An Insurer's Care Transition Program Emphasizes Medication Reconciliation, Reduces Readmissions And Costs.

Adverse drug events and the challenges of clarifying and adhering to complex medication regimens are central drivers of hospital readmissions. Medication reconciliation programs can reduce the incidence of adverse drug events after discharge, but evidence regarding the impact of medication reconciliation on readmission rates and health care costs is less clear. We studied an insurer-initiated care transition program based on medication reconciliation delivered by pharmacists via home visits and telephone and explored its effects on high-risk patients. We examined whether voluntary program participation was associated with improved medication use, reduced readmissions, and savings net of program costs. Program participants had a 50 percent reduced relative risk of readmission within thirty days of discharge and an absolute risk reduction of 11.1 percent. The program saved $2 for every $1 spent. These results represent real-world evidence that insurer-initiated, pharmacist-led care transition programs, focused on but not limited to medication reconciliation, have the potential to both improve clinical outcomes and reduce total costs of care.

Host behaviour-parasite feedback: an essential link between animal behaviour and disease ecology.

Animal behaviour and the ecology and evolution of parasites are inextricably linked. For this reason, animal behaviourists and disease ecologists have been interested in the intersection of their respective fields for decades. Despite this interest, most research at the behaviour-disease interface focuses either on how host behaviour affects parasites or how parasites affect behaviour, with little overlap between the two. Yet, the majority of interactions between hosts and parasites are probably reciprocal, such that host behaviour feeds back on parasites and vice versa. Explicitly considering these feedbacks is essential for understanding the complex connections between animal behaviour and parasite ecology and evolution. To illustrate this point, we discuss how host behaviour-parasite feedbacks might operate and explore the consequences of feedback for studies of animal behaviour and parasites. For example, ignoring the feedback of host social structure on parasite dynamics can limit the accuracy of predictions about parasite spread. Likewise, considering feedback in studies of parasites and animal personalities may provide unique insight about the maintenance of variation in personality types. Finally, applying the feedback concept to links between host behaviour and beneficial, rather than pathogenic, microbes may shed new light on transitions between mutualism and parasitism. More generally, accounting for host behaviour-parasite feedbacks can help identify critical gaps in our understanding of how key host behaviours and parasite traits evolve and are maintained.

The adherence impact of a program offering specialty pharmacy services to patients using retail pharmacies.

BACKGROUND: A new service model integrates the specialty pharmacy's comprehensive service with the retail pharmacy's patient contact, giving patients options for medication delivery to home, pharmacy, or doctor's office. OBJECTIVE: Evaluate the impact of the new service model on medication adherence. DESIGN: Retrospective cohort study SETTINGS: One hundred fifteen CVS retail stores in Philadelphia participated in a pilot from May 2012 to October 2013, and 115 matched CVS retail stores from around the nation served as controls. PATIENTS: All eligible patients from the intervention and control stores received specialty medications through CVS retail pharmacies prior to implementation of the new service model. INTERVENTION: The intervention patients were transitioned from retail pharmacy service to the specialty pharmacy with delivery options. The control patients received standard retail pharmacy services. MAIN OUTCOME MEASURES: Proportion of days covered and first fill persistence were tracked for 12 months before and after program implementation. RESULTS: Under the new service model, 228 patients new to therapy in the post period had a 17.5% increase in the rate of obtaining a second fill as compared to matched controls. Patients on therapy in both the pre- and the post-periods had a pre-post increase of 6.6% in average adherence rates and a pre-post increase of 10.8% in optimal adherence rates as compared to 326 matched controls. CONCLUSION: The study demonstrated significant improvement in both adherence to therapy and first-fill persistence among patients in the new service model integrating specialty pharmacy's comprehensive services with the retail pharmacy's patient contact and medication delivery choices.

Parasite-induced alteration of odour responses in an amphipod-acanthocephalan system.

