Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers.

PURPOSE: To categorize and trend annual out-of-pocket expenditures for arthroscopic rotator cuff repair (RCR) patients relative to total healthcare utilization (THU) reimbursement and compare drivers of patient out-of-pocket expenditures (POPE) in a granular fashion via analyses by insurance type and surgical setting. METHODS: Patients who underwent outpatient arthroscopic RCR in the United States from 2013 to 2018 were identified from the IBM MarketScan Database. Primary outcome variables were total POPE and THU reimbursement, which were calculated for all claims in the 9-month perioperative period. Trends in outcome variables over time and differences across insurance types were analyzed. Multivariable analysis was performed to investigate drivers of POPE. RESULTS: A total of 52,330 arthroscopic RCR patients were identified. Between 2013 and 2018, median POPE increased by 47.5% ($917 to $1,353), and median THU increased by 9.3% ($11,964 to $13,076). Patients with high deductible insurance plans paid $1,910 toward their THU, 52.5% more than patients with preferred provider plans ($1,253, P = .001) and 280.5% more than patients with managed care plans ($502, P = .001). All components of POPE increased over the study period, with the largest observed increase being POPE for the immediate procedure (P = .001). On multivariable analysis, out-of-network facility, out-of-network surgeon, and high-deductible insurance most significantly increased POPE. CONCLUSIONS: POPE for arthroscopic RCR increased at a higher rate than THU over the study period, demonstrating that patients are paying an increasing proportion of RCR costs. A large percentage of this increase comes from increasing POPE for the immediate procedure. Out-of-network facility status increased POPE 3 times more than out-of-network surgeon status, and future cost-optimization strategies should focus on facility-specific reimbursements in particular. Last, ambulatory surgery centers (ASCs) significantly reduced POPE, so performing arthroscopic RCRs at ASCs is beneficial to cost-minimization efforts. CLINICAL RELEVANCE: This study highlights that although payers have increased reimbursement for RCR, patient out-of-pocket expenditures have increased at a much higher rate. Furthermore, this study elucidates trends in and drivers of patient out-of-pocket payments for RCR, providing evidence for development of cost-optimization strategies and counseling of patients undergoing RCR.

Analysis of energy consumption and change structure in major economic sectors of Pakistan.

Studying and analyzing energy consumption and structural changes in Pakistan's major economic sectors is crucial for developing targeted strategies to improve energy efficiency, support sustainable economic growth, and enhance energy security. The logarithmic mean Divisia index (LMDI) method is applied to find the factors' effects that change sector-wise energy consumption from 1990 to 2019. The results show that: (1) the change in mixed energy and sectorial income shows a negative influence, while energy intensity (EI) and population have an increasing trend over the study period. (2) The EI effects of the industrial, agriculture and transport sectors are continuously rising, which is lowering the income potential of each sector. (3) The cumulative values for the industrial, agricultural, and transport sectors increased by 57.3, 5.3, and 79.7 during 2019. Finally, predicted outcomes show that until 2035, the industrial, agriculture, and transport incomes would change by -0.97%, 13%, and 65% if the energy situation remained the same. Moreover, this sector effect is the most crucial contributor to increasing or decreasing energy consumption, and the EI effect plays the dominant role in boosting economic output. Renewable energy technologies and indigenous energy sources can be used to conserve energy and sectorial productivity.

Does digital inclusive finance promote carbon emission reduction of enterprises.

Can the information technology revolution lead to carbon emission reduction for firms? This study extends the limited evidence in the literature and investigate the role and mechanism of digital inclusive finance on enterprises' carbon emissions using panel data of 247 prefectural-level cities and 6019 industrial enterprises in China. Our findings indicate that digital inclusive finance can promote enterprise carbon emission reduction, and this effect remains significant after the instrumental variable estimation test. The effect has regional heterogeneity and the development of digital inclusive finance in the area east of Hu Huanyong line has a significant impact on reducing enterprise carbon emission. The role of digital inclusive finance is heterogeneous in enterprise ownership, with a remarkable effect in non-state-owned enterprises. Sub-dimension analysis indicates that the breadth of coverage, depth of use, and degree of digitalization of digital inclusive finance have differential effects on reducing enterprise carbon emissions. The stepwise regression method shows that the impact of digital inclusive finance on enterprise carbon emissions can be passed through effect of technological progress, environmental protection investment and financing constrain. This study has significant reference value for evaluating the impact of financial inclusion and policy implications in formulating differentiated strategies for achieving carbon emission reduction efficiency in enterprises.

