Prioritizing solutions to incorporate Prosthetics and Orthotics services into Iranian health benefits package: Using an analytic hierarchy process.

INTRODUCTION: Health benefits package (HBP) is regarded as one of the main dimensions of health financing strategy. Even with increasing demands for prosthetics and orthotics (P&O) services to approximately 0.5% of the world's population, only 15% of vulnerable groups have the chance to make use of such benefits. Inadequate coverage of P&O services in the HBP is accordingly one of the leading reasons for this situation in many countries, including Iran. AIMS: The main objective of this study was to find and prioritize solutions in order to facilitate and promote P&O services in the Iranian HBP. STUDY DESIGN: A mixed-methods (qualitative-quantitative) research design was employed in this study. METHODS: This study was conducted in two phases. First, semi-structured interviews were undertaken to retrieve potential solutions. Then an analytic hierarchy process (AHP) reflecting on seven criteria of acceptability, effectiveness, time, cost, feasibility, burden of disease, and fairness was performed to prioritize them. RESULTS: In total, 26 individuals participated in semi-structured interviews and several policy solutions were proposed. Following the AHP, preventive interventions, infant-specific interventions, inpatient interventions, interventions until 6 years of age, and emergency interventions gained the highest priority to incorporate in the Iranian HBP. CONCLUSION: A number of policy solutions were explored and prioritized for P&O services in the Iranian HBP. Our findings provide a framework for decision- and policy-makers in Iran and other countries aiming to curb the financial burdens of P&O users, especially in vulnerable groups.

State Standards for Insurance Access to Oncologists.

As the market for health insurance plans expands, each state is responsible for setting standards to ensure that plans contain adequate coverage for cancer care. Little is currently known about what criteria states use for network adequacy of insurance plans. We contacted representatives of the Department of Insurance (or equivalent) for 50 states and the District of Columbia, as well as searched official state websites to compile data on network adequacy standards for cancer care nationwide. The standards of 16 (31.4%) states contained only qualitative elements for access to an oncologist (eg, "reasonable access"), 7 (13.7%) states included only quantitative elements (eg, travel distance and time restrictions), and 24 (47.1%) states included standards with both qualitative and quantitative elements. Standards from 4 states were not available. States should make certain that robust, transparent protections exist to ensure that patients are able to access high-quality cancer care without experiencing the financial toxicity associated with out-of-network billing.

Costs for Colon Cancer Treatment Comparing Benefit Types and Care Sources in the US Military Health System.

INTRODUCTION: Cancer is one of the leading causes of morbidity and mortality in the USA, contributing largely to US healthcare spending. Provision of services (direct or purchased) and insurance benefit type may impact cost for cancer care. As a common cause of cancer in both men and women, we aim to compare colon cancer treatment costs between insurance benefit types and care sources in the US Military Health System (MHS) to better understand whether and to what extent these system factors impact cancer care costs. MATERIALS AND METHODS: Department of Defense Central Cancer Registry records and MHS Data Repository administrative claims were used to identify MHS beneficiaries aged 18-64 who were diagnosed with primary colon adenocarcinoma and received treatment between 2003 and 2008. The data linkage was approved by the Institutional Review Boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health. Costs to the MHS for each claim related to cancer treatment were extracted from the linked data and adjusted to 2008 USD. We used quantile regression models to compare median cancer treatment costs between benefit types and care sources (direct, purchased, or both), adjusted for demographic, tumor, and treatment characteristics. RESULTS: The median per capita (n = 801) costs for colon cancer care were $60,321 (interquartile range $24,625, $159,729) over a median follow-up of 1.7 years. The model-estimated treatment costs were similar between benefit types. Patients using direct care had significantly lower estimated median costs [$34,145 (standard error $4,326)] than patients using purchased care [$106,395 ($10,559)] or both care sources [$82,439 ($13,330)], controlled for patient demographic, tumor, and treatment characteristics. Differences in cost by care source were noted for patients with later stage tumors and by treatment type. Relative costs were 2-3 times higher for purchased care compared to direct care for patients with late-stage tumors and for patients receiving chemotherapy or radiation treatment. CONCLUSIONS: In the MHS, median cost for colon cancer treatment was lower in direct care compared to purchased care or patients using a combination of direct and purchased care. The variation in cancer treatment costs between care sources may be due to differences in treatment incentives or capabilities. Additional studies on cost differences between direct and purchased services are needed to understand how provision of care affects cancer treatment costs and to identify possible targets for cost reduction.

