Does Consumer Credit Precede or Follow Changes in Cognitive Impairment Among Older Adults? An Investigation in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Trial.

OBJECTIVES: We assessed the relationships between pre- and post-morbid consumer credit history (credit scores, debts unpaid, or in collections) and classification of mild (or greater) cognitive impairment (MCI). METHODS: Generalized Estimating Equation models assessed pre-and post-morbid credit history and MCI risk among 1740 participants aged 65+ in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study, linked to TransUnion consumer credit data. RESULTS: Each 50-point increase in credit score was associated with up to 8% lower odds of MCI in the next 3 years. In contrast, new unpaid collections over doubled the odds of having MCI in the next 3 years. MCI was associated with subsequent credit score declines and a 47%-71% greater risk of having a new unpaid collection in the next 4 years. DISCUSSION: Credit declines may signal risk for future MCI. MCI may lead to financial challenges that warrant credit monitoring interventions for older adults.

Surprise Medical Bills: Are We Any Nearer to a Federal Fix?

The pandemic is shaking up health care delivery and markets. And it's an election year.

Improving Billing Accuracy Through Enterprise-Wide Standardized Structured Reporting With Cross-Divisional Shared Templates.

OBJECTIVE: We describe our experience in implementing enterprise-wide standardized structured reporting for chest radiographs (CXRs) via change management strategies and assess the economic impact of structured template adoption. METHODS: Enterprise-wide standardized structured CXR reporting was implemented in a large urban health care enterprise in two phases from September 2016 to March 2019: initial implementation of division-specific structured templates followed by introduction of auto launching cross-divisional consensus structured templates. Usage was tracked over time, and potential radiologist time savings were estimated. Correct-to-bill (CTB) rates were collected between January 2018 and May 2019 for radiography. RESULTS: CXR structured template adoption increased from 46% to 92% in phase 1 and to 96.2% in phase 2, resulting in an estimated 8.5 hours per month of radiologist time saved. CTB rates for both radiographs and all radiology reports showed a linearly increasing trend postintervention with radiography CTB rate showing greater absolute values with an average difference of 20% throughout the sampling period. The CTB rate for all modalities increased by 12%, and the rate for radiography increased by 8%. DISCUSSION: Change management strategies prompted adoption of division-specific structured templates, and exposure via auto launching enforced widespread adoption of consensus templates. Standardized structured reporting resulted in both economic gains and projected radiologist time saved.

Copagamento dos usuários no programa farmácia popular do Brasil: um estudo exploratório da rede conveniada / Português

Este trabalho tem como objetivo central realizar um dimensionamento dos valores de copagamento dos usuários da rede conveniada (RC) do Programa Farmácia Popular do Brasil (PFPB), bem como explorar potenciais fatores associados à taxa de copagamento (TCP) no programa. O estudo está baseado em um rico conjunto de dados, relativos às vendas dos produtos pelos estabelecimentos farmacêuticos credenciados no período de março de 2006 a setembro de 2019, considerando cerca de 2 bilhões de registros administrativos. O valor de copagamento médio foi calculado a partir da diferença entre a média do preço de venda (PV) e do valor subsidiado (VS) pelo Ministério da Saúde (MS) por embalagem, estratificando-se esse valor por indicação do produto, tipo de medicamento (genérico, similar e referência) e Unidade Federativa (UF). Os resultados encontrados demonstram que a TCP média dos usuários na RC do PFPB foi de 37,6% por embalagem de produto, com tendência de alta a partir de 2016. De 2009 a 2015, constatou-se que a TCP teve propensão à redução para o grupo de produtos com copagamento em todo o período de existência do programa (grupo de copagamento), sendo essa propensão definida, sobretudo, pela TCP média dos medicamentos indicados para a dislipidemia (que respondem por dois terços das autorizações nesse grupo). No período estudado, os medicamentos similares foram sendo substituídos por genéricos. Uma análise específica para o medicamento sinvastatina, usado no tratamento da dislipidemia, mostrou uma baixa concentração de fabricantes no mercado e uma expressiva redução dos seus preços de venda, o que ajuda a entender a dinâmica da TCP. Regionalmente, estados do Norte e do Nordeste tenderam a apresentar uma menor TCP ao longo do período. Em 2019, por exemplo, a TCP para os beneficiários do Norte e do Nordeste foi, respectivamente, 9,0 pontos percentuais (p.p.) e 7,5 p.p. menor que a registrada na região Sudeste. Os resultados deste trabalho demonstram que o subsídio dado pelo MS para a dispensação de medicamentos na RC do PFPB é um fator relevante de determinação do acesso a medicamentos no programa. Reduções desse subsídio no período analisado resultaram em um aumento do copagamento e, consequentemente, da TCP, com diminuição das autorizações no programa, do número de beneficiários e das receitas das farmácias - enquanto aumentos do subsídio levaram à ampliação da demanda e do número de beneficiários. A magnitude do subsídio, entretanto, não é o único fator a determinar o copagamento e a TCP pelos usuários, pois o PV de um mesmo medicamento pode ser afetado pelos tributos em cada UF e pelo grau de concorrência entre os estabelecimentos farmacêuticos e entre os produtos no mercado. Por fim, as evidências produzidas neste estudo preenchem uma lacuna da literatura sobre o PFPB, ao dimensionar a taxa efetiva de copagamento dos usuários no programa, tornando mais evidente a influência dos preços praticados pelas farmácias e dos valores subsidiados pelo governo sobre a dinâmica de acesso da população ao elenco de produtos.

