#Participating #Contesting: Studying Counterpublics' Discourses on Twitter About the Social Acceptability of Medical Assistance in Dying Legislation in Canada.

This article explores debates on medical assistance in dying (MAID) in Canada as they unfolded on Twitter before its adoption in June 2016. The opposition, which came from diverse groups-religious, experts, politicians-led to polarizing debates about the social acceptability of this measure. Our finding shows that the so-called lay citizens refused to leave the discussion to experts and politicians and got involved in the debates around the issue. Our results also show that Twitter was mainly used to share information, hence complementing the role of traditional media. Overall, the platform gave rise to an "ambient political participation," allowing minority or marginalized groups as well as lay citizens to share their knowledge and opinion about MAID. This may have favored a certain form of empowerment.

Cet article explore le déroulement des débats sur Twitter à propos de l'aide médicale à mourir au Canada avant son adoption en juin 2016. L'opposition, qui provenait de divers groupes - religieux, experts, acteurs politiques - a mené à des débats polarisés quant à l'acceptabilité sociale de cette mesure. Nos résultats montrent que les « simples citoyens ¼ ont refusé de laisser la discussion entre les mains des experts et des politiciens, choisissant plutôt de s'investir dans les débats liés à l'enjeu. Nos résultats montrent également que Twitter a principalement été mobilisé dans le but de partager de l'information, complémentant ainsi le rôle des médias traditionnels. De façon générale, la plateforme a laissé court à une « participation politique ambiante ¼, permettant aux minorités ou aux groupes marginalisés, de même qu'aux « simples citoyens ¼, de partager leur connaissance et opinion sur l'aide médicale à mourir. Le tout a pu mener à une certaine forme de capacitation.

Prior Authorization Requirements for Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors Across US Private and Public Payers.

BACKGROUND: Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is) are an innovative treatment option for patients with familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease who require further lowering of low-density lipoprotein cholesterol. However, the high costs of these agents have spurred payers to implement utilization management policies to ensure appropriate use. We examined prior authorization (PA) requirements for PCSK9is across private and public US payers. METHODS AND RESULTS: We conducted an analysis of 2016 formulary coverage and PA data from a large, proprietary database with information on policies governing >95% of Americans with prescription drug coverage (275.3 million lives) within 3872 plans across the 4 major insurance segments (commercial, health insurance exchange, Medicare, and Medicaid). The key measures included administrative PA criteria (prescriber specialty, number of criteria in PA policy or number of fields on PA form, requirements for medical record submission, reauthorization requirements) and clinical/diagnostic PA criteria (approved conditions, required laboratories or other tests, required concomitant therapy, step therapy requirements, continuation criteria) for each of 2 Food and Drug Administration-approved PCSK9is. Select measures (eg, number of PA criteria/fields, medical record submission requirements) were obtained for 2 comparator cardiometabolic drugs (ezetimibe and liraglutide). Between 82% and 97% of individuals were enrolled in plans implementing PA for PCSK9is (depending on insurance segment), and one third to two thirds of these enrollees faced PAs restricting PCSK9i prescribing to a specialist. For patients with familial hypercholesterolemia, diagnostic confirmation via genetic testing or meeting minimum clinical scores/criteria was also required. PA requirements were more extensive for PCSK9is as compared with the other cardiometabolic drugs (ie, contained 3×-11× the number of PA criteria or fields on PA forms and more frequently involved the submission of medical records as supporting documentation). CONCLUSIONS: PA requirements for PCSK9is are greater than for selected other drugs within the cardiometabolic disease area, raising concerns about whether payer policies to discourage inappropriate use may also be restricting access to these drugs in patients who need them.

Medical Assistance in Dying (MAiD): Ten Things Leaders Need to Know.

The provision of MAiD will be in flux for a few years, as legislative challenges are underway. This article addresses what leaders need to know and do to support nurses today and in the future regarding care of patients choosing MAiD. Drawing on complexity leadership theory and research into nurses' experiences in caring for persons choosing MAiD, we share 10 simple yet foundational things a leader must know. Underpinning our key messages are current evidence and familiar nursing concepts such as end-of-life care, death trajectories, conscientious objection, scope of practice, ethics, sense-making and care cultures. These key messages are embedded in a framework of leadership practices where attention to inter-relationships, emergence and innovation are highlighted. They provide nurse leaders with concrete actions to inspire a team dynamic for creating inclusive cultures of quality care. Leadership is needed across healthcare settings where MAiD is being enacted.