Tiny patients, huge impact: a call to action.

The continuation of high-quality care is under threat for the over 70 million children in the United States. Inequities between Medicaid and Medicare payments and the current procedural-based reimbursement model have resulted in the undervaluing of pediatric medical care and lack of prioritization of children's health by institutions. The number of pediatricians, including pediatric subspecialists, and pediatric healthcare centers are declining due to mounting financial obstacles and this crucial healthcare supply is no longer able to keep up with demand. The reasons contributing to these inequities are clear and rational: Medicaid has significantly lower rates of reimbursement compared to Medicare, yet Medicaid covers almost half of children in the United States and creates the natural incentive for medical institutions to prioritize the care of adults. Additionally, certain aspects of children's healthcare are unique from adults and are not adequately covered in the current payment model. The result of decades of devaluing children's healthcare has led to a substantial decrease in the availability of services, medications, and equipment needed to provide healthcare to children across the nation. Fortunately, the solution is just as clear as the problem: we must value the healthcare of children as much as that of adults by increasing Medicaid funding to be on par with Medicare and appreciate the complexities of care beyond procedures. If these changes are not made, the high-quality care for children in the US will continue to decline and increase strain on the overall healthcare system as these children age into adulthood.

Impact of mental health in persons living with rare disease: Findings from the AMCP Market Insights Program.

Within the framework of its Market Insights Program, AMCP convened a panel of experts representing diverse stakeholders to identify alterations to plan design and/or coverage options geared toward improving the diagnosis and treatment of mental health conditions among persons living with rare diseases (PLWRD). PLWRD face unique mental health challenges because of the misunderstood nature of their conditions, potential misdiagnosis, and limited treatment options. Economic burdens arise from increased medical needs, reliance on caregivers, and work disruptions. The interplay of these factors, along with health insurance coverage, creates a distinctive mental health landscape for PLWRD and a need to prioritize mental health support for this patient population. This article aims to (1) summarize expert perspectives on health care system challenges and areas of agreement concerning the management of mental health conditions and (2) advance payers' understanding of their role in supporting mental health care for patients with rare diseases. Addressing mental health needs of PLWRD presents multifaceted challenges. Managed care organizations play a pivotal role in supporting mental health care for PLWRD through their quality improvement initiatives and policies for coverage and reimbursement, which can impact both the rare disease treatment and mental health services PLWRD receive.

Optimizing the management of inherited blood disorders in a changing market: Findings from the AMCP Market Insights Program.

In this market insights program, AMCP brought together a panel of experts representing various stakeholders: national and regional health plans, integrated health care systems, employer benefits groups, clinical experts, the Centers for Disease Control and Prevention, and patient advocacy organizations. The objectives were to gain insights into the current and evolving treatments in hemophilia, sickle cell disease, and ß-thalassemia; measure the effects of recently approved therapies on clinicians, payers, and patients; recognize emerging trends within the stop-loss market; address potential issues and obstacles related to monitoring and reporting outcomes; and identify concerns associated with both existing and emerging contracting and reimbursement models. This article aims to summarize expert perspectives on health care system challenges and strategies concerning the management of inherited blood disorders and to advance managed care professionals' understanding of their role in supporting care for these patients. The experts emphasized that when shaping coverage policies, a patient-centered approach is crucial, focusing on preserving organ function to maintain eligibility for future gene therapies among individuals with inherited blood disorders. These strategies, including benefit design modifications, specialized provider networks, and centralized mechanisms like registries, are vital for evaluating effectiveness, facilitating decision-making, and managing costs and risks associated with new and emerging treatment options for inherited blood disorders.

Financial toxicity, coping strategies, and quality of life among Chinese patients with hematologic malignancies: a cross-sectional study.

