Enrollment Management in Undergraduate Medical School Admissions: A Complementary Framework to Holistic Review for Increasing Diversity in Medicine.

Medical schools implemented holistic review more than a decade ago, which led to more deliberate consideration and inclusion of applicants historically underrepresented in medicine. This article presents a theory of holistic enrollment management that unites holistic review with enrollment management principles. This theory contextualizes medical school admissions as a complex marketplace with multifaceted, competing forces. Applying an enrollment management framework of mission, market, means, and metrics can improve the capacity of a medical school to efficiently advance its mission over time. Medical schools employing a clear, compelling, and focused mission to direct all aspects of the medical education enterprise can more effectively attract applicants who are better prepared to enact that mission throughout their careers. Medical schools share a marketplace and collectively compete to identify, attract, admit, and matriculate the most mission-aligned student body within the pool of applicants they share. Institutions that deliberately mobilize resources within this dynamic marketplace will engage, admit, and matriculate the most suiting applicants and attract even more mission-aligned matriculants over time. Widespread adoption of this holistic framework of enrollment management may enhance the capacity of the medical education system to better capitalize on the existing diversity in the national pool of applicants, encourage more underrepresented applicants to apply in the future, admit and matriculate a more diverse national student body, and ultimately better prepare new physicians to meet the increasingly diverse health care needs of the nation.

Cost and Utilization Outcomes After Exclusion of Dipeptidyl Peptidase-4 Inhibitors and Other Diabetes Drug Category Changes in a Self-Funded, State Employee Managed Care Plan.

BACKGROUND: Dipeptidyl peptidase-4 (DPP-4) inhibitors have repeatedly shown no reduction in the clinical outcomes of cardiovascular death, myocardial infarction, stroke, or all-cause mortality. Because the treatment of diabetes is generally one of the top drug categories by cost to health plans and self-funded employers, it is necessary to evaluate coverage of DPP-4 inhibitors, considering their lack of cardiovascular benefit relative to other treatment options. OBJECTIVE: To describe the cost and utilization outcomes of drugs used to treat diabetes after exclusion of DPP-4 inhibitors in a self-funded managed care plan. METHODS: This study was a retrospective, descriptive analysis of the cost and utilization outcomes after exclusion of DPP-4 inhibitors. Pharmacy claims data and plan membership were analyzed 6 months before DPP-4 inhibitor exclusion (preperiod: December 1, 2016-May 31, 2017) and 6 months after DPP-4 inhibitor coverage ended for all users (postperiod: September 1, 2017-February 28, 2018). The allowed amount, which is not influenced by overlapping plan copay changes, and utilization per member per month (PMPM) were used to estimate the effect of the DPP-4 inhibitor benefit exclusion on plan costs for the antidiabetic class. RESULTS: From preperiod to postperiod, all DPP-4 inhibitor products decreased in utilization by 3.02 claims per 1,000 members per month (PTMPM). Glucagon-like peptide-1 receptor agonists, insulins, sodium-glucose cotransporter-2 inhibitors, and thiazolidinedione claims increased by 0.72, 0.43, 0.30, and 0.48 claims PTMPM, respectively, but there was an absolute decrease of 1.35 claims for antidiabetic medications per 1,000 plan members. However, the days supplied PMPM increased from 2.55 to 2.61 (2.3%) days. Allowed amount PMPM increased by $0.27 from $12.19 in the preperiod to $12.31 in the postperiod (2.2%). However, it is estimated that drug cost inflation accounted for over half of the PMPM increase in allowed costs. CONCLUSIONS: The observed increase in the allowed amount PMPM was attributable in similar amounts by an increase in utilization of medications with higher cost per day supplied and higher drug prices. Future research will evaluate patient-level effects of this benefit change in terms of antidiabetic medication utilization and outcomes. DISCLOSURES: No outside funding supported this study. Davis, Bemberg, and Johnson currently work for or previously worked for the UAMS Evidence-Based Prescription Drug Program, which advises the Employee Benefits Division (EBD) on pharmacy benefit management. The EBD did not provide any additional funding for this study. McAdam-Marx reports grants from AstraZeneca and Sanofi Aventis outside the submitted work. The other authors have no other relevant information to disclose.

Do racial and ethnic group differences in performance on the MCAT exam reflect test bias?

