Limited Options to Manage Specialty Drug Spending

Outlines rising trends in costs of and spending on specialty drugs; health plans' efforts to curb specialty drug spending, including patient cost sharing and utilization management; and efforts to integrate medical and pharmaceutical coverage

Employer-Sponsored Health Insurance: Down, But Not Out

Presents findings from twelve metropolitan areas about employers' efforts to control employee healthcare costs in response to the recession and national healthcare reform by firm size. Projects employer trends through 2014, including greater cost sharing

Implications of Rhode Island’s Global Consumer Choice Compact Medicaid Waiver for Block Granting Medicaid and Other Retrenchment

On January 16, 2009, the Federal government approved Rhode Island’s application for a Global Consumer Choice Compact Medicaid Waiver whereby the state became the first granted permission to operate its entire Medicaid program under the state plan and a single 1115 “research and demonstration” waiver. The Global Waiver has been implemented in the context of Republican proposals to turn Medicaid into a block grant which would give states substantially more flexibility administering the program in exchange for receiving an upfront allotment from the Federal government. Proponents have held up the Global Waiver as a successful example of what might be achieved nationally if all states received block grants to run their Medicaid programs. This study draws lessons from Rhode Island’s Global Waiver for the Medicaid block grant debate. Data derive from 325 archival sources and 26 semi-structured interviews. Results indicate that the Global Waiver is not a block grant but a capped federal match where the state is required to spend its own money before receiving the federal contribution. Moreover, the state did not receive unlimited discretion to administer Medicaid under the Global Waiver nor achieved nearly as much savings as has been claimed. Indeed, most savings obtained by Rhode Island during this time period derive not from efficiencies stemming from the Global Waiver but from increased federal spending and from measures the state could have implemented independently of the waiver. The generosity of the Global Waiver is in marked contrast to most block grant proposals which would substantially reduce the level of federal fiscal support. In the near future, turning Medicaid into a block grant is not going to occur in light of President Obama’s reelection. Identifying the implications of RI’s experience for Medicaid retrenchment and the block grant debate is important, however, as some states eschew expanding the program under the Affordable Care Act and as proponents continue to propose block grant approach to Medicaid reform, both in future budget proposals and presidential party platforms

Implications of Rhode Island’s Global Consumer Choice Compact Medicaid Waiver for Rebalancing Long-Term Care under the Affordable Care Act

Federal approval of Rhode Island’s Global Consumer Choice Compact Global Waiver in 2009 provided Rhode Island with greater flexibility to modify its Medicaid program. Because 96% of long-term care expenditures in Rhode Island were directed toward institutional settings, a primary goal was to facilitate the state’s efforts to shift the locus of long-term care to non-institutional settings. This study draws lessons from Rhode Island’s experience with the Global Waiver for the long-term care rebalancing provisions of the Patient Protection and Affordable Care Act of 2010. Data derive from 325 archival sources and 26 semi-structured interviews. Results suggest that prospectively documenting home- and community-based services (HCBS) capacity is necessary to ensure that sufficient resources are available to meet the complex care needs of an increasingly larger service clientele. Results also suggest that increased reimbursement is especially important for attracting participating providers; so too is maintaining sufficient numbers of state regulators for purposes of monitoring quality. Barring the adoption of even more substantial changes in federal policy than included in the Affordable Care Act the distribution of long-term care spending is likely to remain stagnant in laggard states such as Rhode Island given just how difficult it is to make more than marginal progress despite the provision of additional options and incentives that otherwise should promote rebalancing. Nursing home care continues to be a mandatory benefit while most HCBS remains optional. This leaves investments in HCBS especially vulnerable to the vagaries of state budget and political processes, which when combined with the absence of minimum standards and requirements to cover all geographic areas and target populations, suggest persistent unmet need, both within and across states

Implications of Rhode Island’s Global Consumer Choice Compact Medicaid Waiver for Designing and Implementing State Health Reform

