A New State Plan Option to Integrate Care and Financing for Persons Dually Eligible for Medicare and Medicaid

As health care costs continue to escalate, Congress, the U.S. Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS), state Medicaid agencies, researchers, and policymakers are focusing on identifying new approaches to care delivery and reimbursement for individuals who are dually eligible for both Medicare and Medicaid. Although relatively few in number (9 million), dual eligible beneficiaries are more likely than others to experience poor health, including multiple chronic conditions, functional and cognitive impairments, and a need for continuous care. Sixty-six percent of dual eligibles have three or more chronic conditions; sixty-one percent are considered to be cognitively or mentally impaired. As a result, the dual eligible population, as a whole, is very expensive for both the Medicare and Medicaid programs. In 2006, dual eligible beneficiaries accounted for approximately $230 billion in federal and state spending. This represented almost 36 percent of total Medicare spending and 39 percent of Medicaid spending. Despite this high level of spending, concerns persist with respect to the quality of care these individuals receive, their heightened risk for potentially preventable high-cost episodes of care, and the potential for unmet needs due to differences in the two public programs (Medicare and Medicaid) on which dual eligibles are highly dependent for care

Second-Generation Consumerism: Increasing Consumer Activation to Improve Health Outcomes and Lower Costs for Patients with Chronic Disease

With health care costs increasing, some policymakers have sought to make patients better health care consumers through increased cost-sharing linked with greater information on the cost of care. These may be successful cost containment strategies in the short term. But patients are just as likely to forgo necessary as unnecessary care, which ultimately leads to greater demand for more intensive and expensive care in the long term. Patients can, however, play an important role in preventing the onset of chronic conditions or preventing deterioration in health once they have been diagnosed with a chronic condition. In this chapter we discuss tools available to identify and empower—or activate —patients to be better managers of their health. We also suggest heath care delivery reform options to encourage the expansion of programs that empower patients to improve their health and control personal health care costs, thereby improving health outcomes and containing costs for all

The Essential Health Benefits Provisions of the Affordable Care Act: Implications for People with Disabilities

In establishing minimum coverage standards for health insurance plans, the Affordable Care Act includes an essential health benefits statute that directs the U.S. Secretary of Health and Human Services not to make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life. This issue brief examines how this statute will help Americans with disabilities, who currently are subject to discrimination by insurers based on health status and health care need. The authors also discuss the complex issues involved in implementing the essential benefits provision and offer recommendations to federal policymakers for ensuring that people with disabilities receive the full insurance benefits to which they are entitled

Stable incidence rates of tuberculosis (TB) among human immunodeficiency virus (HIV)-negative South African gold miners during a decade of epidemic HIV-associated TB.

During the last decade, annual tuberculosis (TB) case-notification rates increased 4-fold, to >4000 cases/100000 person-years, in the study workforce, among whom prevalence of human immunodeficiency virus (HIV) was 30% in 2000. Three separate cohort studies, totalling 6454 HIV-negative participants, were combined and analyzed for time trends. Observed incidence of TB varied between 962 (1991-1994) and 1589 (1999-2000) cases/100000 person-years (P=.17, test for trend). There was, however, a progressive increase in age, and, for each period, older age was associated with increased incidence rates of TB (P<.001). Having adjusted for age differences, there was no significant association between incidence of TB and calendar period (P=.81, test for trend). Relative to 1991-1994, multivariate-adjusted incidence-rate ratios were 0.94, for 1995-1997, 0.96, for 1998-1999, and 1.05, for 1999-2000. Preventing a secondary epidemic of TB among HIV-negative individuals may be achievable with conventional means, even in settings with a high burden of HIV-associated TB

Microbicides development programme: engaging the community in the standard of care debate in a vaginal microbicide trial in Mwanza, Tanzania.