The Medical College Admission Test (MCAT) is a standardized examination that assesses fundamental knowledge of scientific concepts, critical reasoning ability, and written communication skills. Medical school admission officers use MCAT scores, along with other measures of academic preparation and personal attributes, to select the applicants they consider the most likely to succeed in medical school. In 2008-2011, the committee charged with conducting a comprehensive review of the MCAT exam examined four issues: (1) whether racial and ethnic groups differ in mean MCAT scores, (2) whether any score differences are due to test bias, (3) how group differences may be explained, and (4) whether the MCAT exam is a barrier to medical school admission for black or Latino applicants. This analysis showed that black and Latino examinees' mean MCAT scores are lower than white examinees', mirroring differences on other standardized admission tests and in the average undergraduate grades of medical school applicants. However, there was no evidence that the MCAT exam is biased against black and Latino applicants as determined by their subsequent performance on selected medical school performance indicators. Among other factors which could contribute to mean differences in MCAT performance, whites, blacks, and Latinos interested in medicine differ with respect to parents' education and income. Admission data indicate that admission committees accept majority and minority applicants at similar rates, which suggests that medical students are selected on the basis of a combination of attributes and competencies rather than on MCAT scores alone.

Variation in the Relationship Between Education and Marriage: Marriage Market Mismatch?

Educational expansion has led to greater diversity in the social backgrounds of college students. We ask how schooling interacts with this diversity to influence marriage formation among men and women. Relying on data from the 1979 National Longitudinal Survey of Youth (N = 3208), we use a propensity score approach to group men and women into social strata and multilevel event history models to test differences in the effects of college attendance across strata. We find a statistically significant, positive trend in the effects of college attendance across strata, with the largest effects of college on first marriage among the more advantaged and the smallest-indeed, negative-effects among the least advantaged men and women. These findings appear consistent with a mismatch in the marriage market between individuals' education and their social backgrounds.

The impact of college education on fertility: evidence for heterogeneous effects.

As college-going among women has increased, more women are going to college from backgrounds that previously would have precluded their attendance and completion. This affords us the opportunity and motivation to look at the effects of college on fertility across a range of social backgrounds and levels of early achievement. Despite a substantial literature on the effects of education on women's fertility, researchers have not assessed variation in effects by selection into college. With data on U.S. women from the National Longitudinal Survey of Youth 1979, we examine effects of timely college attendance and completion on women's fertility by the propensity to attend and complete college using multilevel Poisson and discrete-time event-history models. Disaggregating the effects of college by propensity score strata, we find that the fertility-decreasing college effect is concentrated among women from comparatively disadvantaged social backgrounds and low levels of early achievement. The effects of college on fertility attenuate as we observe women from backgrounds that are more predictive of college attendance and completion.

Five-year examination of utilization and drug cost outcomes associated with benefit design changes including reference pricing for proton pump inhibitors in a state employee health plan.

