Healthcare Provider Utilization and Patient Outcomes: The Call for Enhanced Coordinated Care for Medicare Beneficiaries

Background: The use of complementary and alternative medicine (CAM) and other non-physician health care providers (dentists, optometrists, etc.) has steadily increased in the United States; however, the associated outcomes reported in the Medicare population is limited. Objective: To evaluate the utilization of different healthcare providers by Medicare beneficiaries and assess resultant patient outcomes. Methods: Fourteen outreach events targeting Medicare beneficiaries were conducted throughout Northern/Central California during the 2014 open enrollment period. Trained student pharmacists (working under licensed pharmacist supervision) provided beneficiaries with comprehensive medication therapy management (MTM) services. During each intervention, demographic, quality-of-life, health behavior, and health provider/service utilization data were collected. Results: Of 620 respondents, 525 (84%) and 84 (14%) reported using at least one non-physician healthcare professional or CAM provider, respectively. Beneficiaries who reported using non-physician healthcare providers were significantly (p\u3c0.05) more likely to indicate being ‘very confident’ in managing their chronic health conditions. The number of providers seen with prescriptive authority was correlated with the number of prescription medications taken (rs=0.342, p\u3c0.001). The total number of providers seen was correlated with the number of drug related issues identified (rs= 0.179, p\u3c0.001). Beneficiaries using acupuncturists were significantly (p\u3c0.05) less likely to report having chronic pain. Conclusion: Many beneficiaries have multiple chronic conditions and increasingly utilize a variety of healthcare professionals. As such, bridging the communication chasm between these professionals can improve humanistic outcomes and minimize medication related issues of Medicare beneficiaries. Coordinated care, a key strategy for improving healthcare delivery under the Affordable Care Act, is a step in the right direction

Cost variability of suggested generic treatment alternatives under the Medicare Part D benefit

BACKGROUND: The substitution of generic treatment alternatives for brand-name drugs is a strategy that can help lower Medicare beneficiary out-of-pocket costs. Beginning in 2011, Medicare beneficiaries reaching the coverage gap received a 50% discount on the full drug cost of brand-name medications and a 7% discount on generic medications filled during the gap. This discount will increase until 2020, when beneficiaries will be responsible for 25% of total drug costs during the coverage gap. OBJECTIVE: To examine the cost variability of brand and generic drugs within 4 therapeutic classes before and during the coverage gap for each 2011 California stand-alone prescription drug plan (PDP) and prospective coverage gap costs in 2020 to determine the effects on beneficiary out-of-pocket drug costs. METHODS: Equivalent doses of brand and generic drugs in the following 4 pharmacological classes were examined: angiotensin II receptor blockers (ARBs), bisphosphonates, HMG-CoA reductase inhibitors (statins), and proton pump inhibitors (PPIs). The full drug cost and patient copay/coinsurance amounts during initial coverage and the coverage gap of each drug was recorded based on information retrieved from the Medicare website. These drug cost data were recorded for 28 California PDPs. RESULTS: The highest cost difference between a brand medication and a Centers for Medicare Medicaid Services (CMS)-suggested generic treatment alternative varied between $110.53 and$195.49 at full cost and between $51.37 and$82.35 in the coverage gap. The lowest cost difference varied between $38.45 and$76.93 at full cost and between -$4.11 and$18.52 during the gap. CONCLUSION: Medicare beneficiaries can realize significant out-of-pocket cost savings for their drugs by taking CMS-suggested generic treatment alternatives. However, due to larger discounts on brand medications made available through recent changes reducing the coverage gap, the potential dollar savings by taking suggested generic treatment alternatives during the gap is less compelling and will decrease as subsidies increase

A collaborative approach to combining service, teaching, and research

Objective. To describe a faculty-student collaborative model and its outcomes on teaching, service, and scholarship. Design. A Medicare Part D elective course was offered that consisted of classroom and experiential learning where pharmacy students participated in community outreach events to assist Medicare beneficiaries with Part D plan selection. The course training was expanded to include medication therapy management (MTM) and the administration of immunizations. At the completion of the course, students collaborated with faculty members on research endeavors. Evaluation. During the first 6 years of this course, the class size more than doubled from 20 to 42 students, and all students participating in the course met the IPPE requirements for community outreach. Over that same period, the number of beneficiaries receiving assistance with their Part D plan grew from 72 to 610; and with the help of students starting in 2011, faculty members had 28 poster presentations at national conferences, 7 invited podium presentations at national/international meetings, and published 8 manuscripts in peer-reviewed journals. Conclusion. Through collaborative efforts, this model took an elective course and provided classroom and experiential learning for students, needed health services for the community, and opportunities to pursue wide ranging research projects for faculty members and students

Medicare Part D Plan Optimization: The Need for an Annual Check-Up

Background: Since its inception, Medicare Part D requires beneficiaries to choose from a myriad of insurance plans in order to receive prescription drug coverage. Moreover, each year beneficiaries are confronted with plan cancellations, new plan offerings, changes in existing plan formularies and cost-sharing structure. Objective: This study prospectively examined the relationship between stand-alone prescription drug plan (PDP) costs, subsidy status, and the number of plans offered in California from 2009-2012. Methods: Forty-one community outreach events were held throughout Central/Northern California during the Medicare Part D annual election periods from 2008-2011. In total, 1,578 beneficiaries were assisted, 983 (62.2%) of whom had a PDP. During each intervention, beneficiary subsidy status, cost data for the beneficiary\u27s current plan and lowest cost plan for the upcoming year were recorded from the Medicare website. The percent of beneficiaries that did not need to switch plans to reduce their out-of-pocket (OOP) drug costs was compared to the number of available plans in the subsequent year.Results: On average, 14.3-23.7% of beneficiaries would have been enrolled in the lowest cost plan in the upcoming year had they remained in their current plan. Subsidy recipients were significantly more likely to be in the lowest cost plan each year. The chance of being in the lowest cost plan was significantly negatively correlated to the number of drug plans offered in the subsequent year. Conclusion: Annual Part D plan reexamination is essential to ensure that beneficiaries optimize their prescription medication coverage and minimize their OOP costs