PURPOSE: Financial toxicity is used to describe the financial hardship experienced by cancer patients. Financial toxicity may cause negative consequences to patients, whereas little is known in Chinese context. This study aimed to explore the level of financial toxicity, coping strategies, and quality of life among Chinese patients with hematologic malignancies. PATIENTS AND METHODS: We conducted a prospective, observational study among 274 Chinese patients with hematologic malignancies from November 2021 to August 2022 in Sun Yat-sen University Cancer Center. Clinical data were extracted from electronic clinical records. Data on financial toxicity, coping strategies, and quality of life were collected using PRO measures. Chi-square or independent t test and multivariate logistic regression were performed to explore the associated factors of financial toxicity and quality of life, respectively. Effects of financial toxicity on coping strategies were examined using Chi-square. RESULTS: The mean age of the participants was 50.2 (± 14.6) years. Male participants accounted for 57.3%. About half of the participants reported high financial toxicity. An average median of ¥200,000 on total medical expenditures since the diagnosis was reported. The average median monthly out-of-pocket health expenditure relating to cancer treatment was ¥20,000 (range ¥632-¥172,500) after reimbursement. Reduce daily living expenses (64.9%), borrowing money (55.7%), and choosing cheaper regimens (19.6%) were the commonly used strategies to cope with financial burden. Financial toxicity was negatively associated with quality of life (ß = 0.071, P = 0.001). CONCLUSIONS: Financial toxicity was not uncommon in patients with hematological malignancies. Reducing daily living expenses, abandoning treatment sessions, and borrowing money were the strategies commonly adopted by participants to defray cancer costs. Additionally, participants with high level of financial toxicity tended to have worse quality of life. Therefore, actions from healthcare providers, policy-makers, and other stakeholders should be taken to help cancer patients mitigate their financial toxicity.

Economic cost of management of glaucoma in public and private health facilities in the Tema metropolis in Ghana.

Objectives: This study sought to determine the economic cost of the management of glaucoma among patients seeking care in health facilities in Ghana. Design: A cross-sectional cost-of-illness (COI) study from the perspective of the patients was employed. Setting: The study was conducted in public and private eye care facilities in the Tema Metropolis of Ghana. Participants: About 180 randomly selected glaucoma patients seeking healthcare at two facilities participated in the study. Main outcome measure: Direct cost, including medical and non-medical costs, indirect cost, and intangible burden of management of glaucoma. Results: the cost per patient treated for glaucoma in both facilities was US$60.78 (95% CI: 18.66-107.80), with the cost in the public facilities being slightly higher (US$62.50) than the private facility (US$ 59.3). The largest cost burden in both facilities was from direct cost, which constituted about 94% of the overall cost. Medicines (42%) and laboratory and diagnostics (26%) were the major drivers of the direct cost. The overall cost within the study population was US$10,252.06. Patients paid out of pocket for the frequently used drug- Timolol, although expected to be covered under the National Health Insurance Scheme (NHIS). Patients, however, expressed moderate intangible burdens due to glaucoma. Conclusion: The cost of the management of glaucoma is high from the perspective of patients. The direct costs were high, with the main cost drivers being medicines, laboratory and diagnostics. It is recommended that the National Health Insurance Authority (NHIA) should consider payment for commonly used medications to minimize the burden on patients. Funding: None declared.

Financial Toxicity in Cancer Supportive Care: An International Survey.

PURPOSE: The study aims to explore unmet social needs and sources of financial toxicities in patients as noted by health care professionals and researchers in cancer supportive care, shedding light on potential health disparities. METHODS: In this cross-sectional survey, we anonymously surveyed active members of the Multinational Association of Supportive Care in Cancer (MASCC). The survey, structured in three sections, included questions regarding the routine assessment of social needs during patient consultations, sociodemographic aspects, factors influencing financial toxicity (FT), perceived support for managing FT, and available/desirable resources. RESULTS: A total of 218 MASCC members were included, predominantly from high-income countries (HIC, 73.4%), with many age 41-60 years (56.5%) and female (56.9%). Drug/treatment cost and insurance coverage were the main sources for FT among the HIC, whereas participants from low-middle-income countries (LMIC) considered transportation cost, loss of employment because of cancer diagnosis, and unavailability of return-to-work services as the top three sources of FT. Respondents from LMIC (adjusted odds ratio [aOR], 3.01 [95% CI, 1.15 to 7.93]) and physicians (aOR, 2.67 [95% CI, 1.15 to 6.21]) were more likely to routinely assess financial coverages. Socioeconomic status was consistently ranked as one of the top three sources of financial toxicities by participants from LMIC (34%), HIC excluding the United States (38%), those who do not self-identify as racial/ethnic minority (36%), and physicians (40%). CONCLUSION: This global survey of health care professionals and researchers in HIC and LMIC revealed varying approaches to assessing financial coverage and social needs. Socioeconomic status emerged as a consistent concern across countries, affecting financial toxicities. The study highlights the need for tailored approaches and improved resource visibility while emphasizing clinicians' pivotal role in addressing financial aspects of cancer care.

