Confronting utilization review in New Mexico's Medicaid mental health system: the critical role of "medical necessity"

The insertion of managed care into Medicaid services for the mentally ill has created contention about clinical decision making. At the center of this debate is the matter of what constitutes a medical necessity. Employing ethnographic methodology, this study examines utilization review (UR), the context in which decisions concerning the authorization of mental health care services are made. Interviews carried out in the study contrast ideological underpinnings of providers and advocates of the mentally ill, on the one hand, with employees and administrators of managed care institutions, on the other. The result is an exploration into the ways discourses surrounding the mental health care needs of New Mexico's Medicaid population are being constructed and are determining the actual care they receive.     

New Mexico's First Case of Plague

In 1981 a decision was made by the University of New Mexico School of Medicine to create a new Office of Community Professional Education whose primary function was to create continuing medical education programs tailored to its constituency. To accomplish this, a needs assessment survey was distributed to a stratified random sample of members of the New Mexico Medical Society practicing throughout the state to determine preferred learning styles, locations of programs and times of year, as well as other determinants for attending such programs. The survey was received by 647 physicians and 469 returned them—a response rate of 72.4 percent.Conclusions reached as a result of the needs assessment will serve as a basis of policy formation for the delivery of continuing medical education at the University of New Mexico School of Medicine.     

天气变化对人口死亡率的影响——以广州市和上海市为例

人口死亡率与天气有一定的关系,以广州、上海两市１０个冬季和夏季的逐日死亡资料和气象资料,利用统计学和天气学方法得出,在最高温度达３４℃的“热日”,各类死亡数明显增多;而冬季死亡数随最低温度的下降而略有增加;广州夏季最大死亡率出现在“阴凉型”天气,而上海则是在“晴热型”天气,且上海死亡率受最高温度的影响大于广州;广州和上海冬季死亡率最大的天气均是“严寒型”,但广州死亡率受低温的影响要比上海大．在其他气象要素相似的情况下,风速对死亡率有一定的影响．     

The Impact of a Shipboard Weight Control Program

DENNIS, KAREN E., KAREN W. PANE, BRENDA K. ADAMS, AND BING BING QI. The impact of a shipboard weight control program. Obes Res. 1999;7:60–67. Objective : The specific aim was to determine whether a multifaceted approach to weight loss and physical readiness could be implemented onboard a deployed combatant ship of the U.S. Navy. Research Methods and Procedures : Thirty-nine men (31±6 years old, mean±standard deviation) assigned to the USS ENTERPRISE (CVN 65) during a 6-month Mediterranean deployment who had failed their previous Physical Readiness Test due to excessive body weight (108±11 kg overweight) were randomly assigned to nutrition, cognitivebehavioral obesity treatment plus exercise or to the Navy's usual treatment (control), which is exercise alone. Results : Outcomes for the treatment group were significantly better than the controls, with 8.6±5.0 vs. 5.0±4.1 kg weight loss, 8% vs. 5% reduction in original body weight, and body fat loss of 7% vs. 5%. Triglycerides declined significantly greater in the treatment group than the controls (145 mg/dL to 109 mg/dL vs. 146 mg/dL to 145 mg/dL, p<0.05), whereas depression and eating behaviors significantly improved among treated men. Problematic environmental factors were the limited variety of heart healthy foods in the galley, short meal breaks, and long mess hall lines that led to eating snacks from vending machines and frequent port calls. Discussion : Although greater weight loss than would be expected of a Navy usual care group diluted the treatment effect, the treated men still fared significantly better. The physical readiness implication of this research has the potential to impact Navy health promotion programs and policy, the health and well-being of its personnel, and the Navy's ability to meet mission requirements.     

The Impact of a Funded Research Program on Music Education Policy

Sounds of Learning: The Impact of Music Education is a research program designed to allow researchers to examine the roles of music education in the lives of school-aged children to expand the understanding of music's role in a quality education. The NAMM Foundation, the sponsoring organization, has provided more than $1,000,000 to fund research on the impact of music education on student achievement and success in school; all aspects of a child's growth and development; the uses and functions of music in daily life; and home, school, and community environments. Quality research about the role and impact of music education conducted by experienced researchers who publish in rigorous, peer-reviewed, scientific research journals plays a vital role in moving a public policy agenda forward to achieve expanded access to music education for all children. The goal is that this research will inform policy debates and development to achieve policies that support opportunities for every child to experience the power and benefits of learning music.     

The Impact of a Sport-Based Life Skill Program on Adolescent Prosocial Values

Abstract

This article describes the implementation and evaluation of a sport-based life skills and community service program. The purpose of this investigation was to determine the impact of a combined life skills and community service program on adolescents' prosocial values. The program was part of a national golf and life skills enrichment academy for adolescents (n = 100). It was hypothesized that the life skills component would have a significant impact on adolescents' prosocial values and that participants (n = 42) who were involved in the community service component following the program, when compared to a comparison group (n = 23), would maintain their increased levels of prosocial values. Results indicated that the program had a significant positive impact on adolescents' prosocial values and that the community service experience positively impacted the adolescents' levels of empathic concern and social responsibility. These results are consistent with existing research on participating in community service.     