Legal access to medications: a threat to Brazil's public health system?

BACKGROUND: In Brazil, health is fundamental human right guaranteed by the Constitution of 1988, which created the Brazilian Universal Health System (Sistema Único de Saúde - SUS). The SUS provides medications for outpatient care via policy of pharmaceutical assistance (PA) programmes. Despite the advances in PA policies which include the improvement in access to medications, there has been a significant increase in lawsuits related to health products and services. This study aimed to characterize the medication processes filed between 2010 and 2014 against the Secretary of State for Health of São Paulo (State Health Department of São Paulo - SES/SP), in Brazil, following PA policies. METHODS: This descriptive study used secondary data on medication lawsuits filed against the SES/SP between 2010 and 2014. The data source was the S-Codes computerized system. RESULTS: In the period evaluated, the number of lawsuits filed concerning health-related products increased approximately 63%; requests for medications were predominant. Approximately 30% of the medications involved in court proceedings were supplied via PA programmes. With regard to medications supplied via specialized component, 81.3% were prescribed in disagreement with the protocols published by the Ministry of Health. Insulin glargine was the most requested medication (6.3%), followed by insulin aspart (3.3%). Because there is no scientific evidence that either of these medicines is superior for the treatment of diabetes, neither of them has been incorporated into the SUS by the National Commission for Technology Incorporation. The judicial data showed that most of the lawsuits involved normal proceedings (i.e., individual demands), were filed by private lawyers, and named the State of São Paulo as the sole defendant, demonstrating the individual nature of these claims. The data indicate inequality in the distribution between the number of cases and lawyers and the number of lawsuits and prescribers, evidencing the concentration of lawyers and physicians in filing lawsuits. CONCLUSION: The judicialization of health in the State of São Paulo with the characteristics presented herein is a threat to the SUS.

A survey of assistive technology service providers in the USA.

This study investigates perspectives of assistive technology service (ATS) providers regarding their education and training, interdisciplinary standards of practice, use of a common language framework, funding policies, utilization of evidence and outcomes measurement. A survey underpinned by AT legislations and established guidelines for practice was completed by 318 certified AT providers. More than 30% of the providers reported their education and training as inadequate to fulfil four of the seven primary roles of ATS. Nearly 90% of providers expressed awareness of the International Classification of Functioning, Disability and Health (ICF) domains for interdisciplinary communication. However, only 45% felt that they could effectively utilize the ICF in their documentation. About 75% of the providers acknowledged the lack of a recognized standard for the provision of services. Prevailing inadequacies in funding were negatively impacting the quality of ATS, as expressed by 88% of respondents. Translation of evidence to practice was identified as a major challenge by 41% of service providers. Providers were predominantly documenting outcomes through informal interviews (54%) or non-standard instruments (26%). Findings support the need for strengthening professional curriculum, pre-service and in-service training and an established standard to support effective, interdisciplinary AT services and data collection to support public policy decisions. Implications for Rehabilitation This study validates the need to strengthen education and training of AT service providers by enhancing professional curriculum as well as their engagement in pre-service and in-service training activities. This study draws attention to health care funding policies and practices that critically impact the quality of AT services. This study signifies the need for an established interdisciplinary standard among AT professionals to support effective communication, service coordination and outcomes measurement.

The ACA's Provision on Nondiscrimination Takes Shape.

The Department of Health and Human Services has issued far-reaching regulations to implement the nondiscrimination requirement of the Affordable Care Act. Now commonly called "Section 1557," this ACA provision prohibits discrimination by "any health program or activity, any part of which is receiving Federal financial assistance," on grounds prohibited under previously enacted federal antidiscrimination statutes. The DHHS Office of Civil Rights enforces Section 1557. These new regulations and accompanying commentary give warning of the standards the agency will use in its enforcement efforts. Courts will also give some deference to the DHHS regulations in interpreting the statute in lawsuits by individuals claiming damages against covered health care providers for illegal discrimination under Section 1557. Three central issues are the nature of the rights created in Section 1557 and their relation to the listed federal antidiscrimination statutes, the sorts of health care programs and activities that are covered by Section 1557, and the definition of the personal characteristics, including sexual orientation and gender identity, against which discrimination is prohibited.

Automobile or Other Conveyance and Adaptive Equipment Certificate of Eligibility for Veterans or Members of the Armed Forces With Amyotrophic Lateral Sclerosis Connected to Military Service. Final rule.

