Examining the case for direct contracting: A multistakeholder case study.

BACKGROUND: Employers and pharmacies are challenged by a complex system for prescription payment. Cost plus direct contracts for prescriptions and bundled services may yield benefits. OBJECTIVES: This study aimed to (1) explore direct contracting using multistakeholder interviews, (2) compare employer costs and employee copays for 6 months of prescription charges under their pharmacy benefit manager (PBM) with projected costs under a pharmacy direct contract, (3) project pharmacy revenue, costs, and net profit had these prescriptions been processed through the direct contract, and (4) assess employee satisfaction under the direct contract. METHODS: Semistructured stakeholder interviews were recorded transcribed and analyzed to identify different perspectives on direct contracting. Employer PBM invoices for 412 employee prescriptions over 6 months were analyzed to calculate employer and employee costs and reanalyzed for the invoice cost plus $12 professional fee direct contract. For the pharmacy financial analysis projection, invoice costs and a $9.82 cost of dispensing were subtracted from total revenue to yield an estimated profit had the parties been under the arrangement. A 34-item satisfaction survey was mailed using a 4-contact design with cash incentives to the 20 employees serviced by the direct contract that were analyzed descriptively. RESULTS: Eight stakeholder interviews described the benefits and potential challenges of such direct contracts. The financial analysis suggested the employer costs would be $5664 lower and employee copays would have been $1918 lower had all prescriptions been paid using the direct contract. The estimated profit for the pharmacy was projected at $899. Survey respondents were generally satisfied with the direct contract, but few used the bundled services. CONCLUSION: The direct contract may be financially beneficial for all parties. It also may offer more transparent pricing that may be desirable for the employer and pharmacy. Greater uptake of bundled services may increase the value to the employer.

The association between cost sharing, prior authorization, and specialty drug utilization: A systematic review.

BACKGROUND: Specialty drugs are identified by high monthly costs and complexity of administration. Payers use utilization management strategies, including prior authorization and separate tiers with higher cost sharing, to control spending. These strategies can negatively impact patients' health outcomes through treatment initiation delays, medication abandonment, and nonadherence. OBJECTIVE: To examine the effect of patient cost sharing on specialty drug utilization and the effect of prior authorization on treatment delay and specialty drug utilization. METHODS: We conducted a literature search in the period between February 2021 and April 2022 using PubMed for articles published in English without restriction on date of publication. We included research papers with prior authorization and cost sharing for specialty drugs as exposure variables and specialty drug utilization as the outcome variable. Studies were reviewed by 2 independent reviewers and relevant information from eligible studies was extracted using a standardized form and approved by 2 reviewers. Review papers, opinion pieces, and projects without data were excluded. RESULTS: Forty-four studies were included in this review after screening and exclusions, 9 on prior authorization and 35 on cost sharing. Patients with lower cost sharing via patient support programs experienced higher adherence, fewer days to fill prescriptions, and lower discontinuation rates. Similar outcomes were noted for patients on low-income subsidy programs. Increasing cost sharing above $100 was associated with up to 75% abandonment rate for certain specialty drugs. This increased level of cost sharing was also associated with higher discontinuation rates and odds. At the same time, decreasing out-of-pocket costs increased initiation of specialty drugs. However, inconsistent results on impact of cost sharing on medication possession ratio (MPR) and proportion of days covered (PDC) were reported. Some studies reported a negative association between higher costs and MPR and PDC; however, MPR and PDC of cancer specialty drugs did not decrease with higher costs. Significant delays in prescription initiation were reported when prior authorization was needed. CONCLUSIONS: Higher levels of patient cost sharing reduce specialty drug use by increasing medication abandonment while generally decreasing initiation and persistence. Similarly, programs that reduce patient cost sharing increase initiation and persistence. In contrast, cost sharing had an inconsistent and bidirectional effect on MPR and PDC. Prior authorization caused treatment delays, but its effects on specialty drug use varied. More research is needed to examine the effect of cost sharing and prior authorization on long-term health outcomes.

