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Diabetes Mellitus Tipo 2 , Agonistas Receptor de Péptidos Similares al Glucagón , Asignación de Recursos para la Atención de Salud , Humanos , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Péptido 1 Similar al Glucagón/agonistas , Receptor del Péptido 1 Similar al Glucagón/agonistas , Agonistas Receptor de Péptidos Similares al Glucagón/provisión & distribución , Agonistas Receptor de Péptidos Similares al Glucagón/uso terapéutico , Asignación de Recursos para la Atención de Salud/ética , Asignación de Recursos para la Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/ética , Disparidades en Atención de Salud/estadística & datos numéricos , Receptores de la Hormona Gastrointestinal/agonistas , Poblaciones Vulnerables/estadística & datos numéricosRESUMEN
Background: Among patients with serious illness, palliative care before hospice enrollment is associated with improved quality of life, reduced symptom burden, and earlier transitions to hospice. However, fewer than half of eligible patients receive specialty palliative care referrals. As most hospice clinicians and administrators have experience in specialty palliative care, several emerging programs propose engaging hospice clinicians to provide early palliative care. Objective: We sought to identify barriers and facilitators to upstream palliative care. Design: We conducted a key informant qualitative study among hospice administrators and clinicians. Setting/Subjects: We conducted semi-structured interviews with 23 hospice administrators and clinicians in eight states from March to August 2022. We identified participants using snowball and purposive sampling using states that participate in Medicare Advantage's value-based insurance design Model. Results: Respondents indicated that barriers to early palliative care included inadequate staffing and reimbursement. Hospice clinicians providing community-based palliative care can address access barriers and improve transitions to hospice. Respondents expressed desire for payer guidance in identifying eligible patients but were cautious about payers acting as direct palliative care providers. However, payers could facilitate uptake by broadening and specifying coverage of services to include goals of care conversations and symptom management. Routine referrals initiated by objective measures could potentially increase access. Conclusions: Utilizing hospice providers to provide upstream palliative care can increase access, improve outcomes, and ease the transition to hospice.
RESUMEN
US health care use declined during the initial phase of the COVID-19 pandemic in 2020. Although utilization is known to have recovered in 2021 and 2022, it is unknown how revenue in 2020-22 varied by physician specialty and practice setting. This study linked medical claims from a large national federation of commercial health plans to physician and practice data to estimate pandemic-associated impacts on physician revenue (defined as payments to eligible physicians) by specialty and practice characteristics. Surgical specialties, emergency medicine, and medical subspecialties each experienced a greater than 9 percent adjusted gross revenue decline in 2020 relative to prepandemic baselines. By 2022, pathology and psychiatry revenue experienced robust recovery, whereas surgical and oncology revenue remained at or below baseline. Revenue recovery in 2022 was greater for physicians practicing in hospital-owned practices and in practices participating in accountable care organizations. Pandemic-associated revenue recovery in 2021 and 2022 varied by specialty and practice type. Given that physician financial instability is associated with health care consolidation and leaving practice, policy makers should closely monitor revenue trends among physicians in specialties or practice settings with sustained gross revenue reductions during the pandemic.
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COVID-19 , COVID-19/economía , COVID-19/epidemiología , Humanos , Estados Unidos , Médicos/economía , Pandemias/economía , Medicina/estadística & datos numéricos , SARS-CoV-2 , Especialización/economíaAsunto(s)
Péptido 1 Similar al Glucagón , Obesidad , Humanos , Obesidad/tratamiento farmacológico , Péptido 1 Similar al Glucagón/agonistas , Fármacos Antiobesidad/uso terapéutico , Fármacos Antiobesidad/efectos adversos , Pérdida de Peso/efectos de los fármacos , Receptor del Péptido 1 Similar al Glucagón/agonistas , Liraglutida/uso terapéutico , Hipoglucemiantes/uso terapéuticoRESUMEN
This Viewpoint discusses the benefits and challenges of transitioning to a value-based payment design for health care rather than a fee-for-service system.