The Department of Veterans Affairs (VA) published an Interim Final Rule on February 25, 2015, to amend its adjudication regulations to provide a certificate of eligibility for financial assistance in the purchase of an automobile or other conveyance and adaptive equipment for all veterans with service-connected amyotrophic lateral sclerosis (ALS) and servicemembers serving on active duty with ALS. The amendment authorized automatic issuance of a certificate of eligibility for financial assistance in the purchase of an automobile or other conveyance and adaptive equipment to all veterans with service-connected ALS and members of the Armed Forces serving on active duty with ALS. The intent of this final rule is to confirm the amendment made by the interim final rule without change.

From home deliveries to health care facilities: establishing a traditional birth attendant referral program in Kenya.

OBJECTIVE: To assess the effectiveness of a traditional birth attendant (TBA) referral program on increasing the number of deliveries overseen by skilled birth attendants (SBA) in rural Kenyan health facilities before and after the implementation of a free maternity care policy. METHODS: In a rural region of Kenya, TBAs were recruited to educate pregnant women about the importance of delivering in healthcare facilities and were offered a stipend for every pregnant woman whom they brought to the healthcare facility. We evaluated the percentage of prenatal care (PNC) patients who delivered at the intervention site compared with the percentage of PNC patients who delivered at rural control facilities, before and after the referral program was implemented, and before and after the Kenya government implemented a policy of free maternity care. The window period of the study was from July of 2011 through September 2013, with a TBA referral intervention conducted from March to September 2013. RESULTS: The absolute increases from the pre-intervention period to the TBA referral intervention period in SBA deliveries were 5.7 and 24.0% in the control and intervention groups, respectively (p < 0.001). The absolute increases in SBA delivery rates from the pre-intervention period to the intervention period before the implementation of the free maternity care policy were 4.7 and 17.2% in the control and intervention groups, respectively (p < 0.001). After the policy implementation the absolute increases from pre-intervention to post-intervention were 1.8 and 11.6% in the control and intervention groups, respectively (p < 0.001). CONCLUSION: The percentage of SBA deliveries at the intervention health facility significantly increased compared to control health facilities when TBAs educated women about the need to deliver with a SBA and when TBAs received a stipend for bringing women to local health facilities to deliver. Furthermore, this TBA referral program proved to be far more effective in the target region of Kenya than a policy change to provide free obstetric care.

Preparing for section 501(r).

Steps hospitals should take to prepare for Section 501(r) requirements include the following: Prepare the board for its role in approving updated financial assistance, billing and collections, and emergency medical care policies. Revisit financial assistance policy eligibility requirements. Conduct a policy gap analysis. Review how the current financial assistance policy is publicized and make adjustments where necessary.

The impact of patient assistance programs and the 340B Drug Pricing Program on medication cost.

OBJECTIVES: Patient assistance programs and the 340B Drug Pricing Program promise to improve the financial stability, better serve vulnerable patients, and decrease the burden of cost for uninsured patients. Our objective is to examine the financial impact that PAPs and the 340B Program have on improving medication cost. STUDY DESIGN: Retrospective analysis of medication dispensary data. METHODS: Dispensary data for uninsured patients obtaining medications at 2 community health centers were collected from February 1 to February 29, 2012. Uninsured patients were divided into 2 samples: (1) patients receiving PAP medications and (2) patients receiving 340B medications. The main outcome measured was the patient's cost savings. Cost savings were calculated based on the amount a medication would have cost had it been purchased by patients at prices found on Epocrates software (drugstore.com). A paired sample t test model using continuous variables was utilized to calculate confidence intervals. RESULTS: A total of 1420 PAP and 2772 340B individual medications were dispensed to uninsured patients in February 2012. For patients receiving PAP medications the mean ± standard deviation (SD) for age = 52 ± 10. Average cost was $0.11 (95% CI, $0.04-$0.17) and average savings was $617.36 (95% Cl, $581.32-$653.40). For patients receiving 340B medications the mean ±SD for age = 50 ± 14. Average cost was $11.50 (95% CI, $10.55-$12.45). Average saving was $62.31 (95% CI, $57.99-$66.63). CONCLUSIONS: PAPs and 340B provide significant medication savings for uninsured patient. More research is needed to establish "best practices" for the successful integration of PAPs.

Nine states' use of collaboratives to improve children's health care quality in medicaid and CHIP.