Economic Appraisal of Ontario's Universal Influenza Immunization Program: A Cost-Utility Analysis

Background

In July 2000, the province of Ontario, Canada, initiated a universal influenza immunization program (UIIP) to provide free seasonal influenza vaccines for the entire population. This is the first large-scale program of its kind worldwide. The objective of this study was to conduct an economic appraisal of Ontario''s UIIP compared to a targeted influenza immunization program (TIIP).

Methods and Findings

A cost-utility analysis using Ontario health administrative data was performed. The study was informed by a companion ecological study comparing physician visits, emergency department visits, hospitalizations, and deaths between 1997 and 2004 in Ontario and nine other Canadian provinces offering targeted immunization programs. The relative change estimates from pre-2000 to post-2000 as observed in other provinces were applied to pre-UIIP Ontario event rates to calculate the expected number of events had Ontario continued to offer targeted immunization. Main outcome measures were quality-adjusted life years (QALYs), costs in 2006 Canadian dollars, and incremental cost-utility ratios (incremental cost per QALY gained). Program and other costs were drawn from Ontario sources. Utility weights were obtained from the literature. The incremental cost of the program per QALY gained was calculated from the health care payer perspective. Ontario''s UIIP costs approximately twice as much as a targeted program but reduces influenza cases by 61% and mortality by 28%, saving an estimated 1,134 QALYs per season overall. Reducing influenza cases decreases health care services cost by 52%. Most cost savings can be attributed to hospitalizations avoided. The incremental cost-effectiveness ratio is Can$10,797/QALY gained. Results are most sensitive to immunization cost and number of deaths averted.

Conclusions

Universal immunization against seasonal influenza was estimated to be an economically attractive intervention. Please see later in the article for the Editors'' Summary     

The Fast Changing Landscape of Sequencing Technologies and Their Impact on Microbial Genome Assemblies and Annotation

Background

The emergence of next generation sequencing (NGS) has provided the means for rapid and high throughput sequencing and data generation at low cost, while concomitantly creating a new set of challenges. The number of available assembled microbial genomes continues to grow rapidly and their quality reflects the quality of the sequencing technology used, but also of the analysis software employed for assembly and annotation.

Methodology/Principal Findings

In this work, we have explored the quality of the microbial draft genomes across various sequencing technologies. We have compared the draft and finished assemblies of 133 microbial genomes sequenced at the Department of Energy-Joint Genome Institute and finished at the Los Alamos National Laboratory using a variety of combinations of sequencing technologies, reflecting the transition of the institute from Sanger-based sequencing platforms to NGS platforms. The quality of the public assemblies and of the associated gene annotations was evaluated using various metrics. Results obtained with the different sequencing technologies, as well as their effects on downstream processes, were analyzed. Our results demonstrate that the Illumina HiSeq 2000 sequencing system, the primary sequencing technology currently used for de novo genome sequencing and assembly at JGI, has various advantages in terms of total sequence throughput and cost, but it also introduces challenges for the downstream analyses. In all cases assembly results although on average are of high quality, need to be viewed critically and consider sources of errors in them prior to analysis.

Conclusion

These data follow the evolution of microbial sequencing and downstream processing at the JGI from draft genome sequences with large gaps corresponding to missing genes of significant biological role to assemblies with multiple small gaps (Illumina) and finally to assemblies that generate almost complete genomes (Illumina+PacBio).     

Impact of a New Reimbursement Program on Hepatitis B Antiviral Medication Cost and Utilization in Beijing,China

Background

Hepatitis B virus (HBV) infection is a significant clinical and financial burden for chronic hepatitis B (CHB) patients. In Beijing, China, partial reimbursement on antiviral agents was first implemented for the treatment of CHB patients in July 1, 2011.

Aims

In this study, we describe the medical cost and utilization rates of antiviral therapy for CHB patients to explore the impact of the new partial reimbursement policy on the medical care cost, the composition, and antivirals utilization.

Methods

Clinical and claims data of a retrospective cohort of 92,776 outpatients and 2,774 inpatients with non-cirrhotic CHB were retrieved and analyzed from You''an Hospital, Beijing between February 14, 2008 and December 31, 2012. The propensity score matching was used to adjust factors associated with the annual total cost, including age, gender, medical insurance type and treatment indicator.

Results

Compared to patients who paid out-of-pocket, medical cost, especially antiviral costs increased greater among patients with medical insurance after July 1, 2011, the start date of reimbursement policy. Outpatients with medical insurance had 16% more antiviral utilization; usage increased 3% among those who paid out-of-pocket after the new partial reimbursement policy was implemented.

