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1.
PLoS One ; 15(1): e0227806, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31935256

RESUMO

Since 2010, Indonesian government has initiated a chronic disease management program, Prolanis (Program Pengendalian Penyakit Kronis) targeted for diabetes and hypertension. The program is continued at the commencement of universal health coverage (UHC) in 2014. "This study aimed to report the utilization and cost of the implementation of Prolanis in Indonesia from 2014 to 2016, or two years since the commencement of Indonesian universal health coverage." Secondary data analysis was performed using publicly available data and data obtained from the national health insurance agency (BPJS); while data on disease prevalence were collected from basic national health survey. There was an increase trend of Prolanis participants, from around 11,000 participants in 2014 to more than 250,000 in 2016. More than 70% of participants were adults living in Java, however, the acceptance rate was very low in other area. Across different activities in Prolanis, physical activity was the most participated ones. In comparison to other regions, regions in Java were the most active area. The total expenditure for Prolanis program in 2016 increased almost triple from the annual cost in 2014. However, the cost per person was actually decreased more than 50%. Within two years of UHC implementation, there were increase covered participants and total costs, but cost per individual was decreased and there was significant difference in of cost between Java and outside Java. Further study and routine monitoring-evaluation process by health authority is needed to assess whether the cost difference would affect the service quality.


Assuntos
Diabetes Mellitus/epidemiologia , Hipertensão/epidemiologia , Programas de Assistência Gerenciada , Adulto , Estudos Transversais/economia , Diabetes Mellitus/economia , Custos de Cuidados de Saúde , Humanos , Hipertensão/economia , Indonésia/epidemiologia , Programas de Assistência Gerenciada/economia , Prevalência , Cobertura Universal do Seguro de Saúde/economia
2.
BMC Health Serv Res ; 19(1): 877, 2019 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-31752866

RESUMO

BACKGROUND: In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18-65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy. METHODS: Five procedures conducted on adults aged 18-65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure. RESULTS: After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (≤$1606, for CABG). CONCLUSIONS: This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Programas de Assistência Gerenciada/economia , Mecanismo de Reembolso , Procedimentos Cirúrgicos Operatórios/economia , Adolescente , Adulto , Idoso , Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Colectomia/economia , Ponte de Artéria Coronária/economia , Grupos Diagnósticos Relacionados , Feminino , Reforma dos Serviços de Saúde/legislação & jurisprudência , Humanos , Masculino , Pessoa de Meia-Idade , Militares , Fusão Vertebral/economia , Cuidados Semi-Intensivos/economia , Estados Unidos , Veteranos , Adulto Jovem
4.
N C Med J ; 80(5): 312-316, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31471518

RESUMO

North Carolina's move to Medicaid managed care is part of the larger move to value-based care nationally. Keys to value-based care guide how practices and health systems can navigate the new payment model. The experience of North Carolina's Area Health Education Centers with primary care practices that work on value-based care can serve as an important case study.


Assuntos
Programas de Assistência Gerenciada/organização & administração , Medicaid/organização & administração , Logro , Humanos , Programas de Assistência Gerenciada/economia , Medicaid/economia , North Carolina , Atenção Primária à Saúde/economia , Avaliação de Programas e Projetos de Saúde , Estados Unidos
5.
J Manag Care Spec Pharm ; 25(9): 973-983, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31313621

RESUMO

BACKGROUND: The treatment of postsurgical pain with prescription opioids has been associated with persistent opioid use and increased health care utilization and costs. OBJECTIVE: To compare the health care burden between opioid-naive adult patients who were prescribed opioids after a major surgery and opioidnaive adult patients who were not prescribed opioids. METHODS: Administrative claims data from the IBM Watson Health MarketScan Research Databases for 2010-2016 were used. Opioid-naive adult patients who underwent major inpatient or outpatient surgery and who had at least 1 year of continuous enrollment before and after the index surgery date were eligible for inclusion. Cohorts were defined based on an opioid pharmacy claim between 7 days before index surgery and 1 year after index surgery (opioid use during surgery and inpatient use were not available). To ensure an opioid-naive population, patients with opioid claims between 365 and 8 days before surgery were excluded. Acute medical outcomes, opioid utilization, health care utilization, and costs were measured during the post-index period (index surgery hospitalization and day of index outpatient surgery not included). Predicted costs were estimated from multivariable log-linked gamma-generalized linear models. RESULTS: The final sample consisted of 1,174,905 opioid-naive patients with an inpatient surgery (73% commercial, 20% Medicare, 7% Medicaid) and 2,930,216 opioid-naive patients with an outpatient surgery (74% commercial, 23% Medicare, and 3% Medicaid). Opioid use after discharge was common among all 3 payer types but was less common among Medicare patients (63% inpatient/43% outpatient) than patients with commercial (80% inpatient/75% outpatient) or Medicaid insurance (86% inpatient/81% outpatient). Across all 3 payers, opioid users were younger, were more likely to be female, and had a higher preoperative comorbidity burden than nonopioid users. In unadjusted analyses, opioid users tended to have more hospitalizations, emergency department visits, and pharmacy claims. Adjusted predicted 1-year post-period total health care costs were significantly higher (P< 0.001) for opioid users than nonopioid users for commercial insurance (inpatient: $22,209 vs. $14,439; outpatient: $13,897 vs. $8,825), Medicare (inpatient: $31,721 vs. $26,761; outpatient: $24,529 vs. $15,225), and Medicaid (inpatient: $13,512 vs. $9,204; outpatient: $11,975 vs. $8,212). CONCLUSIONS: Filling an outpatient opioid prescription (vs. no opioid prescription) in the 1 year after inpatient or outpatient surgery was associated with increased health care utilization and costs across all payers. DISCLOSURES: Funding for this study was provided by Heron Therapeutics, which participated in analysis and interpretation of data, drafting, reviewing, and approving the publication. All authors contributed to the development of the publication and maintained control over the final content. Brummett is a paid consultant for Heron Therapeutics and Recro Pharma and reports receipt of research funding from MDHHS (Sub K Michigan Open), NIDA (Centralized Pain Opioid Non-Responsiveness R01 DA038261-05), NIH0DHHS-US-16 PAF 07628 (R01 NR017096-05), NIH-DHHS (P50 AR070600-05 CORT), NIH-DHHS-US (K23 DA038718-04), NIH-DHHS-US-16-PAF06270 (R01 HD088712-05), NIH-DHHS-US-17-PAF02680 (R01 DA042859-05), and UM Michigan Genomics Initiative and holding a patent for peripheral perineural dexmedetomidine. Oderda is a paid consultant for Heron Therapeutics. Pawasauskas is a paid consultant to Heron Therapeutics and Mallinckrodt Pharmaceuticals. England and Evans-Shields are employees of Heron Therapeutics. Kong, Lew, Zimmerman, and Henriques are employees of IBM Watson Health, which was compensated by Heron Therapeutics for conducting this research. Portions of this work were presented as a poster at the AMCP Managed Care and Specialty Pharmacy Annual Meeting 2019; March 25-28, 2019; San Diego, CA.