We examine quality improvement (QI) collaboratives underway in 9 states participating in the Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program. A total of 147 diverse, child-serving practices were participating in the collaboratives. We conducted 256 semistructured interviews with key stakeholders from March to August 2012-2 years into the 5-year demonstration projects-and analyzed states' grant applications, operating plans, and progress reports. The collaboratives have multiple complex aims. In addition to developing patient-centered medical home (PCMH) capability, some states use collaboratives to familiarize practices with CMS's Initial Core Set of Children's Health Care Quality Measures, practice-level quality measurement, and improving QI knowledge and skills. The duration of the collaboratives is longer than other well-known collaborative models. Collaboratives also vary in their methods for targeting areas for improvement and strategies for motivating practice recruitment and engagement. States also vary with respect to the other strategies they use to support QI and PCMH development. All states supplement the collaboratives with practice facilitation; the majority utilized practice-level parent engagement, but only 4 used workforce augmentation (ie, providing care coordinators and QI specialists). Practice staff highly valued aspects of the collaboratives and supplemental strategies, including the opportunity to work with experts and other child-serving practices; states' efforts to provide stipends and align demonstration efforts with other professional requirements or programs; receipt of relevant, customized QI materials; opportunities to learn how care coordinators or QI specialists might work in their practice without the risk of hiring them; and satisfaction from learning more about quality measures, QI concepts and techniques, critical medical home components, and how to identify PCMH capacity and performance gaps. However, practice staff also reported a variety of challenges, including difficulty learning from other practices that have very different preexisting QI and PCMH capacity and patient populations, or that are working on different topic areas and measures; a sometimes overwhelming amount of materials and ideas covered during in-person meetings; difficulty keeping up with Webinars, calls, and Web sites/blogs; and trouble motivating and sharing information with other practice staff not attending collaborative activities. As the demonstration projects continue, states and the national evaluation team will learn more about how best to use collaboratives and complementary strategies to support child-serving practices in QI and PCMH development. States will also search for ways to sustain and spread these activities after the demonstration ends, if they prove effective.

AIDS Drug Assistance Programs: managers confront uncertainty and need to adapt as the Affordable Care Act kicks in.

With the Affordable Care Act set to expand insurance coverage to millions more Americans next year, existing discretionary health programs that receive federal support might find themselves competing for funds as the health reform law is fully implemented. To assess the implications the Affordable Care Act might have for discretionary health programs, we focused on state AIDS Drug Assistance Programs, which provide free medications to low-income HIV patients. We conducted semistructured interviews with program managers from twenty-two states. Many of the managers predicted that their programs will change focus to provide "wrap-around services," such as helping newly insured clients finance out-of-pocket expenses, including copayments, deductibles, and premiums. Although program managers acknowledged that they must adapt to a changing environment, many said that they were overwhelmed by the complexity of the Affordable Care Act, and some expressed fear that state AIDS Drug Assistance Programs would be eliminated entirely. To remain viable, such programs must identify and justify the need for services in the context of the Affordable Care Act and receive sufficient political support and funding.

Proposed regs address new hospital tax-exemption requirements.

Proposed regulations set forth detailed rules for implementing the new tax-exemption requirements of Section 501(r) of the Internal Revenue Code for not-for-profit organizations operating hospital facilities. The proposed regulations provide guidance on the written financial assistance policies (FAPs) that hospital facilities are required to establish. The regulations propose methodologies for determining the amounts that a hospital facility can charge FAP-eligible individuals for emergency and other medically necessary care. They prescribe procedures that hospital facilities would be required to follow before engaging in extraordinary collection actions against an individual.

The undocumented unwell.

Nell Toussaint is not well. In recent years, she has been diagnosed with uterine fibroids, uncontrolled hypertension, nephrotic syndrome, poorly controlled diabetes, hyperlipidemia, and a pulmonary embolism. She also suffers from decreased mobility, shortness of breath, and-perhaps not surprisingly, given her other ailments-anxiety. Toussaint is an indigent undocumented immigrant living in Canada who has been trying to secure medical coverage in the federal courts. In the process, she has sacrificed the medical confidentiality that most of us ordinarily enjoy. Toussaint first came to Canada from Grenada as a visitor in 1999 and remained after the term of her visa expired. At first, she earned enough to sustain a living, but in 2006, her health began to deteriorate, and she was no longer able to work. Although she has received some medical care since then, it has been sporadic, on an emergency basis, and at great expense. When Toussaint applied for medical health coverage under Canada's Interim Medical Health Program, which covers the cost of emergency medical care for legally admitted indigents, her application was rejected. She challenged the decision in federal court on the grounds that her right to life and security of the person under the Canadian Charter had been violated and that the denial of coverage was discriminatory.