Item development for patient-centered care preferences using a three-archetype heuristic: An exploratory study.

Background: Patient-centered care is at the center of the Pharmacists' Patient Care Process; however, little is known about patient-centered care preferences and expectations for pharmacist care. Objective: To develop and test items exploring the applicability of a proposed three-archetype heuristic for patient-centered care preferences and expectations in pharmacist care in a population of older adults using community pharmacies that provided enhanced and integrated services. Methods: This was an exploratory analysis of a cross-sectional survey developed and distributed by postal mail to 17 Medicare-eligible patients at five Community Pharmacy Enhanced Service Network (CPESN) pharmacies in Iowa between November 2021 and January 2022. A total of 15 Likert-type archetype survey items were developed with an item developed for each of five constructs (Nature of Relationship and Locus of Control, Care Customization, Care Longevity, Intent of Communication, and Source of Value) for three archetypes ("Partner," "Client," and "Customer").Items were grouped by archetype to yield three, five-item scales, intended to reflect each archetype. Cronbach alphas (α) were calculated for each scale, measuring internal consistency. K-means clustering with silhouette analysis was performed using a group of archetype items with high internal consistency to identify clusters. Kruskal Wallis and Fisher's exact tests used to determine statistical significance for response means and frequencies between clusters, when appropriate. Results: In total, 17 participants completed the survey (100% response rate). Cronbach alphas for the five-item scales reflecting "Partner," "Client," and "Customer" archetypes were 0.66, 0.33, and - 0.03, respectively. K-means clustering identified two clusters, labeled: "Independent Partner" and "Collaborative Partner." There were significant (p-value <0.05) differences between clusters for four of the 15 Likert-type items, suggesting the "Independent Partner" more autonomous, seek pharmacist expertise less frequently, and value pharmacist collaboration less compared to the "Collaborative Partner." Conclusions: The items comprising the "Partner" archetype scale had a reasonably strong level of internal consistency. Older adults may desire highly tailored, co-created experience created from long-standing relationships with a particular pharmacist.

Patient preferences and willingness-to-pay for community pharmacy-led Medicare Part D consultation services: A discrete choice experiment.

INTRODUCTION: Community pharmacies currently offer Medicare Part D consultation services, often at no-cost. Despite facilitating plan-switching behavior, identifying potential cost-savings, and increasing medication adherence, patient uptake of these services remains low. OBJECTIVES: To investigate patient preferences for specific service-offering attributes and marginal willingness-to-pay (mWTP) for an enhanced community pharmacy Medicare Part D consultation service. METHODS: A discrete choice experiment (DCE) guided by the SERVQUAL framework was developed and administered using a national online survey panel. Study participants were English-speaking adults (≥65 years) residing in the United States enrolled in a Medicare Part D or Medicare Advantage plan and had filled a prescription at a community pharmacy within the last 12 months. An orthogonal design resulted in 120 paired-choice tasks distributed equally across 10 survey blocks. Data were analyzed using mixed logit and latent class models. RESULTS: In total, 540 responses were collected, with the average age of respondents being 71 years. The majority of respondents were females (60%) and reported taking four or more prescription medication (51%). Service attribute levels with the highest utility were: 15-min intervention duration (0.392), discussion of services + a follow-up phone call (0.069), in-person at the pharmacy (0.328), provided by a pharmacist the patient knew (0.578), and no-cost (3.382). The attribute with the largest mWTP value was a service provided by a pharmacist the participant knew ($8.42). Latent class analysis revealed that patient preferences for service attributes significantly differed by gender and difficulty affording prescription medications. CONCLUSIONS: Quantifying patient preference using discrete choice methodology provides pharmacies with information needed to design service offerings that balance patient preference and sustainability. Pharmacies may consider providing interventions at no-cost to subsets of patients placing high importance on a service cost attribute. Further, patient preference for 15-min interventions may inform Medicare Part D service delivery and facilitate service sustainability.

