Total Claims Research Articles

How to Effectively Decrease Patient Co-Payments of High-Cost Drugs Through Innovation: Lessons From the Karmanos Specialty Pharmacy.

High-cost drugs impose a financial burden on patients with cancer. Karmanos Specialty Pharmacy (KSP) developed a process to automate financial assistance (FA) applications to decrease patient drug cost. We evaluate the outcomes of this program on cost to patients and payers. This is an observational, retrospective study of the KSP claims data set from January to December 2019, accessed by 13 statewide cancer centers within Michigan. Drug cost of patients, payers, FA (funds to lower patient drug cost), and types of FA were obtained. A subset analysis was performed to determine drug delivery times. In 2019, 869 prescriptions and 1,722 prescription fills were provided to 463 patients through KSP. The total cost of drug claims was approximately $10 million US dollars (USD) among Medicare patients (58%), approximately $3.4 million USD for privately insured patients (20%), and approximately $3.7 million USD for Medicaid patients (22%). Twenty-seven percent of patients (22% of all prescription fills) required additional FA with initial total co-payment claims of $335,216 USD. $280,988 USD of FA was obtained, which substantially lowered total patient costs by 81%. $250,818 USD of FA obtained was from foundation grants (327 fills), and $21,441 USD from manufacturer co-pay cards (47 fills). An additional $12,260 USD (12 fills) from a Karmanos Patient Assistance Fund was used. There was high dependence on foundation grant assistance among Medicare patients (33% of claims). In a subset analysis, the median time from prescription written to delivery to the patient was < 7 days (0-56 days). Twenty-seven percent of patients (22% of prescriptions fills) in 2019 required additional FA for high-cost drugs. KSP substantially reduced patient cost by implementing an efficient process using additional pharmacy assistants to obtain FA.

Evolving Radiology Trainee Neuroimaging Workloads: A National Medicare Claims-based Analysis

While radiology training programs aim to prepare trainees for clinical practice, the relationship between trainee, and national radiology workforce demands is unclear. This study assesses changing radiology trainee neuroimaging workloads nationwide for neuroimaging studies. Using aggregate Medicare claims files from 2002 to 2018, we identified all computed tomography (CT) and magnetic resonance (MR) examinations of the brain, head and neck, and spine (hereafter "neuroimaging") in Medicare fee-for-service beneficiaries nationwide. Using separate Medicare files, we calculated population utilization rates, and work relative value unit (wRVU) weights of all diagnostic neuroradiology services. Using claims modifiers, we identified services rendered by radiology trainees. Using separate national trainee enrollment files, we calculated mean annual per trainee wRVUs. Between 2002 and 2018, total Medicare neuroimaging claims increased for both radiologists overall (86.1%) and trainees (162.5%), including increases in both CT (102.9% vs 196.8%), and MR (59.9% vs 106.6%). The national percentage of all radiologist neuroimaging wRVUs rendered by trainees increased 46.1% (3.8% of all wRVUs nationally in 2002 to 5.6% in 2018). National trainee increases were present across all neuroimaging services but greatest for head and neck CT (+86.5%). Mean annual per radiology trainee neuroimaging Medicare wRVUs increased +174.9% (42.1 per trainee in 2002 to 115.70 in 2018). Mean per trainee wRVU increases were greatest for spine CT (+394.2%) but present across all neuroimaging services. As neuroimaging utilization in Medicare beneficiaries has grown, radiology trainee neuroimaging workloads have increased disproportionately.

COVID-19 Telehealth Impact Study

Importance: This three-part study characterizes the widespread implementation of telehealth during the first year of the COVID-19 pandemic, giving us insight into the role of telehealth as we enter a stage of “new normal” healthcare delivery in the U.S.&#x0D; Objective: The COVID-19 Telehealth Impact Study was designed to describe the natural experiment of telehealth adoption during the pandemic. Using a large claims data stream and surveys of providers and patients, we studied telehealth in all 50 states to inform healthcare leaders. &#x0D; Design, Setting, Participants: In March 2020, the MITRE Corporation and Mayo Clinic founded the COVID-19 Healthcare Coalition (C19HCC), to respond to the pandemic. We report trends using a dataset of over 2 billion healthcare claims covering over 50% of private insurance activity in the U.S. (January 2019-December 2020), along with key elements from our provider survey (July-August 2020) and patient survey (November 2020 - February 2021).&#x0D; Main Outcomes and Measures: There was rapid and widespread adoption of telehealth in Spring 2020 with over 12 million telehealth claims in April 2020, accounting for 49.4% of total health care claims. Providers and patients expressed high levels of satisfaction with telehealth. 75% of providers indicated that telehealth enabled them to provide quality care. 84% of patients agreed that quality of their telehealth visit was good.&#x0D; Results: Peak levels of telehealth use varied widely among states ranging from 74.9% in Massachusetts to 25.4% in Mississippi. Every clinical discipline saw a steep rise with the largest claims volume in behavioral health. Provision of care by out-of-state provider was common at 6.5% (October-December 2020). Providers reported multiple modalities of telehealth care delivery. 74% of patients indicated they will use telehealth services in the future.&#x0D; Conclusions and Relevance: Innovation shown by providers and patients during this period of rapid telehealth expansion constitutes a great natural experiment in care delivery with evidence supporting widespread clinical adoption and satisfaction on the part of both patients and clinicians. The authors encourage continued broad access to telehealth over the next 12 months to allow telehealth best practices to emerge, creating a more effective and resilient system of care delivery.

