Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 1.047
Filtrar
4.
Medicine (Baltimore) ; 99(9): e19271, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32118735

RESUMO

The objective of this study was to examine the association between county-level socioeconomic factors and brand-name drug prescription drug patterns among medical specialties with overall high brand-name outpatient prescription use.This cross-sectional study used data from 2 publicly available datasets. The 2015 Medicare Part D PUF data quantifies the prescription rates at the county-level and data from the US Census Bureau provides information on socioeconomic status at the county-level.We analyzed 3,821,523 brand-name claims and 14,088,613 generic claims reported by health providers from 40 specialties as provided by the 2015 Medicare Part D dataset. Internal Medicine, Family Practice, General Practice, Cardiology, and Ophthalmology accounted for 71% of the total amount of brand-name drugs filled under Medicare Part D in 2015. As the presence of individuals with an income ≥$100,000 increased in a given county, the likelihood of receiving a brand-name prescription claim increased.A county-level association exists involving socioeconomic factors and outpatient brand-name drug prescription patterns. Future interventions should consider these factors in order to reduce percentage of brand-name drugs filled and decrease health care expenditures.


Assuntos
Medicare Part D/estatística & dados numéricos , Padrões de Prática Médica , Medicamentos sob Prescrição/economia , Adolescente , Adulto , Idoso , Criança , Estudos Transversais , Custos de Medicamentos , Medicamentos Genéricos , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Rhode Island , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
5.
Am J Public Health ; 110(3): 354-356, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31944838

RESUMO

Objectives. To assess older Americans' willingness to trade off the possibility of choosing or changing their prescription drug plan for lower drug spending.Methods. We used data from the Kaiser Family Foundation Health Tracking Poll on prescription drugs carried out in February 2019. This nationwide telephone survey oversampled participants aged 65 years and older who, when weighted, were representative of the US older adult population.Results. Older adults were strongly in favor of the government negotiating drug prices in Medicare Part D (82% support); 60% of older adults would trade off the possibility of choosing or switching their drug plan in favor of lower drug prices. All groups preferred lower spending over plan choice, but this preference was stronger among individuals who were in poorer health, had lower education and income, and found it very difficult to afford the drugs they needed.Conclusions. The results suggest that Medicare beneficiaries could support policies that limit plan choice, as long as drug prices actually decrease.


Assuntos
Custos de Medicamentos , Medicare Part D/normas , Medicamentos sob Prescrição/economia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Renda , Masculino , Medicare Part D/economia , Opinião Pública , Fatores Socioeconômicos , Inquéritos e Questionários , Estados Unidos
6.
Med Care ; 58(5): 427-432, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31985585

RESUMO

RESEARCH OBJECTIVE: Affordable access to medications is important to Medicare enrollees in long-term care (LTC), yet, it is unknown if prescription drug coverage is universal and adequate to meet their high medication needs. STUDY DESIGN: We assessed enrollment in prescription drug coverage, out-of-pocket (OOP) payments and medication use in a nationwide LTC database of prescription-level, resident-level, and facility-level data for the period 2011-2013. Inadequate drug coverage was defined as ≥50% medications paid for OOP. Risk-adjusted generalized estimation equations models were estimated to identify predictors of inadequate drug coverage and total prescription fills. POPULATION STUDIED: A nationwide sample of 332,087 Medicare enrollees observed >100 days in LTC. PRINCIPAL FINDINGS: We found Medicare Part D was the main source of drug coverage (82.4%), followed by private insurance (8.5%), and Veterans Administration (0.2%). No drug coverage could be detected for 8.9% (n=29,378) who paid for all of their medications OOP or received only temporary drug payment assistance. Inadequate drug coverage was identified in another 2721 persons. LTC Medicare enrollees without drug coverage or who had private insurance received significantly fewer prescriptions than if they had been enrolled in Medicare Part D. CONCLUSION: A substantial proportion of Medicare enrollees in LTC have inadequate or no drug coverage and are receiving less medication than indicated by their health needs. POLICY IMPLICATIONS: Medicare Part D is an important policy for ensuring affordable access to medications in LTC. However, expansions are needed to increase enrollment and decrease inadequate drug coverage.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Assistência de Longa Duração , Medicamentos sob Prescrição/economia , Idoso , Idoso de 80 Anos ou mais , Conjuntos de Dados como Assunto , Feminino , Gastos em Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Masculino , Medicare Part D/estatística & dados numéricos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs
8.
Drugs Aging ; 37(2): 137-145, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31845208