Assuntos
Analgésicos Opioides/economia , Analgésicos Opioides/uso terapêutico , Assistência à Saúde/economia , Pacientes Ambulatoriais/educação , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/economia , Analgésicos Opioides/efeitos adversos , Comorbidade , Efeitos Psicossociais da Doença , Feminino , Custos de Cuidados de Saúde , Humanos , Pacientes Internados , Masculino , Programas de Assistência Gerenciada/economia , Medicaid/economia , Medicare/economia , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/etiologia , Dor/tratamento farmacológico , Dor/economia , Aceitação pelo Paciente de Cuidados de Saúde , Estudos Retrospectivos , Estados Unidos
6.
J Ment Health Policy Econ ; 22(2): 43-59, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31319375

RESUMO

BACKGROUND: Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level. METHODS: A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted. RESULTS: For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.


Assuntos
Custo Compartilhado de Seguro , Dedutíveis e Cosseguros , Benefícios do Seguro , Programas de Assistência Gerenciada/organização & administração , Transtornos Mentais/economia , Serviços de Saúde Mental/economia , Saúde Mental , Adolescente , Adulto , Idoso , Gastos em Saúde , Humanos , Programas de Assistência Gerenciada/economia , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
7.
J Manag Care Spec Pharm ; 25(8): 922-926, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31347978

RESUMO

Historically, budget impact models have been used to demonstrate how a new drug or technology entering the market could influence payer budgets, with the hope of influencing coverage of the drug or technology. This article proposes the adaptation of a budget impact model framework to answer the payer question "What is the budget impact of our approaches to managing the utilization of drugs and technologies?" Throughout this article, we also describe lessons learned while collaborating with a U.S. payer to evaluate the budgetary impact of specific antidiabetic drug utilization management approaches. DISCLOSURES: The study discussed in this commentary was supported by grant number F32HS024857 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, which had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or design to submit the manuscript for publication. The findings discussed in this manuscript represent the views of the authors and do not necessarily reflect the views of the Department of Defense, the Defense Health Agency, nor the Departments of the Army, Navy, and Air Force. Hung reports personal fees from CVS Health and BlueCross BlueShield Association, outside the submitted work. Lugo has nothing to disclose. Mullins reports grants and other fees from AHRQ, during the conduct of the study; grants and personal fees from Bayer and Pfizer; and personal fees from Boehringer-Ingelheim, Janssen/J&J, Regeneron, and Sanofi, outside the submitted work. Parts of the study were presented as a poster presentation at the 2017 AMCP Managed Care & Specialty Pharmacy Annual Meeting; March 27-30, 2017; Denver, CO, and as poster and oral presentations at the 2017 AMCP Nexus Meeting; October 16-19, 2017; Dallas, TX. The study was also published as Hung's PhD dissertation.


Assuntos
Hipoglicemiantes/economia , Programas de Assistência Gerenciada/economia , Orçamentos , Custos de Medicamentos , Humanos , Modelos Econômicos , Estados Unidos
8.
J Manag Care Spec Pharm ; 25(8): 913-921, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31347981