The effect of unemployment benefits on health: A propensity score analysis.

In the wake of the Great Recession, an expanding body of research has highlighted the role of social protection policies in mitigating the deleterious effects of adverse socioeconomic experiences. In this paper, we examine whether unemployment benefits - a key pillar of national social protection systems - can offset the negative health consequences of unemployment. Using cross-sectional nationally representative data from the Canadian Community Health Survey covering the period between 2009 and 2014, we employed propensity score matching to estimate the effect of receiving unemployment benefits on self-rated health among the unemployed. After matching benefit recipients to comparable non-recipient 'controls', we found that receiving unemployment benefits was associated with better health outcomes. In our main analyses, benefit recipiency reduced the probability of reporting poor self-rated health among the unemployed by up to 4.9% (95% CI -7.3, -2.5). Sensitivity analyses stratified by socioeconomic position revealed stronger treatment effects among lower income and less educated individuals. By contrast, treatment effects were small or negligible among higher income and more educated individuals. Our findings provide evidence that unemployment benefits can play an important role in offsetting the negative health consequences of unemployment among the socioeconomically disadvantaged. These findings lend support to recent calls, including many from within the field of public health, for governments to respond to current labor market trends by expanding the generosity and scope of social protection policies.

Provider group type and Tdap coverage in pregnancy.

INTRODUCTION: The Advisory Committee on Immunization Practices (ACIP) has focused on maternal Tdap immunization as an important means to protect neonates from pertussis infections. There is little published data on provider and/or clinic characteristics as predictors of maternal Tdap uptake. This study examined differences in maternal Tdap coverage in women delivering at a single academic institution, but cared for prenatally in different clinical settings, in 2013, 2014, and 2015. Additionally, the accuracy and utilization of Vermont's immunization information system (IIS) was assessed. METHODS: This was a retrospective, multiple time-point cross-sectional analysis of annual maternal Tdap coverage in women delivering at a single academic institution in the 3 years following a fundamental change in national maternal Tdap vaccination guidelines. Tdap administration was examined across different obstetric groups using chart review and data from the state's IIS. RESULTS: All obstetric care groups except the resident-staffed clinic significantly increased maternal Tdap coverage in 2014, compared to 2013 coverage, with no further increase in 2015. In contrast, there was no increase in maternal Tdap coverage in 2014 in the resident-staffed clinics, but then a statistically significant increase in 2015. Overall Tdap coverage in 2014 was 80.4%, with variation in Tdap coverage between clinics types. In the subset of women who were cared for by the University-based groups, there was significant variation in Tdap coverage between clinics, despite racial homogeneity, which persisted after adjustment for maternal age and insurance type. The state's IIS was found to be highly accurate, using individual chart review as the "gold standard." DISCUSSION: While we demonstrated high maternal Tdap coverage in women delivering at our institution, differences in clinic type and provider training appeared to impact immunization rates, as well as how quickly evolving national recommendations were adopted. Additionally, the fidelity of the state's IIS data was verified.

Health Benefits and Cost-Effectiveness From Promoting Smartphone Apps for Weight Loss: Multistate Life Table Modeling.

