Out of Control: Patients Are Unwittingly Subjected to Enormous, Unfair, Out-of-Network "Balance Bills"

Excessive medical debt resulting from the provision of health care can cause families and individuals to spend down their savings, forego medical treatment, and even go without paying for food and heat. In the United States, medical bills are the leading cause of individual and family bankruptcy. In 1981, only 8 percent of families filing for bankruptcy protection did so in the aftermath of receiving medical care.However, by 2007, more than 62 percent of all bankruptcies were linked to a medical event, according to a study published in the American Journal of Medicine. And bankruptcy was not limited to the uninsured. To the contrary, the study reported that more than 75 percent of filers had health insurance.One driver of excessive health care bills is a practice known as "balance billing," which refers to bills for the difference between the amount that an insurance company is willing to pay for treatment and a provider's total charges. Providers who are not members of a patient's insurance network have charged patients as much as 9,000 percent of what Medicare would have paid for the same procedure.In contrast, payment for in-network medical services is on average 123 percent of Medicare.Patients can be subjected to balance bills despite making their best efforts to avoid them. For instance, they might receive care at an in-network facility, only to find out later that an out-of-network doctor also provided medical services. This is because many doctors work at hospitals rather than for hospitals, and are not members of the same insurance network as the hospital.Solutions are possible at both the federal and state levels that would protect consumers from balance bills without unduly burdening providers or insurers, or upsetting the existing system of insurance networks. This paper outlines policies that have been implemented at each of these levels and proposes additional protections at the federal level

Beware of a Naive Perspective: A Prebuttal to Possible U.S. Supreme Court Rulings in McCutcheon v. Federal Election Commission (Part 2)

Many believe that U.S. Supreme Court Chief Justice Roberts will provide the swing vote in the court's decision in Shaun McCutcheon v. Federal Election Commission (McCutcheon), a case challenging the constitutionality of caps on the total amount of campaign contributions an individual may make to candidates, political parties, and political action committees. Based on his comments during oral arguments, some have speculated that Roberts will vote to strike down limits on aggregate contributions to candidates but will support maintaining limits on contributions to parties and political action committees (PACs).We illustrated in Part 1 of this two-part series that eliminating limits on aggregate contributions to candidates while leaving other aggregate limits intact would enable joint fundraising committees (JFCs) operated by party leaders and elected officials to solicit contributions as large as $2.5 million from a single donor. This report shows that a supposed middle ground that permitted unlimited aggregate contributions to candidates but retained caps on contributions to parties would also likely end up eroding the integrity of limits on contributions to parties.Under a scenario in which only caps on total contributions to candidates were struck down, the party leaders and elected officials who administer joint fundraising committees would likely end up soliciting checks of more than$2.5 million from major donors. The vast majority of these contributions would be distributed to candidates in increments of $5,200 per recipient. However, because candidates could transfer their share of contributions received from JFCs to party committees, leaders of JFCs, would likely pressure candidates, the majority of whom are running in uncompetitive races, to redirect that money to back party committees.Using conservative estimates about the number of major donors that would contribute$2.5 million to a joint fundraising committee if the court eliminated caps on total contributions to candidates, and data on the number of competitive and non-competitive congressional races in recent election cycles, we estimate that eliminating the aggregate limit on contributions to candidates could enable candidates to transfer more than $74 million to the national party committees combined. Each donor would effectively be contributing the equivalent of more than$1.8 million to party committees, or more than 24 times the legal limit

Beware of a Naive Perspective: A Prebuttal to Possible U.S. Supreme Court Rulings in McCutcheon v. Federal Election Commission (Part 1)

In October 2013, the U.S. Supreme Court heard oral arguments in Shaun McCutcheon v. Federal Election Commission, a case that challenges federal limits on the grand total an individual can contribute to federal candidates, political parties, and political action committees (PACs). In Part 1 of this two-part series, we examine several options available to the court and how potential outcomes could transform how candidates and parties can raise money