RESUMO

BACKGROUND: There is a paucity of studies validating budget impact models. The lack of such studies may contribute to the underuse of budget impact models by payers in formulary decision making. OBJECTIVE: To assess the face validity, internal verification, and predictive validity of a previously published model that assessed the budgetary impact of antidiabetic formulary changes. METHODS: 4 experts with diverse backgrounds were selected and asked questions regarding the face validity of the structure/conceptual model, input data, and results from the budget impact model. To assess internal verification, structured "walk-throughs," unit tests, extreme condition tests, traces, replication tests, and double programming techniques were used. The predictive validity of the model was evaluated by comparing the predicted and realized budget using mean absolute scaled error. "Realized" budgetary impact of the formulary changes was calculated by taking the difference between realized budget in the year after the formulary changes and the budget had there been no formulary changes (i.e., the counterfactual). The counterfactual budget was modeled using the best fit autoregressive integrated moving average model. RESULTS: When assessing the face validity of the model, the 4 experts brought up issues such as how to incorporate other health insurance, recent policy changes, cost inflation, and potential impacts on insulin use. The 6 internal verification techniques caught mistakes in equations, missing data, and misclassified data. The realized budget was found to be lower than the predicted budget, with 13% error and an absolute scaled error of 2.60. After removing the model assumption that past utilization trends would continue, the model's predictive accuracy improved (the absolute scaled error dropped below 1 to 0.48). The "realized" budgetary impact was found to be greater than the predicted budgetary impact, largely because of lower-than-expected utilization. CONCLUSIONS: The budget impact model overpredicted utilization in the year after the formulary changes. Discoveries through the validation process improved the accuracy and transparency of the model. DISCLOSURES: This project was supported by grant number F32HS024857 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ. AHRQ had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or design to submit the manuscript for publication. The findings discussed in this manuscript represent the views of the authors and do not necessarily reflect the views of the Department of Defense, the Defense Health Agency, nor the Departments of the Army, Navy, and Air Force. Hung reports a grant from the AHRQ, during the conduct of the study, and personal fees from CVS Health and BlueCross BlueShield Association, outside the submitted work. Mullins reports grants and personal fees from Bayer and Pfizer and personal fees from Boehringer Ingelheim, Janssen/J&J, Regeneron, and Sanofi-Aventis, outside the submitted work. Mullins, Slejko, and Shaya are employed by the University of Maryland School of Pharmacy. Haines and Lugo have nothing to disclose. Part of this content was previously presented as a poster at the 2017 AMCP Managed Care & Specialty Pharmacy Annual Meeting; March 27-30, 2017; Denver, CO, and as poster and oral presentations at the 2017 AMCP Nexus Meeting; October 16-19, 2017; Dallas, TX. Part of this content was published as Hung's PhD dissertation.


Assuntos
Hipoglicemiantes/economia , Orçamentos , Análise Custo-Benefício/economia , Custos de Medicamentos , Humanos , Seguro Saúde/economia , Programas de Assistência Gerenciada/economia , Modelos Econômicos , Assistência Farmacêutica/economia , Farmácia/métodos
9.
J Manag Care Spec Pharm ; 25(7): 736-738, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31232204

RESUMO

Questions about the clinical significance of improvements to medication adherence resulting from value-based insurance design (VBID) policies persist in the literature. Given the lack of conclusive evidence about effectiveness, in addition to concerns about the cost of implementing VBID programs, it is perhaps not surprising that VBID is not more widely used by managed care plans. Although VBID holds promise for improving chronic medication use, additional evidence is needed if VBID is to become universally adopted. DISCLOSURES: No funding contributed to the writing of this article. The author currently receives funding from Blue-Cross Blue-Shield of Minnesota for unrelated research.


Assuntos
Programas de Assistência Gerenciada/economia , Adesão à Medicação/estatística & dados numéricos , Seguro de Saúde Baseado em Valor/economia , Humanos
10.
J Manag Care Spec Pharm ; 25(7): 817-822, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31232210

RESUMO

BACKGROUND: In the United States, many children with cerebral palsy (CP) obtain health care coverage through managed Medicaid, but little is known about the current demographics or management of this high-need, complex population. OBJECTIVE: To develop U.S. population-level information about the prevalence of CP, management patterns, and costs. METHODS: Data (2013-2015) were analyzed from a managed Medicaid database with coverage of children and adolescents in 15 states. Analyses included demographic information and use of 10 prespecified CP management options often used to manage spasticity. Code-based algorithms were applied to indicate presence of spasticity and determine the likely ambulatory status. RESULTS: In this claims analysis, the prevalence estimate of CP was 1.78 per 1,000 patients. Most (69.8%) children with CP had spasticity, of which 20.8% had hemiplegia, 15.6% diplegia, 32.9% quadriplegia, and 30.5% CP unspecified. Overall, 42.4% of children with CP were not treated with any of the 10 CP management options via Medicaid. Among treated children, the most common management options were physical therapy (37.1%), orthotics (29.9%), oral baclofen (13.5%) and botulinum toxins (9.4%). Overall annualized Medicaid costs were higher for children with CP versus children in the overall database population ($22,383 vs. $1,358). Within the CP population, costs were higher for those children who were likely nonambulatory than for those who were likely ambulatory ($43,687 vs. $10,368, respectively). CONCLUSIONS: Most children with CP have spasticity, and the costs of care are high. This study highlights wide variation in the way CP is managed, with many young patients not receiving CP management options via Medicaid. DISCLOSURES: This analysis was funded by Ipsen Biopharmaceuticals and conducted by Milliman. Pulgar and Bains were employees of Ipsen Biopharmaceuticals during the conduct of this study. Chambers is a consultant for OrthoPediatrics and an employee of the University of California. Pyenson and Ferro are employees of Milliman, as was Sawhney during the analysis. Gooch, Noritz, and Wright report no conflicts of interest. Part of this work was presented as a poster at TOXINS 2017: Basic Science and Clinical Aspects of Botulinum and Other Neurotoxins, held January 18-21, 2017, in Madrid, Spain.