BACKGROUND: Obesity is an important risk factor for many chronic diseases. Mobile health interventions such as smartphone apps can potentially provide a convenient low-cost addition to other obesity reduction strategies. OBJECTIVE: This study aimed to estimate the impacts on quality-adjusted life-years (QALYs) gained and health system costs over the remainder of the life span of the New Zealand population (N=4.4 million) for a smartphone app promotion intervention in 1 calendar year (2011) using currently available apps for weight loss. METHODS: The intervention was a national mass media promotion of selected smartphone apps for weight loss compared with no dedicated promotion. A multistate life table model including 14 body mass index-related diseases was used to estimate QALYs gained and health systems costs. A lifetime horizon, 3% discount rate, and health system perspective were used. The proportion of the target population receiving the intervention (1.36%) was calculated using the best evidence for the proportion who have access to smartphones, are likely to see the mass media campaign promoting the app, are likely to download a weight loss app, and are likely to continue using this app. RESULTS: In the base-case model, the smartphone app promotion intervention generated 29 QALYs (95% uncertainty interval, UI: 14-52) and cost the health system US $1.6 million (95% UI: 1.1-2.0 million) with the standard download rate. Under plausible assumptions, QALYs increased to 59 (95% UI: 27-107) and costs decreased to US $1.2 million (95% UI: 0.5-1.8) when standard download rates were doubled. Costs per QALY gained were US $53,600 for the standard download rate and US $20,100 when download rates were doubled. On the basis of a threshold of US $30,000 per QALY, this intervention was cost-effective for Maori when the standard download rates were increased by 50% and also for the total population when download rates were doubled. CONCLUSIONS: In this modeling study, the mass media promotion of a smartphone app for weight loss produced relatively small health gains on a population level and was of borderline cost-effectiveness for the total population. Nevertheless, the scope for this type of intervention may expand with increasing smartphone use, more easy-to-use and effective apps becoming available, and with recommendations to use such apps being integrated into dietary counseling by health workers.

The $74,973 Question: Are Medicare Beneficiaries Informed Users of Private Medical Care Contracts?

Health-care providers are allowed to opt-out of Medicare, privately contract with beneficiaries, and require that beneficiaries pay the full cost of services. Responses from a nationally representative sample of Medicare beneficiaries reveal that they lack the knowledge necessary to make informed decisions regarding such contracts. For example, only 4.6% of participants knew the correct answer to a real-life $74,973 question, leaving a full 95.4% vulnerable to paying a large bill, even a $74,973 bill, they should not pay. In addition to advocating that Medicare effectively monitor private medical care contracts, social workers should educate beneficiaries and/or their caregivers on the implications of entering into such contracts or refer them to their State Health Insurance Assistance Program or Senior Medicare Patrol program for expert guidance.

The continuum of breast cancer care and outcomes in the U.S. Military Health System: an analysis by benefit type and care source.

PURPOSE: This study investigates transition rates between breast cancer diagnosis, recurrence, and death by insurance benefit type and care source in U.S. Military Health System (MHS). METHODS: The MHS data repository and central cancer registry linked data were used to identify women aged 40-64 with histologically confirmed breast cancer between 2003 and 2007. Three-state continuous time Markov models were used to estimate transition rates and transition rate ratios (TRRs) by TRICARE benefit type (Prime or non-Prime) and care source (direct, purchased, or both), adjusted for demographic, tumor, and treatment variables. RESULTS: Analyses included 2668 women with transitions from diagnosis to recurrence (n = 832), recurrence to death (n = 79), and diagnosis to death without recurrence (n = 91). Compared to women with Prime within each care source, women with non-Prime using both care sources had higher transition rates (TRR 1.47, 95% CI 1.03, 2.10). Compared to those using direct care within each benefit type, women utilizing both care sources with non-Prime had higher transition rates (TRR 1.86, 95% CI 1.11, 3.13), while women with Prime utilizing purchased care had lower transition rates (TRR 0.82, 95% CI 0.68, 0.98). CONCLUSIONS: In the MHS, women with non-Prime benefit plans compared to Prime had higher transition rates along the breast cancer continuum among both care source users. Purchased care users had lower transition rates than direct care users among Prime beneficiaries. IMPLICATIONS FOR CANCER SURVIVORS: Benefit plan and care source may be associated with breast cancer progression. Further research is needed to demonstrate differences in survivorship.

Are You Making an Impact? Evaluating the Population Health Impact of Community Benefit Programs.