Does Insurance Provide Adequate Coverage for Physical Therapy Visits for Common Orthopedic Diagnoses? A Survey Study.

OBJECTIVES: This study aimed to analyze the association between physical therapists' recommended number of visits for a full recovery from common orthopedic injuries/surgeries and the extent of insurance coverage for these visits. METHODS: A prospective observational study was conducted with board-certified physical therapists. A qualitative questionnaire was used to gather physical therapists' demographics and the recommended number of physical therapy visits to achieve a full recovery after 11 common orthopedic diagnoses. Physical therapists also were asked to report whether they believe that insurance provides an adequate number of visits overall. In addition to the qualitative survey, insurance coverage details of major Alabama companies were obtained for comparison. Descriptive statistics of the participating therapists were analyzed for sex, age, degree/training, and years of experience. Kruskal-Wallis statistics were used to analyze variance between the aforementioned groupings when compared with the reported average number of sessions. RESULTS: The survey (N = 251) collected data on the average number of physical therapy sessions that are necessary for a complete recovery as recommended by physical therapists for 11 common orthopedic diagnoses. From this survey, the average number of necessary visits ranged from 11.3 visits (ankle sprains) to 37.3 visits (anterior cruciate ligament reconstruction), with the overall average number of visits being 23.8. Only 24% of physical therapists believed that insurance companies provided enough coverage. Insurance coverage varied but often required additional procedures to allocate the adequate number of visits for the studied orthopedic pathologies. CONCLUSIONS: The majority of practicing physical therapists in Alabama perceive insufficient insurance coverage for physical therapy visits for most orthopedic diagnoses. This study has implications for healthcare decision making and patient-centered rehabilitation goals. Physicians and physical therapists can use this information to optimize treatment decisions and rehabilitation goals. Patients will benefit from improved physical and economic well-being. This study has the potential to drive further research and influence national insurance policies to better serve patients' needs.

Federal transfers to municipalities through parliamentary amendments: implications for SUS funding. / Transferências federais por emendas parlamentares aos municípios: implicações para o financiamento do SUS.

The present article analyzes the transfers from parliamentary amendments by the Ministry of Health to municipalities to finance public health actions and services from 2015 to 2021. A descriptive and exploratory study was carried out with secondary data, including all Brazilian cities. Resources from amendments showed an increase, particularly from 2018 onwards, indicating the expansion of their relevance for financing SUS. From 2016 to 2021, over 80% was allocated to municipalities, representing 9.5% of all federal transfers, with 91.2% for operational expenses. Transfers from amendments differ from regular transfers due to greater instability and per capita variation among the amounts collected by municipalities and due to the fact that they allocate most resources to the Northeast and primary care to the detriment of the Southeast and medium and high complexity care. These transfers represent a differentiated modality of resource allocation in SUS that produces new distortions and asymmetries, with implications for intergovernmental relations, as well as between the executive and legislative powers, increasing the risk of the discontinuity of actions and services and imposing challenges for the municipal management.

O artigo tem como objetivo analisar as transferências por emendas parlamentares do Ministério da Saúde aos municípios para o financiamento de ações e serviços públicos de saúde, de 2015 a 2021. Foi realizado estudo descritivo e exploratório com dados secundários, abrangendo a totalidade de municípios brasileiros. Os recursos provenientes de emendas apresentaram aumento, em especial a partir de 2018, indicando a expansão de sua relevância para o financiamento do SUS. No período de 2016 a 2021, mais de 80% foram alocados aos municípios, representando 9,5% dos repasses federais, com 91,2% de natureza de custeio. As transferências por emendas diferem dos repasses regulares por possuir maior instabilidade e variação per capita entre os montantes captados pelos municípios, e por destinar a maior parte dos recursos ao Nordeste e à atenção primária, em detrimento do Sudeste e da média e alta complexidade. Configura-se uma modalidade diferenciada de alocação de recursos no SUS que produz novas distorções e assimetrias, com implicações para as relações intergovernamentais e entre os poderes executivo e legislativo, ampliando o risco de descontinuidade de ações e serviços e impondo desafios para as gestões municipais.

Cancer cost-related subjective financial distress among breast cancer: a scoping review.