Assuntos
Paralisia Cerebral/terapia , Assistência à Saúde/economia , Programas de Assistência Gerenciada/economia , Medicaid/economia , Adolescente , Paralisia Cerebral/economia , Paralisia Cerebral/fisiopatologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Espasticidade Muscular/epidemiologia , Espasticidade Muscular/etiologia , Prevalência , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
11.
J Manag Care Spec Pharm ; 25(8): 889-897, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31172866

RESUMO

BACKGROUND: Corticosteroids are used in the management of castration-resistant prostate cancer (CRPC) to reduce tumor-related symptoms because of CRPC therapies. Since corticosteroids have been associated with a range of toxicities, their use may increase the economic burden sustained by patients with CRPC. However, the economic impact of using corticosteroids in patients with CRPC has not been well characterized. OBJECTIVE: To assess the effect of previous corticosteroid use on health care resource utilization (HRU) and health care costs among men with CRPC. METHODS: Using administrative claims data (2007-2016), adult chemotherapy-naive patients who initiated CRPC treatment following surgical or medical castration were identified. Based on the cumulative corticosteroid dose during the 12 months before CRPC treatment initiation, patients were grouped into 4 cohorts: no corticosteroid (0 gm), low corticosteroid (< 0.5 gm), medium corticosteroid (0.5-2.0 gm), and high corticosteroid (> 2.0 gm). All-cause HRU and costs (2017 U.S. dollars) were compared between cohorts during the 1-year study period following CRPC treatment initiation using the no corticosteroid cohort as reference. Multivariable regression models were used to adjust for baseline covariates, including age, region, index year, Charlson Comorbidity Index score, presence of bone metastases, baseline all-cause HRU, and corticosteroid-related clinical events during baseline. RESULTS: 9,425 patients were included (no corticosteroid = 6,765, low corticosteroid = 1,660, medium corticosteroid = 655, and high corticosteroid = 345). On average, patients in the no corticosteroid cohort were older and had a lower baseline HRU and comorbidity burden than patients in the other 3 cohorts. During the study period, patients with corticosteroid exposure (across all corticosteroid cohorts) had significantly more inpatient admissions (high corticosteroid vs. no corticosteroid adjusted incidence rate ratio [IRR] = 1.56; P < 0.001), emergency department visits (high corticosteroid vs. no corticosteroid adjusted IRR = 1.30; P = 0.001), and outpatient visits (high corticosteroid vs. no corticosteroid adjusted IRR = 1.11; P < 0.001). In addition, compared with the no corticosteroid cohort, patients with corticosteroid exposure had significantly higher monthly total costs (high corticosteroid vs. no corticosteroid adjusted difference = $2,600; P < 0.001), including medical service costs (high corticosteroid vs. no corticosteroid adjusted difference = $1,564; P < 0.001) and pharmacy costs (high corticosteroid vs. no corticosteroid adjusted difference = $825; P < 0.001). CONCLUSIONS: Cumulative corticosteroid exposure before CRPC treatment initiation was associated with significantly higher HRU and costs. This increase in economic burden was more prominent among patients with annual cumulative corticosteroid doses of more than 2.0 gm. These results suggest that previous corticosteroid use may result in a higher economic burden among patients with CRPC. DISCLOSURES: This study was funded by Astellas Pharma (Northbrook, IL) and Medivation, a Pfizer Company (San Francisco, CA), the codevelopers of enzalutamide. The study sponsor was involved in the study design, data interpretation, and review. All authors contributed to the development of the manuscript and maintained control over the final content. Schultz and Wilson are employed by Astellas Pharma. Schultz owns stock in Gilead Sciences and Shire. Song and Yang are employed by Analysis Group, which received consultancy fees from Astellas Pharma. Ramaswamy is employed by Pfizer, and Lowentritt is employed by Chesapeake Urology and has served as a speaker and consultant for Astellas Pharma, Pfizer, Bayer, Dendreon, and Janssen. A synopsis of the current research was presented in poster format at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2019, which took place in San Diego, CA, on March 25-28, 2019.


Assuntos
Corticosteroides/economia , Corticosteroides/uso terapêutico , Neoplasias de Próstata Resistentes à Castração/tratamento farmacológico , Neoplasias de Próstata Resistentes à Castração/economia , Idoso , Estudos de Coortes , Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde , Recursos em Saúde/economia , Hospitalização/economia , Humanos , Revisão da Utilização de Seguros/economia , Masculino , Programas de Assistência Gerenciada/economia , Aceitação pelo Paciente de Cuidados de Saúde
12.
J Manag Care Spec Pharm ; 25(6): 646-651, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31134855