CONTEXT: The Patient Protection and Affordable Care Act includes a change to the IRS 990 Schedule H, requiring nonprofit hospitals to submit a community health needs assessment every 3 years. Such health care entities are challenged to evaluate the effectiveness of community benefit programs addressing the health needs identified. OBJECTIVE: In an effort to determine the population health impact of community benefit programs in 1 hospital outreach department, researchers and staff conducted an impact evaluation to develop priority areas and overarching goals along with program- and department-level objectives. DESIGN: The longitudinal impact evaluation study design consists of retrospective and prospective secondary data analyses. SETTING: As an urban pediatric hospital, St Louis Children's Hospital provides an array of community benefit programs to the surrounding community. PARTICIPANTS: Hospital staff and researchers came together to form an evaluation team. Data from program evaluation and administrative data for analysis were provided by hospital staff. MAIN OUTCOME MEASURE: Impact scores were calculated by scoring objectives as met or unmet and averaged across goals to create impact scores that measure how closely programs meet the overarching departmental mission and goals. RESULTS: Over the 4-year period, there is an increasing trend in program-specific impact scores across all programs except one, Healthy Kids Express Asthma, which had a slight decrease in year 4 only. IMPLICATIONS: Current work in measuring and assessing the population health impact of community benefit programs is mostly focused on quantifying dollars invested into community benefit work rather than measuring the quality and impact of services. This article provides a methodology for measuring population health impact of community benefit programs that can be used to evaluate the effort of hospitals in providing community benefit. This is particularly relevant in our changing health care climate, as hospitals are being asked to justify community benefit and make meaningful contributions to population health. The Patient Protection and Affordable Care Act includes a change to the IRS 990 Schedule H, requiring nonprofit hospitals to submit a community health needs assessment every 3 years, and requires evaluation of program effectiveness; yet, it does not require any quantification of the impact of community benefit programs. The IRS Schedule H 990 policies could be strengthened by requiring an impact evaluation such as outlined in this article. CONCLUSION: As hospitals are being asked to justify community benefit and make meaningful contributions to population health, impact evaluations can be utilized to demonstrate the cumulative community benefit of programs and assess population health impact of community benefit programs.

A Content Analysis of Nonprofit Hospital Community Health Needs Assessments and Community Benefit Implementation Strategies in Philadelphia.

CONTEXT: Nonprofit hospitals are mandated to perform a community health needs assessment, develop an implementation strategy to address community needs, and invest in improving community health through community benefit investments in order to maintain the tax exemptions afforded nonprofit hospitals. OBJECTIVE: We sought to describe the regional health needs identified across community health needs assessments and the portfolio of implementation strategies reported to address those needs. DESIGN: The study provides a content analysis of community health needs assessments and implementation strategies for nonprofit hospitals in one urban region. SETTING: The study focused on nonprofit hospitals in Philadelphia, Pennsylvania. MAIN OUTCOME MEASURES: Community benefit documents were coded to characterize health needs and intervention activities using the 4 health factor categories of the County Health Rankings framework: clinical care, health behaviors, social and economic factors, and physical environment. RESULTS: Hospitals predominantly identified health needs related to access to care, especially mental health and dental care, and insurance coverage and costs of care. In many instances, there is little alignment between needs identified through the community health needs assessments and the reported implementation strategies. Specifically, dental care, behavioral health, substance abuse, social factors, and health care and prescription drug costs were all cited as important community needs but were infrequently targeted by implementation strategies. CONCLUSIONS: Nonprofit hospital community health needs assessments in Philadelphia predominantly identify needs related to access to care and to some extent health behaviors. There is incomplete alignment between the needs identified in hospital assessments and the needs targeted in implementation strategies, underscoring a need for regional coordination in community benefit investments. Improved regional coordination between hospitals serving the region may offer the opportunity to eliminate duplicative efforts and increase the amount of funds available to address unmet needs.

Regional Variation in 30-Day Ischemic Stroke Outcomes for Medicare Beneficiaries Treated in Get With The Guidelines-Stroke Hospitals.

