Clinical significance of comprehensive genomic profiling tests covered by public insurance in patients with advanced solid cancers in Hokkaido, Japan.

BACKGROUND: Comprehensive cancer genomic profiling has been used recently for patients with advanced solid cancers. Two cancer genomic profiling tests for patients with no standard treatment are covered by Japanese public health insurance since June 2019. METHODS: We prospectively analyzed data of 189 patients with solid cancers who underwent either of the two-cancer genomic profiling tests at Hokkaido University Hospital and its liaison hospitals and whose results were discussed in molecular tumor board at Hokkaido University Hospital between August 2019 and July 2020. RESULTS: All 189 patients had appropriate results. Actionable gene alterations were identified in 93 patients (49%). Frequent mutations included PIK3CA (12%) mutation, BRCA1/2 alteration (7%), ERBB2 amplification (6%) and tumor mutation burden-High (4%). The median turnaround time from sample shipping to acquisition by the expert panel was 26 days. Although 115 patients (61%) were provided with information for genotype-matched therapies, only 21 (11%) received them. Notably, four of eight patients below the age of 20 years were provided information for genotype-matched therapies, and three received them. Their response rates and disease control rates were 29% and 67%, respectively. Most patients who did not undergo the genotype-matched therapies were provided information for only investigational drugs in phases I and II at distant clinical trial sites in central Japan. Twenty-six patients were informed of suspected germline findings, while 11 patients (42%) received genetic counseling. CONCLUSIONS: The publicly reimbursed cancer genomic profilings may lead to the modest but favorable therapeutic efficacy of genotype-matched therapy for solid cancer patients with no standard therapy. However, poor access to genotype-matched therapy needs to be resolved.

Flood insurance in Canada: implications for flood management and residential vulnerability to flood hazards.

Insurance coverage of damage caused by overland flooding is currently not available to Canadian homeowners. As flood disaster losses and water damage claims both trend upward, insurers in Canada are considering offering residential flood coverage in order to properly underwrite the risk and extend their business. If private flood insurance is introduced in Canada, it will have implications for the current regime of public flood management and for residential vulnerability to flood hazards. This paper engages many of the competing issues surrounding the privatization of flood risk by addressing questions about whether flood insurance can be an effective tool in limiting exposure to the hazard and how it would exacerbate already unequal vulnerability. A case study investigates willingness to pay for flood insurance among residents in Metro Vancouver and how attitudes about insurance relate to other factors that determine residential vulnerability to flood hazards. Findings indicate that demand for flood insurance is part of a complex, dialectical set of determinants of vulnerability.

Evidence needs, training demands, and opportunities for knowledge translation in social security and insurance medicine: A European survey.

OBJECTIVE: To perform a European survey of the evidence needs and training demands of insurance medicine professionals related to professional tasks and evidence-based practice. DESIGN: International survey. SUBJECTS: Professionals working in insurance medicine. METHODS: Experts designed an online questionnaire including 26 questions related to 4 themes: evidence needs; training demands; evidence-seeking behaviour; and attitudes towards evidence-based medicine. Descriptive statistics were presented by country/conference and the total sample. RESULTS: A total of 782 participants responded. Three-quarter of participants experienced evidence needs at least once a week, related to mental disorders (79%), musculoskeletal disorders (67%) and occupational health (65%). Guidelines (76%) and systematic reviews (60%) were the preferred types of evidence and were requested for assessment of work capacity (64%) and prognosis of return-to-work (51%). Evidence-based medicine was thought to facilitate decision-making in insurance medicine (95%). Fifty-two percent of participants felt comfortable finding, reading, interpreting, and applying evidence. Countries expressed similar needs for reviews on typical topics. CONCLUSION: This study reveals evidence gaps in key areas of insurance medicine, supporting the need for further research, guidelines and training in evidence-based insurance medicine. Importantly, insurance medicine professionals should recognize that evidence-based practice is crucial in producing high-quality assessments.

Medication Use in the Management of Comorbidities Among Individuals With Autism Spectrum Disorder From a Large Nationwide Insurance Database.

