Pharmacy Benefit Manager Reform: Lessons From Ohio.
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ABSTRACT:
SUBMITTER: Royce TJ
PROVIDER: S-EPMC7251257 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:The high costs associated with pharmaceuticals and the accompanying stakeholders are being closely evaluated in the search for solutions. As a major stakeholder in the U.S. pharmaceutical market, the practices of pharmacy benefit manager (PBM) organizations have been under increased scrutiny. Examples of controversial practices have included incentives driving formulary status and prohibiting pharmacists from disclosing information on lower-cost prescription alternatives. Ethical investigations have been largely omitted within the debate on the responsibilities of these organizations in the health care system. Ethical analysis of organizational practices is justified based on the potential impact during health care delivery. The objective of this study was to analyze several specific PBM practices using multiple ethical decision-making models to determine their ethical nature. This study systematically applied multiple ethical decision-making models and codes of ethics to a variety of practices associated with PBM-related dilemmas encountered in the pharmaceutical environment. The assessed scenarios resulted in mixed outcomes. PBM practices were both ethical and unethical depending on the applied ethical model. Despite variation across applied models, some practices were predominately ethical or unethical. The point of sale rebates were consistently determined as ethical, whereas market consolidation, gag clauses, and fluctuation of pharmacy reimbursements were all predominantly determined as unethical. The application of using provider codes of ethics created additional comparison and also contained mixed findings. This study provided a unique assessment of PBM practices and provides context from a variety of ethical perspectives. To the knowledge of the authors, these perspectives have not been previously applied to PBM practices in the literature. The application of ethical decision-making models offers a unique context to current health care dilemmas. It is important to analyze health care dilemmas using ethics-based frameworks to contribute solutions addressing complexities and values of all stakeholders in the health care environment.
| S-EPMC6631892 | biostudies-other
Project description:BackgroundReducing inappropriate antibiotic prescriptions (Rxs) is a major quality improvement initiative in the United States. Tracking antibiotic prescribing trends is 1 method of assessing improvement in antibiotic prescribing. The purpose of this study was to assess longitudinal antibiotic prescribing practices among dental specialists.MethodsThis was a retrospective ecological longitudinal trend study. The authors calculated monthly systemic antibiotic Rx counts, and rates per 100,000 beneficiaries, from a pharmacy benefits manager in the United States from 2013 through 2015. The authors calculated average annual antibiotic Rx rates (AARs) for the 3-year study period. The authors used a quasi-Poisson regression model to analyze antibiotic Rx trends. The authors quantified seasonal trends, when present, via peak-to-trough ratios (PTTRs).ResultsDental specialists prescribed 2.4 million antibiotics to the cohort of 38 million insurance beneficiaries during the 3-year study period (AAR = 2,086 Rxs per 100,000 beneficiaries). Oral and maxillofacial surgeons prescribed the most antibiotics (1,172,104 Rxs; AAR = 1,018 Rxs per 100,000 beneficiaries), followed by periodontists (527,038 Rxs; AAR = 457 Rxs per 100,000 beneficiaries), and endodontists (447,362 Rxs; AAR = 388 Rxs per 100,000 beneficiaries). Longitudinal antibiotic prescribing trends were stable among all dental specialties in the regression models (P > .05). The authors observed substantial seasonal variation in antibiotic Rxs in 2 specialties: pediatric dentistry (PTTR, 1.18; 95% confidence interval, 1.13 to 1.25) and orthodontics and dentofacial orthopedics (PTTR, 1.41; 95% confidence interval, 1.21 to 1.71), with the highest rates of antibiotic Rxs in the spring and winter.ConclusionsAntibiotic prescribing practices for dental specialists remained stable. The authors observed seasonal trends in 2 specialties.Practical implicationsPublic health efforts are needed improve antibiotic prescribing among dental specialties.