A Priori Ratemaking Selection Using Multivariate Regression Models Allowing Different Coverages in Auto Insurance

A comprehensive auto insurance policy usually provides the broadest protection for the most common events for which the policyholder would file a claim. On the other hand, some insurers offer extended third-party car insurance to adapt to the personal needs of every policyholder. The extra coverage includes cover against fire, natural hazards, theft, windscreen repair, and legal expenses, among some other coverages that apply to specific events that may cause damage to the insured’s vehicle. In this paper, a multivariate distribution, based on a conditional specification, is proposed to account for different numbers of claims for different coverages. Then, the premium is computed for each type of coverage separately rather than for the total claims number. Closed-form expressions are given for moments and cross-moments, parameter estimates, and for a priori premiums when different premiums principles are considered. In addition, the severity of claims can be incorporated into this multivariate model to derive multivariate claims’ severity distributions. The model is extended by developing a zero-inflated version. Regression models for both multivariate families are derived. These models are used to fit a real auto insurance portfolio that includes five types of coverage. Our findings show that some specific covariates are statistically significant in some coverages, yet they are not so for others.

Trends in Cardiac Care Utilization under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, India

Background: Ayushman Bharat, the flagship scheme of the Government of India, was launched in September 2018 to achieve the vision of universal health coverage in India. Objectives: One of the important components of Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojna (PM-JAY) that provides a benefit cover of INR 5 lakhs per family per year for secondary and tertiary care hospitalization. Methods: The present study explores key trends in the utilization of cardiac care packages under the Ayushman Bharat AB PM-JAY. This would have an implication in making cardiac care more accessible by bridging the existing gaps in cardiac care delivery under PM-JAY. All cardiac claims under PM-JAY were analyzed for a period of 17 months (from the inception of the scheme in September 2018 to February 2020). Results: The analysis shows that claims from cardiac (cardiology as well as cardiothoracic and vascular surgery) specialty accounted for 5% of the total PM-JAY claim volume, however, it shares in the total claim volume. It was significantly higher at 26% indicating that a very high proportion of the scheme was utilized to provide free cardiac care to beneficiaries coming from the poorest segment of the population. Conclusion: The analysis also indicates significant variation in the supply of the cardiac facilities and the need to further develop health infrastructure for cardiac care, particularly in certain states where the supply is found to be inadequate.

Epidemiologic Burden of Hospitalization Among Adult Filipinos with Supraventricular Tachycardia Requiring Radiofrequency Ablation

INTRODUCTION: Radiofrequency catheter ablation (RFA) is an interventional cardiac electrophysiologic procedure that uses heat energy for definitive management of supraventricular tachycardias. It is a class I recommendation for chronic management of most supraventricular arrhythmias. No local data exist in the incidence hospitalization for SVT and utilization of RFA for this condition. The study aimed to obtain the prevalence of hospitalization of patients with supraventricular tachycardias where RFA is utilized, including the patients’ demographic profile, length of hospitalization, and mortality rate. METHODOLOGY: Philippine Health Insurance Corporation claims for hospitalization from January 1, 2017, to December 31, 2018, were reviewed. Data analysis was done using median and interquartile range for continuous data, and frequency and percentage distribution for categorical data. RESULTS: There were 1121 and 1149 claims for hospitalization for SVTs (atrial paroxysmal tachycardia, atrioventricular paroxysmal tachycardia, nodal paroxysmal tachycardia, and junctional tachycardia) in 2017 and 2018, respectively. This represents four hospitalization claims for SVT per 10,000 of the total PHIC claims. The majority of patients were female with median age of 52 years. Only 25 and 19 patients underwent radiofrequency ablation in 2017 and 2018, respectively. The majority of these patients were male and younger with a median age of 31 years. No mortality was recorded among patients admitted for catheter ablation. CONCLUSION: In 2017 and 2018, hospitalization claims for SVT requiring catheter ablation were 0.04% (four hospitalization claims for SVT per 10,000 of the total claims) in both years. The majority of patients were admitted with pharmacologic therapy on discharge with very low utilization of radiofrequency ablation for long-term management. KEYWORDS: arrhythmia, supraventricular tachycardia, radiofrequency ablation, prevalence, hospitalization

