Introduction to the Cost Control Measures of Medicaid Prescription Drugs in the United States and Its Enlighten- ment to China / 中国药房

OBJECTIVE：To study the cost control measures for Medicaid prescription drugs in the United States ，and to provide reference for medical insurance cost control in China. METHODS ：The policy documents ，academic papers and news reports were studied to comb the practice of drug cost control policy of Medicaid project in the United States and its impact on medical insurance costs. The suggestions were put forward for medical insurance cost control in China. RESULTS & CONCLUSIONS：The cost control measures of Medicaid prescription drugs adopted in the United States include drug utilization management and drug cost control measure. The former included the list of preferred drugs ，pre-authorization and step therapy ， prescription cost limit ，while the latter included the upper limit control of drug expenditure growth ，closed drug list management ， etc. The list of preferred drugs is the basis of a series of drug cost control measures ，which provides a policy framework for prior authorization and step therapy ；pre-authorization and step therapy are the specific ways to controlling the cost ，and the use of low-cost drugs is encouraged through the guidance of specific cases ；the prescription cost limit starts from controlling the drug cost of a single patient and saves the medical insurance expenditure from another angle ；the drug growth caps control is controlling the total cost of medical insurance expenditure from aspect of overall cost ，which is a supplement to the traditional method ；closed drug list management is a new policy attempt to break through the limitation of preferred drug list. The prescription drug cost control measures adopted by Medicaid project can effectively reduce the drug expenditure to a certain extent ，but it also has the possibility of harming the interests of patients because it can interfere with doctors ’prescription right. China should further strengthen the role of medical insurance in the medical service system ，and carefully learn from the management measures of Medicaid drug utilization in the United States ；improve the dynamic control mechanism of medical insurance expenditure ，take special measures for key drugs ； improve the drug list management mechanism ，pay attention to the three links of access， exit and dynamic adjustment ， guide medical cn institutions to use drugs rationally.

The Effect of Health Literacy and Self-care Performance on Health Care Utilization of Medicaid Elderly

PURPOSE: The purpose of this study was to examine the effect of health literacy and self-care performance on health care utilization of medicaid elderly.METHODS: A total of 203 medicaid elderly over 65 and living in B-metropolitan city were interviewed. Data were analyzed with descriptive statistics, t-test, ANOVA, Pearson's correlation coefficients and Hierarchical Multiple regression.RESULTS: The average score of the health literacy was 7.88±2.84 out of 12. The average score of self-care was 3.26±0.77 points on the 5 point scale. The frequency of health care utilization by the subjects was 6.65±5.25 a month. The health literacy and self-care performance showed a statistically significant positive correlation. The health literacy and self-care performance showed a statistically significant negative correlation with health care utilization. The factors affecting health care utilization of the subjects were self-care performance, health literacy, and religion, and the explanatory power was 25%.CONCLUSION: The results indicate that the self-care performance, health literacy, religion are significant factors of health care utilization in medicaid elderly. Therefore, it is necessary to develop strategies to improve their self-care performance and health literacy for reasonable health care utilization. Also, it is necessary to provide the elderly with correct information about medical use from accessible religious institutions, senior community center, and welfare centers.

Social Network, Self-Care Agency and Quality of Life of High-risk Beneficiaries in Case Management of Medicaid

PURPOSE: This study investigates the social network, self-care agency, and quality of life of high-risk beneficiaries in case management of Medicaid and the correlations between these variables. It also identifies influencing factors on their quality of life. METHODS: The subjects included 187 individuals chosen from the high-risk beneficiaries in case management of Medicaid in D Metropolitan City. Data was collected through direct interviews based on a structured questionnaire on home visits. RESULTS: The perceived health status was the most influential factor in their quality of life, followed by self-care agency, mutual support network, and natural support network in order. These factors explained 40.6% of their quality of life. CONCLUSION: These findings raise a need to develop a nursing intervention program to increase the self-care agency of the high-risk beneficiaries in case management of Medicaid.