Provisions in the Medicaid statute permit states to apply for waivers from traditional program requirements. On January 16, 2009, the federal government approved Rhode Island\u27s Global Consumer Choice Compact Waiver. In exchange for a cap on combined federal and state spending of $12.075 billion through 2013, Rhode Island received greater flexibility to adopt certain Medicaid program changes. This study analyzes the design and implementation of the Global Waiver to draw general lessons for health reform at the state-level, a key concern given ongoing state discretion to improve their health care systems under the Patient Protection and Affordable Care Act. Data derive from 325 archival sources and 26 semi-structured interviews. The Global Waiver would not have happened without political and ideological alignment between Rhode Island’s Republican Governor and the Bush administration and the fractured nature of the waiver’s opposition across provider and advocacy groups. The waiver was motivated largely by ongoing fiscal and programmatic pressures. Development was dominated by state officials, working over a short time period characterized by growing budgetary uncertainty. Dissatisfaction in the level of outside input contributed to distrust among stakeholder groups. Subsequent legislative constraints together with insufficient administrative personnel and antiquated information systems hampered implementation. So too did remaining divisions among those overseeing, advocating, and serving different beneficiary communities. Specific lessons include: ensuring sufficient levels of stakeholder input and transparency throughout the program design, approval, and implementation process; devoting adequate personnel and informational resources to program administration, including coordination across disparate elements of the state bureaucracy; and carefully considering the breadth and timing of the reform strategy pursued; factors that promote adoption, for example, may, in turn, impede implementation

Data Files: The Role of Bus Stop Features in Facilitating Accessibility

These datasets support a final report published on NITC’s website “The Role of Bus Stop Features in Facilitating Accessibility”: https://nitc.trec.pdx.edu/research/project/1214. The DOI for the final report is: https://dx.doi.org/10.15760/trec.254

Altered Regulation of Aquaporin Gene Expression in Allergen and IL-13-Induced Mouse Models of Asthma

IL-13 is known to affect many processes that contribute to an asthmatic phenotype, including inflammation, fibrosis, and mucus production. Members of the aquaporin (AQP) family of transmembrane water channels are targets of regulation in models of lung injury and inflammation. Therefore, we examined AQP mRNA and protein expression in allergen and IL-13-induced mouse models of asthma. Lungs from ovalbumin sensitized and ovalbumin challenged (OVA/OVA) and IL-13 treated mice showed airway thickening, increased mucus production, and pulmonary eosinophilia. Pulmonary function tests showed a significant increase in methacholine-induced airway hyperreactivity in OVA/OVA and IL-13-treated mice as compared with controls. Quantitative PCR analysis revealed differential regulation of AQPs in these two models. AQP1 and AQP4 mRNA expression was downregulated in the OVA/OVA model, but not in the IL-13 model. AQP5 mRNA was reduced in both models, whereas AQP3 was upregulated only in the IL-13 model. Western analysis showed that diminished expression of an apically localized aquaporin, (AQP5), and concomitant upregulation of a basolateral aquaporin (AQP3 or AQP4) are characteristic features of both inducible asthma models. These results demonstrate that aquaporins are common targets of gene expression in both allergen and IL-13 induced mouse models of asthma

Intravenous doxycycline, azithromycin, or both for severe scrub typhus

BACKGROUND: The appropriate antibiotic treatment for severe scrub typhus, a neglected but widespread reemerging zoonotic infection, is unclear. METHODS: In this multicenter, double-blind, randomized, controlled trial, we compared the efficacy of intravenous doxycycline, azithromycin, or a combination of both in treating severe scrub typhus. Patients who were 15 years of age or older with severe scrub typhus with at least one organ involvement were enrolled. The patients were assigned to receive a 7-day course of intravenous doxycycline, azithromycin, or both (combination therapy). The primary outcome was a composite of death from any cause at day 28, persistent complications at day 7, and persistent fever at day 5. RESULTS: Among 794 patients (median age, 48 years) who were included in the modified intention-to-treat analysis, complications included those that were respiratory (in 62%), hepatic (in 54%), cardiovascular (in 42%), renal (in 30%), and neurologic (in 20%). The use of combination therapy resulted in a lower incidence of the composite primary outcome than the use of doxycycline (33% and 47%, respectively), for a risk difference of −13.3 percentage points (95% confidence interval [CI], (21.6 to −5.1; P=0.002). The incidence with combination therapy was also lower than that with azithromycin (48%), for a risk difference of −14.8 percentage points (95% CI, −23.1 to −6.5; P<0.001). No significant difference was seen between the azithromycin and doxycycline groups (risk difference, 1.5 percentage points; 95% CI, −7.0 to 10.0; P=0.73). The results in the per-protocol analysis were similar to those in the primary analysis. Adverse events and 28-day mortality were similar in the three groups. CONCLUSIONS: Combination therapy with intravenous doxycycline and azithromycin was a better therapeutic option for the treatment of severe scrub typhus than monotherapy with either drug alone. (Funded by the India Alliance and Wellcome Trust; INTREST Clinical Trials Registry–India number, CTRI/2018/08/015159.