Epidemiologic Burden of Hospitalization Among Adult Filipinos for Cardiac Arrhythmias Requiring Permanent Pacemaker Implantation

BACKGROUND: Symptomatic bradycardia, commonly attributed to sinus node dysfunction/ sick sinus syndrome, or atrioventricular (AV) blocks or conduction disorders from chronic fascicular blocks, is treated by implantation of a permanent pacemaker. Despite it being a class 1 recommendation, there is a perception based on informal surveys that permanent pacemaker implantation (PPI) is underutilized. The Philippines showed slow growth in the volume of implantation from 1049 in 2015 to 1225 in 2016. The Philippine pacemaker data after 2016 are incomplete and unreliable because of the lack of a national registry. It is the aim of this study to ascertain the prevalence of cardiac arrhythmias requiring PPI and the volume of its utilization in the Philippines. OBJECTIVES: The aims of this study were to (1) to determine the prevalence of hospitalization claims in 2017 and 2018 for cardiac arrhythmias requiring PPI, (2) to determine the regional distribution of arrhythmias requiring PPI, (3) to determine the regional distribution of hospitalization claims for PPI, (4) to determine the number of hospitalization claims for specific cases requiring PPI and the corresponding mortality rate, (5) to determine the number of hospitalization claims for PPI and the corresponding mortality rate, and (6) to describe the demographic profile of patients with indications and with claims for PPI, as well as the duration of hospitalization and type of facilities where the hospital claims were filed. METHODS: This is a descriptive study of Filipino patients 19 years or older, admitted for cardiac arrhythmias requiring PPI in the Philippine Health Insurance Corporation (PhilHealth)–accredited hospitals in 2017 and 2018. The data for disease prevalence were gathered from the database of PhilHealth using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) of the World Health Organization. The procedures that the patients underwent were determined using the latest PhilHealth Relative Value Scale (RVS) codes. Other variables gathered were the demographic data, diagnosis, region, duration of hospital stay, type of facility on admission, and the status on discharge. Qualitative data were tabulated and presented as frequency and percent distribution. Quantitative data were reported as median with corresponding quartiles (Q1 and Q3). RESULTS: Based on the 2017 and 2018 database of PhilHealth, out of the nationwide total medical admissions, there were 958 total claims for arrhythmias requiring pacemaker implantation in 2017 and 1144 total claims in 2018. The prevalence in both years was similar (0.04%). There were 549 and 683 total claims for PPI, in 2017 and 2018, respectively, and preponderantly done in the National Capital Region. Sick sinus syndrome/tachycardia–bradycardia syndrome had the greatest number of total claims for both years. More than half of the patients who had PPI were females. The median age was similar (67 and 68 years old for both years and 73 and 75 years old in 2017 and 2018, based on ICD-10 and RVS codes, respectively). The duration of hospitalization was a median of 4 days (ICD-10 codes) and 5 to 6 days (RVS codes). Most of the hospital claims for cardiac arrhythmias (76%–79%) requiring PPI were filed in private facilities. Mortality among those diagnosed was 3.6% for complete atrioventricular block and 0.3% for sick sinus syndrome but was low among those who underwent PPI (0.8%–2.2%).. CONCLUSION: The prevalence of hospitalization claims for arrhythmias requiring PPI was 0.04%, both in 2017 and 2018. There is a big gap between the number of cases requiring a permanent pacemaker and the number that underwent the procedure. Hospitalization claims, based on ICD-10 codes and RVS codes, were centralized in the National Capital Region and private hospitals. The mortality rate among those who had the procedure was low. KEYWORDS: arrhythmia, permanent pacemaker insertion or implantation, prevalence, hospitalization, PhilHealth

Lessons learned from Ohio workers' compensation claims to mitigate hazards in the landscaping services industry.