BACKGROUND: HIV prevention research in resource-limited countries is associated with a variety of ethical dilemmas. Key amongst these is the question of what constitutes an appropriate standard of health care (SoC) for participants in HIV prevention trials. This paper describes a community-focused approach to develop a locally-appropriate SoC in the context of a phase III vaginal microbicide trial in Mwanza City, northwest Tanzania. METHODS: A mobile community-based sexual and reproductive health service for women working as informal food vendors or in traditional and modern bars, restaurants, hotels and guesthouses has been established in 10 city wards. Wards were divided into geographical clusters and community representatives elected at cluster and ward level. A city-level Community Advisory Committee (CAC) with representatives from each ward has been established. Workshops and community meetings at ward and city-level have explored project-related concerns using tools adapted from participatory learning and action techniques e.g. chapati diagrams, pair-wise ranking. Secondary stakeholders representing local public-sector and non-governmental health and social care providers have formed a trial Stakeholders' Advisory Group (SAG), which includes two CAC representatives. RESULTS: Key recommendations from participatory community workshops, CAC and SAG meetings conducted in the first year of the trial relate to the quality and range of clinic services provided at study clinics as well as broader standard of care issues. Recommendations have included streamlining clinic services to reduce waiting times, expanding services to include the children and spouses of participants and providing care for common local conditions such as malaria. Participants, community representatives and stakeholders felt there was an ethical obligation to ensure effective access to antiretroviral drugs and to provide supportive community-based care for women identified as HIV positive during the trial. This obligation includes ensuring sustainable, post-trial access to these services. Post-trial access to an effective vaginal microbicide was also felt to be a moral imperative. CONCLUSION: Participatory methodologies enabled effective partnerships between researchers, participant representatives and community stakeholders to be developed and facilitated local dialogue and consensus on what constitutes a locally-appropriate standard of care in the context of a vaginal microbicide trial in this setting. TRIAL REGISTRATION: Current Controlled Trials ISRCTN64716212

The Affordable Care Act: U.S. Vaccine Policy and Practice

When fully implemented, the Patient Protection and Affordable Care Act, amended by the Health and Education Reconciliation Act will extend health insurance coverage to 94 percent of Americans while establishing a comprehensive set of strategies to improve care and contain costs. The central provisions of the Act – guaranteed affordable and accessible coverage – take effect January 1, 2014. Important insurance reforms aimed at improving coverage become effective before that date, as do a series of investments aimed at improving the accessibility and quality of health care. This report has several aims: 1) to examine how the laws address vaccine policy and practice; 2) to assess how access to vaccines and immunization services will be affected; and 3) to assess the extent to which health reform addresses recommendations of the National Vaccine Advisory Committee\u27s (NVAC) Vaccine Finance Working Group (VFWG) 2008

“Making Every Second Count”: Utilizing TikTok and Systems Thinking to Facilitate Scientific Public Engagement and Contextualization of Chemistry at Home

TikTok is a social media video-based phone application which enables creative and engaging videos to be shared on social media platforms worldwide. TikTok has been applied to create fun, exciting, and engaging 15–60 s long chemistry outreach educational videos, to encourage public dissemination of science with a systems thinking approach. With the creation of an online TikTok account called “The Chemistry Collective” by undergraduate students, 16 educational videos were created, with approximately 8,500 views. Upon surveying participants, viewers of these TikTok videos strongly agreed that they had learned something new about chemistry since watching these videos (4.66/5.00) and had an increased interest in chemistry (82.7% agreed). As such, TikTok can be used to enhance public and undergraduate student engagement with chemistry and science education, together with facilitating the ability of the public to understand how chemistry can be fun, can be performed at home, and is part of our daily lives

Polycyclic aromatic hydrocarbons (PAH) and polychlorinated biphenyls (PCB) in urban soils of Greater London, UK