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Compra Basada en Calidad , Humanos , Estados Unidos , Mecanismo de ReembolsoAsunto(s)
Atención a la Salud , Diabetes Mellitus Tipo 2 , Agonistas Receptor de Péptidos Similares al Glucagón , Hipoglucemiantes , Obesidad , Receptores de la Hormona Gastrointestinal , Humanos , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/epidemiología , Péptido 1 Similar al Glucagón/agonistas , Receptor del Péptido 1 Similar al Glucagón/agonistas , Hipoglucemiantes/uso terapéutico , Receptores de la Hormona Gastrointestinal/agonistas , Agonistas Receptor de Péptidos Similares al Glucagón/provisión & distribución , Agonistas Receptor de Péptidos Similares al Glucagón/uso terapéutico , Obesidad/complicaciones , Obesidad/tratamiento farmacológico , Obesidad/epidemiología , Estados Unidos/epidemiología , Riesgo , Fármacos Antiobesidad/uso terapéutico , Accesibilidad a los Servicios de Salud/economía , Disparidades en Atención de Salud/economía , Disparidades en Atención de Salud/etnología , Atención a la Salud/economía , Atención a la Salud/ética , Atención a la Salud/etnología , Atención a la Salud/normasRESUMEN
Background: Patients with serious illnesses have unmet symptom and psychosocial needs. Specialty palliative care could address many of these needs; however, access varies by geography and health system. Virtual visits and automated referrals could increase access and lead to improved quality of life, health outcomes, and patient-centered care for patients with serious illness. Objectives: We sought to understand referring clinician perspectives on barriers and facilitators to utilizing virtual tools to increase upstream access to palliative care. Design: Participants in this multisite qualitative study included practicing clinicians who commonly place palliative care referrals across multiple specialties, including hematology/oncology, family medicine, cardiology, and geriatrics. All interviews were transcribed and subsequently coded and analyzed by trained research coordinators using Atlas.ti software. Settings/Subjects: This study included 23 clinicians (21 physicians, 2 nonphysicians) across 5 specialties, 4 practice settings, and 7 states in the United States. Results: Respondents felt that community-based specialty palliative services including symptom management, advance care planning, physical therapy, and mental health counseling would benefit their patients. However, they had mixed feelings about automated referrals, with some clinicians feeling hesitant about not being alerted to such referrals. Many respondents were supportive of virtual palliative care, particularly for those who may have difficulty accessing physician offices, but most respondents felt that such care should only be provided after an initial in-person consultation where clinicians can meet face-to-face with patients. Conclusion: Clinicians believe that automated referrals and virtual palliative care could increase access to the benefits of specialty palliative care. However, virtual palliative care models should give attention to iterative communication with primary clinicians and the perceived need for an initial in-person visit.
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Cuidados Paliativos , Investigación Cualitativa , Humanos , Masculino , Femenino , Estados Unidos , Persona de Mediana Edad , Adulto , Derivación y Consulta , Actitud del Personal de Salud , Telemedicina , Accesibilidad a los Servicios de SaludRESUMEN
OBJECTIVES: To describe trends in US health care spending in a large, national, and commercially insured population during the COVID-19 pandemic. STUDY DESIGN: Cross-sectional study of commercially insured members enrolled between May 1, 2018, and December 31, 2021. METHODS: The study utilized a population-based sample of continuously enrolled members in a geographically diverse federation of Blue Cross Blue Shield plans across the United States. Our sample excluded Medicare and Medicare Advantage beneficiaries. The COVID-19 exposure period was defined as 2020-2021; 2018-2019 were pre-COVID-19 years. We defined 4 post-COVID-19 periods: March 1 to April 30, 2020; May 1 to December 31, 2020; January 1 to March 31, 2021; and April 1 to December 31, 2021. The primary outcome was inflation-adjusted overall per-member per-month (PMPM) medical spending adjusted for age, sex, Elixhauser comorbidities, area-level racial composition, income, and education. RESULTS: Our sample included 97,319,130 individuals. Mean PMPM medical spending decreased from $370.92 in January-February 2020 to $281.00 in March-April 2020. Between May and December 2020, mean PMPM medical spending recovered to-but did not exceed-prepandemic levels. Mean PMPM medical spending stayed below prepandemic levels between January and March 2021, rose above prepandemic baselines between April and June 2021, and decreased below baseline between July and December 2021. CONCLUSIONS: The COVID-19 pandemic induced a spending shock in 2020, and health care spending did not recover to near baseline until mid-2021, with some emerging evidence of pent-up demand. The observed spending below baseline through the end of 2021 will pose challenges to setting spending benchmarks for alternative payment and shared savings models.
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COVID-19 , Pandemias , Anciano , Humanos , Estados Unidos/epidemiología , Estudios Transversales , Medicare , Gastos en Salud , COVID-19/epidemiologíaRESUMEN
With the world grappling with continued spread of monkeypox internationally, vaccines play a crucial role in mitigating the harms from infection and preventing spread. However, countries with the greatest need - particularly historically endemic countries with the highest monkeypox case-fatality rates - are not able to acquire scarce vaccines. This is unjust, and requires rectification through equitable allocation of vaccines globally. We propose applying the Fair Priority Model for such allocation, which emphasizes three key principles: 1) preventing harm; 2) prioritizing the disadvantaged; and 3) treating people with equal moral concern. Post-exposure prophylaxis (PEPV) has the most potential to mitigate harm, and so ensuring countries have sufficient supply for PEPV should be the first priority. And historically endemic countries, which face disadvantages that compound potential harms from monkeypox, should be the first recipients of such vaccines. Once sufficient supply is allocated for countries to apply PEPV, global allocation could move on to pre-exposure prophylaxis (PrEP), again prioritizing historically endemic countries first before distribution to the rest of the global community, based on projected number of cases and vulnerability to harm.