Synergy of debris mitigation and removal

At the beginning of the twenty-first century there was considerable effort made using evolutionary models to assess the effectiveness of post-mission disposal (PMD) and other mitigation measures to stabilise the growth of the debris population in low Earth orbit (LEO). Subsequently, this activity led to the recommendation of a “25-year rule” for the post-mission disposal of spacecraft and orbital stages intersecting the LEO region. At the time, it was anticipated that the 25-year rule, together with passivation and suppression of mission-related debris, would be sufficient to prevent the continued growth of the LEO debris population. However, in the last decade both the LEO debris environment and the debris modelling capability have seen significant changes. In particular, recent population growth has been driven by a number of major break-ups, including the intentional destruction of the Fengyun-1C spacecraft and the collision between Iridium 33 and Cosmos 2251. State-of-the-art evolutionary models now indicate that mitigation measures alone are insufficient to stabilise the LEO debris population. Consequently, this has led to considerable interest in the remediation of the debris environment and, especially, in debris removal. Yet there is a reluctance to revisit the role of PMD within the wider goal of remediation even though it does not provide the solution that was expected. Thus, there is a risk that the approach to remediation will follow a sequential, “over-the-fence” philosophy, which tends to deliver costly, and less than optimal solutions. In this paper, we present a new and large study of debris mitigation and removal using the University of Southampton’s evolutionary model, DAMAGE, together with the latest MASTER model population of objects > 10 cm in LEO. Here, we have employed a concurrent approach to remediation, whereby changes to the PMD rule and the inclusion of other mitigation measures have been considered alongside multiple removal strategies. In this way, we have been able to demonstrate the synergy of these measures and to identify aggregate solutions to the space debris problem. The results suggest that reducing the PMD decay rule offers benefits that include an increase in the effectiveness of debris removal and a corresponding increase in the confidence that these combined measures will lead to the stabilisation of the LEO debris population

Kinematic Leg Therapy Device

ME450 Capstone Design and Manufacturing Experience: Fall 2015This project’s sponsor, Dr. Ben Dwamena, was a young aspiring engineering student in Ghana until he was encouraged down the medical path in his early schooling. Dr. Dwamena has no use of his legs and needs a wheelchair to move about. There are many downsides that are associated from this type of physical assistance: bed sores, muscle atrophy, poor blood circulation, kidney stones, and urinary health issues. Dr. Dwamena was able to purchase a standup wheelchair that helps with a few of these ailments, but he wanted to create a better wheelchair. To improve blood circulation, decrease muscle atrophy, and lessen the chances of bed sores, Dr. Dwamena asked the University of Michigan to create an automated leg moving device that would work in his stand up wheelchair. The device would mimic a stand-still walking motion while he is in the standing position in his wheelchair. This would help with all the alignments listed above. The objective of this project was to provide a more accessible and user friendly method of kinesiotherapy for individuals without the use of their legs.http://deepblue.lib.umich.edu/bitstream/2027.42/117340/1/ME450-F15-Project23-FinalReport.pd

Laboratory Measurement of the Anticoagulant Activity of the Non–Vitamin K Oral Anticoagulants

AbstractBackgroundNon–vitamin K oral anticoagulants (NOACs) do not require routine laboratory monitoring. However, laboratory measurement may be desirable in special situations and populations.ObjectivesThis study’s objective was to systematically review and summarize current evidence regarding laboratory measurement of the anticoagulant activity of dabigatran, rivaroxaban, and apixaban.MethodsWe searched PubMed and Web of Science for studies that reported a relationship between drug levels of dabigatran, rivaroxaban, and apixaban and coagulation assay results. Study quality was evaluated using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2).ResultsWe identified 17 eligible studies for dabigatran, 15 for rivaroxaban, and 4 for apixaban. For dabigatran, a normal thrombin time excludes clinically relevant drug concentrations. The activated partial thromboplastin time (APTT) and prothrombin time (PT) are less sensitive and may be normal at trough drug levels. The dilute thrombin time (R2 = 0.92 to 0.99) and ecarin-based assays (R2 = 0.92 to 1.00) show excellent linearity across on-therapy drug concentrations and may be used for drug quantification. For rivaroxaban and apixaban, anti-Xa activity is linear (R2 = 0.89 to 1.00) over a wide range of drug levels and may be used for drug quantification. Undetectable anti-Xa activity likely excludes clinically relevant drug concentrations. The PT is less sensitive (especially for apixaban); a normal PT may not exclude clinically relevant levels. The APTT demonstrates insufficient sensitivity and linearity for quantification.ConclusionsDabigatran, rivaroxaban, and apixaban exhibit variable effects on coagulation assays. Understanding these effects facilitates interpretation of test results in NOAC-treated patients. More information on the relationship between drug levels and clinical outcomes is needed

Long term health care use and costs in patients with stable coronary artery disease : a population based cohort using linked electronic health records (CALIBER)