BACKGROUND: We explored regional variation in 30-day ischemic stroke mortality and readmission rates and the extent to which regional differences in patients, hospitals, healthcare resources, and a quality of care composite care measure explain the observed variation. METHODS AND RESULTS: This ecological analysis aggregated patient and hospital characteristics from the Get With The Guidelines-Stroke registry (2007-2011), healthcare resource data from the Dartmouth Atlas of Health Care (2006), and Medicare fee-for-service data on 30-day mortality and readmissions (2007-2011) to the hospital referral region (HRR) level. We used linear regression to estimate adjusted HRR-level 30-day outcomes, to identify HRR-level characteristics associated with 30-day outcomes, and to describe which characteristics explained variation in 30-day outcomes. The mean adjusted HRR-level 30-day mortality and readmission rates were 10.3% (SD=1.1%) and 13.1% (SD=1.1%), respectively; a modest, negative correlation (r=-0.17; P=0.003) was found between one another. Demographics explained more variation in readmissions than mortality (25% versus 6%), but after accounting for demographics, comorbidities accounted for more variation in mortality compared with readmission rates (17% versus 7%). The combination of hospital characteristics and healthcare resources explained 11% and 16% of the variance in mortality and readmission rates, beyond patient characteristics. Most of the regional variation in mortality (65%) and readmission (50%) rates remained unexplained. CONCLUSIONS: Thirty-day mortality and readmission rates vary substantially across HRRs and exhibit an inverse relationship. While regional variation in 30-day outcomes were explained by patient and hospital factors differently, much of the regional variation in both outcomes remains unexplained.

Benefit Type and Care Source in Relation to Mammography Screening and Breast Cancer Stage at Diagnosis Among DoD Beneficiaries.

BACKGROUND: Type of insurance and out-of-pocket costs influence the use of medical care. Specifically, type of insurance can impact an individual's likelihood of receiving a screening mammogram. Additionally, variation in tumor stage at diagnosis exists for patients with different types of insurance. It is not clear whether different benefit types and care sources differ in breast cancer care and outcomes among Department of Defense (DoD) beneficiaries. METHODS: The objective of this study was to examine differences in screening mammography and tumor stage at diagnosis between different benefit types (TRICARE Prime vs. non-Prime) and among different care sources (direct care, purchased care, and both) in the DoD Military Health System. Study subjects were women 40 to 64 years of age, diagnosed with malignant breast cancer between 2003 and 2007. Multivariable logistic regression analyses were conducted to assess differences by benefit type and care source in receipt of screening mammography before diagnosis and tumor stage at diagnosis. FINDINGS: A total of 2,668 women were included in this study. Patients with Prime were more likely to receive a screening mammography and have an earlier tumor stage than those with non-Prime. Women with direct care were more likely to have an earlier tumor stage but less likely to receive a screening mammogram than those with purchased care. DISCUSSION: In an equal access health care system, the use of mammography screening and tumor stage at diagnosis may differ by benefit type and care source among DoD beneficiaries. To our knowledge, this was the first study to assess mammography screening and tumor stage differences by benefit type and care source in the Military Health System. Although underlying reasons for the differences are not clear, they may be related to out-of-pocket costs, distance from medical treatment facilities, and frequency of doctor visits for other medical problems. Further research is needed to assess these differences and related factors among DoD beneficiaries.

Does the Medicare Part D Decision-Making Experience Differ by Rural/Urban Location?

PURPOSE: Although much has been written about Medicare Part D enrollment, much less is known about beneficiaries' personal experiences with choosing a Part D plan, especially among rural residents. This study sought to address this gap by examining geographic differences in Part D enrollees' perceptions of the plan decision-making process, including their confidence in their choice, their knowledge about the program, and their satisfaction with available information. METHODS: We used data from the 2012 Medicare Current Beneficiary Survey and included adults ages 65 and older who were enrolled in Part D at the time of the survey (n = 3,706). We used ordered logistic regression to model 4 outcomes based on beneficiaries' perceptions of the Part D decision-making and enrollment process, first accounting only for differences by rurality, then adjusting for sociodemographic, health, and coverage characteristics. FINDINGS: Overall, half of all beneficiaries were not very confident in their Part D knowledge. Rural beneficiaries had lower odds of being confident in the plan they chose and in being satisfied with the amount of information available to them during the decision-making process. After adjusting for all covariates, micropolitan residents continued to have lower odds of being confident in the plan that they chose. CONCLUSIONS: Policy-makers should pay particular attention to making information about Part D easily accessible for all beneficiaries and to addressing unique barriers that rural residents have in accessing information while making decisions, such as reduced Internet availability. Furthermore, confidence in the decision-making process may be improved by simplifying the Part D program.

Few Disparities in Baseline Laboratory Testing After the Diuretic or Digoxin Initiation by Medicare Fee-For-Service Beneficiaries.