Odour-related behaviours in aquatic invertebrates are important and effective anti-predator behaviours. Parasites often alter invertebrate host behaviours to increase transmission to hosts. This study investigated the responses of the amphipod Hyalella azteca when presented with two predator chemical cues: (i) alarm pheromones produced by conspecifics and (ii) kairomones produced by a predatory Green Sunfish (Lepomis cyanellus). We compared the responses of amphipods uninfected and infected with the acanthocepalan parasite Leptorhynchiodes thecatus. Uninfected amphipods reduced activity and increased refuge use after detecting both the alarm pheromones and predator kairomones. Infected amphipods spent significantly more time being active and less time on the refuge than uninfected amphipods, and behaved as if they had not detected the chemical stimulus. Therefore, L. thecatus infections disrupt the amphipods' anti-predator behaviours and likely make their hosts more susceptible to predation.

The effect of a nematode parasite on feeding and dung-burying behavior of an ecosystem engineer.

Dung beetles (genus Phanaeus) consume feces in both their larval and adults forms and because of their unique dietary niche, and behaviors associated with the burial of feces, are considered ecosystem engineers. In addition, because these insects subsist on a diet composed exclusively of feces, it is likely they encounter parasitic propagules more frequently than other animals do. Parasites often alter their host's behavior, so we set out to test whether Physocephalus sexalatus (a cosmopolitan nematode parasite of ungulates) does so in ways that affect the dung beetle's role as an ecosystem engineer and/or its predator-prey relationships (transmission of the parasite). Classic tests of anti-predator behavior did not reveal behavioral differences based on the beetles' infection status. However, this parasite did alter the beetles' behaviors in ways that could be critical for its role in fecal processing and therefore ecosystem engineering. Infected beetles exhibited anorexic behavior and consumed only half the amount of feces ingested by similar uninfected beetles. Infected beetles also buried less feces and did so in tunnels that were significantly shorter than those created by uninfected beetles. Fecal burial is naturally beneficial because it aerates the soil, incorporates nitrogenous compounds, and increases the flow of water thereby making soil and pastureland more productive. We showed that the nematode parasite P. sexalatus itself becomes an ecosystem engineer as it modifies the behavior of its already influential intermediate host.

Behavioural fever is a synergic signal amplifying the innate immune response.

Behavioural fever, defined as an acute change in thermal preference driven by pathogen recognition, has been reported in a variety of invertebrates and ectothermic vertebrates. It has been suggested, but so far not confirmed, that such changes in thermal regime favour the immune response and thus promote survival. Here, we show that zebrafish display behavioural fever that acts to promote extensive and highly specific temperature-dependent changes in the brain transcriptome. The observed coupling of the immune response to fever acts at the gene-environment level to promote a robust, highly specific time-dependent anti-viral response that, under viral infection, increases survival. Fish that are not offered a choice of temperatures and that therefore cannot express behavioural fever show decreased survival under viral challenge. This phenomenon provides an underlying explanation for the varied functional responses observed during systemic fever. Given the effects of behavioural fever on survival and the fact that it exists across considerable phylogenetic space, such immunity-environment interactions are likely to be under strong positive selection.

Impact of a patient-centered pharmacy program and intervention in a high-risk group.