Feature of Visiting Patients to a Wide Regional Emergency Center According to Insurance Status

PURPOSE: In Korea, emergency department overcrowding in large hospitals have caused social concern. Moreover, patients with low socioeconomic status visit the emergency department more frequently. This kind of visitation also causes a burden on the national budget, but emergent patient should be treated in emergency department regardless of economic state. So, on establishment of policy about the patient with low socioeconomic status, the frequency of emergency visitation alone is difficult to obtain a sufficient basis for policy-making. METHODS: We retrospectively analyzed adult patients with a disease who visited the Pusan Wide-regional Emergency Center in 2015. Korean Triage and Acuity Scale level I, II or III were defined as emergency, and level IV or V was defined as non-emergency. The ratio of emergency and non-emergency was compared in the National Health Insurance and Medicaid database. RESULTS: The number of patients with National Health Insurance was 16,208 (90.3%) and with Medicaid was 1,737 (9.7%). Among those with National Health Insurance, there were 12,720 (78.5%) emergency cases and 3,488 (21.5%) non-emergency cases. Among those with Medicaid, 1,379 (79.4%) emergency cases and 358 (20.6%) non-emergency cases. Between National Health Insurance and Medicaid, there was no statistically significant difference in the ratio of emergency and non-emergency (p=0.380) CONCLUSION: Accessibility of emergency and non-emergency patients with National Health Insurance and Medicaid to Pusan Wide-regional Emergency Center was not different.

The Effect of Copayment on Medical Aid Beneficiaries in Korea

PURPOSE: This study was to ascertain whether there are differences in health care utilization and expenditure for Type I Medical Aid Beneficiaries before and after applying Copayment. METHODS: This study was one-group pretest posttest design study using secondary data analysis. Data for pretest group were collected from claims data of the Korea National Health Insurance Corporation and data for posttest group were collected through door to-door interviews using a structured questionnaire. A total of 1,364 subjects were sampled systematically from medical aid beneficiaries who had applied for copayment during the period from December 12, 2007 to September 25, 2008. RESULTS: There was no negative effect of copayment on accessibility to medical services, medication adherence (p=.94), and quality of life (p=.25). Some of the subjects' health behaviors even increased preferably after applying for copayment including flu prevention (p<.001), health care examination (p=.035), and cancer screening (p=.002). However, significant suppressive effects of copayment were found on outpatient hospital visiting days (p<.001) and outpatient medical expenditure (p<.001). CONCLUSION: Copayment does not seem to be a great influencing factor on beneficiaries'accessibility to medical services and their health behavior even though it has suppressive effects on outpatients' use of health care.

The Effects of the Designated Doctor System on Health Care Utilization of Medical Aid Beneficiaries with Chronic Diseases

PURPOSE: This study was conducted to examine differences in health care utilization and related costs between before and after the introduction of the designated doctor system, and to find out factors making the differences. METHODS: Data were collected from 200 medical aid beneficiaries having one or more chronic diseases, registered in the designated doctor system during the year of 2012, and the relationship between the use of health services and claimed medical expenses was analyzed through paired t-test and multiple regression analysis using the SPSS 18.0 program. RESULTS: There was a decrease in the number of total benefit days and the number of outpatient and medication days, but some cases showed an increase after the designation of medical institution. In general, hospital stay increased after the introduction of the system. However, the number of medical institutions utilized was reduced in most cases after designation. Conversely, medical expenses increased in most cases after the designation of medical institution. CONCLUSION: These results suggest that a detailed scheme to designate medical institutions should be made in consideration of the seriousness of illness and classification of medical institutions not only for the beneficiaries' enhanced health but for the effective management of medical aid fund.

Health Maintenance Organization-Federally Qualified Health Center (HMO-FQHC) Collaboration to Provide After-Hours Pediatric Primary Care: A Feasibility Study.