Au-delà de l’ethnicité et de la parenté en Afghanistan : une approche ethnographique des liens transversaux de coopération

La persistance du tribalisme et les tensions ethniques sont régulièrement invoquées pour expliquer la prolongation de la guerre en Afghanistan. Le cas des Hazaras traité ici illustre la logique segmentaire inhérente à l’anthropologie politique de l’Afghanistan. L’émergence progressive de la dimension ethnique sur la scène politique afghane ainsi que le poids persistant des relations de parenté ne doivent pas conduire à négliger la prégnance des liens transversaux de solidarité qui peuvent se développer entre voisins, camarades de classe ou collègues. Les relations sociales quotidiennes suivent des logiques complexes. Pour faire face à l’insécurité et diminuer les risques, les Afghans tendent à diversifier leurs relations sociales, mais aussi leurs activités économiques et leurs affiliations politiques. La fragmentation sociale et le factionnalisme politique apparaissent dès lors comme des éléments structurels qui tendent à un certain équilibre des entités politiques en présence.L’ethnicisation de la scène politique afghane est située dans son contexte historique ; elle apparaît dès lors comme le résultat plus que la cause de la guerre.The persistence of tribalism and ethnic tensions are regularly invoked to explain the prolongation of the war in Afghanistan. The case of the Hazaras, treated here, illustrates the segmentary logic inherent in the political anthropology of Afghanistan. The gradual emergence of the ethnic dimension on the Afghan political scene and the lasting weight of kinship must not lead us to overlook the significance of transversal ties of solidarity, which can develop between neighbors, classmates or colleagues. Everyday social relations follow complex patterns. To cope with uncertainty and reduce risks, the Afghans tend to diversify their social relations as well as their economic activities and political affiliations. Social fragmentation and political factionalism therefore appear as structural elements that tend to keep a balance between political blocks. The ethnicization of the Afghan political scene is situated in its historical context; it appears thus to be the result more than the cause of the war

British Women Writers and the French Revolution. Citizens of the World

Le récent article de Matthew O. Grenby dans le n° 342 d’octobre-décembre 2005 des Annales Historiques de la Révolution française soulignait la vitalité et l’abondance des travaux anglo-saxons concernant l’impact de la Révolution française sur la littérature anglaise, ce dont témoignait la riche bibliographie qui suivait son analyse historiographique. Le nouvel ouvrage d’Adriana Craciun, spécialiste de littérature britannique, en est un exemple. Il s’insère dans la lignée de ses recherches pré..

Jean-François Kosta-Théfaine, Le Chant de la douleur dans les poésies de Christine de Pizan

Cet essai propose un examen du thème de la douleur dans les poésies de Christine de Pizan. On sait combien le deuil marque l’œuvre de Christine et est la clé de voûte de son entrée en écriture. Deuil triple en quelque sorte avec la disparition première du roi modèle, Charles V, puis du père Thomas de Bologne, enfin de l’époux, Étienne du Castel. Peu à peu s’effondre la stabilité matérielle de Christine et, selon ce qu’elle dit, son univers affectif, puisque – fait rare à l’époque – elle prése..

Cabbage and fermented vegetables : From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID-19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS-CoV-2 binds to its receptor, the angiotensin-converting enzyme 2 (ACE2). As a result of SARS-CoV-2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT(1)R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID-19. The nuclear factor (erythroid-derived 2)-like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT(1)R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof-of-concept of dietary manipulations that may enhance Nrf2-associated antioxidant effects, helpful in mitigating COVID-19 severity.Peer reviewe

Nrf2-interacting nutrients and COVID-19 : time for research to develop adaptation strategies

There are large between- and within-country variations in COVID-19 death rates. Some very low death rate settings such as Eastern Asia, Central Europe, the Balkans and Africa have a common feature of eating large quantities of fermented foods whose intake is associated with the activation of the Nrf2 (Nuclear factor (erythroid-derived 2)-like 2) anti-oxidant transcription factor. There are many Nrf2-interacting nutrients (berberine, curcumin, epigallocatechin gallate, genistein, quercetin, resveratrol, sulforaphane) that all act similarly to reduce insulin resistance, endothelial damage, lung injury and cytokine storm. They also act on the same mechanisms (mTOR: Mammalian target of rapamycin, PPAR gamma:Peroxisome proliferator-activated receptor, NF kappa B: Nuclear factor kappa B, ERK: Extracellular signal-regulated kinases and eIF2 alpha:Elongation initiation factor 2 alpha). They may as a result be important in mitigating the severity of COVID-19, acting through the endoplasmic reticulum stress or ACE-Angiotensin-II-AT(1)R axis (AT(1)R) pathway. Many Nrf2-interacting nutrients are also interacting with TRPA1 and/or TRPV1. Interestingly, geographical areas with very low COVID-19 mortality are those with the lowest prevalence of obesity (Sub-Saharan Africa and Asia). It is tempting to propose that Nrf2-interacting foods and nutrients can re-balance insulin resistance and have a significant effect on COVID-19 severity. It is therefore possible that the intake of these foods may restore an optimal natural balance for the Nrf2 pathway and may be of interest in the mitigation of COVID-19 severity