RESUMO

BACKGROUND: Dipeptidyl peptidase-4 (DPP-4) inhibitors have repeatedly shown no reduction in the clinical outcomes of cardiovascular death, myocardial infarction, stroke, or all-cause mortality. Because the treatment of diabetes is generally one of the top drug categories by cost to health plans and self-funded employers, it is necessary to evaluate coverage of DPP-4 inhibitors, considering their lack of cardiovascular benefit relative to other treatment options. OBJECTIVE: To describe the cost and utilization outcomes of drugs used to treat diabetes after exclusion of DPP-4 inhibitors in a self-funded managed care plan. METHODS: This study was a retrospective, descriptive analysis of the cost and utilization outcomes after exclusion of DPP-4 inhibitors. Pharmacy claims data and plan membership were analyzed 6 months before DPP-4 inhibitor exclusion (preperiod: December 1, 2016-May 31, 2017) and 6 months after DPP-4 inhibitor coverage ended for all users (postperiod: September 1, 2017-February 28, 2018). The allowed amount, which is not influenced by overlapping plan copay changes, and utilization per member per month (PMPM) were used to estimate the effect of the DPP-4 inhibitor benefit exclusion on plan costs for the antidiabetic class. RESULTS: From preperiod to postperiod, all DPP-4 inhibitor products decreased in utilization by 3.02 claims per 1,000 members per month (PTMPM). Glucagon-like peptide-1 receptor agonists, insulins, sodium-glucose cotransporter-2 inhibitors, and thiazolidinedione claims increased by 0.72, 0.43, 0.30, and 0.48 claims PTMPM, respectively, but there was an absolute decrease of 1.35 claims for antidiabetic medications per 1,000 plan members. However, the days supplied PMPM increased from 2.55 to 2.61 (2.3%) days. Allowed amount PMPM increased by $0.27 from $12.19 in the preperiod to $12.31 in the postperiod (2.2%). However, it is estimated that drug cost inflation accounted for over half of the PMPM increase in allowed costs. CONCLUSIONS: The observed increase in the allowed amount PMPM was attributable in similar amounts by an increase in utilization of medications with higher cost per day supplied and higher drug prices. Future research will evaluate patient-level effects of this benefit change in terms of antidiabetic medication utilization and outcomes. DISCLOSURES: No outside funding supported this study. Davis, Bemberg, and Johnson currently work for or previously worked for the UAMS Evidence-Based Prescription Drug Program, which advises the Employee Benefits Division (EBD) on pharmacy benefit management. The EBD did not provide any additional funding for this study. McAdam-Marx reports grants from AstraZeneca and Sanofi Aventis outside the submitted work. The other authors have no other relevant information to disclose.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Inibidores da Dipeptidil Peptidase IV/economia , Custos de Medicamentos/estatística & dados numéricos , Hipoglicemiantes/economia , Programas de Assistência Gerenciada/estatística & dados numéricos , Diabetes Mellitus Tipo 2/economia , Inibidores da Dipeptidil Peptidase IV/uso terapêutico , Uso de Medicamentos/economia , Uso de Medicamentos/estatística & dados numéricos , Planos de Assistência de Saúde para Empregados/economia , Planos de Assistência de Saúde para Empregados/estatística & dados numéricos , Humanos , Hipoglicemiantes/uso terapêutico , Revisão da Utilização de Seguros/estatística & dados numéricos , Seguro de Serviços Farmacêuticos/economia , Seguro de Serviços Farmacêuticos/estatística & dados numéricos , Programas de Assistência Gerenciada/economia , Estudos Retrospectivos
13.
J Manag Care Spec Pharm ; 25(5): 538-543, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31039066

RESUMO

Managed care organizations are growing more sophisticated in their ability to analyze data. There are increasing numbers of data analysts at managed care organizations, as well as more types of real-time, or "live," data available. These data range from pharmacy claims and enrollment files to medical claims, medical records, and linkages to external data. Moreover, the data are often curated in a way that allows for easier data analysis. Using these data, managed care residents are often required to perform a project to evaluate a utilization management policy or clinical program. Yet, there is a lack of guidance specific to managed care organizations on how to conduct such a research study using "live" claims data. This Viewpoint article provides a primer for managed care residents and other managed care professionals who are seeking to use data to help inform decisions on how to manage their beneficiaries' health and costs. DISCLOSURES: There was no funding source for this manuscript. Hung reports a grant from the Agency for Healthcare Research and Quality and personal fees from Blue Cross Blue Shield Association, outside the submitted work. Gedey, Groeneweg, and Jay have nothing to disclose.


Assuntos
Revisão da Utilização de Seguros/normas , Programas de Assistência Gerenciada/organização & administração , Assistência Farmacêutica/organização & administração , Pesquisa em Farmácia/métodos , Projetos de Pesquisa , Interpretação Estatística de Dados , Humanos , Internato e Residência , Programas de Assistência Gerenciada/economia , Assistência Farmacêutica/economia , Pesquisa em Farmácia/normas , Estados Unidos
14.
Inquiry ; 56: 46958019841506, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30983463

RESUMO

Disenrollment rates are one way that policy makers assess the performance of Medicare Advantage (MA) health plans. We use 3 years of data published by the Centers for Medicare & Medicaid Services (CMS) to examine the characteristics of MA contracts with high disenrollment rates from 2015 to 2017 and the relationship between disenrollment rates in MA contracts and 6 patient experiences of care performance measures. We find that MA contracts with high disenrollment rates were significantly more likely to be for-profit, small, and enroll a greater proportion of low-income and disabled individuals. After adjusting for plan characteristics, contracts with the highest levels of disenrollment were statistically significantly more likely to perform poorly on all 6 patient experience measures. CMS should consider additional oversight of MA contracts with high levels of disenrollment and consider publishing disenrollment rates at the plan level instead of at the contract level.


Assuntos
Programas de Assistência Gerenciada/economia , Medicare Part C/economia , Medicare Part C/tendências , Indicadores de Qualidade em Assistência à Saúde , /economia , Humanos , Programas de Assistência Gerenciada/normas , Pobreza , Setor Privado , Estados Unidos
15.
JAMA Netw Open ; 2(4): e191549, 2019 04 05.
Artigo em Inglês | MEDLINE | ID: mdl-30951156