RESUMO

BACKGROUND: Antiepileptic drugs (AEDs) are commonly used by nursing home residents, both on- and off-label. The landscape of AED use has changed over the past two decades; however, despite this, contemporaneous research on AED use in US nursing home residents is scant. OBJECTIVE: The aim of this study was to estimate the prevalence of AED use, describe prescribing patterns, identify factors associated with AED use, and assess whether these factors differ among AEDs with expanded indications in older adults (i.e. gabapentin, pregabalin, topiramate, and lamotrigine). METHODS: We conducted a cross-sectional study among 549,240 long-stay older residents who enrolled in fee-for-service Medicare and lived in 15,111 US nursing homes on 1 September 2016. Demographics and conditions associated with AED indications, epilepsy comorbidities, and safety data came from the Minimum Data Set Version 3.0 (MDS 3.0). Medicare Part D claims were used to identify AED use. Robust Poisson models and multinomial logistic models for clustered data estimated adjusted prevalence ratios (aPR), adjusted odds ratios (aOR), and 95% confidence intervals (CIs). RESULTS: Overall, 24.0% used AEDs (gabapentin [13.3%], levetiracetam [4.7%], phenytoin [1.9%], pregabalin [1.8%], and lamotrigine [1.2%]). AED use was associated with epilepsy (aPR 3.73, 95% CI 3.69-3.77), bipolar disorder (aPR 1.20, 95% CI 1.18-1.22), pain (aPRmoderate/severe vs. no pain 1.42, 95% CI 1.40-1.44), diabetes (aPR 1.27, 95% CI 1.26-1.28), anxiety (aPR 1.12, 95% CI 1.11-1.13), depression (aPR 1.17, 95% CI 1.15-1.18), or stroke (aPR 1.08, 95% CI 1.06-1.09). Residents with advancing age (aPR85+ vs. 65-74 years 0.73, 95% CI 0.73-0.74), Alzheimer's disease/dementia (aPR 0.87, 95% CI 0.86-0.88), or cognitive impairment (aPRsevere vs. no impairment 0.62, 95% CI 0.61-0.63) had decreased AED use. Gabapentinoid use was highly associated with pain (aORmoderate/severe vs. no pain 2.07, 95% CI 2.01-2.12) and diabetes (aOR 1.79, 95% CI 1.76-1.82), but not with an epilepsy indication. CONCLUSIONS: AED use was common in nursing homes, with gabapentin most commonly used (presumably for pain). That multiple comorbidities were associated with AED use underscores the need for future studies to investigate the safety and effectiveness of AED use in nursing home residents.


Assuntos
Anticonvulsivantes/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Epilepsia/tratamento farmacológico , Casas de Saúde/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Anticonvulsivantes/administração & dosagem , Anticonvulsivantes/efeitos adversos , Comorbidade , Estudos Transversais , Epilepsia/epidemiologia , Feminino , Humanos , Masculino , Medicare Part D , Prevalência , Estados Unidos
9.
Health Serv Res ; 54(6): 1174-1183, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31667832

RESUMO

OBJECTIVE: To understand the mechanisms that have held Part D beneficiary premiums stable despite increasing reinsurance subsidies. DATA SOURCES: Secondary data on Part D plan bids, federal subsidies, and claims from 2007 through 2015. STUDY DESIGN: Comparisons of standardized, enrollment-weighted average Part D plan bids and reinsurance bids with plan and reinsurance liability calculated from Part D claims data. DATA COLLECTION/EXTRACTION METHODS: Part D plan payment data were merged with premium data to derive plan bids, which were merged with claims-based spending measures. PRINCIPAL FINDINGS: Plan bids and reinsurance bids increasingly diverged from the spending observed in the claims data over the study period. This divergence was attributable to the growth in rebates and systematic under-bidding of expected reinsurance payments, enabling plans to hold premiums low and collect excess federal subsidies of approximately 3 percent of total Part D spending in 2015. CONCLUSIONS: Revenue from rebates and excess federal subsidies via reinsurance reconciliation has played an important role in holding Part D premiums low, despite increasing federal reinsurance subsidies. While policy makers should consider implementing reforms to address these misincentives in the program, doing so is likely to result in unavoidable premium increases to levels more reflective of actual net spending.