BACKGROUND: The medication therapy management (MTM) program identified high-risk members in a large employer group and invited them to participate in an MTM program. The intervention consisted of at least 3 consultations with a clinical pharmacist to review and discuss drug therapy. The goal was to improve drug therapy adherence and clinical outcomes. OBJECTIVE: To assess the impact of MTM on plan-paid health care costs, utilization of medical services, overall days supply of targeted medications, and medication possession ratios (MPRs). METHODS: The MTM and control group comprised eligible members of a large employer prescription benefit plan who were identified between October 1, 2007, and November 12, 2008, and invited to participate. Control group members were selected from targeted members who declined. After propensity score matching to ensure similarity of groups at baseline, each group had 2,250 members. Baseline comparisons and post-period impact analyses between groups were conducted using bivariate analysis. Post-period analyses used tests for paired comparisons. The MTM and control group members were studied for the year before and after their individual program invitations. We measured pre-post differences between the MTM members and controls in total heath care costs, inpatient visits, emergency room (ER) visits, total days supply, and MPRs for 5 conditions: diabetes, hypertension, dyslipidemia, depression, and asthma. RESULTS: MTM members significantly reduced their plan-paid health care costs by 10.3% or $977, compared with an increase of 0.7% or $62 in the control group (P = 0.048). Inpatient visits in the MTM group decreased by 18.6%, while the control group experienced an increase of 24.2% (P less than 0.001). While both groups had decreases in ER visits, the groups were not significantly different (P = 0.399). Average days supply for the MTM group increased by 72.7 days over baseline; for the control group, it decreased by 111.1 days (P less than 0.001). MTM members with hypertension and dyslipidemia had pre-post increases in MPR of 2.29% and 2.10%, respectively, while the control group had decreases of 2.31% and 2.61% (both P less than 0.001). The mean MPRs for members with diabetes, depression, and asthma did not change in either group. Program costs per patient in 2009 were estimated to be $478. The program had a return on investment (ROI) of 2.0 in 2009. CONCLUSIONS: This study found that the pharmacist-managed MTM program to reconcile the medication therapies of high-risk patients and improve adherence, as measured by MPR, was effective in reducing total health care costs. The results show that those patients in the intervention group with hypertension and dyslipidemia had significant improvements in medication adherence, as compared with the control group. In fact, the intervention group used significantly more days of therapy in the intervention period, and the control group used significantly fewer days than either group used during the baseline period. MTM interventions were associated with a significant decrease in the MTM members' overall plan-paid health care costs, driven largely by decreases in inpatient utilization and mediated by increases in average days supply and in MPR increases for hypertension and dyslipidemia. Overall, the MTM program was cost-effective. The ROI estimated for this program of 2.0 is only slightly lower than the average disease management ROIs reported in the literature.

An overview of parasite-induced behavioral alterations - and some lessons from bats.

An animal with a parasite is not likely to behave like a similar animal without that parasite. This is a simple enough concept, one that is now widely recognized as true, but if we move beyond that statement, the light that it casts on behavior fades quickly: the world of parasites, hosts and behavior is shadowy, and boundaries are ill-defined. For instance, at first glance, the growing list of altered behaviors tells us very little about how those alterations happen, much less how they evolved. Some cases of parasite-induced behavioral change are truly manipulative, with the parasite standing to benefit from the changed behavior. In other cases, the altered behavior has an almost curative, if not prophylactic, effect; in those cases, the host benefits. This paper will provide an overview of the conflicting (and coinciding) demands on parasite and host, using examples from a wide range of taxa and posing questions for the future. In particular, what does the larger world of animal behavior tell us about how to go about seeking insights - or at least, what not to do? By asking questions about the sensory-perceptual world of hosts, we can identify those associations that hold the greatest promise for neuroethological studies of parasite-induced behavioral alterations, and those studies can, in turn, help guide our understanding of how parasite-induced alterations evolved, and how they are maintained.

The Affordable Care Act's pre-existing condition insurance plan: enrollment, costs, and lessons for reform.

The Pre-Existing Condition Insurance Plan (PCIP) is the temporary, federal high-risk pool created under the Affordable Care Act to provide coverage to uninsured individuals with preexisting conditions until 2014, when exchange coverage becomes avail­able to them. Nearly 78,000 people have enrolled since the program was implemented two years ago. This issue brief compares the PCIP with state-based high-risk pools that existed prior to the Affordable Care Act and considers programmatic differences that may have resulted in lower-than-anticipated enrollment and higher-than-anticipated costs for the PCIP. PCIP coverage, like state high-risk pool coverage, likely remains unaffordable to most lower-income individuals with preexisting conditions, but provides much needed access to care for those able to afford it. Operational costs of these programs are also quite high, making them less than optimal as a means of broader coverage expansion.

The validity of claims-based risk estimation in underinsured populations.