RESUMO

Importance: Targeted drug delivery (TDD) has potential for cost savings compared with conventional medical management (CMM). Despite positive clinical and economic evidence, TDD remains underused to treat cancer pain. Objective: To assess the cost of TDD and CMM in treating cancer-related pain. Design, Setting, and Participants: This retrospective economic evaluation using propensity score-matched analysis was conducted using MarketScan commercial claims data on beneficiaries receiving TDD and CMM or CMM only for cancer pain from January 1, 2009, to September 30, 2015. Participants were matched on age, sex, cancer type, comorbidity score, and pre-enrollment characteristics. Data analysis was performed from June 1 to September 30, 2017. Main Outcomes and Measures: Total 2-, 6-, and 12-month costs, number of health care encounters, length of hospital stay, additional components of cost, and health care utilization. Results: A total of 376 TDD and CMM patients (mean [SD] age, 51.88 [9.98] years; 216 [57.5%] female) and 4839 CMM only patients (mean [SD] age, 51.52 [11.16] years; 3005 [62.1%] female) were identified for study inclusion. After matching, 536 patients were included in the study: 268 patients in the TDD and CMM group and 268 in the CMM only group. Compared with CMM only, TDD and CMM was associated with mean total cost savings of $15 142 (95% CI, $3690 to $26 594; P = .01) at 2 months and $63 498 (95% CI, $4620 to $122 376; P = .03) at 12 months; cost savings at 6 months were not statistically different ($19 577; 95% CI, -$12 831 to $51 984; P = .24). The TDD and CMM group had fewer inpatient visits (2-month mean difference [MD], 1.0; 95% CI, 0.8-1.2; P < .001; 6-month MD, 1.3; 95% CI, 0.8-1.7; P < .001; 12-month MD, 2.3; 95% CI, 1.2-3.4; P < .001) and shorter hospital stays (2-month MD, 6.8 days; 95% CI, 5.0-8.7 days; P < .001; 6-month MD, 6.8 days; 95% CI, 3.1-10.5 days; P < .001; 12-month MD, 10.6 days; 95% CI, 2.9-18.3 days; P = .007). Use of CMM only was associated with greater opioid use at 12 months (MD, 3.2; 95% CI, 0.4-6.0; P = .03). Conclusions and Relevance: Compared with CMM alone, TDD and CMM together were associated with significantly lower cost and health care utilization. The findings suggest that TDD is a cost-saving therapy that should be considered in patients with cancer for whom oral opioids are inadequate or produce intolerable adverse effects and should be expanded as health care systems transition to value-based models.


Assuntos
Dor do Câncer/tratamento farmacológico , Sistemas de Liberação de Medicamentos/normas , Custos de Cuidados de Saúde/estatística & dados numéricos , Manejo da Dor/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Analgésicos Opioides/economia , Analgésicos Opioides/uso terapêutico , Sistemas de Liberação de Medicamentos/economia , Feminino , Humanos , Tempo de Internação/economia , Masculino , Programas de Assistência Gerenciada/economia , Programas de Assistência Gerenciada/normas , Pessoa de Meia-Idade , Manejo da Dor/métodos , Estudos Retrospectivos
16.
Med Sci Monit ; 25: 2879-2885, 2019 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-31002103

RESUMO

BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common disease that occurs all over the world. Models of care, initially accessed from the clinical point of view, must also be evaluated in terms of their economic effectiveness, as health care systems are limited. The Integrated Care Model (ICM) is a procedure dedicated to patients suffering from advanced COPD that offers home-oriented support from a multidisciplinary team. The main aim of the present study was to evaluate the cost-effectiveness of the ICM. MATERIAL AND METHODS We included 44 patients in the study (31 males, 13 females) with an average age 72 years (Me=71). Costs of care were estimated based on data received from public payer records and included general costs, COPD-related costs, and exacerbation-related costs. To evaluate cost-effectiveness, cost-effectiveness analysis (CEA) was used. The incremental cost-effectiveness ratio (ICER) was calculated based on changes in health care resources utilization and the value of costs observed in 2 consecutive 6-month periods before and after introducing ICM. RESULTS Costs of care of all types decreased after introducing ICM. Demand for ambulatory visits changed significantly (p=0.037) together with a substantial decrease in the number of emergency department appointments and hospitalizations (p=0.033). ICER was more profitable for integrated care than for standard care when assessing costs of avoiding negative parameters such as hospitalizations (-227 EUR), exacerbations-related hospitalizations (-312 EUR), or emergency procedures (-119 EUR). CONCLUSIONS ICM is a procedure that meets the criteria of cost-effectiveness. It allows for avoiding negative parameters such as unplanned hospitalizations with higher economic effectiveness than the standard type of care used in managing COPD.


Assuntos
Prestação Integrada de Cuidados de Saúde/economia , Prestação Integrada de Cuidados de Saúde/métodos , Programas de Assistência Gerenciada/economia , Doença Pulmonar Obstrutiva Crônica/economia , Doença Pulmonar Obstrutiva Crônica/terapia , Idoso , Análise Custo-Benefício , Progressão da Doença , Feminino , Custos de Cuidados de Saúde , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econométricos , Polônia
17.
J Manag Care Spec Pharm ; 25(8): 904-912, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31007119