Assuntos
Reforma dos Serviços de Saúde/organização & administração , Reforma dos Serviços de Saúde/estatística & dados numéricos , Medicare Part D/organização & administração , Medicare Part D/estatística & dados numéricos , Humanos , Estados Unidos
12.
J Manag Care Spec Pharm ; 25(12): 1358-1365, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31778617

RESUMO

BACKGROUND: The American College of Cardiology/American Heart Association recommends statins for adults aged 40-75 years with a cardiovascular disease risk factor and a 10-year risk of cardiovascular events of 7.5%-19.9%. OBJECTIVE: To examine the association of county-level social determinant measures of health and composition of health services with use of statin prescriptions under Medicare Part D. METHODS: We used 2013 Medicare Part D prescriber county-level data to construct 2 measures of statin use: (1) statin beneficiaries ÷ total beneficiaries (prevalence [ßPR]) and (2) statin days supplied ÷ (total beneficiaries × 365; adequacy of supply [ßAS]). We used multivariable regression to estimate the association of each measure with county-level demographics and health service measures. RESULTS: A 1 standard deviation (SD) increase in the proportion of African Americans living in a county is associated with a 0.096 SD decrease in adequacy of supply (ßAS = -0.096; 95% CI = -0.14 to -0.06). The proportion of county residents aged 65+ years who are female was associated with higher prevalence and adequacy of supply (ßPR = 0.06; 95% CI = 0.02 to 0.11; ßAS = 0.09; 95% CI = 0.05 to 0.14). Counties with higher proportions of Medicare Part D prescription expenditures receiving low-income subsidies had lower adequacy of supply (ßAS = -0.28; 95% CI = -0.32 to -0.23). Counties with a higher proportion of Medicare Part D prescribers who are nurse practitioners was associated with lower prevalence and adequacy of supply (ßPR = -0.39; 95% CI = -0.44 to -0.35; ßAS = -0.42; 95% CI = -0.47 to -0.37). CONCLUSIONS: Race and ethnicity, income, and distribution of provider types were significantly associated with county-level variation in statin use, despite being unlikely to measure differences in actual medical need. Such variation more likely reflects predisposing and enabling factors potentially affected by social, economic, and public health policy. Tracking variation in county-level statin use associated with these factors could help policymakers assess progress in reducing health care disparities and better target program resources. DISCLOSURES: No funding was received for this work. Karpinski reports employment by Aetna, Anthem, and Ingenio-Rx. Vanness reports unrelated consulting fees from CHEORS, Evidera, BMS, Novartis, and Merck. Look has nothing to disclose.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Medicamentos sob Prescrição/economia , Afro-Americanos , Idoso , Feminino , Humanos , Masculino , Medicare Part D/economia , Estados Unidos
13.
J Manag Care Spec Pharm ; 25(11): 1236-1242, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31663464

RESUMO

BACKGROUND: New hepatitis C virus (HCV) drugs-direct-acting antivirals (DAAs)-are highly effective but costly, which raises a concern about limited access to DAAs by vulnerable populations. Previous studies of disparities in DAA use across patient groups showed mixed results, but their generalizability was limited due to using data from commercial insurers or from 2014 only-the first year DAAs were available. Disparities in DAA use in a national cohort in the years when more DAAs were available is unknown. OBJECTIVE: To examine whether disparities in DAA use by patient race/ethnicity and socioeconomic status in Medicare changed between 2014 and 2016. METHODS: The study population was made up of chronic hepatitis C patients in fee-for-service Medicare with Part D between 2014 and 2016. We used multinomial logistic regression to estimate adjusted odds ratios (aOR) of using DAAs by patient race/ethnicity and socioeconomic status. We estimated the model separately for 2014 and 2014-2016. RESULTS: Of 281,810 Medicare patients who were followed to the end of 2016, a total of 90,419 (32.1%) filled prescriptions for DAAs. In the 2014 analysis, blacks were less likely to use DAAs than whites (aOR = 0.95; 95% CI = 0.91-0.99). However, in the 2014-2016 analysis, blacks had higher odds of using DAAs than whites (aOR = 1.24; 95% CI = 1.22-1.27). No significant Hispanic-white gap existed during the study period. Income was positively associated with DAA use in both periods. Between 2014 and 2016, patients who received a Part D low-income subsidy had lower odds of using DAAs than patients who did not (aOR = 0.90; 95% CI = 0.88-0.92), and patients in areas with the higher income tertiles were more likely to initiate DAAs than those in areas with the lowest income tertile. CONCLUSIONS: DAA use among Medicare patients remained far below the level needed to eradicate HCV. The black-white gap in HCV treatment was closed by 2016, but disparities by patient socioeconomic status remained. DAA use also varied by patient age and health risk, as well as across geographic regions. Continued efforts to improve DAA uptake in all HCV patients are needed to eradicate HCV. DISCLOSURES: This study was supported by the National Institute on Aging (1 R01 AG055636-01A1) and National Institute of Child Health & Human Development (R24 HD04025). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Feldman owns stock in Gilead Sciences and Abbvie. No other potential competing interest exists.