Aims: Examine feasibility, implementation and impact of a Health Maintenance Organization (HMO)-Federally Qualified Health Center (FQHC) collaboration in providing after-hours care as an Emergency Department (ED) diversion strategy. Study Design: Prospective study using pre-post comparison design. Methodology: Service enhancement program with the addition of after-hours clinic services coupled with a Texas Children’s Health Plan outreach campaign were conducted in Houston, Texas to promote the increased availability of clinic services during a six month period from September 2006 to February 2007 to enrolled Medicaid and State Children’s Health Insurance Program (SCHIP) enrollees. Claims data were used to identify after-hours clinic utilization and a pre-post analysis compared ED use rates of after-hours clinic users, non-users within the service area, and other enrollees in the health plan. Start-up costs provided by community funders amounted to 46,000 dollars (onetime payment) and marketing outreach campaign was supported with 52,000 dollars from TCHP. Results: During the intervention time frame, September 1, 2006 thru February 28, 2007, at least 194 enrollees visited the after-hours clinic. An impact on ED utilization was not found and the six-month post intervention ED utilization for both the intervention and comparison groups increased when compared to the six-month baseline measurement period. Conclusion: Establishing and promoting the after-hours clinic during this project targeting HMO enrollees was determined to be feasible with at least 194 enrollees who resided in the targeted area visiting the after-hours clinic at the FQHC.A six-month study period was long enough to examine the feasibility of providing after-hours pediatric health services, but probably not long enough to assess the full impact of after-hours health services on ED use. Further study, over an entire year allowing for the incorporation of both high and low seasonal trends will be essential to definitively assess if and HMO-FQHC collaboration on an after-hours clinic is an effective strategy to reduce ED visits in a traditionally underserved population of children covered under the Medicaid and SCHIP.

Factors related to the experience of illegal dental treatments among Korean adults: The Fourth Korea National Health and Nutrition Examination Survey, 2007-2009 / 대한구강보건학회지

OBJECTIVES: The aim of the study was to analyze the factors related to the illegal dental treatment experience (IDTX) among Korean adults. METHODS: The raw data for the analysis of IDTX among Korean adults were obtained from the dataset of the Fourth Korea National Health and Nutrition Examination Survey conducted in 2007-2009. Stratified weighted subjects aged > or =45 years were selected according to region by using clustered sampling methods. In total, the data of 9,254 subjects, who participated in the interview and dental examinations related to the experience of illegal dental treatments, were analyzed using chi-square test, general linear model, and logistic regression analysis with complex sampling design by considering demographic and socioeconomic variables (age, gender, region, educational level, household income, and medical and dental delivery system) as well as oral status variables (prosthesis and number of natural remaining teeth). RESULTS: IDTX rate was 30% among adults aged > or =65 years. The age group with a high IDTX rate coincided with the age group with a high number of lost teeth. Most of the IDTX cases were presumed to be prosthetic treatments. The model comprising demographic, socioeconomic, and oral status variables had the highest explanation power. Significant variables were educational level, household income, prosthesis status, and number of remaining teeth. Women and persons under the medicaid system were more likely to undergo illegal dental treatments. CONCLUSIONS: Comprehensive prosthetic treatments are suggested to be included in the care services of the national health insurance and medicaid system to reduce the number of illegal dental treatments.

Case Management for Medical Aid Beneficiaries in Korea: Findings from Case-control Study

PURPOSE: This study was to evaluate effects of case management provided for 7 months for medical aid in Korea. METHODS: This study was a retrospective comparative study using secondary data analysis. Data from two pre-existing survey were reanalyzed. The data were collected through door to-door interviews using the structured questionnaire. For the medical service use, claims data from the Korea National Health Insurance Corporation was used. Subjects were 73 in the intervention group and 118 in the control group. RESULTS: There was no significant change in the intervention group in self-care ability (p = .296), medication adherence (p = .194) or quality of life (p = .903) compared to those of the control group. For hospital visiting days, it appeared to decrease in the intervention group (p = .038) but with no significant difference from that of the control group (p = .157). Neither were there significant differences in medical expenditures (p = .605). CONCLUSION: Although the effect of case management in this study appeared extremely limited, the short intervention period and characteristics of the medical aid beneficiaries and the limit of controlling only the demand side were discussed as factors to be considered. Nurses have been carrying out professional roles in case management in Korea. However more efforts are needed to develop case management as an area for nursing specialization.