The landscaping services industry is one of the more dangerous in the United States, with higher rates of both fatal and nonfatal injuries than the all-industry average. This study uses claims from the Ohio Bureau of Workers' Compensation (OHBWC) database to identify high rates of occupational injuries and illnesses in this industry in Ohio. The causes of those illnesses and injuries are highlighted to identify common factors. The OHBWC database includes injured-worker industry identification, occupation, business size, demographics, diagnoses, and free-text descriptions of injury circumstances. We identified landscaping service industry claims from 2001 to 2017, and describe annual claim counts and rates. Over the 17-year period, 18,037 claims were accepted, with "Struck by object or equipment" and "Overexertion involving outside sources" being the most common events or exposures. Sprains and fractures were the most prevalent of the more serious lost-time (LT) injuries. Free-text descriptions of claims indicate that arborist work and loading/unloading of work vehicles and trailers are particularly hazardous. Younger and shorter-tenured workers were injured most frequently, although the average workers' age was higher for LT claims. The total cost of claims to the OHBWC from the landscaping services industry for 2001-2017 was over $226,000,000. Almost $214,000,000, or 94.4%, was for LT injuries and illnesses, even though LT claims comprise only 18% of total claims. Targeted improvements in landscaper safety could come from controlling events leading to LT claims. Engineering controls and improved training are strongly recommended to reduce falls, overexertion, and struck-by injuries.

Impact of a pharmaceutical care incentive program on the asthma medication ratio among pediatric patients with persistent asthma enrolled in a Medicaid program.

BACKGROUND: Asthma is one of the leading chronic disease states in pediatric patients in Texas. Pharmacy-led interventions such as targeted asthma education, scheduled consultations, and monitoring have shown success in improving asthma outcomes. However, no studies have evaluated the impact of the pharmaceutical care incentive (PCI) programs on Texas Medicaid pediatric beneficiaries. OBJECTIVES: To (1) describe the prevalence of asthma medication utilization and persistent asthma among Medicaid pediatric patients in Texas Health Service Region 11 (HSR 11) and (2) describe the prevalence and impact of PCI program interventions offered by pharmacists to Medicaid pediatric patients or their caregivers at the point-of-service in their medication utilization and asthma medication ratio (AMR). METHODS: This study used a 2-year longitudinal assessment of Medicaid pharmacy claims for beneficiaries aged between 0 and 18 years, with continuous enrollment, and at least 1 asthma medication claim during 2018 and 2019. The prevalence of asthma medication utilization during the study period was described. Also, the prevalence of PCI interventions among beneficiaries with at least 1 asthma medication was described. The prevalence of PCI interventions was also estimated for beneficiaries with persistent asthma. The AMR for beneficiaries with persistent asthma was calculated and compared for those with and without at least 1 PCI intervention. RESULTS: 22,051 beneficiaries with continuous enrollment between the ages of 0 and 18 years and with at least 1 pharmacy claim for an asthma medication during the study period were included. The overall prevalence of asthma medication utilization was 14.55%. 374 (1.70%) beneficiaries with at least 1 asthma medication received at least 1 asthma PCI intervention. Among beneficiaries that received at least 1 asthma PCI intervention, 158 (42.25%) were on rescue medication only; 4 (1.07%) were on maintenance medication only; and 212 (56.68%) were on rescue and maintenance medications. The overall prevalence of persistent asthma was 4.86%. 52 (0.76%) persistent asthma cases received at least 1 asthma PCI intervention after the index date. The overall unadjusted mean AMR (SD) for the 6,885 beneficiaries with persistent asthma was 0.50 (0.19). The adjusted AMR (SD) among beneficiaries with persistent asthma was reported at 0.530 (0.026) for beneficiaries who received at least 1 PCI intervention and 0.483 (0.002) for beneficiaries who did not receive a PCI intervention (P = 0.066). Beneficiaries with persistent asthma generated 64.35% of the total asthma pharmacy claims during 2019. CONCLUSIONS: Despite a high utilization of asthma medications among Medicaid pediatric beneficiaries, pharmacists servicing this group are underusing the PCI program interventions. An increase in the AMR among patients with persistent asthma receiving PCI interventions was observed when compared with those without PCI interventions. However, the difference was not statistically significant. Subsequent studies should include larger groups of beneficiaries receiving PCI interventions to establish the effect of PCI interventions on AMR before widespread implementation. DISCLOSURES: This research project was supported by the Global Institute for Hispanic Health (GIHH) through research grant M1803961. The authors have nothing to disclose. A part of this study was presented as a poster at the AMCP 2020 Virtual Annual Meeting and Exposition Meeting, April 21-24, 2020.