Medicare Part D plan-selection experience: qualitative findings from a national cross-sectional survey.

Background: A variety of services exit to assist eligible beneficiaries select Medicare Part D insurance plans; however, selecting an optimal plan remains a challenge. While patients would benefit from evaluating and switching their Medicare Part D plan on a yearly basis, few choose to do so. Objective: The objective of this study was to describe the Medicare Part D plan selection experience across all US states. Methods: This was a qualitative analysis using data from a cross-sectional Qualtrics panel survey administered in January 2022. Descriptive statistics were generated for demographic and patient-specific items for individuals who provided open-ended survey item responses. Open-coding and content analysis were used to analyze responses to the open-ended survey item. Results: Overall, 540 responses were received, with the largest number of responses from Florida (11%, 61). A total of 101 respondents (18.7%) of survey respondents provided open-ended comments. Qualitative analysis identified four response categories: Benefit design, Plan information and selection assistance, Plan Switching, and Plan-selection experience. Conclusions: Overall, participants expressed frustrations with high costs and plan restrictions. Many participants needed plan-selection assistance, with some individuals switching plans each year. Recent legislation may address difficulties related to medication costs; however, additional focus on resources and educational interventions may improve the Medicare Part D experience.

A qualitative exploration of patient preferences for Medicare Part D consultation services offered in a community pharmacy setting.

BACKGROUND: Community pharmacies currently offer Medicare Part D consultation services to help eligible beneficiaries select prescription medication insurance. Despite these service offerings, there is a paucity of information on patient preferences for these service offerings and optimal service delivery from the patient perspective. OBJECTIVES: The objectives of this study were to (1) evaluate patient expectations of and willingness-to-pay (WTP) for community pharmacy Medicare Part D consultation services, (2) identify components of Medicare Part D consultation services associated with service quality, and (3) explore differences in preferences and service expectations between services-experienced and service-naive patients. METHODS: This was a qualitative exploratory study, with data collected using interviews and a follow-up supplemental survey with participants recruited from 5 community pharmacies across the state of Iowa participating in the Community Pharmacy Enhanced Services Network. A total of 17 patients contacted the research team for participation. Interviews were recorded and transcribed, with qualitative data analysis performed using template analysis guided by the SERVQUAL framework. Interview participants were invited to complete a supplemental survey. Descriptive statistics and frequencies were generated for survey items. Service-experienced and service-naive survey responses Pearson chi-square and Welch t tests were used to determine significant differences between service-experienced and service-naive responses for categorical and continuous variables, respectively. RESULTS: In total, all 17 patients who contacted the research team agreed to participate in interviews, with 8 service-experienced and 9 service-naive interviews completed. Template analysis identified 14 subdomains across the SERVQUAL domains. Similarities and differences in service preferences between groups were identified, focusing on patient-pharmacist trust, past service experience, and WTP. All interview participants completed supplemental surveys, with no statistically significant differences between service-experienced and service-naive participant characteristics identified. CONCLUSIONS: Service-experienced patients emphasized components of the service that contribute to service quality and generally reported higher WTP values. Many service-naive patients were unaware community pharmacies provided consultation services, suggesting that pharmacists may benefit from considering how services are offered to patients based on the specific preferences and expectations and consider ways to increase awareness of service offerings.

Community Pharmacy Medicare Part D Consultations: Plan-Switching Decisions and Chronic Medication Adherence.

OBJECTIVES: (1)To compare Part D plan switching for users and nonusers of a pharmacy-led Medicare Part D consultation service and (2) to evaluate the effect of service use on chronic medication adherence. METHODS: This was a longitudinal study, occurring in one independently owned community pharmacy in Iowa. Medicare Part D beneficiaries who used the service were compared to nonusers. Dispensing data were used to compare planswitching and the effect of service use on chronic medication adherence between service users and nonusers. Proportion of days covered (PDC) was used to evaluate medication adherence. RESULTS: In the 2017 and 2018 plan year, 79 and 138 Medicare beneficiaries used the service, respectively. These individuals were compared to 849 Medicare beneficiaries and a random sample of 101 beneficiaries in respective years. The respective switching rates for service users in 2018 and 2019 plan year were 43% and 15.9%, compared to 4% switching rates in both years for nonusers. Using the Medicare Part D consultation yielded a statistically significant positive effect on switching in both plan years (P values < .05) and a statistically significant positive effect on PDC between years (P value <.05). CONCLUSION: The use of a pharmacist-led Medicare Part D consultation resulted in increased plan switching and improved chronic medication adherence.

Iowa community pharmacies' experiences with Medicaid managed care.

OBJECTIVES: To describe Iowa community pharmacies' experiences and satisfaction with the transition to Medicaid managed care and conduct a qualitative evaluation of the effect of Medicaid managed care on 3 independent community pharmacies. DESIGN: Cross-sectional descriptive study. Mixed methods were used: the quantitative phase was a mailed survey and the qualitative phase involved interviews. SETTING AND PARTICIPANTS: The mail survey was sent to Iowa-registered community pharmacies whose names and addresses were obtained from the Iowa Board of Pharmacy website. Interviews with pharmacists and other pharmacy staff were conducted at 3 Iowa independent community pharmacies. OUTCOME MEASURES: Pharmacy satisfaction and experiences with the Iowa Medicaid managed care program. RESULTS: The 265 returned surveys yielded a 27.4% response rate. Eight pharmacists and pharmacy staff were interviewed in the qualitative phase. Mean satisfaction with the Medicaid managed care organizations (MCOs) was 3.1 on a scale of 1-7, with 1 being extremely dissatisfied, and 7 being extremely satisfied. Respondents were most satisfied with the ease of joining the plans' pharmacy networks (mean = 4.1) and least satisfied with the availability of payment for nondispensing-related services (2.3), plans' communication with patients (2.7), and plans' communication with pharmacies (3.0). Pharmacies also reported problems with patients' access to prescriptions. The MCOs ranked lowest in satisfaction when compared with the largest private payer, the largest Medicare Part D plan, and the previous state-run Medicaid program. The themes that emerged from the interviews were as follows: confusion caused by multiple MCOs, plan-communication challenges, product-coverage challenges, problems related to durable medical equipment, and payment challenges. CONCLUSION: The transition from a state-run fee-for-service Medicaid program to Medicaid managed care in Iowa created many challenges for community pharmacies. Different procedures and product coverage across the 3 MCOs were particularly problematic.

Cost-Savings and Patient Experience with a Pharmacy-Led Medicare Part D Consultation Service.

BACKGROUND: There are many Medicare Part D plans, making it difficult for patients to choose the optimal plan. The decision to remain on current Medicare plans is reinforced by patient inertia and uncertainty associated with plan-switching decisions. By helping patients identify more cost-effective plans, pharmacists and pharmacy personnel have the ability to inform plan-switching decisions resulting in lower out-of-pocket (OOP) costs. OBJECTIVES: This study evaluates 1) patient experience with a pharmacy Medicare Part D consultation service and 2) potential out-of-pocket savings based on a patient's best plan for 2019 compared to continuation of a patient's 2018 Medicare Part D plan. METHODS: This study was a retrospective descriptive analysis and took place at a single, independently owned community pharmacy. Patients received free individual consultations with a pharmacist that included a medication review and information on all available Part D plans. Patients were selected to receive the service using pharmacy software to identify potential inefficiencies in current Part D plans. Data on satisfaction and perceived pharmacist role in providing Medicare Part D information were collected via an in-person survey administered at the pharmacy. Potential out-of-pocket cost savings were determined using cost information provided for patient specific medication regimens entered into Medicare.gov, the online platform for Medicare Part D plan information. RESULTS: Of the 318 patients identified, 79 used the consultation service. Out of 79 patients who used the service in fall of 2017, 44 completed the survey for a response rate of 56%.Patients generally reported good experiences with the service. Open-ended responses revealed patients utilize a variety of helpers for plan information and decisions. A subset of 14 patients were identified as having clear plan-switching decisions and were included in the cost-savings analysis. CONCLUSIONS: Patients using a free Medicare Part D plan consultation were satisfied with the service, suggesting that helpers were an important resource n their plan-selection process. Using the pharmacist-led Part D consultation may result in decreases in out-of-pocket cost savings due to identification of optimal Medicare Part D plans.

Medication adherence among chronic condition patients in the Medicaid coverage gap.

BACKGROUND: People with incomes below the Federal Poverty Level (FPL) do not qualify for health insurance subsidies and may not be eligible for Medicaid. Patients in this Medicaid Coverage Gap may have difficulty paying for their medications. OBJECTIVE: To estimate medication adherence and the prevalence of underinsurance among chronic condition patients in the Medicaid Coverage Gap. METHODS: A retrospective cohort study was conducted using 2014-2016 data extracted from the Medical Expenditure Panel Survey. The sample included non-elderly patients with prescription fills (≥2) for at least one of five chronic conditions (hypertension, hyperlipidemia, diabetes, depression and anxiety disorder) and income below the FPL. Medication adherence was measured using Medication Possession Ratio (MPR), and adjusted using patient demographics, health conditions, and health care utilization. The prevalence of underinsurance also was examined. RESULTS: Of the 316 patients, 60.4% were female, with an average age of 50, and an average of 3 health conditions. The weighted MPR was 72.0% and 44.6% had an adjusted MRP ≥80%. Nearly 80% of the patients were either continuously uninsured (21.6%) or underinsured (59.0%). CONCLUSIONS: A significant proportion of chronic condition patients in Medicaid Coverage Gap were underinsured and less than half were adherent to their medications.

Framework for assessing pharmacy value.

INTRODUCTION: Excess spending and poor quality in the US healthcare system has led to proliferation of performance-based payment models. These models have the potential to enhance value by creating a meritocratic system whereby providers delivering the best patient care are rewarded, while providers failing to provide such care are given incentives to improve. However, early experience suggests that unless these systems are appropriately designed, payments can be withheld from high performers, bonuses paid to low performers, and health disparities can be worsened. Performance-based payments are new to community pharmacies, and opportunity exists to strengthen pharmacy value measurement and potentially avoid problems observed with other performance-based payment models. MODEL CONSTRUCTION AND APPLICATION: This article describes the process by which a framework to assess community pharmacy value was developed, then applies the framework to produce a draft composite pharmacy performance measure. The pharmacy value framework addresses potential shortcomings of existing community pharmacy performance measures through four key principles: 1) theory-based quality and spending measures, 2) scoring which accounts for measure reliability, 3) full risk-adjustment, and 4) a value matrix to identify high and low value pharmacies. Based on these principles, a draft community pharmacy composite performance measure was developed, and was successful in dividing community pharmacies into high, typical, and low value categories. CONCLUSION: By using this framework to develop future composite measures, payers may find closer alignment between performance-based payments and actual pharmacy performance. This early work is intended to encourage further research into the establishment of a scientifically firm foundation for pharmacy performance measurement. More testing is needed to determine reliability, validity, and comparative superiority of any composite measure derived from this framework before it is used to support performance-based pharmacy payment models.

Third-party reimbursement for generic prescription drugs: The prevalence of below-cost reimbursement in an environment of maximum allowable cost-based reimbursement.

OBJECTIVES: To examine average prescription gross margin (GM) for prescriptions and to evaluate the prevalence of below-cost reimbursement for generic prescriptions across different third-party payers and therapeutic categories. DESIGN: A retrospective descriptive study using 2015 dispensing data from a single independently owned pharmacy in Iowa. To calculate GM, the pharmacy's actual acquisition cost was subtracted from the third-party reimbursement rate for each generic prescription. The frequency of negative GMs was calculated for the top 6 plans and the top 10 therapeutic categories by prescription volume. SETTING: A single, independently owned community pharmacy in Iowa. PARTICIPANTS: Prescription dispensing records for the pharmacy's largest private and public payers by prescription volume. INTERVENTION: Gross margins were calculated on a payer and United States Pharmacopeia (USP) medication category level. MAIN OUTCOME MEASURES: GM for generic prescriptions reimbursed under cost for specific payers and USP medication categories. RESULTS: The 2015 prescription volume for the study pharmacy was 70,866 prescriptions, of which 88% were generic. For all prescriptions, the mean GM was $6.63 per prescription, and the median GM was $3.49 per prescription. Generic medications had a mean GM of $4.66 (median, $2.86), and brand name medications had a mean GM of $21.83 (median, $16.15). The percentage of generic prescriptions paid below acquisition cost was 15.1% overall and ranged from 4.1% for Iowa Medicaid to 25.9% for one of the private payers. The most common USP medication category by prescription volume was cardiovascular agents, representing 25.2% of generic prescriptions. For the 10.9% of these prescriptions reimbursed below cost, the mean GM was -$6.80. The 2 USP medication categories with the largest negative mean GM for generic prescriptions were analgesics and anticonvulsants, with mean GMs of -$10.10 and -$11.30, respectively. CONCLUSION: The current maximum allowable cost-based reimbursement system often results in inadequate payment for generic prescription drugs. The amount of underpayment varies substantially by payer and therapeutic class.

Medicare Part D Beneficiaries' Plan Switching Decisions and Information Processing.

Medicare Part D beneficiaries tend not to switch plans despite the government's efforts to engage beneficiaries in the plan switching process. Understanding current and alternative plan features is a necessary step to make informed plan switching decisions. This study explored beneficiaries' plan switching using a mixed-methods approach, with a focus on the concept of information processing. We found large variation in beneficiary comprehension of plan information among both switchers and nonswitchers. Knowledge about alternative plans was especially poor, with only about half of switchers and 2 in 10 nonswitchers being well informed about plans other than their current plan. We also found that helpers had a prominent role in plan decision making-nearly twice as many switchers as nonswitchers worked with helpers for their plan selection. Our study suggests that easier access to helpers as well as helpers' extensive involvement in the decision-making process promote informed plan switching decisions.

Informal learning processes in support of clinical service delivery in a service-oriented community pharmacy.

The evolving health care system necessitates pharmacy organizations' adjustments by delivering new services and establishing inter-organizational relationships. One approach supporting pharmacy organizations in making changes may be informal learning by technicians, pharmacists, and pharmacy owners. Informal learning is characterized by a four-step cycle including intent to learn, action, feedback, and reflection. This framework helps explain individual and organizational factors that influence learning processes within an organization as well as the individual and organizational outcomes of those learning processes. A case study of an Iowa independent community pharmacy with years of experience in offering patient care services was made. Nine semi-structured interviews with pharmacy personnel revealed initial evidence in support of the informal learning model in practice. Future research could investigate more fully the informal learning model in delivery of patient care services in community pharmacies.

Provider Visits for Asthma: Potential Barriers for Insured Children.

OBJECTIVE: The barriers to provider visits for asthma in insured children are not well understood. Our objective was to examine the relationship between parent, family, and child attributes and asthma visits in insured children. METHODS: This retrospective, cross-sectional analysis of 2007 Medical Expenditure Panel Survey-Household Component data included insured children 0-17 years old reported to have active asthma. We summed the number of provider visits during which asthma was treated or diagnosed to represent the frequency of asthma visits during the year. Probit models were used to estimate the relationship between parent, family, and child attributes and asthma visits. RESULTS: Seventy percent of the 542 children did not have an asthma visit during the year. Children with parents employed full time were 16 percentage points less likely to have an asthma visit than children whose parents were not working (P=.01). CONCLUSION: Many insured children go more than a year without seeing a provider for their asthma, signaling that insurance is not sufficient to guarantee children will receive asthma monitoring. The attributes related to asthma visits suggest potential barriers that providers might want to consider to increase participation in asthma visits.

The role of satisfaction and switching costs in Medicare Part D choices.

BACKGROUND: Most U.S. states had over 50 Medicare Prescription Drug Plans (PDPs) in 2007. Medicare beneficiaries are expected to switch Part D plans based on their health and financial needs; however, the switching rate has been low. Such consumer inertia potentially has negative effects on both beneficiaries and the insurance market, resulting in a critical need to investigate its cause. OBJECTIVES: To 1) describe how Medicare beneficiaries who were satisfied with their current Part D plan differed from those who were not satisfied; 2) examine the effect of switching costs on consideration of switching among Medicare beneficiaries who were dissatisfied with their current Part D plan. METHODS: Data from the 2007 Prescription Drug Study supplement to the Health and Retirement Study (HRS) survey were used in this study. The satisfied and dissatisfied groups were compared in terms of cost variables, switching costs, and perception of Part D complexity. Structural equation modeling was used to examine relationships among switching costs, Part D complexity, cost variables, and consideration of switching for beneficiaries who were dissatisfied with their current Part D coverage. RESULTS: Out of 467 participants, a total of 255 (54.6%) were satisfied with their current Part D plan. The satisfied group paid lower out-of-pocket costs ($50.63 vs. $114.60) and premiums ($30.88 vs. $40.77) than the dissatisfied group. They also had lower switching costs. Only 11.3% of the dissatisfied beneficiaries switched plans. Among respondents who were dissatisfied with their current plan, those who perceived Part D as complex had high switching costs and were less likely to consider switching plans. Out-of-pocket cost did not have a statistically significant association with consideration of switching. CONCLUSIONS: Medicare beneficiaries who were satisfied with their current Part D plans had lower out-of-pocket costs and premiums as well as higher switching costs. Among beneficiaries who were dissatisfied with their current Part D plan, those who had higher switching costs were less likely to consider switching Part D plans.

What do cancer patients worry about when making decisions about treatment? Variation across racial/ethnic groups.

The aim of this study was to determine the issues patients worry about when making decisions about cancer treatment. A total of 5,044 colorectal and lung cancer patients from the Cancer Care Outcomes Research and Surveillance Consortium reported their level of worry about (1) treatment side effects, (2) treatment costs, (3) time away from family, (4) time away from work, and (5) transportation to treatment sites. Using multivariable logistic regression, we evaluated the association of sociodemographic, clinical, and psychosocial variables with worry. Overall, 75 % of patients worried about side effects of treatments; 40 %, the cost of treatment; 50 %, time away from family; 52 %, time away from work; and 22 %, about transportation. In multivariable analyses, across all worry domains, older patients had lower odds of reporting worry (p values < 0.001). Patients who perceived less than excellent quality of care, self-assessed their health as less than excellent, and those with a higher cancer stage were more likely to report worry. Asian patients were more likely to report worry than Whites about the cost of treatment and transportation, and relative to Whites, Hispanics were more likely to report worry about transportation (p values < 0.05). Black patients were less likely to report worry about time away from work. Patients worry about issues beyond treatment side effects when making treatment decisions. The pattern of worry varies along sociodemographic, clinical, and psychosocial factors, including race and ethnicity. Understanding the source of patient worry and identifying interventions to alleviate worry are important to delivering patient-centered cancer care.

Factors related to receipt of well-child visits in insured children.