Why it is unethical to charge migrant women for pregnancy care in the National Health Service.

Pregnancy care is chargeable for migrants who do not have indefinite leave to remain in the UK. Women who are not 'ordinarily resident', including prospective asylum applicants, some refused asylum-seekers, unidentified victims of trafficking and undocumented people are required to pay substantial charges in order to access antenatal, intrapartum and postnatal services as well as abortion care within the National Health Service. In this paper, we consider the ethical issues generated by the exclusion of pregnancy care from the raft of services which are free to all. We argue that charging for pregnancy care amounts to sex discrimination, since without pregnancy care, sex may pose a barrier to good health. We also argue that charging for pregnancy care violates bodily autonomy, entrenches the sex asymmetry of sexual responsibility, centres the male body and produces health risks for women and neonates. We explore some of the ideological motivations for making maternity care chargeable, and suggest that its exclusion responds to xenophobic populism. We recommend that pregnancy care always be free regardless of citizenship or residence status, and briefly explore how these arguments bear on the broader moral case against chargeable healthcare for migrants.

Unlike Medical Spending, Medical Bills In Collections Decrease With Patients' Age.

Health policy is often designed to help protect patients' financial security. However, there is limited understanding of the role medical debt plays in household finances. We used credit report data on more than four million Americans to study the age profile of people whose medical bills were sent to a US collections agency in 2016. We found that, unlike health care use and spending, medical collections decreased substantially with age. The average size of medical debt decreased nearly 40 percent from patients age twenty-seven to sixty-four, with increases in health insurance coverage and incomes likely playing important mediating roles. However, the frequency of medical collections-that is, the proportion of people with a collection by age-was less closely tied to insurance coverage rates. A potential explanation is that most medical collections were relatively modest in size, with more than half of them less than $600 annually. As a result, medical collections could still occur under typical insurance plans. We discuss how these results could inform policies targeting medical debt and insurance regulation, such as restrictions on age rating.

Geisinger: All-in and Thumbs-up On Electronic Payment to Providers.

Now that Geisinger is confident in the payment process for providers, it will continue to innovate new ways to improve the member experience. The goal is to be not just one of the top companies for members and not just one of the top health care organizations, but one of top organizations among all the companies in the United States.

A historical review of the U.S. Navy's busiest recompression chamber in the Pacific theater with a current perspective on caring for civilian divers within its area of responsibility: short communication.

