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1.
Health Aff (Millwood) ; 43(7): 933-941, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38950305

RESUMO

The Next Generation Accountable Care Organization (NGACO) model (active during 2016-21) tested the effects of high financial risk, payment mechanisms, and flexible care delivery on health care spending and value for fee-for-service Medicare beneficiaries. We used quasi-experimental methods to examine the model's effects on Medicare Parts A and B spending. Sixty-two ACOs with more than 4.2 million beneficiaries and more than 91,000 practitioners participated in the model. The model was associated with a $270 per beneficiary per year, or approximately $1.7 billion, decline in Medicare spending. After shared savings payments to ACOs were included, the model increased net Medicare spending by $56 per beneficiary per year, or $96.7 million. Annual declines in spending for the model grew over time, reflecting exit by poorer-performing NGACOs, improvement among the remaining NGACOs, and the COVID-19 pandemic. Larger declines in spending occurred among physician practice ACOs and ACOs that elected population-based payments and risk caps greater than 5 percent.


Assuntos
Organizações de Assistência Responsáveis , Gastos em Saúde , Medicare , Organizações de Assistência Responsáveis/economia , Estados Unidos , Humanos , Medicare/economia , Planos de Pagamento por Serviço Prestado/economia , COVID-19/economia , Redução de Custos
2.
JAMA Netw Open ; 7(5): e2411742, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38758556

RESUMO

Importance: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas. Objective: To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas. Design, Setting, and Participants: This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021. Exposure: Prescribing of buprenorphine by NHSC clinicians. Main Outcomes and Measures: The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics. Results: During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation. Conclusions and Relevance: These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.


Assuntos
Buprenorfina , Medicaid , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Padrões de Prática Médica , Buprenorfina/uso terapêutico , Humanos , Estados Unidos , Estudos Transversais , Feminino , Masculino , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Medicaid/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Pessoa de Meia-Idade , Antagonistas de Entorpecentes/uso terapêutico
3.
Psychiatr Serv ; 74(6): 636-643, 2023 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-36751906

RESUMO

OBJECTIVE: To help address the opioid epidemic, the U.S. Health Resources and Services Administration expanded the National Health Service Corps (NHSC) to include two new loan repayment programs (LRPs)-the Substance Use Disorder LRP and the Rural Community LRP-to supplement the existing standard LRP. In this article, the authors aimed to describe the role of these NHSC programs in addressing workforce shortages and providing substance use disorder treatment, including for opioid use disorder, in underserved areas. METHODS: Administrative data on NHSC clinician locations were merged with county-level data to characterize the communities served by NHSC clinicians. Primary data from surveys and key informant interviews with NHSC site administrators (N=9) and clinicians (N=9) were used to describe changes in NHSC clinician service delivery due to the COVID-19 pandemic. RESULTS: The NHSC LRP expansion increased the number of clinicians providing behavioral health treatment in underserved areas, especially rural areas. A majority of NHSC sites surveyed have increased their provision of substance use disorder treatment since the COVID-19 pandemic began. CONCLUSIONS: This article demonstrates the valuable role of these NHSC programs as resources that policy makers can use to mitigate the challenges of health care workforce shortages and burnout.


Assuntos
COVID-19 , Área Carente de Assistência Médica , Humanos , Pandemias , Medicina Estatal , Pessoal de Saúde
4.
J Interpers Violence ; 33(9): 1519-1548, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-26663611

RESUMO

Violence against women by their husbands is a problem for women worldwide. However, the majority of women do not seek help. This article presents findings from a national survey in India on empowerment-related correlates of help-seeking behaviors for currently married women who experienced spousal violence. We examined individual-, relationship-, and state-level measures of empowerment on help-seeking from informal and formal sources. Findings indicate that help-seeking is largely not associated with typical measures of empowerment or socio-economic development, whereas state-level indicators of empowerment may influence help-seeking. Although not a target of this study, we also note that injury from violence and the severity of the violence were among the strongest factors related to seeking help. Taken together, the low prevalence of help-seeking and lack of strong individual-level correlates, apart from severe harm, suggests widespread barriers to seeking help. Interventions that affect social norms and reach women and men across social classes in society are needed in addition to any individual-level efforts to promote seeking help for spousal violence.


Assuntos
Comportamento de Busca de Ajuda , Poder Psicológico , Maus-Tratos Conjugais , Adolescente , Adulto , Idoso , Revelação , Violência Doméstica , Feminino , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Prevalência , Delitos Sexuais , Classe Social , Normas Sociais , Maus-Tratos Conjugais/psicologia , Inquéritos e Questionários , Adulto Jovem
5.
Psychiatr Serv ; 67(3): 282-8, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26567930

