1 (136.2), respectively. In contrast, the mean cost (SD) for the non-MTM group increased during the 6 months post-index date by $10.7 (24.2), $246.4 (248.4), and $289.0 (269.5) for pharmacy, medical, and total expenditure, respectively. When comparing the 2 groups, the MTM group had statistically significantly lower costs per patient for pharmacy expenditures (difference of -31.9 ± 25.1, P less than 0.0001), medical expenditures (difference of -$325.6 ± 271.2, P less than 0.0001), and total direct expenditures (difference of -$359.3 ± 219.2, P less than 0.0001). Given the net benefit of MTM services ($359.3) and the average cost of MTM service ($134.6), the ROI was $1.67 per $1 in MTM cost. Regarding clinical outcomes, while no statistically significant differences were observed in clinical outcomes, MTM services demonstrated clinical benefits. At the post-index period, the percentage of patients who had achieved their goals increased from 55% to 70% for BP and from 13.0% to 21.7% for normal BMI compared with the pre-index period. In terms of the extent of improvement in disease stages, clinical improvements in the stages of hypertension (χ2 =12.77, P less than 0.05) as well as BMI (χ2 =6.39, P less than 0.05) at the endpoint were observed. Cardiovascular-related pharmacy, all-cause medical, and total expenditures were statistically lower among beneficiaries who received MTM services compared with those who did not. In addition, MTM services had a positive ROI and demonstrated clinical significances by the increasing number of patients who achieved treatment goals and improved disease stages for hypertension and BMI.

A cost-benefit analysis: implementing temporary disability insurance in Washington State

Five states and Puerto Rico currently provide disability insurance to persons unable to work due to temporary disability. No states have adopted such policies since 1969. Labor unions and other advocacy groups have advanced bills in Washington and Oregon that would establish a public disability insurance plan to provide partial wage replacement for serious illness, accident and pregnancy. This paper estimates annual costs and benefits for a temporary disability insurance program in Washington State under the assumption that it would mirror the disability provisions in California without paid family leave.