Assuntos
Antivirais/uso terapêutico , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hepatite C Crônica/tratamento farmacológico , Medicare Part D/estatística & dados numéricos , Afro-Americanos/estatística & dados numéricos , Idoso , Antivirais/economia , Estudos de Coortes , Custos de Medicamentos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/economia , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Masculino , Medicare Part D/economia , Pessoa de Meia-Idade , Fatores Socioeconômicos , Estados Unidos
14.
Otolaryngol Head Neck Surg ; 161(4): 605-612, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31547772

RESUMO

OBJECTIVE: To associate pharmaceutical industry payments to brand-name prescriptions by otolaryngologists. STUDY DESIGN: Retrospective cross-sectional analysis. SETTING: Open Payments Database and the Medicare Part D Participant User File 2013-2016. SUBJECTS AND METHODS: We identified otolaryngologists receiving nonresearch industry payments and prescribing to Medicare Part D recipients. Records were linked by physician name and state. The value of industry payments and the percentage of brand-name drugs prescribed per hospital referral region (HRR) were characterized as medians. Industry payments were correlated to the rate of brand-name prescription by Kendall's τ correlation. This was repeated at the individual physician level and stratified by payment type. RESULTS: In total, 8167 otolaryngologists received a median of $434 (interquartile range, $138-$1278) in industry compensation over 11 (3-26) payments. Brand-name drugs made up a median of 12.9% (8.6%-18-4%) of each physician's drug claims. The number (τ = 0.05, P < .001) and dollar amount (τ = 0.04, P < .001) of industry payments were correlated with the rate of brand-name drug prescription at the individual physician level. The number of industry payments was also associated with the rate of brand-name prescription by HRR (τ = 0.14, P < .001), but the dollar amount was not. By HRR, food and beverage payments received by physicians were associated with the rate of brand-name drug prescription (τ = 0.04, P < .001), but travel and lodging payments were not. CONCLUSIONS: Industry financial transactions are associated with brand-name drug prescriptions in otolaryngologists, and these associations are stronger at the regional level than at the individual physician level. These correlations are of modest strength and should be interpreted cautiously by readers.


Assuntos
Indústria Farmacêutica/economia , Doações , Medicare Part D , Otorrinolaringologistas/economia , Padrões de Prática Médica/economia , Conflito de Interesses , Estudos Transversais , Custos de Medicamentos , Humanos , Otorrinolaringologistas/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Medicamentos sob Prescrição/economia , Estudos Retrospectivos , Estados Unidos
17.
Medicine (Baltimore) ; 98(32): e16646, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31393363

RESUMO

To examine whether the Medicare Part D program had an impact on the generic drug prescription rate among residents in long-term care facilities.We analyzed prescription data for 3 drug classes (atypical antipsychotic, proton pump inhibitor, and statin) obtained from a regional online pharmacy serving long-term care centers in Pennsylvania from January 2004 to December 2007.Difference-in-difference is used as a primary analysis method, and different regression methods (probit and multinomial) are used to accommodate different types of outcome measures.Contrary to expectations, the Part D program did not have a statistically significant impact on the generic prescription rate in the long-term care setting during the study period. Only the statin class showed a dramatic increase in generic drug prescriptions, mainly due to the loss of patent protection for one of the most popular brand-name drugs in the class.The complex dynamics of the prescription drug market, particularly the availability of generic versions of popular prescription medications, had a bigger role in increasing the prescription rate of generic drugs than the Part D program. This warrants the need to relax prescription medicines' patent policies and for further study on the impact of such policies.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Medicamentos Genéricos , Seguro de Serviços Farmacêuticos/estatística & dados numéricos , Medicare Part D/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Antipsicóticos , Estudos de Casos e Controles , Prescrições de Medicamentos/classificação , Substituição de Medicamentos , Revisão de Uso de Medicamentos , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases , Assistência de Longa Duração/estatística & dados numéricos , Masculino , Inibidores da Bomba de Prótons , Estados Unidos
18.
Value Health ; 22(8): 871-877, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31426927