Extensive and Unregulated Use of On-Pack Promotional Claims in Commercially Available Baby Foods in the UK

ObjectivesThe number, variety and use of commercially available complementary baby foods (CACF) in the UK is increasing. There are growing concerns about the nutritional quality and promotion of these products. We aimed to explore the use of on-pack claims and categorize the nature of promotional claims in CACF. MethodsWe surveyed all CACF available from online UK supermarkets and Amazon in 2020. CACF were classified according to product type (e.g., puree, snack). On-pack promotional claims were recorded and classified as marketing, composition, health (e.g., supports the nervous system) and nutrient claims (e.g., added iron). Claims which encouraged the use of CACF but did not refer to health or nutrient qualities were defined as marketing claims (e.g., 2-of 5-a-day). Claims emphasizing the presence or absence of ingredient/s were defined as composition claims (e.g., low salt). The WHO Nutrient Profile Model draft for infants and young children and the European Union regulation on Health and Nutrition claims informed the classification. ResultsA total of 6265 claims were identified in 724 surveyed products. Marketing (99%,720) and composition claims (98%,713) were found on almost all CACF, compared with nutrient (35%,254) and health claims (6%,41). The median (Q1, Q3) number of total claims per product was 9 (7,10), marketing claims 5 (3,6) composition 3 (2,4), nutrient 0 (0,1) and 0 (0,0) health. The main marketing claims were texture related (e.g., super smooth, chunky bits) on 83% of the products (602) and taste related (e.g., flavours for tiny taste buds, first tastes) on 70% (506) of products. Claims mentioning fruit and veg (e.g., hidden veggies, perfect fruit & veg snack) were used on 42% of the products (307). The main composition claims were organic (62%,452), nothing artificial (58%, 426) and no added sugar (58%, 422). Baby led weaning claims (BLW) (e.g., encourages self-feeding, ideal finger food) were found on 72% of snacks. Snacks had significantly higher (P < 0.01) number of BLW claims (99%, 209), compared to the rest of products with BLW claims (i.e., purees, meals, cereals, deserts, sauces, stock cubes, dry ingredients). ConclusionsPromotional claims on CACF packaging are extensively used. CACF are promoted using “healthy halo” connotations that might confuse parents. Regulations on their use should be implemented to avoid inappropriate marketing. Funding SourcesNone.

Characterizing patient assistance program use and patient responsiveness to specialty drug price for multiple sclerosis in a mid-size integrated health system.

BACKGROUND: There is concern that increasingly common use of patient assistance programs (PAPs), out-of-pocket assistance provided by manufacturers or foundations, distorts our understanding of patient behavior and insurance design incentives. Yet the current literature on prescription drug cost sharing largely overlooks their use. PAPs prevalence and impact on drug demand and price elasticity is a major knowledge gap. OBJECTIVE: To examine the use of PAPs among patients with multiple sclerosis (MS) and the association with drug demand in a specialty pharmacy program within a regional integrated health system that facilitates their use. METHODS: We used pharmaceutical claims data from December 2017 to December 2018 linked to detailed payer information from Kaiser Permanente Washington to characterize the prevalence of PAPs for users of 7 MS specialty drug molecules. We estimated price elasticity of demand (PED) in a two-part model by using the presence of copayment assistance as a source of cost variation. The first part estimated marginal probability of a claim in a given month with a probit model, comparing PAP users and nonusers, whereas the second part estimated days supplied of a medication, given a claim was made as a measure for demand. RESULTS: Of 789 unique patients, 480 (60.7%) used PAPs in at least 1 drug claim during the 13-month time frame, and 248 patients (31.4%) used PAPs for all of their MS drug claims. When used, copay assistance covered 100% of out-of-pocket (OOP) charges for 98% of claims and reduced patient annual OOP cost by $3,493 on average. People who used PAPs had much higher OOP charges, a lower Charlson comorbidity score, and were more likely to have insurance through an exchange. The OOP costs charged to patients was higher for claims where patient assistance was used than claims where assistance was not used ($294 vs $42, P < 0.001). Total claim amount was higher for claims that used assistance ($6,169) than claims that did not ($5,503, P < 0.001). The probability of a patient having a drug claim in a given month was 1.9% higher among those using patient assistance, although this finding was not significant (P = 0.258). An average change in price of -$168.21 with PAP use led to an average change in demand of -0.05 days, for an overall price elasticity of demand (SD = 0.028, P = 0.852) given PAP use of 0.005, indicating that the presence of PAPs did not significantly affect demand. PED estimates were not statistically significant by drug, and the exclusion of Medicare patients did not change this interpretation. CONCLUSIONS: In a mid-size integrated health system in the state of Washington, a program that promotes adherence to specialty drugs via facilitated PAP use was found to reduce patient OOP costs but had no effect on prescription drug utilization. Payers may consider embracing PAPs to remove patient financial barriers to necessary medications and use tools other than cost sharing to influence patient consumption of specialty drugs. DISCLOSURES: This manuscript was funded in part through a Pre-Doctoral Fellowship in Health Outcomes from the PhRMA Foundation awarded to Brouwer for the completion of her dissertation work. Yeung receives some salary support from Kaiser Permanente. The other authors have nothing to disclose.