On the island Nation of Guam, the United States Department of Defense has stationed military personnel from every service branch. Guam is utilized as a strategic waypoint for the U.S. military in the Pacific theater. As the largest service branch in the region, the Navy has placed a few Diving Medical Officers in Guam to collectively manage and treat patients with recompression therapy. Guam is also a popular tourist destination, with multiple recreational diving companies certifying individuals who are looking to take advantage of the beautiful warm water and exotic marine life. Unfortunately, with an increase in training and certifying inexperienced divers, came an increase in the operational tempo of the U.S. Navy's recompression chamber on Guam. The recompression chamber on Naval Base Guam (NBG) has been treating patients since 1971. With the only multiplace chamber in the Mariana Islands, Diving Medical Officers, with the accompanying chamber staff, treat military personnel, active-duty sponsored patients and civilian patients. Treating civilian patients by military providers through military treatment facilities presents multiple issues that must be addressed in an effort to provide efficient quality medical care. This article reviews the records, documents, and activity of the NBG chamber over the last four decades. Through the obtained data the information provides projected financial reimbursement from civilian patients. The article also sheds light on areas of needed improvement with regard to data collection, third-party financial collection efforts and the necessity of an inclusive electronic health record (EHR) for military and civilian patients.

Developing a Mobile Health Application to Assist With Clinic Flow, Documentation, Billing, and Research in a Specialty Clinic.

In specialty clinics, a staff physician is often required to direct patient flow through the clinic and performs all documentation for coding/billing. In response to the workload created by increased patient volume, many specialty clinics have implemented protocols for both disease treatment and coordination of clinic flow. In this article, we review the literature on using mobile technology to assist with patient care, clinic flow, disease treatment, and documentation/billing. We also describe the development and implementation of a mobile application in our pulmonary clinic designed to automate patient flow, assist the physician in documentation/billing, and gather research data including review of initial user data and lessons learned.

Mental health and debt collection: a story of progress? Exploring changes in debt collectors' attitudes and practices when working with customers with mental health problems, 2010-2016.

BACKGROUND: In recent years, the UK debt collection industry has taken steps to improve its policies and practices in relation to customers with mental health problems. Little data, however, have been collected to evidence change. AIMS: This paper examines whether the reported attitudes and practices of debt collection staff when working with customers with mental health problems have changed between 2010 and 2016. METHOD: This paper draws on descriptive and regression analyses of two cross-sectional surveys of debt collection staff: one conducted in 2010 and one conducted in 2016. RESULTS: All variables analysed show statistically significant changes between 2010 and 2016 indicative of improved reported attitudes and practices. CONCLUSIONS: While results suggest an improvement in attitudes and practice may have occurred between 2010 and 2016, research is required to understand this potential shift, its likely causes, and concrete impact on customers.

Consumer credit as a novel marker for economic burden and health after cancer in a diverse population of breast cancer survivors in the USA.

BACKGROUND: Consumer credit may reflect financial hardship that patients face due to cancer treatment, which in turn may impact ability to manage health after cancer; however, credit's relationship to economic burden and health after cancer has not been evaluated. METHODS: From May to September 2015, 123 women with a history of breast cancer residing in Pennsylvania or New Jersey completed a cross-sectional survey of demographics, socioeconomic position, comorbidities, SF-12 self-rated health, economic burden since cancer diagnosis, psychosocial stress, and self-reported (poor to excellent) credit quality. Ordinal logistic regression evaluated credit's contribution to economic burden and self-rated health. RESULTS: Mean respondent age was 64 years. Mean year from diagnosis was 11.5. Forty percent of respondents were Black or Other and 60% were White. Twenty-four percent self-reported poor credit, and 76% reported good to excellent credit quality. In adjusted models, changing income, using savings, borrowing money, and being unable to purchase a health need since cancer were associated with poorer credit. Better credit was associated with 7.72 ([1.22, 14.20], p = 0.02) higher physical health t-score, and a - 2.00 ([- 3.92, - 0.09], p = 0.04) point change in psychosocial stress. CONCLUSIONS: This exploratory analysis establishes the premise for consumer credit as a marker of economic burden and health for breast cancer survivors. Future work should validate these findings in larger samples and for other health conditions. IMPLICATIONS FOR CANCER SURVIVORS: Stabilizing and monitoring consumer credit may be a potential intervention point for mitigating economic burden after breast cancer.

[An epidemiological but invisibilized marker: indebtedness within an Afromexican town in Oaxaca]. / Un marcador epidemiológico invisibilizado: el endeudamiento en una población afromexicana de Oaxaca.