Conclusions

Direct medical costs and antiviral utilization rates of CHB patients with medical insurance were higher than those from paid out-of-pocket payments, even after adjusting for inflation and other factors. Thus, a new partial reimbursement program may positively optimize the cost and standardization of antiviral treatment.     

The Impact of Japan's 2004 Postgraduate Training Program on Intra-Prefectural Distribution of Pediatricians in Japan

Objective

Inequity in physician distribution poses a challenge to many health systems. In Japan, a new postgraduate training program for all new medical graduates was introduced in 2004, and researchers have argued that this program has increased inequalities in physician distribution. We examined the trends in the geographic distribution of pediatricians as well as all physicians from 1996 to 2010 to identify the impact of the launch of the new training program.

Methods

The Gini coefficient was calculated using municipalities as the study unit within each prefecture to assess whether there were significant changes in the intra-prefectural distribution of all physicians and pediatricians before and after the launch of the new training program. The effect of the new program was quantified by estimating the difference in the slope in the time trend of the Gini coefficients before and after 2004 using a linear change-point regression design. We categorized 47 prefectures in Japan into two groups: 1) predominantly urban and 2) others by the definition from OECD to conduct stratified analyses by urban-rural status.

Results

The trends in physician distribution worsened after 2004 for all physicians (p value<.0001) and pediatricians (p value = 0.0057). For all physicians, the trends worsened after 2004 both in predominantly urban prefectures (p value = 0.0012) and others (p value<0.0001), whereas, for pediatricians, the distribution worsened in others (p value = 0.0343), but not in predominantly urban prefectures (p value = 0.0584).

Conclusion

The intra-prefectural distribution of physicians worsened after the launch of the new training program, which may reflect the impact of the new postgraduate program. In pediatrics, changes in the Gini trend differed significantly before and after the launch of the new training program in others, but not in predominantly urban prefectures. Further observation is needed to explore how this difference in trends affects the health status of the child population.     

More Evidence on the Impact of India's Conditional Cash Transfer Program,Janani Suraksha Yojana: Quasi-Experimental Evaluation of the Effects on Childhood Immunization and Other Reproductive and Child Health Outcomes

Background

In 2005, India established a conditional cash transfer program called Janani Suraksha Yojana (JSY), to increase institutional delivery and encourage the use of reproductive and child health-related services.

Objective

To assess the effect of maternal receipt of financial assistance from JSY on childhood immunizations, post-partum care, breastfeeding practices, and care-seeking behaviors.

Methods

We use data from the latest district-level household survey (2007–2008) to conduct a propensity score matching analysis with logistic regression. We conduct the analyses at the national level as well as separately across groups of states classified as high-focus and non-high-focus. We carry out several sensitivity analyses including a subgroup analysis stratified by possession of an immunization card.

Results

Receipt of financial assistance from JSY led to an increase in immunization rates ranging from 3.1 (95%CI 2.2–4.0) percentage points for one dose of polio vaccine to 9.1 (95%CI 7.5–10.7) percentage points in the proportion of fully vaccinated children. Our findings also indicate JSY led to increased post-partum check-up rates and healthy early breastfeeding practices around the time of childbirth. No effect of JSY was found on exclusive breastfeeding practices and care-seeking behaviors. Effect sizes were consistently larger in states identified as being a key focus for the program. In an analysis stratified by possession of an immunization card, there was little to no effect of JSY among those with vaccination cards, while the effect size was much larger than the base case results for those missing vaccination cards, across nearly all immunization outcomes.

Conclusions

Early results suggest the JSY program led to a significant increase in childhood immunization rates and some healthy reproductive health behaviors, but the structuring of financial incentives to pregnant women and health workers warrants further review. Causal interpretation of our results relies on the assumption that propensity scores balance unobservable characteristics.     

The Cost and Impact of the Interim Federal Health Program Cuts on Child Refugees in Canada

Introduction

On June 30, 2012, Interim Federal Health Program (IFHP) funding was cut for refugee claimant healthcare. The potential financial and healthcare impacts of these cuts on refugee claimants are unknown.

Methods

We conducted a one-year retrospective chart review spanning 6 months before and after IFHP funding cuts at The Hospital for Sick Children, a tertiary care children''s hospital in Toronto. We analyzed emergency room visits characteristics, admission rates, reasons for admission, and financial records including billing from Medavie Blue Cross.

Results

There were 173 refugee children visits to the emergency room in the six months before and 142 visits in the six months after funding cuts. The total amount billed to the IFHP program during the one-year of this study was $131,615. Prior to the IFHP cuts, 46% of the total emergency room bills were paid by IFHP compared to 7% after the cuts (p<0.001).