Association between industry payments and prescriptions of long-acting insulin: An observational study with propensity score matching.

The rapidly increased spending on insulin is a major public health issue in the United States. Industry marketing might be one of the upstream determinants of physicians' prescription of long-acting insulin-the most commonly used and costly type of insulin, but the evidence is lacking. We therefore aimed to investigate the association between industry payments to physicians and subsequent prescriptions of long-acting insulin. Using the databases of Open Payments and Medicare Part D, we examined the association between the receipt of industry payments for long-acting insulin in 2016 and (1) the number of claims; (2) the costs paid for all claims; and (3) the costs per claim of long-acting insulin in 2017. We also examined the association between the receipt of payments and the change in these outcomes from 2016 to 2017. We employed propensity score matching to adjust for the physician-level characteristics (sex, years in practice, specialty, and medical school attended). Among 145,587 eligible physicians treating Medicare beneficiaries, 51,851 physicians received industry payments for long-acting insulin worth $22.3 million. In the propensity score-matched analysis including 102,590 physicians, we found that physicians who received the payments prescribed a higher number of claims (adjusted difference, 57.8; 95% CI, 55.8 to 59.7), higher costs for total claims (adjusted difference, +$22,111; 95% CI, $21,387 to $22,836), and higher costs per claim (adjusted difference, +$71.1; 95% CI, $69.0 to $73.2) of long-acting insulin, compared with physicians who did not receive the payments. The association was also found for changes in these outcomes from 2016 to 2017. Limitations to our study include limited generalizability, confounding, and possible reverse causation. Industry marketing payments to physicians for long-acting insulin were associated with the physicians' prescriptions and costs of long-acting insulin in the subsequent year. Future research is needed to assess whether policy interventions on physician-industry financial relationships will help to ensure appropriate prescriptions and limit overall costs of this essential drug for diabetes care.

Banks’ international assets and sovereign default risk

PurposeThis paper aims to investigate the nexus between banks’ foreign assets and sovereign default risk in a panel of 15 developed economies. The empirical evidence suggests that banks’ foreign exposure is an important determinant of sovereign default probability.Design/methodology/approachUsing data from the consolidated banking statistics (total foreign claims on ultimate risk basis) by the Bank of International Settlements, the author constructs a measure of bank international exposure to peer countries. This measure is then used as the target variable in a panel regression for sovereign credit default swaps. The model includes 15 European and non-European developed economies. Identification is discussed extensively in the paper.FindingsQuantitatively, a 1% increase in banks’ cross-border claims increases sovereign default risk by about 0.19%. The relationship is weaker when banks are more capitalised. On the other hand, governments are more vulnerable to credit risk spillovers from banks’ international portfolios when having higher debt to GDP ratios.Originality/valueTo the best of the author’s knowledge, this is the first paper that attempts explicitly to establish an empirical connection between banks’ international assets and sovereign default risk. To the author’s opinion, this paper represents a contribution to our understanding of how sovereign credit risk spills over across countries. It also extends significantly the existing literature on the determinants of sovereign risk (that primarily focused on fundamentals, market characteristics – such as liquidity – and global factors). This paper ultimately sheds some new light on the role of intermediaries in the international transmission of credit risk, also adding to today’s discussion about the linkages between banks and sovereigns.

Opioid prescription patterns among urologists as compiled from within Medicare.

We aimed to evaluate opioid prescribing patterns of urologists across the United States (U.S.) and the District of Columbia (D.C.) using publicly available data from Medicare Part D. Our secondary analysis was to identify any loco-regional trends that may exist within the U.S. We queried publicly reported information from the Part D prescriber database, which is compiled from beneficiaries enrolled within the Medicare Part D prescription drug program. Only providers with the specialty description of urologist were included in this study. Between 2013 and 2017, a five-year average of 452 901 opioid claims by 9640 urologists - amounting to $5 357 114 USD and comprising 3.78% of all claims made - were identified. The state of Maine featured the highest percentage of opioid claims in relation to all claims (5.81%). West Virginia had the greatest average total opioid claims per provider (90), while Michigan featured the highest average proportion of opioid claims per provider (10.63%). The fewest opioid claims were processed within the Mid-Atlantic and New England regions. A multitude of factors likely contributes to variability between states. Urologists should be increasingly aware of their individual prescription tendencies and use available drug monitoring programs to reduce unnecessary prescriptions, all while providing more targeted and appropriate pain management.