| S-EPMC7954126 | biostudies-literature
Project description:With the deepening of health insurance reform in China, the integration of social health insurance schemes was put on the agenda. This paper aims to illustrate the achievements and the gaps in integration by demonstrating the trends in benefits available from the three social health insurance schemes, as well as the influencing factors. Data were drawn from the three waves of the China Health and Nutrition Survey (2009, 2011, 2015) undertaken since health reforms commenced. χ2, Kruskal-Wallis test, and the Two-Part model were employed in the analysis. The overall reimbursement rate of the Urban Employee Basic Medical Insurance (UEBMI) is higher than that of Urban Resident Basic Medical Insurance (URBMI) or the New Rural Cooperative Medical Scheme (NRCMS) (p < 0.001), but the gap has narrowed since health reform began in 2009. Both the outpatient and inpatient reimbursement amounts have increased through the URBMI and NRCMS. Illness severity, higher institutional level, and inpatient service were associated with significant increases in the amount of reimbursement received across the three survey waves. The health reform improved benefits covered by the URBMI and NRCMS, but gaps with the UEBMI still exist. The government should consider more the release of health benefits and how to lead toward healthcare equity.
| S-EPMC8199469 | biostudies-literature
Project description:ObjectiveTo identify factors associated with small group employer participation in New Mexico's State Coverage Insurance (SCI) program.Data sourcesTelephone surveys of employers participating in SCI (N=269) and small employers who inquired about SCI (N=148) were fielded September 2008-January 2009.Study designDescriptive and multivariate analyses investigated differences between employer samples, including employer characteristics, concerns that applied to the business when deciding whether to participate in SCI, prior offerings of insurance to workers, and perceived affordability of the program.Data collection/extraction methodsUnweighted employer samples yielded 88 and 75 percent response rates for the participating and inquiring employers, respectively.Principal findingsThe administrative issue most commonly selected by inquiring employers as applying to their business was difficulty understanding how eligibility requirements applied to their business and its employees (53.5 percent). Inquiring businesses were significantly more likely to report concern about affording to pay the premiums in the first month (35.6 versus 18.7 percent) and the cost to the business over the long run (46.5 versus 26.6 percent) relative to participating employers. From the model results, businesses with the fewest full-time employees (zero to two) were 19 percentage points less likely to participate relative to businesses with six or more full-time employees.ConclusionsAdministrative and cost barriers to participation in SCI reported by employers suggest that the tax credit offered to small businesses under new federal provisions, which merely offsets the employer portion of premium, could be more effective if accompanied by additional supports to businesses.
| S-EPMC3037782 | biostudies-literature
Project description:ObjectiveTo assess the impact of a pharmacy benefit change on mail order pharmacy (MOP) uptake.Data sources/study settingRace-stratified, random sample of diabetes patients in an integrated health care delivery system.Study designIn this natural experiment, we studied the impact of a pharmacy benefit change that conditionally discounted medications if patients used MOP and prepaid two copayments. We compared MOP uptake among those exposed to the benefit change (n = 2,442) and the reference group with no benefit change (n = 8,148), and estimated differential MOP uptake across social strata using a difference-in-differences framework.Data collection/extraction methodsAscertained MOP uptake (initiation among previous nonusers).Principal findingsThirty percent of patients started using MOP after receiving the benefit change versus 9 percent uptake among the reference group (p < .0001). After adjustment, there was a 26 percentage point greater MOP uptake (benefit change effect). This benefit change effect was significantly smaller among patients with inadequate health literacy (15 percent less), limited English proficiency (14 percent less), and among Latinos and Asians (24 and 16 percent less compared to Caucasians).ConclusionsConditionally discounting medications delivered by MOP effectively stimulated MOP uptake overall, but it unintentionally widened previously existing social gaps in MOP use because it stimulated less MOP uptake in vulnerable populations.