RESUMO

OBJECTIVE: This study used nationally representative household survey data to examine the association between mental illness and experiences with usual care providers and health plans among persons with public or private insurance (N=25,176). METHODS: Data were from the 2004-2012 Medical Expenditure Panel Surveys. Mental illness was assessed with symptom scales of serious psychological distress and depression at two time points, and persons were categorized by whether mental illness was episodic or persistent over time. Questions about experiences with providers (four questions) and plans (five questions) were based on the Consumer Assessment of Healthcare Providers and Systems survey. Rates of problems with plans and providers were reported for each category of mental illness, and multivariate regression was used to examine the association of problems with mental illness. RESULTS: Rates of problems with health plans were high, specifically for treatment approvals, finding information, and customer service, and were higher among persons with mental illness. Rates of problems with providers were lower than problems with plans, but persons with mental illness were more likely to report problems, specifically that doctors do not explain treatment options, respect treatment choices, or seek participation in decisions. CONCLUSIONS: Persons with mental illness reported experiencing more clinical and administrative problems at their usual source of care, although the reasons were not clear. Efforts by plans to improve health care before and after the clinical encounter and by providers to design treatments in line with patient preferences may improve experiences for all patients and particularly for those with mental illness.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Transtornos Mentais/economia , Serviços de Saúde Mental , Adolescente , Adulto , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Escalas de Graduação Psiquiátrica , Inquéritos e Questionários , Estados Unidos , Adulto Jovem
6.
Int J Aging Hum Dev ; 81(3): 155-75, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26668178

RESUMO

This study examines the role of mother's health and socioeconomic status on daughter's self-rated health using data spanning three decades from the National Longitudinal Surveys of Mature Women and Young Women (N = 1,848 matched mother-daughter pairs; 1,201 White and 647 African American). Using nested growth curve models, we investigated whether mother's self-rated health affected the daughter's self-rated health and whether socioeconomic status mediated this relationship. Mother's health significantly influenced daughters' self-rated health, but the findings were mediated by mother's socioeconomic status. African American daughters reported lower self-rated health and experienced more decline over time compared with White daughters, accounting for mother's and daughter's covariates. Our findings reveal maternal health and resources as a significant predictor of daughters' self-rated health and confirm the role of socioeconomic status and racial disparities over time.


Assuntos
Nível de Saúde , Mães , Saúde da Mulher/estatística & dados numéricos , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Escolaridade , Feminino , Humanos , Renda , Classe Social , População Branca/estatística & dados numéricos
7.
Womens Health Issues ; 24(3): e261-9, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24794541

RESUMO

BACKGROUND: Breast reconstruction after mastectomy offers clinical, cosmetic, and psychological benefits compared with mastectomy alone. Although reconstruction rates have increased, racial/ethnic disparities in breast reconstruction persist. Insurance coverage facilitates access to care, but few studies have examined whether health insurance ameliorates disparities. METHODS: We used the Nationwide Inpatient Sample for 2002 through 2006 to examine the relationships between health insurance coverage, race/ethnicity, and breast reconstruction rates among women who underwent mastectomy for breast cancer. We examined reconstruction rates as a function of the interaction of race and the primary payer (self-pay, private health insurance, government) while controlling for patient comorbidity, and we used generalized estimating equations to account for clustering and hospital characteristics. FINDINGS: Minority women had lower breast reconstruction rates than White women (adjusted odds ratio [AOR], 0.57 for African American; AOR, 0.70 for Hispanic; AOR, 0.45 for Asian; p < .001). Uninsured women (AOR, 0.33) and those with public coverage were less likely to undergo reconstruction (AOR, 0.35; p < .001) than privately insured women. Racial/ethnic disparities were less prominent within insurance types. Minority women, whether privately or publicly insured, had lower odds of undergoing reconstruction than White women. Among those without insurance, reconstruction rates did not differ by race/ethnicity. CONCLUSIONS: Insurance facilitates access to care, but does not eliminate racial/ethnic disparities in reconstruction rates. Our findings-which reveal persistent health care disparities not explained by patient health status-should prompt efforts to promote both access to and use of beneficial covered services for women with breast cancer.


Assuntos
Neoplasias da Mama/cirurgia , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Cobertura do Seguro , Seguro Saúde , Mastectomia/economia , Adulto , Neoplasias da Mama/economia , Neoplasias da Mama/etnologia , Neoplasias da Mama/psicologia , Etnicidade/estatística & dados numéricos , Feminino , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Mamoplastia/economia , Mamoplastia/psicologia , Mamoplastia/estatística & dados numéricos , Prontuários Médicos , Pessoa de Meia-Idade , Análise Multivariada , Patient Protection and Affordable Care Act , Análise de Regressão , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
8.
Health Aff (Millwood) ; 32(10): 1723-30, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24101061

RESUMO

The cost of mental health services has always been a great barrier to accessing care for people with mental health problems. This article documents changes in insurance coverage and cost for mental health services for people with public insurance, private insurance, and no coverage. In 2009-10 people with mental health problems were more likely to have public insurance and less likely to have private insurance than in 1999-2000. Although access to specialty care remained relatively stable for people with mental illnesses, cost barriers to care increased among the uninsured and the privately insured who had serious mental illnesses. The rise in cost barriers among those with private insurance suggests that the current financing of care in the private insurance market is insufficient to alleviate cost burdens and has implications for reforms under the Affordable Care Act. People with mental health problems who are newly eligible to purchase private insurance under the act might still encounter high cost barriers to accessing care.