Interpretation

After the cuts to the IFHP, The Hospital for Sick Children was unable to obtain federal health coverage for the vast majority of refugee claimant children registered under the IFHP. This preliminary analysis showed that post-IFHP cuts healthcare costs at the largest tertiary pediatric institution in the country increased.     

The Changing State of Surfactant Lipids: New Insights from Ancient Animals

SYNOPSIS. Pulmonary surfactant is a mixture of phospholipids(including disaturated phospholipids), cholesterol and proteinslining the air-liquid interface within the lung. Surfactantacts to reduce surface tension, thereby increasing lungcomplianceand also preventing edema. The saccular lungs, or other gas-holdingstructures, of nonmammals have 7–70% more surfactant/cm²of surface than lungs of mammals. Nonmammalian surfactant actsas an antiglue that decreases the inflation pressures of collapsedlungs by reducing the adherence of apposing epithelial surfaces.The autonomic nervous system appears to be the primary systemcontrolling release of surfactant in nonmammals. The lipid compositionis highly conserved within the vertebrates, except that surfactantof teleost fish is dominated by cholesterol whereas tetrapodsurfactant consists primarily of disaturated phospholipids (DSP).The dipnoan Neoceratodus forsteri demonstrates a "fish-type"surfactant profile while the other derived dipnoans demonstratea surfactant profile similar to that of tetrapods. Homologyof the surfactant protein SP-A within the vertebrates pointsto a single evolutionaryorigin for the system and indicatesthat fish surfactant is a "protosurfactant". Amongst the tetrapods,the relative proportions of DSP and cholesterol vary in responseto lung structure, habitat, and body temperature (T_b) but notin relation to phytogeny. The cholesterol content of surfactantis elevated in species with simple saccular lungs, in aquaticspecies, and in species with low T_b. The DSP content is highestin complex lungs, particularly ofaquatic species or specieswith high T_b. The cholesterol content of surfactant also increasesin response to acute decreases in Tb in lizards and torpid marsupials,presumably to maintain fluidity of the lipid mixture.     

The Environmental Impact of Two Australian Rock Lobster Fishery Supply Chains under a Changing Climate

Understanding the potential future impacts of climate change along the supply chain for highly traded fisheries products can inform choices to enhance future global seafood security. We examine the supply chains of the Australian tropical rock lobster fishery (TRL) and southern rock lobster fishery (SRL), with similar destination markets but different catch methods and fishing communities. A boat‐to‐market analysis allows for comparison and illustration of the effects of single supply‐chain aspects. We used life cycle assessment to provide an overview of the environmental footprint, expressed as global warming potential (GWP), eutrophication, and cumulative energy demand, for two lobster products: live animals and frozen tails. The export phase contributed 44% and 56% of GWP of live‐weight lobster for SRL and TRL, respectively. The SRL fishery currently produces 68% of the combined 1,806.7 tonnes of lobster product and 78% of the combined global warming for the two fisheries over the whole supply chain. We develop climate adaptation options that: (1) reduce the overall footprint; (2) consider alternative supply‐chain strategies (e.g., reduce cost); and (3) predicted impact of future climate change. Adaptation options include: more direct export routes and change in the export transport mode. Value adding and product differentiation, which can level out seasonality and thus spread risk, is likely to become increasingly important for both increases and decreases in predicted climate‐induced abundance of fish species.     

Rapid Emergence of Free-Riding Behavior in New Pediatric Immunization Programs

Background

Mathematical models have formalized how free-rider effects can threaten the stability of high vaccine coverage levels under established voluntary vaccination programs. However, little research has addressed the question of when free-riding begins to develop when a new vaccine is first introduced in a population.

Methodology/Principal Findings

Here, we combine a game theoretical model of vaccinating behavior with an age-structured compartmental model to analyze rational vaccinating behavior in the first years of a universal immunization program, where a new vaccine is free to all children of a specified age. The model captures how successive birth cohorts face different epidemiological landscapes that have been shaped by the vaccinating decisions of previous birth cohorts, resulting in a strategic interaction between individuals in different birth cohorts. The model predicts a Nash equilibrium coverage level of for the first few birth cohorts under the new program. However, free-riding behavior emerges very quickly, with the Nash equilibrium vaccine coverage dropping significantly within 2-5 years after program initiation. Subsequently, a rich set of coupled dynamics between infection prevalence and vaccinating behaviors is possible, ranging from relatively stable (but reduced) coverage in later birth cohorts to wide fluctuations in vaccine coverage from one birth cohort to the next. Individual tolerance for vaccine risk also starts out at relatively high levels before dropping significantly within a few years.

Conclusions/Significance

These results suggest that even relatively new immunization programs can be vulnerable to drops in vaccine coverage caused by vaccine scares and exacerbated by herd immunity effects, necessitating vigilance from the start.