Epidemiology of hospitalizations with hallucinogen use disorder: a 17-year U.S. National study

Objective To assess time-trends and outcomes of hallucinogen use disorder hospitalizations. Methods The U.S. National Inpatient Sample (NIS) data from 1998 to 2014 were used. People hospitalized with hallucinogen use disorder as primary or secondary diagnosis were assessed. Rates were calculated per 100,000 NIS claims. Multivariable-adjusted logistic regression analyses assessed the association of patient and hospital characteristics with outcomes. Results The national U.S. rates per 100,000 total NIS claims for hallucinogen use disorder hospitalizations increased from 1998–2000 to 2013–2014 and outcomes worsened over time: 1 hospitalizations, from 22.8 to 40.4 (1.8-fold); 2 in-hospital mortality rate, from 0.3 to 0.6 (2.3-fold); and 3 non-home discharge, from 4.2 to 6.3 (1.5-fold), respectively. Various patient and hospital characteristics were associated with worse healthcare utilization outcomes and in-hospital mortality. Conclusions Hallucinogen use disorder hospitalizations were common and increased from 1998 to 2014 in the U.S. interventions targeting modifiable patient and hospital factors can potentially reduce this burden.

Determining Critical Yield Index of Area Yield Insurance based on Basis Risk Constraint

Area yield index insurance at district level faces heterogeneous basis risk due to geographical conditions which implies to obtain unprecise critical index . Clustering and zone-based area yield scheme can reduce heterogeneous basis risk that leads to determine the suitable alternative for . On the previous research, we have obtained 7 clusters and 2 level of paddy productivity based on clustering assumption from primary data in Java. The suitable clustering assumption for calculating is cluster based assumption, which gives the homogeneous paddy productivity under 7 clusters in Java. Therefore, our goal is to develop area yield index at district level (cluster based) with minimize basis risk at certain constraints for paddy farmer productivity in Java Indonesia. There are some methods for calculating such as mean, median, winsor mean, one sigma, two sigma and (first quartile) method on the basis risk constraints using confusion matrix. Furthermore, two basis risk constraints are the difference between overpayment and shortfall is not extremely far, and total basis risk does not exceed 20% of its total claim occurrence. Two sigma method has the lowest basis risk, overpayment, and shortfall, but it has lowest pure premium, small probability of claim, and low range of claim. Hence, we consider to use (first quartile) method as alternative and suitable method to calculate that satisfied two basis risk constraints. In conclusion, our research provides analytical calculation for area yield index at district level with pure premium as Rp 152,151 using ( method), which is sufficient to cover the total claim and consistent with the simulation.

Workers' compensation costs for healthcare caregivers: Home healthcare, long‐term care, and hospital nurses and nursing aides

Healthcare workers (nurses and nursing aides) often have different exposures and injury risk factors depending on their occupational subsector and location (hospital, long-term care, or home health care). A total of 5234 compensation claims for nurses and nursing aides who suffered injuries to their lower back, knee, and/or shoulder over a 5-year period were obtained from the Ohio Bureau of Workers' Compensation and analyzed. Injury causation data was also collected for each claim. The outcome variables included indemnity costs, medical costs, total costs, and the number of lost work days. The highest prescribed morphine equivalent dose for opioid medications was also calculated for each claim. Home healthcare nurses and nursing aides had the highest average total costs per claim. Hospital nurses and nursing aides had the highest total claim costs, of $5 million/year. Shoulder injuries for home healthcare nursing aides (HHNAs) had the highest average total claim costs ($20,600/injury) for all occupation, setting, and body area combinations. Opioids were most frequently prescribed for home healthcare nurses (HHNs) and nursing aides (18.9% and 17.7% having been prescribed opioids, respectively). Overexertion was the most common cause for HHN and nursing aide claims. With the rapidly expanding workforce in the home healthcare sector, there is a potential health crisis from the continued expansion of home healthcare worker injuries and their associated costs. In addition, the potential for opioid drug usage places these workers at risk for future dependence, overdose, and prolonged disability. Future research is needed to investigate the specific and ideally reversible causes of injury in claims categorized as caused by overexertion.