OBJECTIVES: To demonstrate a threat to validity in using claims-based risk tools with chronically ill, underinsured populations. STUDY DESIGN: We tracked disease burden of high-risk pool beneficiaries with potentially disabling health conditions receiving enhanced health insurance benefits through a federally funded research demonstration. At baseline, beneficiaries paid high premiums and cost sharing for risk pool coverage, and most met common criteria for underinsurance. Study benefits provided intervention group members premium and cost-sharing subsidies and additional coverage; control group members paid usual premiums and coinsurance and received usual benefits. We hypothesized that enhanced benefits for the intervention group would increase or stabilize health status measures and decrease case-mix weights, reflecting stabilized or reduced disease burden. METHODS: The SF-12v2 health survey was used to measure health status and the Johns Hopkins Adjusted Clinical Groups (ACGs), Version 8.2 with DX-PM model and prior cost for a non-elderly population, was used to measure disease burden. FINDINGS: Over a 3-year period, SF-12v2 scores showed stable health status for the intervention group and significant decline for the control group, while ACG case-mix weights, major illnesses, and chronic condition counts rose significantly for the intervention group but remained stable for the control group. Increased resource utilization for the intervention group appears to have driven increases in ACG measures. CONCLUSIONS: When high cost-sharing constrains access to care, risk tools that rely on medical claims may not provide an accurate measure of disease burden.

Early implementation of pre-existing condition insurance plans: providing an interim safety net for the uninsurable.

The Pre-Existing Condition Insurance Plan (PCIP) is a temporary program implemented under the Patient Protection and Affordable Care Act to make health insurance coverage available to uninsured individuals with preexisting conditions until 2014, when exchange-based health insurance becomes available to all. The PCIP program began enrolling applicants in July 2010. This issue brief examines enrollment trends, early changes to plan structures and premiums, and estimates of out-of-pocket costs by utilization pattern and type of plan. It also provides information about the age and medical conditions of early PCIP enrollees. Although PCIP enrollment has been lower than expected due to affordability issues, a lack of public awareness, and the requirement that applicants be uninsured for six months, the plans are nonetheless playing an important role in making coverage available to otherwise uninsurable Americans with preexisting conditions.

Pre-Existing Condition Insurance Plans created by the Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act includes a provision for the establishment of a temporary high-risk pool, also called the Pre-Existing Condition Insurance Plan (PCIP), to quickly make health insurance available to uninsured individuals with preexisting conditions, many of whom previously had been denied coverage. Twenty-seven states elected to administer the PCIPs for their citizens, while the remaining states and the District of Columbia chose to let their PCIPs be federally administered. This issue brief examines eligibility, benefits, premiums, cost-sharing, and oversight of the PCIP programs, as well as variation of the plans from state to state. The PCIPs will run through December 31, 2013, at which time participants will be transitioned to exchange coverage.

Change in human social behavior in response to a common vaccine.

PURPOSE: The purpose of this study was to test the hypothesis that exposure to a directly transmitted human pathogen-flu virus-increases human social behavior presymptomatically. This hypothesis is grounded in empirical evidence that animals infected with pathogens rarely behave like uninfected animals, and in evolutionary theory as applied to infectious disease. Such behavioral changes have the potential to increase parasite transmission and/or host solicitation of care. METHODS: We carried out a prospective, longitudinal study that followed participants across a known point-source exposure to a form of influenza virus (immunizations), and compared social behavior before and after exposure using each participant as his/her own control. RESULTS: Human social behavior does, indeed, change with exposure. Compared to the 48 hours pre-exposure, participants interacted with significantly more people, and in significantly larger groups, during the 48 hours immediately post-exposure. CONCLUSIONS: These results show that there is an immediate active behavioral response to infection before the expected onset of symptoms or sickness behavior. Although the adaptive significance of this finding awaits further investigation, we anticipate it will advance ecological and evolutionary understanding of human-pathogen interactions, and will have implications for infectious disease epidemiology and prevention.

Health care behaviors and decision-making processes among enrollees in a state high-risk insurance pool: focus group findings.