OBJECTIVE:: To explore indebtedness dynamics in an Afromexican town by an inclusive epidemiological approach. MATERIALS AND METHODS:: Qualitative study through 75 questionnaires, 20 interviews to depth and six focal groups in a support process to the Municipal Health Commission in Santiago Tapextla, Oaxaca. RESULTS:: Catastrophic expenses due to insufficient medical care were the principal causal item. Indebtedness processes with patrimonial loss are dominant, generating dependence spirals of difficult resolution that impact the familiar dynamics and the pathology evolution. CONCLUSIONS:: In spite of its inexistence within sanitary official programs, indebtedness dynamics constitute an epidemiological marker by the uncovering of structural inattention conditions that reflect the imposed, naturalized and pathogenic hierarchization proper of coloniality. To analyze this process at local and global levels is a complex but essential public health task.

Un marcador epidemiológico invisibilizado: el endeudamiento en una población afromexicana de Oaxaca / An epidemiological but invisibilized marker: indebtedness within an Afromexican town in Oaxaca

Resumen: Objetivo: Explorar las dinámicas de endeudamiento en una población afromexicana desde una perspectiva epidemiológica incluyente. Material y métodos: Estudio cualitativo mediante 75 cuestionarios, 20 entrevistas a profundidad y seis grupos focales en un proceso de acompañamiento a la Comisión Municipal de Salud en Santiago Tapextla, Oaxaca. Resultados: Los gastos catastróficos por requerimientos médicos fueron el principal rubro causal de endeudamiento, acarreando pérdida patrimonial y espirales de dependencia, con impacto en la dinámica familiar y en la evolución de la patología. Conclusiones: A pesar de su soslayo en programas sanitarios oficiales, las dinámicas de endeudamiento constituyen un marcador epidemiológico al develar condiciones de desatención estructural que expresan la jerarquización impuesta, naturalizada y patogénica propia de la colonialidad. Analizar dicho fenómeno a nivel local y global constituye una tarea de salud pública compleja, pero esencial.

Abstract: Objective: To explore indebtedness dynamics in an Afromexican town by an inclusive epidemiological approach. Materials and methods: Qualitative study through 75 questionnaires, 20 interviews to depth and six focal groups in a support process to the Municipal Health Commission in Santiago Tapextla, Oaxaca. Results: Catastrophic expenses due to insufficient medical care were the principal causal item. Indebtedness processes with patrimonial loss are dominant, generating dependence spirals of difficult resolution that impact the familiar dynamics and the pathology evolution. Conclusions: In spite of its inexistence within sanitary official programs, indebtedness dynamics constitute an epidemiological marker by the uncovering of structural inattention conditions that reflect the imposed, naturalized and pathogenic hierarchization proper of coloniality. To analyze this process at local and global levels is a complex but essential public health task.

Variation in outpatient consultant physician fees in Australia by specialty and state and territory.

OBJECTIVES: To determine the mean, median and 10th and 90th percentile levels of fees and out-of-pocket costs to the patient for an initial consultation with a consultant physician; to determine any differences in fees and bulk-billing rates between specialties and between states and territories. DESIGN, PARTICIPANTS AND SETTING: Analysis of 2015 Medicare claims data for an initial outpatient appointment with a consultant physician (Item 110) in 11 medical specialties representative of common adult non-surgical medical care (cardiology, endocrinology, gastroenterology, geriatric medicine, haematology, immunology/allergy, medical oncology, nephrology, neurology, respiratory medicine and rheumatology). MAIN OUTCOME MEASURES: Mean, median, 10th and 90th percentile levels for consultant physician fees and out-of-pocket costs, by medical specialty and state or territory; bulk-billing rate, by medical specialty and state/territory. RESULTS: Bulk-billing rates varied between specialties, with only haematology and medical oncology bulk-billing more than half of initial consultations. Bulk-billing rates also varied between states and territories, with rates in the Northern Territory (76%) nearly double those elsewhere. Most private consultations require a significant out-of-pocket payment by the patient, and these payments varied more than fivefold in some specialties. CONCLUSION: Without data on quality of care in private outpatient services, the rationale for the marked variations in fees within specialties is unknown. As insurers are prohibited from providing cover for the costs of outpatient care, the impact of out-of-pocket payments on access to private specialist care is unknown.