O acesso aos serviços de saúde por emigrantes brasileiros nos Estados Unidos / Access to health service by brazilian emigrants in the United States

A análise do atual contexto político e econômico existente nos EUA, que envolve o acesso e utilização de serviços de saúde pelos imigrantes, diz respeito aos mais de 20 milhões de indivíduos estrangeiros que residem naquele país e não possuem seguro de saúde. Essa população corresponde a 43,8 por cento de 46 milhões de pessoas que não possuem cobertura de provedores privados de saúde nos EUA, sendo 10,5 milhões residentes sem a documentação exigida para viver no País. Para explorar as necessidades, o acesso e a utilização dos serviços de saúde americanos pelos emigrantes de Governador Valadares, MG, Brasil, o presente estudo entrevistou uma amostra de 14 emigrantes valadarenses selecionada por meio da técnica bola de neve. Foram elaboradas questões relacionadas à documentação, local de residência, profissões exercidas, necessidade, acesso e utilização de serviços de saúde. As informações recolhidas junto aos emigrantes residentes nos Estados de Massachusetts e Connecticut permitem afirmar a viabilidade do acesso e da utilização dos serviços de saúde subsidiados pelos governos federal e estaduais e de organizações não governamentais.

Research on the medicaid-based hospital information system / 中国医学装备

Objective: To improve the low relief fund utilization rate, make the city minimal assurance relief patients enjoy double Medicaid assistance account and agricultural insurance or Medicare reimbursement policy. Methods: Based on the actual work, and actively explore, innovation, in the Oracle database platform, the transformation of His in outpatient service charge settlement system, establishing patient account data, through a patient's unique index related agricultural insurance or Medicare patient file information. Results:The outpatient service charge settlement system enabled for tailored low mental patients. Conclusion:the patients fully enjoy minimal assurance relief assistance account and agricultural insurance or Medicare reimbursement policy ofdouble Medicaid, andfirst diagnosis and treatment forbusiness conducted a preliminary exploration.

The Financial Mechanism of American Medicaid and the Medical Expenditure Expansion / 中国卫生经济

Objective: Analysis on the financial influences of for Medicaid expenditure expansion. Methods: Using Economics analysis to study the relation between the method of Federal Medicaid grants and scope of States Medicaid. Results and Conclusion:The design of transfer payment motivated the states government to pursue maximizing Federal grants , which led to the medical expenditure expansion. The Policy aims on establishing unify Medicaid policy in the nation and all grants raised from the Federal government.

Outcomes and Efficiency of National Gastric Cancer Screening Program in Korea

BACKGROUND/AIMS: The National Cancer Screening Program (NCSP) for Medicaid recipients has contributed to reduction of cancer-related mortality in Korea. Although biennial gastric cancer screening by endoscopy has been increasing in Korea as part of the NCSP, few studies have evaluated its efficiency. Therefore, we analyzed the outcomes and efficiency of the NCSP for gastric cancer using endoscopy in Korea. MATERIALS AND METHODS: We reviewed results from the NCSP for gastric cancer at Chung-Ang University Yong-San Hospital in Korea from March 2003 to March 2008. The study population comprised of Medicaid recipients more than 40 years old, who were taken from the National Health Insurance Corporation. RESULTS: A total of 7,278 asymptomatic subjects underwent endoscopy for gastric cancer screening. The mean age of the screened subjects was 51.3 years for men and 48.9 years for women. The male to female ratio of the screened subjects was 1.2:1. Gastric cancer was diagnosed in 32 (0.44%) of 7,278 subjects (22 men and 10 women). Their mean age was 54.4 years. Of these, 21 subjects (0.29%) were diagnosed as early gastric cancer (EGC) and 11 subjects (0.15%) were diagnosed as advanced gastric cancer. The proportion of EGCs among total gastric cancers was 65.6%. CONCLUSIONS: Despite accomplishments of the NCSP for gastric cancer in Korea, its effectiveness remains an issue. Efficiency and cost-effectiveness analysis will be needed for successful progression.