PURPOSE: To better understand the relationship between health insurance coverage and health care behaviors of persons with potentially disabling conditions enrolled in a state high-risk insurance pool. DESIGN: Six focus groups with risk pool enrollees at two sites. SETTING: Suburban areas in the state of Kansas. PARTICIPANTS: Forty-two individuals 29 to 62 years, all with potentially disabling physical or mental health conditions. METHOD: Qualitative analysis of focus group transcripts using pile sorting and theme identification. RESULTS: High premiums and deductibles limit participants' ability to afford basic health services and access to prescription medications despite their middle-class socioeconomic status. Participants report delaying or forgoing needed medical care because of lack of coverage and/or out-of-pocket costs. They employ numerous and potentially dangerous strategies to minimize costs, especially for prescription medications. Some report "saving up" needed procedures until their total costs will exceed that year's deductible. CONCLUSION: Individuals in the risk pool were making medical decisions on the basis of cost rather than need. Many shared stories of medical complications as a result of delayed care, and most expressed stress related to the difficulty of making decisions about their care and use of prescribed medications. The individual, nongroup insurance market, with its higher out-of-pocket costs, may not meet the needs of people with chronic health conditions.

Does high-risk pool coverage meet the needs of people at risk for disability?

State high-risk insurance pools serve people denied coverage because of pre-existing conditions. With benefit plans modeled on the individual market, these pools generally require higher out-of-pocket expenditures and provide fewer benefits than employer-sponsored plans, while their beneficiaries have very intensive needs. We profile 416 working adults enrolled in a state high-risk pool and document their health conditions and health care utilization. High-risk pool and federal employee benefits are compared to assess insurance structure and implications for health and disability outcomes.

Medicaid's expenditures for newer pharmacotherapies for adults with disabilities.

Medicaid's drug expenditures have grown at double-digit inflation rates since 2000. These prescription drug costs are important contributors to increasing health care costs for disabled persons. In spite of this knowledge, little has been reported about specific patterns of medication use among disabled enrollees. We analyzed Kansas Medicaid data to describe trends in medication use patterns across 3 years among disabled beneficiaries. The marked shifts toward newer medications and disproportionate contributions of newer, more expensive medications to overall prescription costs for antipsychotics, antidepressants, anticonvulsants, antiulcer medications, anti-inflammatory agents, and opioids have implications for both policy and practice.

Transition to Medicare Part D: an early snapshot of barriers experienced by younger dual eligibles with disabilities.

OBJECTIVE: This study assessed the impact of transition from Medicaid drug coverage to Medicare Part D on a sample of dually eligible adults younger than age 65 years with disabilities. STUDY DESIGN: Telephone survey of employed adults participating in the Kansas Medicaid Buy-In program, Working Healthy, about their experiences in accessing medications after their transition to Part D. METHODS: A total of 328 (55%) individuals from a random sample of 600 agreed to participate in a survey administered by a university-based research unit during February and March 2006, which included 18 questions with yes/no, multiple choice, and open-ended responses. Participants resembled other Kansas dual eligibles demographically and medically, other than having slightly higher rates of mental illness and lower rates of mental retardation and some physical conditions. Participants' 2004 Medicare and Medicaid claims data were analyzed to obtain an overview of their comorbidities and previous prescription use. RESULTS: Twenty percent of participants reported difficulty obtaining medications, including drugs in Part D-protected classes; 13% were required to switch medications; and 8% stopped taking at least 1 medication. More than half did not know they could change plans monthly, potentially improving their access to medications. CONCLUSION: The high incidence of access problems despite Centers for Medicare & Medicaid Services (CMS) safeguards points to the need for ongoing monitoring of Part D. If the problems persist, CMS must be willing to modify the program and/or better enforce the rules already in place to avoid adverse outcomes for beneficiaries with disabilities.

Facultative virulence: a strategy to manipulate host behaviour?

Examples of behavioural manipulation by parasites are numerous, but the processes underlying these changes are not well characterized. From an evolutionary point of view, behavioural changes in infected hosts have often been interpreted as illustrations of the extended phenotype concept, in which genes in one organism (the parasite) have phenotypic effects on another organism (the host). Here, we approach the problem differently, suggesting that hosts, by cooperating with manipulative parasites rather than resisting them, might mitigate fitness costs associated with manipulation. By imposing extra fitness costs on their hosts in the absence of compliance, parasites theoretically have the potential to select for cooperative behaviour by their hosts. Although this 'mafia-like' strategy remains poorly documented, we believe that it has substantial potential to resolve issues specific to the evolution of behavioural alterations induced by parasites.