Our objective was to identify factors related to receipt of the recommended number of well-child visits in insured children. We hypothesized parent insurance status would be related to receipt of well-child visits, with those with uninsured parents more likely to have fewer visits than recommended. Data for the study came from the 2007 Medical Expenditure Panel Survey-Household Component. The sample included children <18 years of age with full-year insurance coverage and parents who were insured or uninsured the entire year. The outcome variable indicated whether children had received fewer than the recommended number of well-child visits in physician offices or outpatient departments. Parent, family, and child characteristics were measured. Forty-eight percent of the 4,650 children included in the study had fewer well-child visits than recommended. Children whose parents did not visit a physician during the year and children whose parents had not completed high school were more likely to miss recommended visits. Parent insurance status did not affect well-child visits. We identified child, family, and parent factors influencing well-child visits in insured children, including the parent's own use of physician visits. Contrary to our hypothesis, well-child visits were not influenced by parent insurance status. Determining which insured children are at greater risk of missing recommended well-child visits aids policymakers in identifying those who may benefit from interventions to improve use of preventive care.

Assessing changes in third-party gross margin for a single community pharmacy.

OBJECTIVES To assess changes in prescription gross margin from 2008 to 2011 using a random sample of prescriptions, analyze changes in prescription gross margin from 2008 to 2011 using a market basket of prescription drugs, and investigate impact of changes in prescription mix from 2008 to 2011 on prescription gross margins. DESIGN Longitudinal, retrospective, descriptive case study. SETTING Single independent pharmacy in Iowa City, IA, from March and April of 2008-11. PARTICIPANTS Prescription dispensing records for the pharmacy's largest private and Part D payers by prescription volume, as well as Medicaid and cash payers. INTERVENTION Random sampling and market basket approaches were used for gross margin calculation. MAIN OUTCOME MEASURES Prescription gross margins and generic dispensing rate. RESULTS Data were collected for 2,400 prescription records for the random sample and 4,860 prescriptions for the market basket sample. The median random sample and market basket gross margin dollars (GMDs) from 2008 to 2011 decreased from $9.55 to $7.22 and from $9.60 to $8.50, respectively. The percent of dispensed prescriptions that was generic increased from 62.65% in 2008 to 73.64% in 2011, and GMDs were significantly lower for generic products. CONCLUSION Third-party prescription drug gross margins in the study pharmacy varied substantially by payer and decreased over time. Pharmacies must continue to monitor changes in prescription margins and investigate ways to enhance alternative revenue sources to maintain profitability.

Exploring relationships among pharmacy service use, patronage motives, and patient satisfaction.

OBJECTIVES: To describe and identify significant relationships among pharmacy service use, general and service-specific patient satisfaction, pharmacy patronage motives, and marketing awareness in a service-oriented, independent community pharmacy. DESIGN: Cross-sectional study. SETTING: Midwest United States during May through July 2011. PARTICIPANTS: Stratified random sample of 500 participants. INTERVENTION: Self-reported questionnaire mailed to participants. MAIN OUTCOME MEASURES: Patient satisfaction, pharmacy service use, patronage motives, marketing awareness, and demographics. RESULTS: Study participants were mostly satisfied with the pharmacy services on global and service-specific measures. Patronage motives of relationships, pharmacy atmosphere, and quality previous experience were associated with increased pharmacy service use at the study pharmacy, while a unique service patronage motivation was associated with decreased pharmacy service use at the study pharmacy. Participants citing pharmacy atmosphere and personnel competency as patronage motives did not use pharmacies other than the study pharmacy more often, whereas participants citing unique services as a patronage motive used pharmacies other than the study pharmacy more often. Direct marketing awareness increased pharmacy service awareness but not use. CONCLUSION: Offering unique services may not be enough to bring in patients loyal to all services provided in a pharmacy. Pharmacists should focus on developing strong relationships with patients and conveying competence when delivering appropriate, quality pharmacy services in a professional pharmacy atmosphere.