Surface soils from a 19 km2 area in east London, UK were analysed for polycyclic aromatic hydrocarbons (PAH) and polychlorinated biphenyls (PCB) (n = 76). ∑16 PAH ranged from 4 to 67 mg/kg (mean, 18 mg/kg) and ∑50 PAH ranged from 6 to 88 mg/kg (mean, 25 mg/kg). ∑7 PCB ranged from 1 to 750 μg/kg (mean, 22 μg/kg) and ∑tri-hepta PCB ranged 9 to 2600 μg/kg (mean, 120 μg/kg). Compared to other international cities concentrations were similar for PAH but higher for PCB. Normal background concentrations (NBC) were calculated and compared to risk-based human health generic assessment criteria (GAC). Benzo[a]pyrene NBC for urban (6.9 mg/kg), semi-urban (4.4 mg/kg) and urban + semi urban (6 mg/kg) domains exceed residential (1 mg/kg) and allotment (2.2 mg/kg) LQM/CIEH GAC (at 6% SOM) and the Indeno[1,2,3-cd]pyrene NBC for urban (6.8 mg/kg) and urban + semi-urban (5.2 mg/kg) domains exceed the residential (4.2 mg/kg) LQM/CIEH GAC (at 6% SOM). Capsule Abstract: Normal background concentrations of polycyclic aromatic hydrocarbons and polychlorinated biphenyls are elevated in east London soils and in some cases exceed regulatory assessment criteria

Cluster randomised trials with a binary outcome and a small number of clusters: comparison of individual and cluster level analysis method.

BACKGROUND: Cluster randomised trials (CRTs) are often designed with a small number of clusters, but it is not clear which analysis methods are optimal when the outcome is binary. This simulation study aimed to determine (i) whether cluster-level analysis (CL), generalised linear mixed models (GLMM), and generalised estimating equations with sandwich variance (GEE) approaches maintain acceptable type-one error including the impact of non-normality of cluster effects and low prevalence, and if so (ii) which methods have the greatest power. We simulated CRTs with 8-30 clusters, altering the cluster-size, outcome prevalence, intracluster correlation coefficient, and cluster effect distribution. We analysed each dataset with weighted and unweighted CL; GLMM with adaptive quadrature and restricted pseudolikelihood; GEE with Kauermann-and-Carroll and Fay-and-Graubard sandwich variance using independent and exchangeable working correlation matrices. P-values were from a t-distribution with degrees of freedom (DoF) as clusters minus cluster-level parameters; GLMM pseudolikelihood also used Satterthwaite and Kenward-Roger DoF. RESULTS: Unweighted CL, GLMM pseudolikelihood, and Fay-and-Graubard GEE with independent or exchangeable working correlation matrix controlled type-one error in > 97% scenarios with clusters minus parameters DoF. Cluster-effect distribution and prevalence of outcome did not usually affect analysis method performance. GEE had the least power. With 20-30 clusters, GLMM had greater power than CL with varying cluster-size but similar power otherwise; with fewer clusters, GLMM had lower power with common cluster-size, similar power with medium variation, and greater power with large variation in cluster-size. CONCLUSION: We recommend that CRTs with ≤ 30 clusters and a binary outcome use an unweighted CL or restricted pseudolikelihood GLMM both with DoF clusters minus cluster-level parameters

Tuberculosis control in South African gold mines: mathematical modeling of a trial of community-wide isoniazid preventive therapy.

A recent major cluster randomized trial of screening, active disease treatment, and mass isoniazid preventive therapy for 9 months during 2006-2011 among South African gold miners showed reduced individual-level tuberculosis incidence but no detectable population-level impact. We fitted a dynamic mathematical model to trial data and explored 1) factors contributing to the lack of population-level impact, 2) the best-achievable impact if all implementation characteristics were increased to the highest level achieved during the trial ("optimized intervention"), and 3) how tuberculosis might be better controlled with additional interventions (improving diagnostics, reducing treatment delay, providing isoniazid preventive therapy continuously to human immunodeficiency virus-positive people, or scaling up antiretroviral treatment coverage) individually and in combination. We found the following: 1) The model suggests that a small proportion of latent infections among human immunodeficiency virus-positive people were cured, which could have been a key factor explaining the lack of detectable population-level impact. 2) The optimized implementation increased impact by only 10%. 3) Implementing additional interventions individually and in combination led to up to 30% and 75% reductions, respectively, in tuberculosis incidence after 10 years. Tuberculosis control requires a combination prevention approach, including health systems strengthening to minimize treatment delay, improving diagnostics, increased antiretroviral treatment coverage, and effective preventive treatment regimens