BACKGROUND: The Arkansas State Employee Benefits Division (EBD) is a self-insured program comprising public school and other state employees, their spouses, and dependents. Previous research published in JMCP (2006) showed drug cost savings of $2.20 per member per month (PMPM; 37.6%) or annualized savings of $3.4 million associated with a benefit design change and coverage of the proton pump inhibitor (PPI) omeprazole over-the-counter (OTC) beginning in March 2004. On May 1, 2005, brand esomeprazole was excluded from coverage, with current users grandfathered for 4 months until September 2005. Reference pricing for PPIs, including esomeprazole but excluding generic omeprazole, was implemented on September 1, 2005, and the beneficiary cost share for all PPIs except generic omeprazole was determined from comparison of the PPI actual price to the $0.90 omeprazole OTC reference price per unit. OBJECTIVE: To examine PPI utilization and drug costs before and after (a) excluding esomeprazole from coverage (with grandfathering current users) and (b) implementing a therapeutic maximum allowable cost (TMAC), or reference-pricing benefit design, for the PPI class in a large state employee health plan with fairly stable enrollment of approximately 127,500 members in 2005 through 2008 and approximately 128,000 members in 2009 Q1. METHODS: The pharmacy claims database for the EBD was used to examine utilization and cost data for PPIs in a longitudinal analysis for the 61-month period from March 1, 2004, through March 31, 2009. Pharmacy claims data were compared for the period 14 months prior to esomeprazole exclusion (preperiod), 4 months during the esomeprazole exclusion (postperiod 1), and the ensuing 43 months of PPI reference pricing (postperiod 2). PPI cost and utilization data for the intervention group of approximately 127,500 beneficiaries were compared with a group of 122 self-insured employers with a total of nearly 1 million beneficiaries whose pharmacy benefits did not include reference pricing for PPIs. RESULTS: Despite 79% of existing esomeprazole users being grandfathered during the 4-month esomeprazole-exclusion period (postperiod 1), the share of omeprazole OTC claims increased from 35.2% to 42.5% (+ 7.3 percentage points) of all PPI claims, and esomeprazole claims decreased from 16.7% to 12.0% (-4.7 percentage points), with little change in the use of other PPIs. The average allowed charge (price) per day of PPI drug therapy decreased in postperiod 1 by 8.9% from $2.81 to $2.56, while utilization increased by 2.2% from 1.83 days PMPM to 1.87 days PMPM; the net plan cost PMPM decreased by $0.40 PMPM from $3.78 to $3.38 (-10.6%), representing a reduction in spending of $35,664 per month while the average member copayment per claim was essentially unchanged. In the 43 months of reference pricing in postperiod 2, PPI utilization was essentially unchanged at 1.82 days PMPM compared with the preperiod (1.83 days PMPM) and 2.7% lower than the esomeprazole-exclusion period (1.87 days PMPM); however, price (charge per day) decreased by 38.4% during refer- RESEARCH ence pricing to $1.73 from $2.81 in the preperiod and by 32.4% compared with $2.56 in the esomeprazole-exclusion period, despite an increase in the average pharmacy dispensing fee to $5.21 per PPI claim. Net plan cost decreased by $1.87 PMPM (49.5%) to $1.91 PMPM during reference pricing compared with the preperiod ($3.78 PMPM) and by $1.47 PMPM (43.5%) compared with the esomeprazole-exclusion period 1 ($3.38 PMPM). Beneficiary costs (copayment per claim) for PPIs decreased to $1.24 PMPM ($23.27 per claim) compared with the preperiod ($1.37 PMPM, $24.95 per claim) and compared with the esomeprazole-exclusion period ($1.40 PMPM, $25.06 per claim). The reductions in net plan costs represented lower plan spending for the 43 months of reference pricing (postperiod 2) of approximately $9.4 million or an average of approximately $219,500 per month compared with the preperiod or $7.9 million (approximately $183,900 per month) compared with the esomeprazole-exclusion period. Compared with a group of self-insured health plans without pharmacy benefit reference pricing of PPIs, the cost savings over the 43-month period from September 1, 2005, through March 31, 2009, were approximately $7.2 million or $1.31 PMPM. CONCLUSIONS: For this state employee health plan, the policy change that excluded esomeprazole from coverage but grandfathered current users was associated with a relatively small reduction in PMPM spending on PPIs compared with the subsequent policy change that applied reference pricing to the PPI class based on the price (drug cost plus dispensing fee) for omeprazole OTC. Over 43 months of reference pricing, net plan costs fell dramatically by 49.5% PMPM compared with the preperiod or decreased by 43.5% compared with the esomeprazole-exclusion period. While utilization was essentially unchanged compared with the 18 months before reference pricing, the average pharmacy dispensing fee per PPI claim increased, and beneficiary costs PMPM decreased.

Commentary: criminal background checks for entering medical students: history, current issues, and future considerations.

In this commentary, the authors aim to contextualize the history and rationale for what has become the Association of American Medical Colleges-facilitated criminal background check process for entering medical students. As the process was being considered, many issues with a standardized process were identified. There were concerns that demographic or socioeconomic factors might unfairly burden certain applicants or discourage them from applying to medical school. On the other hand, a unified, national program would minimize cost and enhance quality assurance. The authors discuss these issues. Lessons learned in the first three years of the program are also addressed, including some unexpected and favorable consequences such as the identification of accepted applicants with at-risk behaviors (e.g., substance abuse), who would have otherwise gone undetected. Several challenges remain, including the fact that the criminal background check process creates an enhanced role for prehealth advisors and encourages undergraduate institutions to establish standards and processes relating to professionalism. While this is, no doubt, an evolving program which needs continued oversight and ongoing reevaluation, the authors support the continued advancement of the criminal background check process for entering medical students.

Cyclooxygenase-2 activity following traumatic brain injury in the developing rat.

Cyclooxygenase (COX) is the rate-limiting enzyme in the production of prostaglandins. COX-2, the predominant COX isoform in brain, is induced by synaptic activity. COX-2-generated prostaglandins are important regulators for a range of activities under physiologic conditions. However, under pathologic conditions, COX-2 activity can produce reactive oxygen species and toxic prostaglandin metabolites that can exacerbate brain injury. In this study, we examine the developmental production of COX-2 and test the ability of a COX-2 inhibitor, SC58125, to attenuate traumatic brain injury in developing rats. We show that constitutive COX-2 concentration is low (0.5-fold adult concentration) during the first postnatal week and then increases to 3-fold of adult levels between days 14-60. Controlled cortical impact (CCI) at postnatal day (PND) 17, but not PND 7, caused an additional 3-fold increase in COX-2 content and was associated with an increase in the COX-2 product PGE2. Treatment with the COX-2 inhibitor SC58125 in PND17 rats exposed to CCI attenuated the rise in PGE2 but did not attenuate lesion volume or improve performance in the Morris water maze.