RESUMO

OBJECTIVES: To evaluate expenditures and sources of payment for prescription drugs in the United States from 1997 to 2015. METHODS: The Medical Expenditures Panel Survey (MEPS) was used for this analysis. Individuals with one or more prescription medicines were eligible for inclusion. Outcomes were the inflation-adjusted cost per prescription across all payment sources (self or family, public, private, and other sources) before and after the Medicare Part D benefit and the Affordable Care Act. RESULTS: The cost per prescription increased from $38.56 in 1997 to $73.34 in 2015. Nevertheless, consumers' out-of-pocket expenditures decreased from $18.19 to $9.61, whereas public program expenditures per prescription increased from $5.61 to $34.43 over this time. Out-of-pocket expenditures of individuals in the low-income group and near-poor group had larger declined percentages from 51.4% to 20.4% and 46.5% to 17.2% relative to individuals in higher-income groups before and after implementation of the Medicare Part D, respectively. Over 90% prescription purchases were covered by medical insurance by 2015. The per-prescription cost for medications consumed by uninsured individuals increased at a lower rate from $31.83 to $54.96 versus $40.12 to $75.58 for privately insured and $36.00 to $70.96 for publicly insured (P < .001). CONCLUSIONS: Prescription drugs expenditures have increased over the past 2 decades, but public sources now pay for a growing proportion of prescription drugs cost regardless of health insurance coverage or income level. Out-of-pocket expenditures have significantly decreased for persons with lower incomes since the implementation of Medicare Part D and the Affordable Care Act.


Assuntos
Renda/estatística & dados numéricos , Seguro de Serviços Farmacêuticos/estatística & dados numéricos , Medicamentos sob Prescrição/economia , Adolescente , Adulto , Distribuição por Idade , Idoso , Criança , Pré-Escolar , Feminino , Financiamento Pessoal/estatística & dados numéricos , Humanos , Lactente , Cobertura do Seguro/estatística & dados numéricos , Masculino , Assistência Médica/estatística & dados numéricos , Medicare Part D/estatística & dados numéricos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/estatística & dados numéricos , Distribuição por Sexo , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs/estatística & dados numéricos , Adulto Jovem
20.
JAMA ; 322(5): 422-429, 2019 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-31386135

RESUMO

Importance: Although independent charity patient assistance programs improve patient access to costly prescription drugs, recent federal investigations have raised questions about their potential to increase pharmaceutical spending and to violate the federal Anti-Kickback Statute. Little is known about the design of the programs, patient eligibility, or drug coverage. Objective: To examine the eligibility criteria of the independent charity patient assistance programs and the drugs covered by them. Design, Setting, and Participants: Descriptive cross-sectional study of the 6 largest independent charities offering patient assistance programs for patients including, but not limited to, Medicare beneficiaries in 2018. These charities offered 274 different disease-specific patient assistance programs. Drugs were identified for subgroup analysis that had any use reported on the Medicare Part D spending dashboard and any off-patent brand-name drugs that incurred more than $10 000 in Medicare spending per beneficiary in 2016. Exposures: Support by independent charity patient assistance programs. Main Outcomes and Measures: The primary outcomes were the characteristics of patient assistance programs, including assistance type, insurance coverage (vs uninsured), and income eligibility. The secondary outcomes were the cost of the drugs covered by the patient assistance programs and the coverage of expensive off-patent brand-name drugs vs substitutable generic drugs. Results: Among the 6 independent charity foundations included in the analysis, their total revenue in 2017 ranged from $24 million to $532 million, and expenditures on patient assistance programs ranged from $24 million to $353 million, representing on average, 86% of their revenue. Of the 274 patient assistance programs offered by these organizations, 168 (61%) provided only co-payment assistance, and the most common therapeutic area covered was cancer or cancer treatment-related symptoms (113 patient assistance programs; 41%). A total of 267 programs (97%) required insurance coverage as an eligibility criterion (ie, excluded uninsured patients). The most common income eligibility limit was 500% of the federal poverty level. The median annual cost of the drugs per beneficiary covered by the programs was $1157 (interquartile range, $247-$5609) compared with $367 (interquartile range, $100-$1500) for the noncovered drugs. Off-patent brand-name drugs (cost: >$10 000) were covered by a mean of 3.1 (SD, 2.0) patient assistance programs, whereas their generic equivalents were covered by a mean of 1.2 (SD, 1.0) patient assistance programs. Conclusions and Relevance: In 2018, among 274 patient assistance programs operated by the 6 independent charity foundations, the majority did not provide coverage for uninsured patients. Medications that were covered by the patient assistance programs were generally more expensive than those that were not covered.


Assuntos
Instituições de Caridade/economia , Definição da Elegibilidade , Renda , Pessoas sem Cobertura de Seguro de Saúde , Medicamentos sob Prescrição/economia , Instituições de Caridade/legislação & jurisprudência , Estudos Transversais , Custos de Medicamentos , Indústria Farmacêutica/economia , Gastos em Saúde , Humanos , Cobertura do Seguro , Assistência Médica/economia , Medicare Part D , Estados Unidos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA