Subject(s)
Diabetes Mellitus, Type 2 , Glucagon-Like Peptide-1 Receptor Agonists , Health Care Rationing , Humans , Diabetes Mellitus, Type 2/drug therapy , Glucagon-Like Peptide 1/agonists , Glucagon-Like Peptide-1 Receptor/agonists , Glucagon-Like Peptide-1 Receptor Agonists/supply & distribution , Glucagon-Like Peptide-1 Receptor Agonists/therapeutic use , Health Care Rationing/ethics , Health Care Rationing/statistics & numerical data , Healthcare Disparities/ethics , Healthcare Disparities/statistics & numerical data , Receptors, Gastrointestinal Hormone/agonists , Vulnerable Populations/statistics & numerical dataABSTRACT
Background: Among patients with serious illness, palliative care before hospice enrollment is associated with improved quality of life, reduced symptom burden, and earlier transitions to hospice. However, fewer than half of eligible patients receive specialty palliative care referrals. As most hospice clinicians and administrators have experience in specialty palliative care, several emerging programs propose engaging hospice clinicians to provide early palliative care. Objective: We sought to identify barriers and facilitators to upstream palliative care. Design: We conducted a key informant qualitative study among hospice administrators and clinicians. Setting/Subjects: We conducted semi-structured interviews with 23 hospice administrators and clinicians in eight states from March to August 2022. We identified participants using snowball and purposive sampling using states that participate in Medicare Advantage's value-based insurance design Model. Results: Respondents indicated that barriers to early palliative care included inadequate staffing and reimbursement. Hospice clinicians providing community-based palliative care can address access barriers and improve transitions to hospice. Respondents expressed desire for payer guidance in identifying eligible patients but were cautious about payers acting as direct palliative care providers. However, payers could facilitate uptake by broadening and specifying coverage of services to include goals of care conversations and symptom management. Routine referrals initiated by objective measures could potentially increase access. Conclusions: Utilizing hospice providers to provide upstream palliative care can increase access, improve outcomes, and ease the transition to hospice.
Subject(s)
Anti-Obesity Agents , Obesity , Humans , Anti-Obesity Agents/administration & dosage , Anti-Obesity Agents/economics , Obesity/drug therapy , Obesity/economics , Weight Loss/drug effects , Cost-Effectiveness Analysis , Glucagon-Like Peptide-1 Receptor Agonists/administration & dosage , Glucagon-Like Peptide-1 Receptor Agonists/economics , Health Services Accessibility/economics , Fees, PharmaceuticalABSTRACT
US health care use declined during the initial phase of the COVID-19 pandemic in 2020. Although utilization is known to have recovered in 2021 and 2022, it is unknown how revenue in 2020-22 varied by physician specialty and practice setting. This study linked medical claims from a large national federation of commercial health plans to physician and practice data to estimate pandemic-associated impacts on physician revenue (defined as payments to eligible physicians) by specialty and practice characteristics. Surgical specialties, emergency medicine, and medical subspecialties each experienced a greater than 9 percent adjusted gross revenue decline in 2020 relative to prepandemic baselines. By 2022, pathology and psychiatry revenue experienced robust recovery, whereas surgical and oncology revenue remained at or below baseline. Revenue recovery in 2022 was greater for physicians practicing in hospital-owned practices and in practices participating in accountable care organizations. Pandemic-associated revenue recovery in 2021 and 2022 varied by specialty and practice type. Given that physician financial instability is associated with health care consolidation and leaving practice, policy makers should closely monitor revenue trends among physicians in specialties or practice settings with sustained gross revenue reductions during the pandemic.
Subject(s)
COVID-19 , COVID-19/economics , COVID-19/epidemiology , Humans , United States , Physicians/economics , Pandemics/economics , Medicine/statistics & numerical data , SARS-CoV-2 , Specialization/economicsABSTRACT
This Viewpoint discusses the benefits and challenges of transitioning to a value-based payment design for health care rather than a fee-for-service system.
Subject(s)
Value-Based Purchasing , Humans , United States , Reimbursement MechanismsSubject(s)
Delivery of Health Care , Diabetes Mellitus, Type 2 , Glucagon-Like Peptide-1 Receptor Agonists , Hypoglycemic Agents , Obesity , Receptors, Gastrointestinal Hormone , Humans , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/drug therapy , Diabetes Mellitus, Type 2/epidemiology , Glucagon-Like Peptide 1/agonists , Glucagon-Like Peptide-1 Receptor/agonists , Hypoglycemic Agents/therapeutic use , Receptors, Gastrointestinal Hormone/agonists , Glucagon-Like Peptide-1 Receptor Agonists/supply & distribution , Glucagon-Like Peptide-1 Receptor Agonists/therapeutic use , Obesity/complications , Obesity/drug therapy , Obesity/epidemiology , United States/epidemiology , Risk , Anti-Obesity Agents/therapeutic use , Health Services Accessibility/economics , Healthcare Disparities/economics , Healthcare Disparities/ethnology , Delivery of Health Care/economics , Delivery of Health Care/ethics , Delivery of Health Care/ethnology , Delivery of Health Care/standardsABSTRACT
Background: Patients with serious illnesses have unmet symptom and psychosocial needs. Specialty palliative care could address many of these needs; however, access varies by geography and health system. Virtual visits and automated referrals could increase access and lead to improved quality of life, health outcomes, and patient-centered care for patients with serious illness. Objectives: We sought to understand referring clinician perspectives on barriers and facilitators to utilizing virtual tools to increase upstream access to palliative care. Design: Participants in this multisite qualitative study included practicing clinicians who commonly place palliative care referrals across multiple specialties, including hematology/oncology, family medicine, cardiology, and geriatrics. All interviews were transcribed and subsequently coded and analyzed by trained research coordinators using Atlas.ti software. Settings/Subjects: This study included 23 clinicians (21 physicians, 2 nonphysicians) across 5 specialties, 4 practice settings, and 7 states in the United States. Results: Respondents felt that community-based specialty palliative services including symptom management, advance care planning, physical therapy, and mental health counseling would benefit their patients. However, they had mixed feelings about automated referrals, with some clinicians feeling hesitant about not being alerted to such referrals. Many respondents were supportive of virtual palliative care, particularly for those who may have difficulty accessing physician offices, but most respondents felt that such care should only be provided after an initial in-person consultation where clinicians can meet face-to-face with patients. Conclusion: Clinicians believe that automated referrals and virtual palliative care could increase access to the benefits of specialty palliative care. However, virtual palliative care models should give attention to iterative communication with primary clinicians and the perceived need for an initial in-person visit.
Subject(s)
Palliative Care , Qualitative Research , Humans , Male , Female , United States , Middle Aged , Adult , Referral and Consultation , Attitude of Health Personnel , Telemedicine , Health Services AccessibilityABSTRACT
Importance: Costs of employer-sponsored health care benefits have increased faster than workers' wages for several decades, with important implications for disparities in earnings and wage stagnation. Objective: To quantify how growth in employer-sponsored health insurance (ESI) premiums may have been associated with reduced annual wages, disparities in earnings by race and ethnicity and wage level, and wage stagnation among US families with ESI. Design, Setting, and Participants: In this economic evaluation, serial cross-sectional analyses were performed of US families receiving ESI from 1988 to 2019 based on data from the Consumer Expenditure Survey, Kaiser Employer Health Benefits Survey, US Census Bureau's Current Population Survey, and federal payroll taxation rates. Statistical analysis was conducted from February 2022 to July 2023. Main Outcomes and Measures: Percentage of annual compensation associated with health care premiums (after accounting for tax deductibility) and lost wages associated with growth in cost of premiums from 1989 to 2019 based on 1988 compensation. To assess disparities, analyses were stratified by race and ethnicity and wage level. Results: In 1988, 44.7 million individuals (head of household: mean [SD] age, 43.3 [13.1] years; 30.1% were female; and 2.4% identified as Asian, 6.2% as Hispanic, 8.6% as non-Hispanic Black, and 82.8% as non-Hispanic White) were covered by ESI family plans; this number remained similar in 2019 at 44.8 million individuals (head of household: mean [SD] age, 47.1 [12.9] years; 41.3% were female; and 1.3% identified as Asian, 9.9% as Hispanic, 9.9% as non-Hispanic Black, and 78.9% as non-Hispanic White). In 1988, the mean (SD) household size was 3.3 (1.3) people, and in 2019, it was 3.4 (1.3) people. If ESI costs had remained at the same proportion of the 1988 average compensation package, then in 2019, the median US family with ESI could have earned $8774 (95% CI, $8354-$9195) more in annual wages. During all 32 years, health care premiums as a percentage of compensation were greater for non-Hispanic Black and Hispanic families than for non-Hispanic White families. By 2019, 13.8% (95% CI, 13.5%-14.1%) of compensation among non-Hispanic White families with ESI went to premium costs compared with 19.2% (95% CI, 18.8%-19.7%) among non-Hispanic Black families and 19.8% (19.3%-20.3%) among Hispanic families with ESI. In 2019, health care premiums as a percentage of compensation at the 95th percentile of earnings for families with ESI were 3.9% (95% CI, 3.8%-4.0%) compared with 28.5% (95% CI, 27.8%-29.2%) at the 20th percentile of earnings. From 1988 to 2019, the mean cumulative lost earnings associated with growth in health care premiums for the median US family with ESI was $125â¯340 (95% CI, $120â¯155-$130â¯525) in 2019 dollars, 4.7% of earnings over the 32-year period. Conclusions and Relevance: This economic evaluation of US families receiving ESI suggests that 3 decades of increasing health care premiums were likely associated with reduced annual earnings and increased earnings inequality by race and ethnicity and wage level and were meaningfully associated with wage stagnation.
Subject(s)
Costs and Cost Analysis , Income , Insurance , Adult , Female , Humans , Male , Middle Aged , Cross-Sectional Studies , Ethnicity , Insurance/economics , Racial GroupsSubject(s)
Fee Schedules , Medicare , Physicians , Aged , Humans , Fee Schedules/economics , Medicare/economics , Medicare Part B/economics , Physicians/economics , Relative Value Scales , United StatesABSTRACT
OBJECTIVES: To describe trends in US health care spending in a large, national, and commercially insured population during the COVID-19 pandemic. STUDY DESIGN: Cross-sectional study of commercially insured members enrolled between May 1, 2018, and December 31, 2021. METHODS: The study utilized a population-based sample of continuously enrolled members in a geographically diverse federation of Blue Cross Blue Shield plans across the United States. Our sample excluded Medicare and Medicare Advantage beneficiaries. The COVID-19 exposure period was defined as 2020-2021; 2018-2019 were pre-COVID-19 years. We defined 4 post-COVID-19 periods: March 1 to April 30, 2020; May 1 to December 31, 2020; January 1 to March 31, 2021; and April 1 to December 31, 2021. The primary outcome was inflation-adjusted overall per-member per-month (PMPM) medical spending adjusted for age, sex, Elixhauser comorbidities, area-level racial composition, income, and education. RESULTS: Our sample included 97,319,130 individuals. Mean PMPM medical spending decreased from $370.92 in January-February 2020 to $281.00 in March-April 2020. Between May and December 2020, mean PMPM medical spending recovered to-but did not exceed-prepandemic levels. Mean PMPM medical spending stayed below prepandemic levels between January and March 2021, rose above prepandemic baselines between April and June 2021, and decreased below baseline between July and December 2021. CONCLUSIONS: The COVID-19 pandemic induced a spending shock in 2020, and health care spending did not recover to near baseline until mid-2021, with some emerging evidence of pent-up demand. The observed spending below baseline through the end of 2021 will pose challenges to setting spending benchmarks for alternative payment and shared savings models.
Subject(s)
COVID-19 , Pandemics , Aged , Humans , United States/epidemiology , Cross-Sectional Studies , Medicare , Health Expenditures , COVID-19/epidemiologyABSTRACT
With the world grappling with continued spread of monkeypox internationally, vaccines play a crucial role in mitigating the harms from infection and preventing spread. However, countries with the greatest need - particularly historically endemic countries with the highest monkeypox case-fatality rates - are not able to acquire scarce vaccines. This is unjust, and requires rectification through equitable allocation of vaccines globally. We propose applying the Fair Priority Model for such allocation, which emphasizes three key principles: 1) preventing harm; 2) prioritizing the disadvantaged; and 3) treating people with equal moral concern. Post-exposure prophylaxis (PEPV) has the most potential to mitigate harm, and so ensuring countries have sufficient supply for PEPV should be the first priority. And historically endemic countries, which face disadvantages that compound potential harms from monkeypox, should be the first recipients of such vaccines. Once sufficient supply is allocated for countries to apply PEPV, global allocation could move on to pre-exposure prophylaxis (PrEP), again prioritizing historically endemic countries first before distribution to the rest of the global community, based on projected number of cases and vulnerability to harm.
Subject(s)
Mpox (monkeypox) , Pre-Exposure Prophylaxis , Vaccines , Humans , Mpox (monkeypox)/epidemiology , Mpox (monkeypox)/prevention & control , Post-Exposure Prophylaxis , Vulnerable PopulationsABSTRACT
The COVID-19 pandemic revealed numerous weaknesses in pandemic preparedness and response, including underfunding, inadequate surveillance, and inequitable distribution of countermeasures. To overcome these weaknesses for future pandemics, WHO released a zero draft of a pandemic treaty in February, 2023, and subsequently a revised bureau's text in May, 2023. COVID-19 made clear that pandemic prevention, preparedness, and response reflect choices and value judgements. These decisions are therefore not a purely scientific or technical exercise, but are fundamentally grounded in ethics. The latest treaty draft reflects these ethical considerations by including a section entitled Guiding Principles and Approaches. Most of these principles are ethical-they establish core values that undergird the treaty. Unfortunately, the treaty draft's set of principles are numerous, overlapping, and show inadequate coherence and consistency. We propose two improvements to this section of the draft pandemic treaty. First, key guiding ethical principles should be clearer and more precise than they currently are. Second, the link between ethical principles and policy implementation should be clearly established and define boundaries on acceptable interpretation, ensuring that signatories abide by these principles.
Subject(s)
COVID-19 , Pandemics , Humans , Pandemics/prevention & control , International CooperationABSTRACT
This Viewpoint discusses the Medicare Physician Fee Schedule and its flaws, including how they might be remedied by severing CMS dependence on Relative Value Update Committee estimates of time and intensity.
Subject(s)
Fee Schedules , Medicare Part B , Physicians , Relative Value Scales , Aged , Humans , Fee Schedules/economics , Fee Schedules/ethics , Medicare/economics , Medicare/ethics , Medicare Part B/economics , Medicare Part B/ethics , Physicians/economics , Physicians/ethics , United States , Ethics, MedicalABSTRACT
It has become increasingly difficult for individuals to exercise meaningful control over the personal data they disclose to companies or to understand and track the ways in which that data is exchanged and used. These developments have led to an emerging consensus that existing privacy and data protection laws offer individuals insufficient protections against harms stemming from current data practices. However, an effective and ethically justified way forward remains elusive. To inform policy in this area, we propose the Ethical Data Practices framework. The framework outlines six principles relevant to the collection and use of personal data-minimizing harm, fairly distributing benefits and burdens, respecting autonomy, transparency, accountability, and inclusion-and translates these principles into action-guiding practical imperatives for companies that process personal data. In addition to informing policy, the practical imperatives can be voluntarily adopted by companies to promote ethical data practices.