RESUMO

BACKGROUND: The Biologics Price Competition and Innovation Act (BPCIA) of 2009, which included pathways for FDA approval of biosimilar products, was designed to promote more affordable, expanded patient access to biologic therapies. Achieving these BPCIA goals depends on overcoming formidable barriers to biosimilar adoption. Managed care and specialty pharmacy professionals are uniquely qualified to inform initiatives to address these barriers. OBJECTIVE: To assess perceptions regarding strategies for overcoming barriers to biosimilar adoption among managed care and specialty pharmacy professionals by conducting a survey study. METHODS: Invitations to complete the online survey were emailed by the Academy of Managed Care Pharmacy (AMCP) to members and customers and to contacts sourced from a commercial database. In addition to questions on respondent demographics and perceptions of biosimilars, the survey listed 16 strategies for overcoming key barriers to biosimilar adoption. On a 5-point scale, participants rated their opinion on the likelihood that each strategy would have the potential to assist in achieving BPCIA goals. The survey also listed 6 barriers to biosimilar adoption. On a 5-point scale, participants rated their perceived difficulty in overcoming each barrier. The survey concluded with an open-text item that asked participants to list 3 additional strategies for overcoming biosimilar adoption barriers. Response frequencies were calculated to describe participants' ratings of the strategies and barriers. Statistical analyses were conducted to assess whether the ratings differed among respondents grouped by work organization. For the open-text item, we conducted qualitative content analyses to categorize strategies by stakeholder groups that might take primary implementation roles. RESULTS: A total of 300 managed care and specialty pharmacy professionals completed the survey. There was considerable variation in the preferences, policies, and practices regarding biosimilar adoption among respondents' work organizations. Responses to several survey items reflected positive attitudes about the safety and efficacy of biosimilars; for example, 84% agreed or strongly agreed that FDA-approved biosimilars are safe and effective for patients who switch from a reference biologic. Based on pooled percentages for ratings of likely and extremely likely to overcome barriers to biosimilar adoption, the highest-rated strategies were for prescriber education about evidence from switching studies (91%) and FDA guidance on pharmacy-level substitution of reference biologics with biosimilars (90%). The lowest-rated strategies were for requiring therapeutic drug monitoring for patients who switch to biosimilars (39%) and using quotas to incentivize providers to prescribe biosimilars (40%). For the qualitative analysis, the highest numbers of respondents' suggested strategies indicated primary implementation roles of biosimilar manufacturers (40%), the federal government (26%), and managed care organizations (15%). CONCLUSIONS: Reflecting the unique knowledge, perspectives, and practices of managed care and specialty pharmacy professionals, the study findings are relevant to informing and advancing initiatives for achieving BPCIA goals. DISCLOSURES: The survey study reported in this article was part of a continuing education program funded by an independent educational grant, which was awarded by Sandoz, a Novartis Division, to PRIME Education. The Academy of Managed Care Pharmacy (AMCP) received grant funding from PRIME to assist in developing the survey and writing the manuscript. The grantor had no role in the study design, execution, analysis, or reporting. Greene and Pardo are employed by PRIME. Singh and Carden are employed by AMCP. Greene, Singh, Carden, and Pardo have no other disclosures. Lichtenstein received an honorarium from PRIME for serving as faculty for the continuing education program and has been a consultant for Pfizer, Cellceutix, and Merck.


Assuntos
Medicamentos Biossimilares/economia , Comércio/economia , Programas de Assistência Gerenciada/economia , Aprovação de Drogas/economia , Indústria Farmacêutica/economia , Objetivos , Humanos , Medicina/métodos , Assistência Farmacêutica/economia , Farmácias/economia , Farmácia/métodos , Inquéritos e Questionários , Estados Unidos , United States Food and Drug Administration
18.
J Manag Care Spec Pharm ; 25(4): 461-467, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30917076

RESUMO

BACKGROUND: Drugs for inflammatory conditions are one of the highest expenditure therapeutic classes for health plans. Published literature for adherence, persistence, nonadherence risk factors, and health care costs are incomplete for newer biologic agents. OBJECTIVES: To (a) examine differences in adherence, persistence, switch patterns, and health care costs among high-cost specialty anti-inflammatory medications and (b) suggest risk factors for nonadherence in rheumatoid arthritis. METHODS: In this exploratory retrospective cohort study, we used medical and pharmacy claims from 1.2 million enrollees in commercial health plans administrated by Premera Blue Cross, the largest not-for-profit health plan in the Pacific Northwest. We included members with rheumatoid arthritis who used the following high-cost disease-modifying antirheumatic drugs: abatacept, adalimumab, anakinra, apremilast, certolizumab, etanercept, golimumab, infliximab, rituximab, sekukinumab, tocilizumab, tofacitinib, and ustekinumab. Adherence was calculated via medication possession ratio. Persistence was calculated as the amount of days between the initial fill and final fill plus days supply. Switch rates for adalimumab and etanercept were calculated as the percentage of members who switched to another target drug during the observation period. Direct medical costs (total health care costs) and health care costs excluding specialty agents were calculated using the net allowable amount per claim for the duration of each therapy. Adherence, persistence, and costs of care were also examined for concurrent methotrexate use for the most used target drugs. RESULTS: The most commonly used drugs were abatacept (n = 47), adalimumab (n = 226), and etanercept (n = 252). Nonadherence in certain subgroups was associated with higher mean monthly health care costs, excluding specialty agents (etanercept cohort: +$1,063 for nonmethotrexate users; +$492 for nonadherent methotrexate users), but adherence was associated with higher total health care costs (+$883 for etanercept). Relative to specialty pharmacies, retail was associated with 9% higher nonadherence. Concurrent methotrexate use was associated with higher persistence (+307 and +192 days with adalimumab and etanercept). The most commonly switched-to drug after adalimumab/etanercept was abatacept (n = 39). CONCLUSIONS: This exploratory study raises signals suggesting that retail pharmacies may be associated with higher nonadherence; nonadherence may be associated with increased health care costs, excluding specialty agents; adherence may increase total health care costs; and methotrexate use may be associated with increased persistence. Future research should confirm these findings. DISCLOSURES: This research was part of an internship awarded to Khilfeh by the AMCP Foundation/Pfizer Summer Internship Program and funded by Pfizer. Gross is an employee of Pfizer. The other authors have nothing to disclose. A portion of this research was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting as a continuing education session entitled "The Evolving Role of Real-World Data in Health Care Decision Making" on March 29, 2017, in Denver, CO, and at AMCP Nexus 2016 as a poster on October 3-6, 2016, in National Harbor, MD.