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Mpox , Profilaxis Pre-Exposición , Vacunas , Humanos , Mpox/epidemiología , Mpox/prevención & control , Profilaxis Posexposición , Poblaciones VulnerablesRESUMEN
This Viewpoint discusses the Medicare Physician Fee Schedule and its flaws, including how they might be remedied by severing CMS dependence on Relative Value Update Committee estimates of time and intensity.
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Tabla de Aranceles , Medicare Part B , Médicos , Escalas de Valor Relativo , Anciano , Humanos , Tabla de Aranceles/economía , Tabla de Aranceles/ética , Medicare/economía , Medicare/ética , Medicare Part B/economía , Medicare Part B/ética , Médicos/economía , Médicos/ética , Estados Unidos , Ética MédicaRESUMEN
It has become increasingly difficult for individuals to exercise meaningful control over the personal data they disclose to companies or to understand and track the ways in which that data is exchanged and used. These developments have led to an emerging consensus that existing privacy and data protection laws offer individuals insufficient protections against harms stemming from current data practices. However, an effective and ethically justified way forward remains elusive. To inform policy in this area, we propose the Ethical Data Practices framework. The framework outlines six principles relevant to the collection and use of personal data-minimizing harm, fairly distributing benefits and burdens, respecting autonomy, transparency, accountability, and inclusion-and translates these principles into action-guiding practical imperatives for companies that process personal data. In addition to informing policy, the practical imperatives can be voluntarily adopted by companies to promote ethical data practices.
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Confidencialidad , Privacidad , HumanosRESUMEN
The COVID-19 pandemic has helped to clarify the fair and equitable allocation of scarce medical resources, both within and among countries. The ethical allocation of such resources entails a three-step process: (1) elucidating the fundamental ethical values for allocation, (2) using these values to delineate priority tiers for scarce resources, and (3) implementing the prioritisation to faithfully realise the fundamental values. Myriad reports and assessments have elucidated five core substantive values for ethical allocation: maximising benefits and minimising harms, mitigating unfair disadvantage, equal moral concern, reciprocity, and instrumental value. These values are universal. None of the values are sufficient alone, and their relative weight and application will vary by context. In addition, there are procedural principles such as transparency, engagement, and evidence-responsiveness. Prioritising instrumental value and minimising harms during the COVID-19 pandemic led to widespread agreement on priority tiers to include health-care workers, first responders, people living in congregate housing, and people with an increased risk of death, such as older adults and individuals with medical conditions. However, the pandemic also revealed problems with the implementation of these values and priority tiers, such as allocation on the basis of population rather than COVID-19 burden, and passive allocation that exacerbated disparities by requiring recipients to spend time booking and travelling to appointments. This ethical framework should be the starting point for the allocation of scarce medical resources in future pandemics and other public health conditions. For instance, allocation of the new malaria vaccine among sub-Saharan African countries should be based not on reciprocity to countries that participated in research, but on maximally reducing serious illness and deaths, especially among infants and children.
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COVID-19 , Niño , Humanos , Anciano , Pandemias/prevención & control , Asignación de Recursos para la Atención de Salud , Principios Morales , Salud PúblicaRESUMEN
Countermeasures for mpox (formerly known as monkeypox), primarily vaccines, have been in limited supply in many countries during outbreaks. Equitable allocation of scarce resources during public health emergencies is a complex challenge. Identifying the objectives and core values for the allocation of mpox countermeasures, using those values to provide guidance for priority groups and prioritisation tiers, and optimising allocation implementation are important. The fundamental values for the allocation of mpox countermeasures are: preventing death and illness; reducing the association between death or illness and unjust disparities; prioritising those who prevent harm or mitigate disparities; recognising contributions to combating an outbreak; and treating similar individuals similarly. Ethically and equitably marshalling available countermeasures requires articulating these fundamental objectives, identifying priority tiers, and recognising trade-offs between prioritising the people at the highest risk of infection and the people at the highest risk of harm if infected. These five values can provide guidance on preferable priority categories for a more ethically sound response and suggest methods for optimising allocation of countermeasures for mpox and other diseases for which countermeasures are in short supply. Properly marshalling available countermeasures will be crucial for future effective and equitable national responses to outbreaks.
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Monkeypox virus , Mpox , Humanos , Mpox/epidemiología , Mpox/prevención & control , Brotes de Enfermedades/prevención & control , Salud PúblicaRESUMEN
This Viewpoint suggests that professional societies should continue to advocate for equitable access for patients to all necessary medical care including abortion care.