Factors related to the consumption of illegal dental treatments in Korean adults / 대한구강보건학회지

OBJECTIVES: The aim of the study was to analyze the factors that are related to the illegal dental treatment experience (IDTX), among the Korean adults. METHODS: The raw data for the analysis of IDTX, among the Korean adults, which were aged 17 years and over, were obtained from the dataset of the Korean National Oral Health Survey (KNOHS), which was conducted in 2006. Stratified weighted total 11,808 samples were selected by region and clustered sampling methods. The data of weighted total 11,808 samples were analyzed, using a chi-square test and a logistic regression analysis, by demographic socioeconomic variables of age, gender, area, educational level, occupation, national health insurance, and monthly income. RESULTS: IDTX rate was under 10%, among the adults aged 35~44 years or below the age group. However, it increased to 18.9%, among the adults aged 45~54 years and overtook over 30% among the adults 55 years and over. The age group of high IDTX rate was coincided to the age group of high number of lost teeth. Most of IDTX were presumed to prosthetic treatments. In IDTX rate of samples, aged 45 years and over, odds ratio of females' was 1.3, compared to that of the males'; odds ratio of metropolitan area, 1.2 compared to rural area. IDTX rate was higher among the middle school or below educational level group compared to that of college or over educational level group. IDTX rate of medicaid or not joined to national health insurance group was 31.3%, higher than that of national health insurance group. IDTX rates of low monthly income group, less than 4 million KRW were higher than monthly income group of 4 million KRW or more. CONCLUSIONS: To supply the prosthetic treatments for the population of medicaid and national health insurance is needed to remove illegal dental treatments in Korea.

The Effects of the Designated Doctor System on the Health of Medical Aid Beneficiaries

PURPOSE: Medical Aid Beneficiaries were surveyed to identify differences in health behaviors, adherence to drug regimen, and quality of life between those people in the Designated Doctor System and those who are not. METHODS: A total of 1,327 study subjects were separated into three groups: those in the Designated Doctor System for 2 years, those in for 1 year, and those not in the system. RESULTS: After the introduction of the Designated Doctor System, 55.8% and 67.9%, respectively, of the subjects in the Designated Doctor System complained of inconvenience in relation to hospital use and the patient referral process. Also, the rate of emergency room use or hospitalization guided by the Designated Doctor System was only 8.7% and 6.5%, respectively. There were no significant differences in health behaviors and adherence to drug regimens between those in the Designated Doctor System and those who are not. CONCLUSION: This study was carried out early in the introduction of the system. Therefore, it is necessary to monitor the positive and negative effects of the Designated Doctor System for a full reflection of its impact.

Change in Healthcare Utilization by Disease Severity after Case Management for Medicaid

PURPOSE: This study examined change in healthcare utilization by disease severity after case management (CM) for Medicaid. METHODS: Data were extracted from survey data on "Healthcare utilization and health status of Medicaid beneficiaries" conducted in 2007 and 2008 by the Ministry for Health, Welfare and Family Affairs. This study was designed to compare change in healthcare utilization between the CM group and the non-CM group. The subjects were 528 Type I Medicaid beneficiaries who utilized healthcare more than 365 days during 2006. RESULTS: In beneficiaries having fewer than 3 among the 11 notified diseases, the CM group showed a significantly larger decrease in outpatient day, outpatient expense, medication day, and medication expense than the non-CM group. In beneficiaries having 3 or more among the 11 notified diseases, however, there was no significant difference in healthcare utilization between the CM group and the non-CM group. CONCLUSION: CM worked effectively on Medicaid beneficiaries outpatient healthcare utilization for mild diseases. However, its effects on hospitalization, which is a major cause increasing the total expense, were not observed. Therefore, a future study is needed to develope strategies to reduce hospitalization and care for Medicaid beneficiaries with severe diseases.

The Effects of Tele-care Case Management Services for Medical Aid Beneficiaries

PURPOSE: This study was done to analyze the effects of tele-care case management services using secondary data. METHODS: A descriptive research design was utilized, and the participants were 134 medical aid beneficiaries who were in either the high-risk group or the preventive group. Case management services were delivered by 8 care managers. Data were analyzed using PAWS Statistics 17 through descriptive statistics and paired t-test. RESULTS: After the case management intervention, the participants' health quality of life, self-care competency, and reasonable medical care utilization increased significantly for the high-risk group. However there were no significant changes in the preventive group. CONCLUSION: The results showed that the tele-care case management services were effective for high-risk medical aid beneficiaries. Further studies with controls for constitutional variables and a comparison group are required to validate the robustness of the effectiveness of the case management program in the present study.