Assuntos
Anti-Inflamatórios/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Idoso , Anti-Inflamatórios/economia , Antirreumáticos/economia , Artrite Reumatoide/economia , Estudos de Coortes , Custos de Medicamentos/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Fatores Imunológicos/economia , Fatores Imunológicos/uso terapêutico , Masculino , Programas de Assistência Gerenciada/economia , Pessoa de Meia-Idade , Noroeste dos Estados Unidos , Estudos Retrospectivos , Fatores de Risco
19.
J Manag Care Spec Pharm ; 25(3): 342-349, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30816818

RESUMO

BACKGROUND: Traditional budget impact models predict the financial consequences of a new drug entering the market. This study provides an example of applying the budget impact framework to a new research question of interest to managed care organizations-what is the budget impact of our formulary and utilization management (UM) policy changes? OBJECTIVE: To predict the 3-year annual budgetary impact of TRICARE's antidiabetic formulary and UM policy changes using TRICARE claims data. METHODS: A budget impact model was built in Microsoft Excel using health plan claims data for a 3-year time horizon. Model outcomes included spending on antidiabetic medications and medications used for side effect treatment. In sensitivity analyses, medical costs from inpatient, outpatient, and emergency room visits were also estimated. Model inputs included health plan antidiabetic medication utilization, as well as publicly available drug cost, rebate, dispensing fee, and patient cost-sharing estimates. Type of enrollee and pharmacy were also incorporated into the model. Sensitivity analyses varied estimates for utilization switch rates between preferred and nonpreferred agents, drug costs, rebates, and dispensing fees, as well as predicted impact from implementation delays. RESULTS: For the 623,827 affected by the formulary and UM policy changes, the model predicted annual savings that increased from $24 million in the first year to $43 million in the third year after the changes. The majority of savings came from drug acquisition costs, as opposed to rebates, copays, and dispensing fees. Sensitivity analyses found savings across all varied parameters and scenarios except an unlikely scenario when 0% of utilization switched from nonpreferred to preferred agents. The model also predicted that the formulary and UM policy changes would lead to $529,439 in savings from medical visit costs in Year 3. CONCLUSIONS: This budget impact model predicted cost savings from the payer's formulary and UM policy changes. DISCLOSURES: This project was supported by grant number F32HS024857 from the Agency for Healthcare Research and Quality (AHRQ), which contracted with the University of Maryland School of Pharmacy to conduct this study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ, which had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or design to submit the manuscript for publication. The findings discussed in this manuscript represent the views of the authors and do not necessarily reflect the views of the Department of Defense, the Defense Health Agency, nor the Departments of the Army, Navy, and Air Force. Hung reports a grant from the AHRQ, during the conduct of the study, and personal fees from CVS Health and BlueCross BlueShield Association, outside the submitted work. Mullins reports grants and personal fees from Bayer and Pfizer and personal fees from Boehringer-Ingelheim, Janssen/J&J, Regeneron, and Sanofi, outside the submitted work. Mullins, Slejko, and Shaya are employed by the University of Maryland School of Pharmacy. Haines and Lugo have nothing to disclose. Part of this content was previously presented as a poster at the 2017 AMCP Managed Care & Specialty Pharmacy Annual Meeting; March 27-30, 2017; Denver, CO, and as poster and oral presentations at the 2017 AMCP Nexus Meeting; October 16-19, 2017; Dallas, TX. Part of this content was published as Hung's PhD dissertation.


Assuntos
Orçamentos , Hipoglicemiantes/economia , Programas de Assistência Gerenciada/economia , Modelos Econômicos , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Custos de Medicamentos , Feminino , Formulários Farmacêuticos como Assunto , Humanos , Hipoglicemiantes/administração & dosagem , Hipoglicemiantes/efeitos adversos , Masculino , Pessoa de Meia-Idade , Política Organizacional
20.
J Health Care Poor Underserved ; 30(1): 202-220, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30827978

RESUMO

School-based health centers (SBHCs) have been suggested as potential medical homes, but may experience challenges implementing the patient-centered medical home (PCMH) model. It is currently unknown if there are PCMH variations among different types of SBHCs. The purpose of this study was to examine the associations between SBHC characteristics and PCMH capacity. Using 2013-2014 National Census of School-Based Health Centers data, SBHC PCMH Index scores were calculated and used as outcomes in linear regression models examining associations between PCMH capacity and SBHC characteristics. The mean PCMH capacity score for all SBHCs was 68.59%, with higher scores in the Comprehensive Care domain than in the Care Quality domain. Managed care arrangements, Medicaid PCMH initiatives, more funding sources, and higher patient billing activity were all positively associated with overall PCMH capacity. Having higher percentages of students who are members of racial/ethnic minority groups was negatively associated with overall PCMH capacity.


Assuntos
Programas de Assistência Gerenciada/economia , Medicaid/economia , Assistência Centrada no Paciente/organização & administração , Serviços de Saúde Escolar/organização & administração , Grupos Étnicos/estatística & dados numéricos , Humanos , Grupos Minoritários/estatística & dados numéricos , Fatores Socioeconômicos , Estudantes/estatística & dados numéricos , Estados Unidos
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