Importance: Although there is no pharmacological treatment for autism spectrum disorder (ASD) itself, behavioral and pharmacological therapies have been used to address its symptoms and common comorbidities. A better understanding of the medications used to manage comorbid conditions in this growing population is critical; however, most previous efforts have been limited in size, duration, and lack of broad representation. Objective: To use a nationally representative database to uncover trends in the prevalence of co-occurring conditions and medication use in the management of symptoms and comorbidities over time among US individuals with ASD. Design, Setting, and Participants: This retrospective, population-based cohort study mined a nationwide, managed health plan claims database containing more than 86 million unique members. Data from January 1, 2014, to December 31, 2019, were used to analyze prescription frequency and diagnoses of comorbidities. A total of 26 722 individuals with ASD who had been prescribed at least 1 of 24 medications most commonly prescribed to treat ASD symptoms or comorbidities during the 6-year study period were included in the analysis. Exposures: Diagnosis codes for ASD based on International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Main Outcomes and Measures: Quantitative estimates of prescription frequency for the 24 most commonly prescribed medications among the study cohort and the most common comorbidities associated with each medication in this population. Results: Among the 26 722 individuals with ASD included in the analysis (77.7% male; mean [SD] age, 14.45 [9.40] years), polypharmacy was common, ranging from 28.6% to 31.5%. Individuals' prescription regimens changed frequently within medication classes, rather than between classes. The prescription frequency of a specific medication varied considerably, depending on the coexisting diagnosis of a given comorbidity. Of the 24 medications assessed, 15 were associated with at least a 15% prevalence of a mood disorder, and 11 were associated with at least a 15% prevalence of attention-deficit/hyperactivity disorder. For patients taking antipsychotics, the 2 most common comorbidities were combined type attention-deficit/hyperactivity disorder (11.6%-17.8%) and anxiety disorder (13.1%-30.1%). Conclusions and Relevance: This study demonstrated considerable variability and transiency in the use of prescription medications by US clinicians to manage symptoms and comorbidities associated with ASD. These findings support the importance of early and ongoing surveillance of patients with ASD and co-occurring conditions and offer clinicians insight on the targeted therapies most commonly used to manage co-occurring conditions. Future research and policy efforts are critical to assess the extent to which pharmacological management of comorbidities affects quality of life and functioning in patients with ASD while continuing to optimize clinical guidelines, to ensure effective care for this growing population.

Reasons for not receiving the HPV vaccine among eligible adults: Lack of knowledge and of provider recommendations contribute more than safety and insurance concerns.

BACKGROUND: The upward trends of vaccine exemptions in Texas are alarming. While HPV vaccine rates in this State are among the lowest nationwide, factors that contribute to the low HPV vaccination uptake among adults remain unknown. In this study, we examined the main reasons for not receiving HPV vaccination among age-eligible adults. METHODS: The Texas health screening survey (2018), a multistage area probability design-based survey of a representative sample of Texas residents, was used to identify 907 eligible adults (age ≥ 18 years) respondents, including 724 women aged ≤ 26 years in 2007 (≤38 years in 2018), and 183 men aged ≤ 21 years in 2011 (≤28 years in 2018). Participants who reported having never received an HPV shot, where asked the main reason for not receiving the vaccine. RESULTS: Overall, 58.5% (95%CI: 55.1-62.0) of vaccine eligible adults reported having never received the HPV vaccine. The most commonly reported reasons for not receiving it were: did not know about the vaccine (18.5% (14.9-22.1)), and provider did not recommend (14.1% (10.9-17.4)). In contrast, commonly perceived reasons such as: safety concerns (7.2% (4.8-9.5)), lack of insurance (3.4% (1.7-5.1), and concerns about increasing sexual activity if vaccinated (0.2% (0.0-0.5)), were less frequently reported. CONCLUSION: Among vaccine-eligible adults, safety and sexuality concerns do not appear to be the prime factors underlying low HPV vaccination rates. Rather than emphasizing them, educational interventions should aim at improving vaccine's knowledge, and enhancing provider recommendations on the necessity of HPV vaccination.

Adherence of US Insurance Payer Policies to the American Society of Radiation Oncology Stereotactic Radiosurgery Model Policy.

PURPOSE: The medical necessity of stereotactic radiosurgery (SRS) is nonuniform across insurance policies. The American Society for Radiation Oncology (ASTRO) created a model policy based on the consensus of the radiation oncology community to communicate medically necessary indications for SRS. We compared the current insurance policies for SRS with those of the ASTRO model policy. METHODS AND MATERIALS: We identified 58 insurance payers and 3 national benefits managers with SRS policies. Among these, 7 insurance payers were excluded for policies that were not reviewed after 2015 and for not detailing individual medically necessary indications. For each of the indications listed in ASTRO's model policy, we determined the proportion of payers that considered SRS medically necessary. We compared these proportions for national versus regional payers and policies updated in the last 12 months versus those updated less often using Fisher exact and χ2 tests. RESULTS: All insurance policies reviewed considered SRS as medically necessary for brain metastases, medically refractory trigeminal neuralgia, and arteriovenous malformations. Compared with national payers, regional payers were less likely to deem other schwannomas, and a boost for large cranial or spinal lesions medically necessary (P < .05). The indication with the lowest coverage was medically refractory movement disorders (44.4%), followed by medically refractory epilepsy (33.3%). However, policies that were updated within the last year were more likely to deem medical necessity for epilepsy, movement disorders, hemangioblastoma, pineal gland tumors, and other schwannomas. CONCLUSIONS: Significant discrepancy remains among insurance policies for several indications in ASTRO's model policy for SRS; however, national payers and those with recent policy updates have a greater concordance with the ASTRO model policy.

Accuracy of diagnostic information submitted to an insurance company.