Abstract PS7-49: Assessment of patient out-of-pocket cost for palbociclib therapy in advanced breast cancer

Abstract Assessment of patient out-of-pocket cost for palbociclib therapy in advanced breast cancerBackground:Palbociclib has demonstrated improved outcomes in patients with advanced hormone receptor positive (HR+)/human epidermal growth factor 2 (HER2) negative breast cancer when used in combination with endocrine therapy 1,2. The current average wholesale price of therapy with this medication class exceeds $190,000 per year (at full dose). Financial toxicity is a major concern in the oncology population and can decrease patient quality of life and may result in non-adherence 3,4. Our objective was to describe the out-of-pocket cost burden for patients treated with palbociclib. Methods:A retrospective review of patients newly initiated on palbociclib therapy between May 5, 2018 and May 30, 2019 was completed at our institution. Patients were included if they were 18 years of age and older, newly starting palbociclib for advanced or metastatic HR+/HER2- breast cancer, had US-based insurance, and received palbociclib from our internal specialty pharmacy. Cost information was collected utilizing dispensing reports and additional patient-specific information was obtained from the EHR. Descriptive statistics were performed on the collected data. Results:A total of 44 patients were included in the cost analysis. Primary sources of coverage for these patients included commercial insurance (n=13), Medicare (n=25), and state/federal insurance (n=6). We first assessed costs with primary insurance coverage alone. The sum of all the initial cycle out-of-pocket copays after primary insurance totaled $49,108. The median individual copay was $291, the range was $0 to $2,943, and 9 of the 44 patients had no copay after the primary insurance was applied. The impact of assistance programs, which include independent grant funding, copay cards, vouchers, and secondary Medicaid plans, was significant. After applying primary insurance and aid from assistance programs, the sum of all initial cycle out-of-pocket copays reduced from $49,108 to $3,172. After assistance, 33 of the 44 patients had an initial copay cost of $0. Over 90% of the out-of-pocket total was from two patients (one each with a copay of $2,467 and $497). Ultimately, Mayo Clinic Specialty Pharmacy helped patients avoid $45,851 in first cycle out-of-pocket copays, of which $41,079 and $4,772 were for Medicare and commercially-insured patients, respectively. Copay cost by type of insurance was assessed. All patients with commercial insurance (n=13) had no actual copay for the first cycle. Medicare patients (n=25) are not eligible for copay cards and had larger pre-assistance copays compared to commercial patients (median $2,454 vs. $45). Vouchers or grants were utilized by 16 out of 25 Medicare covered patients. State/Federal insurance included 2 Tricare and 4 Medicaid patients. While ineligible for copay card assistance, the copays for these patients were low, ranging from $0-$28. Standard Medicare D plans do not have an out of pocket maximum for the year. The catastrophic phase requires an ongoing copay of 5% of the total claim cost, resulting in approximately a $600 per month copay for the remainder of the calendar year during the study period. When combined with the first cycle cost of approximately $2500, the yearly out-of-pocket cost for a patient with a standard Medicare D plan is roughly $10,000. Conclusion:Patients initiating therapy with palbociclib are commonly faced with high out-of-pocket costs. The availability, eligibility, and use of financial assistance programs are imperative in decreasing the financial toxicity. Specialty pharmacies play an important role in obtaining financial assistance which leads to decreased out-of-pocket expenses for patients. Citation Format: Allison P Golbach, Matthew D Smith, Jodi L Taraba, Karthik V Giridhar. Assessment of patient out-of-pocket cost for palbociclib therapy in advanced breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-49.

Second Order Asymptotics Formula for Discounted Total Claims with Constant Interest Force

In this article, we analyse discounted total claims of insurance company, where the claim-size distribution is second order subexponential and the claim-number forms a renewal process. Using the asymptotic theory of the right-tail probability of randomly weighted sums, we study the right tail probability of discounted aggregate claims, and obtain a second order asymptotic expression, which was established uniformly for any finite-time level. The result is superior to the first order asymptotic formula.

Claim Amount Forecasting and Pricing of Automobile Insurance Based on the BP Neural Network

The BP neural network model is a hot issue in recent academic research, and it has been successfully applied to many other fields, but few researchers apply the BP neural network model to the field of automobile insurance. The main method that has been used in the prediction of the total claim amount in automobile insurance is the generalized linear model, where the BP neural network model could provide a different approach to estimate the total claim loss. This paper uses a genetic algorithm to optimize the structure of the BP neural network at first, and the calculation speed is significantly improved. At the same time, by considering the overfitting problem, an early stop method is introduced to avoid the overfitting problem. In the model, a three-layer BP neural network model, which includes the input layer, hidden layer, and output layer, is trained. With consideration of various factors, a total claim amount prediction model is established, and the trained BP neural network model is used to predict the total claim amount of automobile insurance based on the data of the training set. The results show that the accuracy of the prediction by using the BP neural network model to both the data of Shandong Province and to the data of six cities is over 95%. Then, the predicted total claim amount is used to calculate premiums for five cities in Shandong Province according to credibility theory. The results show that the average premium of the five cities is slightly higher than the actual claim amount of the city. The combination of BP neural network and credibility theory can perform accurate claim amount estimation and pricing for automobile insurance, which can effectively improve the current situation of the automobile insurance business and promote the development of insurance industry.