PURPOSE: This article provided a comprehensive scoping review, synthesizing existing literature on the financial distress faced by breast cancer patients. It examined the factors contributing to financial distress, the impact on patients, coping mechanisms employed, and potential alleviation methods. The goal was to organize existing evidence and highlight possible directions for future research. METHODS: We followed the scoping review framework proposed by the Joanna Briggs Institute (JBI) to synthesize and report evidence. We searched electronic databases, including PubMed, Web of Science, Embase, and Cochrane Library, for relevant literature. We included English articles that met the following criteria: (a) the research topic was financial distress or financial toxicity, (b) the research subjects were adult breast cancer patients, and (c) the article type was quantitative, qualitative, or mixed-methods research. We then extracted and integrated relevant information for reporting. RESULTS: After removing duplicates, 5459 articles were retrieved, and 43 articles were included based on the inclusion and exclusion criteria. The articles addressed four main themes related to financial distress: factors associated with financial distress, impact on breast cancer patients, coping mechanisms, and potential methods for alleviation. The impact of financial distress on patients was observed in six dimensions: financial expenses, financial resources, social-psychological reactions, support seeking, coping care, and coping lifestyle. While some studies reported potential methods for alleviation, few discussed the feasibility of these solutions. CONCLUSIONS: Breast cancer patients experience significant financial distress with multidimensional impacts. Comprehensive consideration of possible confounding factors is essential when measuring financial distress. Future research should focus on exploring and validating methods to alleviate or resolve this issue.

The real-world observational prospective study of health outcomes with dulaglutide and liraglutide in type 2 diabetes patients (TROPHIES): resource use and costs of treatment in clinical practice in France, Germany, and Italy.

AIMS: To describe healthcare resource utilization (HCRU) and associated costs after initiation of injectable glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy by adult patients with type 2 diabetes (T2D) in the prospective, observational, 24-month TROPHIES study in France, Germany, and Italy. MATERIALS AND METHODS: HCRU data for cost calculations were collected by treating physicians during patient interviews at baseline and follow-up visits approximately 6, 12, 18, and 24 months after GLP-1 RA initiation with once-weekly dulaglutide or once-daily liraglutide. Costs were evaluated from the national healthcare system (third-party payer) perspective and updated to 2018 prices. RESULTS: In total, 2,005 patients were eligible for the HCRU analysis (1,014 dulaglutide; 991 liraglutide). Baseline patient characteristics were generally similar between treatment groups and countries. The largest proportions of patients using ≥2 oral glucose-lowering medications (GLMs) at baseline (42.9-43.4%) and month 24 (44.0-45.1%) and using another injectable GLM at month 24 (15.3-23.2%) were in France. Mean numbers of primary and secondary healthcare contacts during each assessment period were highest in France (range = 4.0-10.7) and Germany (range = 2.9-5.7), respectively. The greatest proportions (≥60%) of mean annualized costs per patient comprised medication costs. Mean annualized HCRU costs per patient varied by treatment cohort and country: the highest levels were in the liraglutide cohort in France (€909) and the dulaglutide cohort in Germany (€883). LIMITATIONS: Limitations included exclusion of patients using insulin at GLP-1 RA initiation and collection of HCRU data by physician, not via patient-completed diaries. CONCLUSIONS: Real-world HCRU and costs associated with the treatment of adults with T2D with two GLP-1 RAs in TROPHIES emphasize the need to avoid generalization with respect to HCRU and costs associated with a particular therapy when estimating the impact of a new treatment in a country-specific setting.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have become frequent treatments of hyperglycemia in type-2 diabetes (T2D). Not all types of clinical study provide information about the cost of these treatments or the effects they might have on use of other medicines and equipment to control T2D or the need for visits to a doctor or nurse and different types of treatment in hospital. This study collected this information during the regular care of adults in France, Germany, or Italy who were prescribed either dulaglutide or liraglutide (both types of GLP-1 RAs) by their family doctor or a specialist in T2D. There were differences in costs and the need for other medicines and medical services between people using either dulaglutide or liraglutide and for people who were using the same GLP-1 RA in each of the three countries. The information from this study could be used to more accurately understand the overall costs and medical care needed when patients use dulaglutide or liraglutide in France, Germany, or Italy.

An innovative business model using established Medicare items for delivery of cardiac rehabilitation: A value proposition for primary care.

BACKGROUND: Approximately 70% of Australians do not attend cardiac rehabilitation (CR). A potential solution is integrating CR into primary care OBJECTIVE: To propose a business model for primary care providers to implement CR using current Medicare items. DISCUSSION: Using the chronic disease management plan, general practitioners (GPs) complete four clinical assessments at 1-2 weeks, 8-12 weeks, and 6 and 12 months after discharge. The net benefit of applying this model, compared with claiming the most used standard consultation Item 23, in Phase II CR is up to $505 per patient and $543 in Phase III CR. The number of rural GPs providing CR in partnership with the Country Access To Cardiac Health (CATCH) through the GP hybrid model has increased from 28 in 2021 to 32 in 2022. This increase might be attributed to this value proposition. The biggest limitation is access to allied health services in the rural areas.