The Effects of Case Management for Medicaid on Healthcare Utilization by the Medicaid System

PURPOSE: This study examined the effects of case management (CM) for Medicaid on healthcare utilization considering the Medicaid system. METHODS: Data were extracted from survey data on "Healthcare utilization and health status of Medicaid beneficiaries" conducted in 2007 and 2008 by the Ministry for Health, Welfare and Family Affairs. This study was designed to compare the effects on healthcare utilization between the CM group and the non-CM group. The subjects were 535 Type I Medicaid beneficiaries who utilized healthcare more than 365 days during 2006. RESULTS: The outpatient days and medication days of the CM group decreased significantly more than those of the non-CM group with the copayment system. There were no significant differences of healthcare utilization between the CM group and the non-CM group with the designated doctor system. CONCLUSION: CM worked effectively on Medicaid beneficiaries' outpatient healthcare utilization with the copayment system. However, its effects on hospitalization, which is a major cause increasing the total expense, were not observed. Therefore, future studies are needed to develop strategies to reduce hospitalization and Medicaid beneficiaries' outpatient healthcare utilization with the designated doctor system.

Comparison of Case Management between Tele Care Regions and General Care Regions in Korean Medicaid / 간호행정학회지

PURPOSE: The purpose of the study was to compare recipients' health behavior, attitude to using medicaid, medication compliance, and the changes in hospital cost and visit-day of in-patient and out-patient care between tele-care regions (TCR) and general care regions (GCR) in Korean medicaid. METHOD: The design of the study was ex-post facto comparing recipients in TCR and GCR. The sample included 625 persons in TCR and 410 persons in GCR. To collect materials, the case manager interviewed recipients of medicaid and filled out questionnaires which were analyzed through SAS/PC 9.1. RESULTS: In studying health behavior and medication, compliance was not significant. However, the attitude to using medicaid was significantly more positive in TCR than in GCR. In out-patients, the change of hospital visit-day was not significant between TCR and GCR, but TCR showed a reduction in hospital cost compared to GCR. For in-patient recipients, GCR showed a greater reduction in changes in hospital cost and visit-day compared to TCR. CONCLUSIONS: The results of the study show that attitudes to using medicaid via telephone are positive and results are more effective than hospital visit consultation, and the cost of out-patient care could be reduced.

Factors influencing Health-related Quality of Life in Korean Medicaid Beneficiaries

PURPOSE: The purpose of this study was to identify the factors which influence health-related quality of life (HRQoL) in Korean Medicaid beneficiaries. The relationships among sociodemographic factors, health status, health behavior, and HRQoL were analyzed METHODS: Data from the 2007 survey on Health Services Use and Health Status of Medicaid Beneficiaries conducted by the Ministry for Health Welfare and Family Affairs were examined. To analyze the sample survey data, descriptive statistics, correlation and hierarchical multiple survey regression analysis with SAS 9.1.3 package were used with SURVEYMEANS and SURVEYREG procedures, which incorporate the sample design into the analyses in order to make statistically valid inference for the whole Medicaid population. RESULTS: The HRQoL correlated with limitations in Activities of Daily Living (ADL) (r=-.509, p<.001), stress (r=-.387, p<.001), depression (r=-.385, p<.001), alcohol consumption (r=.216, p<.001), and exercise (r=.293, p<.001). Significant factors that affect HRQoL of Medicaid beneficiaries were gender, region, limitations in ADL, stress, depression, alcohol consumption, and regular exercise. These variables explained 44.6% of HRQoL (F= 215.00, p<.001). CONCLUSION: The results indicate that to improve the HRQoL of Medicaid beneficiaries it is important to develop nursing intervention programs that focus on psychological health and health behavior and to give consideration to differences in gender and region.