Findings from two studies of the utilization of the mental health benefit under the Washington, D.C., area Blue Cross and Blue Shield Federal Employees Program suggest that diagnostic information submitted to insurance companies on claims forms is often inaccurate and therefore of little use for claims or peer review. The authors conclude that inaccurate information is submitted primarily because of legitimate concerns about patient confidentially. The urge that special claims and peer review procedures be developed to assure confidentiality of sensitive clinical information. A pilot project developed by the Washington Psychiatric Society and Blue Cross and Blue Shield is offered as an example of the kinds of systems that need to be devised.

Developing genetic privacy legislation: the South Carolina experience.

The availability of presymptomatic and predisposition genetic testing has spawned the need for legislation prohibiting health insurance discrimination on the basis of genetic information. The federal effort, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, falls short by protecting only those who access insurance through group plans. A committee of University of South Carolina professionals convened in 1996 to develop legislation in support of genetic privacy for the state of South Carolina. The legislation prevents health insurance companies from denying coverage or setting insurance rates on the basis of genetic information. It also protects the privacy of genetic information and prohibits performance of genetic tests without specific informed consent. In preparing the bill, genetic privacy laws from other states were reviewed, and a modified version of the Virginia law adopted. The South Carolina Committee for the Protection of Genetic Privacy version went a step further by including enforcement language and excluding Virginia's sunset clause. The definition of genetic information encompassed genetic test results, and importantly, includes family history of genetic disease. Our experience in navigating through the state legislature and working through opposition from the health insurance lobby is detailed herein.

The use of genetic tests and genetic information by life insurance companies: does this differ from the use of routine medical information?

Questions regarding insurance companies' access to and use of genetic test results and genetic information have been raised since the advent of the Human Genome Project. The ability to place applicants of similar risks in groups, a process known as underwriting, is critical to the availability and affordability of individually underwritten life, disability income, and long-term care insurance. This paper focuses on how life insurance companies use medical information and particularly genetic test results and other genetic information in the risk assessment process. Issues and concerns raised about differences between routine medical information and genetic information are addressed and policies with regard to privacy and confidentiality are presented.

Insurance of horses and the role of the veterinary surgeon.

Various type of insurance policies covering the risks against mortality, economic slaughter and loss of use, breeding failures and payment of veterinary fees are discussed. The role of the veterinary surgeon in supplying certificates of health and in relation to claims, including those involving destruction on humane grounds, are considered.

DRGs and hospital case records: implications for Medicare case mix accuracy.

As Medicare moves to DRG-based prospective payment, it is not clear whether the federal government has adequate data upon which to formulate DRG prices and assess hospital case mix. This study compares the Medicare case mix of Minneapolis-St. Paul hospitals based on the historical information submitted for billing purposes on the Medicare claim with the actual case mix of hospitals as described in the medical record chart. It was found that for the same patients, the DRG based on the claim matched the DRG on the medical record approximately half of the time. These "mismatches" resulted in a statistically significant understatement of hospitals' case mix, and have obvious implications for the setting of DRG prices and equitable hospital reimbursement.

Medicare program; criteria and standards for evaluating intermediary and carrier performance during fiscal year 1986--HCFA. General notice with comment period.

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program for fiscal year 1986. The results of these evaluations are considered whenever we enter into, renew, or terminate an intermediary or carrier agreement or take other contract actions; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries.

Criteria and standards for evaluating intermediary and carrier performance--HCFA. General notice with comment period.

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning June 1, 1990. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary or carrier agreement or takes other contract actions; assigns or reassigns providers of services to an intermediary; or designates regional or national intermediaries. This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act, which requires us to publish for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.

Medicare program; criteria and standards for evaluating intermediary and carrier performance during fiscal year 1988--HCFA. General notice with comment period.

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program for the fiscal year beginning October 1, 1987. The results of these evaluations are considered whenever we enter into, renew, or terminate an intermediary or carrier contract or take other contract actions; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries. In addition, this notice describes the methodology used for identifying contractors for competitive replacement under section 2326 of the Deficit Reduction Act of 1984.

Health Care Financing Administration--Medicare program; intermediary nominations, contracts, evaluations, and notices. Final regulation.

These final regulations establish criteria and standards for evaluating the performance of agencies or organizations serving or desiring to serve as fiscal intermediaries under the Medicare program. They also authorize the Administrator to assign or reassign providers of services to particular intermediaries or to designate a single intermediary to serve a class of providers on a regional or national basis after considering intermediary performance measured against the criteria and standards. Affected providers and intermediaries will be given a notice of assignment or reassignment and intermediaries will be afforded a hearing. The purpose of these regulations is to promote increased efficiency in the administration of the Medicare program.

How (and why) to shop the stop-loss insurance market.

Stop-loss insurance is capitation's "escape clause," which permits you to assume risk without risking ruin. But which stop-loss coverage is right for you? Here are 11 questions to ask before you decide.