Aims To examine long term health care utilisation and costs of patients with stable coronary artery disease (SCAD). Methods and results Linked cohort study of 94,966 patients with SCAD in England, 1st January 2001 to 31st March 2010, identified from primary care, secondary care, disease and death registries. Resource use and costs, and cost predictors by time and 5-year cardiovascular (CVD) risk profile were estimated using generalised linear models. Coronary heart disease hospitalisations were 20.5% in the first year and 66% in the year following a non-fatal (myocardial infarction, ischaemic or haemorrhagic stroke) event. Mean health care costs were £3,133 per patient in the first year and £10,377 in the year following a non-fatal event. First year predictors of cost included sex (mean cost £549 lower in females); SCAD diagnosis (NSTEMI cost £656 more than stable angina); and co-morbidities (heart failure cost £657 more per patient). Compared with lower risk patients (5-year CVD risk 3.5%), those of higher risk (5-year CVD risk 44.2%) had higher 5-year costs (£23,393 vs. £9,335) and lower lifetime costs (£43,020 vs. £116,888). Conclusion Patients with SCAD incur substantial health care utilisation and costs, which varies and may be predicted by 5-year CVD risk profile. Higher risk patients have higher initial but lower lifetime costs than lower risk patients as a result of shorter life expectancy. Improved cardiovascular survivorship among an ageing CVD population is likely to require stratified care in anticipation of the burgeoning demand

Mechanisms of action and outcomes for students in Recovery Colleges

Objective\ud Recovery Colleges are widespread, with little empirical research on how they work and outcomes they produce. This study aimed to co-produce a change model characterising mechanisms of action and outcomes for mental health service users attending as students at a Recovery College.\ud Methods\ud A systematised review identified all Recovery College publications. Inductive collaborative data analysis by academic researchers and co-researchers with lived experience of ten key papers informed a theoretical framework for mechanisms and outcome for students, which was refined through deductive analysis of 34 further publications. A change model was co-produced and then refined through stakeholder interviews (n=33).\ud Results\ud Three mechanisms of action for Recovery College students were identified: empowering environment (safety, respect, supporting choices), enabling different relationships (power, peers, working together) and facilitating personal growth (e.g. co-produced learning, strengths, celebrating success). Outcomes were change in the student (e.g. self-understanding, self-confidence) and changes in the student’s life (e.g. occupational, social, service use). A co-produced change model mapping mechanisms of action to outcomes was created.\ud Conclusions\ud The key features identified as differentiating Recovery Colleges from traditional services are an empowering environment, enabling relationships and growth orientation. Recovery Colleges may benefit most attenders, but mental health service users to particularly encourage to enrol may include those who lack confidence, those who services struggle to engage with, those who will benefit from exposure to peer role models, and those lacking social capital. The change model provides the first testable characterisation of mechanisms and outcomes, allowing formal evaluation of Recovery Colleges

Using electronic health records to predict costs and outcomes in stable coronary artery disease

OBJECTIVES: To use electronic health records (EHR) to predict lifetime costs and health outcomes of patients with stable coronary artery disease (stable-CAD) stratified by their risk of future cardiovascular events, and to evaluate the cost-effectiveness of treatments targeted at these populations. METHODS: The analysis was based on 94 966 patients with stable-CAD in England between 2001 and 2010, identified in four prospectively collected, linked EHR sources. Markov modelling was used to estimate lifetime costs and quality-adjusted life years (QALYs) stratified by baseline cardiovascular risk. RESULTS: For the lowest risk tenth of patients with stable-CAD, predicted discounted remaining lifetime healthcare costs and QALYs were £62 210 (95% CI £33 724 to £90 043) and 12.0 (95% CI 11.5 to 12.5) years, respectively. For the highest risk tenth of the population, the equivalent costs and QALYs were £35 549 (95% CI £31 679 to £39 615) and 2.9 (95% CI 2.6 to 3.1) years, respectively. A new treatment with a hazard reduction of 20% for myocardial infarction, stroke and cardiovascular disease death and no side-effects would be cost-effective if priced below £72 per year for the lowest risk patients and £646 per year for the highest risk patients. CONCLUSIONS: Existing EHRs may be used to estimate lifetime healthcare costs and outcomes of patients with stable-CAD. The stable-CAD model developed in this study lends itself to informing decisions about commissioning, pricing and reimbursement. At current prices, to be cost-effective some established as well as future stable-CAD treatments may require stratification by patient risk