| S-EPMC4329275 | biostudies-literature
Project description:This paper comments on Naoki Ikegami's editorial entitled "Financing long-term care: lessons from Japan." Adding to the editorial, this paper focuses on analyzing the political and cultural foundations of long-term care (LTC) reform. Intergenerational solidarity and inclusive, prudential public deliberation are needed for the establishment or reform of LTC systems. Among various lines of ethical reasoning related to LTC, Confucian ethics and other familist ethics are specifically important in the societies that share these values. The core issue in the debates around LTC reform is how to (re-)define the scope of social entitlements and accordingly to allocate the responsibility for care between states and families, between social groups, and between generations with limited resources.
| S-EPMC7054645 | biostudies-literature
Project description:Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm.To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices.An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies.Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect.The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.
| S-EPMC5965082 | biostudies-other
Project description:BackgroundPhylogenetic analysis of large, multiple-gene datasets, assembled from public sequence databases, is rapidly becoming a popular way to approach difficult phylogenetic problems. Supermatrices (concatenated multiple sequence alignments of multiple genes) can yield more phylogenetic signal than individual genes. However, manually assembling such datasets for a large taxonomic group is time-consuming and error-prone. Additionally, sequence curation, alignment and assessment of the results of phylogenetic analysis are made particularly difficult by the potential for a given gene in a given species to be unrepresented, or to be represented by multiple or partial sequences. We have developed a software package, TaxMan, that largely automates the processes of sequence acquisition, consensus building, alignment and taxon selection to facilitate this type of phylogenetic study.ResultsTaxMan uses freely available tools to allow rapid assembly, storage and analysis of large, aligned DNA and protein sequence datasets for user-defined sets of species and genes. The user provides GenBank format files and a list of gene names and synonyms for the loci to analyse. Sequences are extracted from the GenBank files on the basis of annotation and sequence similarity. Consensus sequences are built automatically. Alignment is carried out (where possible, at the protein level) and aligned sequences are stored in a database. TaxMan can automatically determine the best subset of taxa to examine phylogeny at a given taxonomic level. By using the stored aligned sequences, large concatenated multiple sequence alignments can be generated rapidly for a subset and output in analysis-ready file formats. Trees resulting from phylogenetic analysis can be stored and compared with a reference taxonomy.ConclusionTaxMan allows rapid automated assembly of a multigene datasets of aligned sequences for large taxonomic groups. By extracting sequences on the basis of both annotation and BLAST similarity, it ensures that all available sequence data can be brought to bear on a phylogenetic problem, but remains fast enough to cope with many thousands of records. By automatically assisting in the selection of the best subset of taxa to address a particular phylogenetic problem, TaxMan greatly speeds up the process of generating multiple sequence alignments for phylogenetic analysis. Our results indicate that an automated phylogenetic workbench can be a useful tool when correctly guided by user knowledge.
| S-EPMC1766369 | biostudies-literature
Project description:SummaryHere we introduce a Fiji plugin utilizing the HPC-as-a-Service concept, significantly mitigating the challenges life scientists face when delegating complex data-intensive processing workflows to HPC clusters. We demonstrate on a common Selective Plane Illumination Microscopy image processing task that execution of a Fiji workflow on a remote supercomputer leads to improved turnaround time despite the data transfer overhead. The plugin allows the end users to conveniently transfer image data to remote HPC resources, manage pipeline jobs and visualize processed results directly from the Fiji graphical user interface.Availability and implementationThe code is distributed free and open source under the MIT license. Source code: https://github.com/fiji-hpc/hpc-workflow-manager/, documentation: https://imagej.net/SPIM_Workflow_Manager_For_HPC.Supplementary informationSupplementary data are available at Bioinformatics online.
| S-EPMC6761944 | biostudies-literature
Project description:Intermediate lung nodules are frequently discovered in CT imaging as either incidental or part of cancer screening. The Lung Nodule Manager allows for a quick retrieval of guidelines by physicians and health care professionals to determine the proper management and follow-up for patients.
| S-EPMC6456644 | biostudies-literature