Assuntos
Acessibilidade aos Serviços de Saúde/economia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde , Serviços de Saúde Mental/economia , Adolescente , Adulto , Política de Saúde , Humanos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act , Setor Privado , Setor Público , Pesquisa Qualitativa , Adulto Jovem
9.
Eur J Pharmacol ; 590(1-3): 120-6, 2008 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-18593637

RESUMO

Menthol and related compounds were investigated for modulation of recombinant human gamma-aminobutyric acid type A (GABA(A), alpha(1)beta(2)gamma(2s)) receptor currents expressed in Xenopus oocytes. Sub-maximal (EC(20)) GABA currents were typically enhanced by co-applications of 3-300 microM (+)-menthol (e.g. by approximately 2-fold at 50 microM) > isopulegol > isomenthol> alpha-terpineol >> cyclohexanol. We studied menthol's actions on GABA(A) receptors compared to sedatives (benzodiazepines) and intravenous anesthetics (barbiturates, steroids, etomidate and propofol). Flumazenil (a benzodiazepine antagonist) did not inhibit menthol enhancements while currents directly activated by 50 microM propofol were significantly inhibited (by 26+/-3%) by 50 microM (+)-menthol. GABA(A) receptors containing beta(2) subunits with either a point mutation in a methionine residue to a tryptophan at the 286 position (in transmembrane domain 3, TM-3) or a tyrosine to a tryptophan at the 444 position (TM-4) are insensitive to modulation by propofol. Enhancements of GABA EC(20) currents by menthol were equally abolished in GABA(A) alpha(1)beta(2)(M286W)gamma(2s) and alpha(1)beta(2)(Y444W)gamma(2s) receptors while positive modulations by benzodiazepines, barbiturates and steroids were unaffected. Menthol may therefore exert its actions on GABA(A) receptors via sites distinct from benzodiazepines, steroids and barbiturates, and via sites important for modulation by propofol. Finally, using an in vivo tadpole assay, addition of (+)-menthol resulted in a loss of righting reflex with an EC(50) of 23.5+/-4.7 microM (approximately10-fold less potent anesthesia than propofol). Thus, menthol and analogs share general anesthetic action with propofol, possibly via action at similar sites on the GABA(A) receptor.


Assuntos
Anestésicos Gerais/farmacologia , Anestésicos Intravenosos/farmacologia , Mentol/farmacologia , Propofol/farmacologia , Receptores de GABA-A/efeitos dos fármacos , Animais , Cicloexanóis/farmacologia , Flumazenil/farmacologia , Flunitrazepam/farmacologia , Pentobarbital/farmacologia , Pregnanolona/farmacologia , Xenopus
10.
Anesth Analg ; 98(5): 1297-304, table of contents, 2004 May.
Artigo em Inglês | MEDLINE | ID: mdl-15105205

RESUMO

UNLABELLED: gamma-aminobutyric acid type A receptors (GABA(A)-R) mediate synaptic inhibition and meet many pharmacological criteria required of important general anesthetic targets. During synaptic transmission GABA release is sufficient to saturate, maximally activate, and transiently desensitize postsynaptic GABA(A)-Rs. The resulting inhibitory postsynaptic currents (IPSCs) are prolonged by volatile anesthetics like isoflurane. We investigated the effects of isoflurane on maximally activated and desensitized GABA(A)-R currents expressed in Xenopus oocytes. Wild-type alpha(1)beta(2) and alpha(1)beta(2)gamma(2s) receptors were exposed to 600 microM GABA until currents reached a steady-state desensitized level. At clinical concentrations (0.02-0.3 mM), isoflurane produced a dose-dependent enhancement of steady-state desensitized current in alpha(1)beta(2) receptors, an effect that was less apparent in receptors including a gamma(2s)-subunit. When serine at position 270 is mutated to histidine (alpha(1)(S270H)) in the second transmembrane segment of the alpha(1)-subunit, the currents evoked by sub-saturating concentrations of GABA became less sensitive to isoflurane enhancement. In addition, isoflurane enhancements of desensitized currents were greatly attenuated by this mutation and were undetectable in alpha(1)(S270H)beta(2)gamma(2s) receptors. In conclusion, isoflurane enhancement of GABA(A)-R currents evoked by saturating concentrations of agonist is subunit-dependent. The effects of isoflurane on desensitized receptors may be partly responsible for the prolongation of IPSCs during anesthesia. IMPLICATIONS: Isoflurane enhances desensitized gamma-aminobutyric acid type A receptor (GABA(A)-R) currents, an effect that is subunit-dependent and attenuated by a mutation in an alpha(1)-subunit pore residue of the GABA(A)-R. As GABA release at inhibitory synapses is typically saturating, isoflurane modulation of desensitized receptors may be partly responsible for prolongation of inhibitory postsynaptic currents during anesthesia.


Assuntos
Anestésicos Inalatórios/farmacologia , Isoflurano/farmacologia , Receptores de GABA-A/efeitos dos fármacos , Receptores de GABA-A/genética , Animais , DNA Complementar/efeitos dos fármacos , DNA Complementar/genética , Relação Dose-Resposta a Droga , Humanos , Cinética , Mutação/genética , Mutação/fisiologia , Oócitos/metabolismo , Xenopus
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