Real-world economic burden associated with disease progression from metastatic castration-sensitive to castration-resistant prostate cancer on treatment in the United States.

BACKGROUND: The advent of next-generation imaging will likely reduce nonmetastatic prostate cancer (PC) prevalence and increase identification of metastatic prostate cancer cases, resulting in two predominant advanced stages in the metastatic setting. There is a need to characterize changes in health care resource utilization (HRU) and costs when metastatic castration-sensitive PC (mCSPC) progresses to metastatic castration-resistant PC (mCRPC) to identify value drivers from current and new treatments. OBJECTIVE: To describe treatment patterns, HRU, and total health care costs among patients with mCSPC, before and after progression to mCRPC. METHODS: Clinical data from the Flatiron Metastatic PC Core Registry (January 1, 2013, to December 1, 2021) and linked claims from Komodo Health (January 1, 2014, to December 1, 2021) were used to identify patients with progression from mCSPC to mCRPC (date of progression was the index date) and subsequently initiated first-line mCRPC therapy on/after January 1, 2017. Treatment patterns and all-cause/PC-related HRU and health care costs were described per-patient-per-month (PPPM), separately for no more than 12 months pre-index (mCSPC disease state) and post-index (mCRPC disease state). Costs (payer's perspective) included those for services/procedures from medical claims and costs from pharmacy claims. Continuous HRU and costs were compared between the mCSPC and mCRPC disease states using Wilcoxon signed rank tests. RESULTS: Among 296 patients with mCSPC progressing to mCRPC (median age 69.0 years, 60.5% White, 15.9% Black), use of systemic therapies with androgen deprivation therapy increased dramatically from 35.1% in the mCSPC disease state to 92.9% in the mCRPC disease state, and use of androgen deprivation therapy monotherapy decreased from 25.7% to 2.4%, respectively. Although 39.2% received none of these therapies in the mCSPC disease state, this proportion decreased to 4.7% after transition to mCRPC. The mean number of days with PC-related outpatient visits increased from 1.57 to 2.16 PPPM in the mCSPC and mCRPC disease states (P < 0.001). From the mCSPC to mCRPC disease states, mean all-cause total health care costs PPPM increased from $4,424 (medical costs: $2,846) to $9,717 (medical costs: $4,654), and mean PC-related total health care costs PPPM increased from $2,859 (medical costs: $1,626) to $8,012 (medical costs: $3,285; all P < 0.001). CONCLUSIONS: In this real-world study of patients with disease progression from mCSPC to mCRPC in US clinical practice, nearly 2-in-3 patients did not receive treatment with additional systemic therapies before progression to castration resistance. Post-progression, mean PC-related total costs increased nearly 3-fold, with a more than 2-fold increase in PC-related medical costs. Use of additional systemic therapies may delay the time and cost associated with disease progression to castration resistance.

Cheaper is not always better: Drug shortages in the United States and a value-based solution to alleviate them.

Drug shortages threaten patients' access to medications and are associated with adverse health outcomes and increased costs. Drug shortages disproportionately occur among generic drugs of limited profitability, most notably drugs administered by injection. In this perspective, we discuss how reimbursement and purchasing practices that were meant to create an efficient marketplace for generics have generated strong price pressure that threatens profitability in certain markets. We further explain how, faced with limited profitability, manufacturers lack incentives to invest in resilient supply chains, and in some cases, engage in cost-containment strategies or decide to exit the market, ultimately contributing to shortages. We propose the development and implementation of value-based reimbursement to provide needed incentives for drug purchasers and manufacturers to establish a more reliable supply chain as part of the policy solution to reduce the number and extent of drug shortages. This reimbursement model would necessitate the development of a rating system that measures supply chain resilience and maturity for each generic product. This rating would then be applied as a value-based modifier to reimbursement rates for generic products. The proposed model would result in higher reimbursement rates for generic products from more dependable supply chains, generating incentives for manufacturers to invest in supply chain resiliency. We propose the application of this reimbursement system originally in Medicare given Congressional interest on reforming Medicare payment to prevent drug shortages.