BACKGROUND: Despite the persistence of significant disparities, few evaluations examine disparities in laboratory testing by race/ethnicity, age, sex, Medicaid eligibility, and number of chronic conditions for Medicare fee-for-service beneficiaries' newly prescribed medications. In Medicare beneficiaries initiating diuretics or digoxin, this study examined disparities in guideline-appropriate baseline laboratory testing and abnormal laboratory values. METHODS AND RESULTS: To evaluate guideline-concordant testing for serum creatinine and serum potassium within 180 days before or 14 days after the index prescription fill date, we constructed retrospective cohorts from 10 states of 99 711 beneficiaries who had heart failure or hypertension initiating diuretic in 2011 and 8683 beneficiaries who had heart failure or atrial fibrillation initiating digoxin. Beneficiaries initiating diuretics were less likely to have testing if they were non-Hispanic Black (relative risk [RR], 0.99; 95% confidence interval [CI], 0.98-0.99) than non-Hispanic White. Beneficiaries initiating diuretics and beneficiaries initiating digoxin were more likely to have testing if they had multiple chronic conditions relative to 0 to 1 conditions. Beneficiaries initiating diuretics with laboratory values were more likely to have an abnormal serum creatinine value at baseline if they were non-Hispanic Black (RR, 2.57; 95% CI, 1.91-3.44), other race (RR, 2.11; 95% CI, 1.08-4.10), or male (RR, 2.75; 95% CI, 2.14-3.52) or an abnormal serum potassium value if they were aged ≥76 years (RR, 1.29; 95% CI, 1.09-1.51) or male (RR, 1.17; 95% CI, 1.03-1.33). CONCLUSIONS: Testing rates were consistently high, so there were negligible disparities in guideline-concordant testing of creatinine and potassium after the initiation of digoxin or diuretics by Medicare beneficiaries.

To your health!: Re-examining the health benefits of moderate alcohol use.

Although excessive alcohol use and alcohol misuse contribute to a broad range of health problems, recent research indicates that moderate alcohol consumption may in fact be beneficial. The present study builds on previous research to investigate the associations between alcohol use and self-rated health status among young adults. Using data collected in 2008 from the National Longitudinal Survey of Adolescent to Adult Health (Add Health), we use ordered probit models to determine whether the protective effects of moderate alcohol use are present after controlling for demographic, lifestyle, family background, and health-related characteristics. Our findings generally support earlier research with older samples, but some key gender differences are present. For women (n = 8275), moderate drinkers have better self-rated health status relative to former drinkers, infrequent drinkers, and light drinkers. Among men (n = 7207), the effects are mixed and less often significant. Differences in results between men and women point to the need for further gender-specific research and studies with other measures of health.

Association among change in medical costs, level of comorbidity, and change in adherence behavior.

OBJECTIVES: Interventions to improve medication adherence are effective, but resource intensive. Interventions must be targeted to those who will potentially benefit most. We examined what heterogeneity exists in the value of adherence based on levels of comorbidity, and the changes in spending on medical services that followed changes in adherence behavior. STUDY DESIGN: Retrospective cohort study examining medical spending for 2 years (April 1, 2011, to March 31, 2013) in commercial insurance beneficiaries. METHODS: Multivariable linear modeling was used to adjust for differences in patient characteristics. Analyses were performed at the patient/condition level in 2 cohorts: adherent at baseline and nonadherent at baseline. RESULTS: We evaluated 857,041 patients, representing 1,264,797 patient therapies consisting of 40% high cholesterol, 48% hypertension, and 12% diabetes. Among those with 3 or more conditions, annual savings associated with becoming adherent were $5341, $4423, and $2081 for patients with at least diabetes, hypertension, and high cholesterol, respectively. The increased costs for patients in this group who became nonadherent were $4653, $7946, and $4008, respectively. Depending on the condition and the direction of behavior change, savings were 2 to 7 times greater than the value for individuals with fewer than 3 conditions. In most cases, the value of preventing nonadherence (ie, persistence) was greater than the value of moving people who are nonadherent to an adherent state. CONCLUSIONS: There is important heterogeneity in the impact of medication adherence on medical spending. Clinicians and policy makers should consider this when promoting the change of adherence behavior.