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Full-Text Articles in Insurance

Lowering Out Of Pocket Drug Costs For Consumers, Mylissa K. Price Jan 2019

Lowering Out Of Pocket Drug Costs For Consumers, Mylissa K. Price

Commonwealth Medicine Publications

Prohibiting gag clauses could help lower consumer out-of-pocket pharmacy costs - if Pharmacy Benefits Managers don't raise prices to make-up the difference. Mylissa Price closes our blog series on President Trump's Blueprint to Lower Drug Costs in this final entry.


Deciphering State Medicaid Programs, Rachel Gershon Jan 2019

Deciphering State Medicaid Programs, Rachel Gershon

Commonwealth Medicine Publications

State Medicaid programs vary substantially from one another. For members, researchers, policymakers, and advocates trying to decipher a state’s Medicaid program, this variation can be a source of frustration, because the details of this variation can be hard to locate.


The Implementation Process For Pharmacogenomic Testing For Cancer-Targeted Therapies, Ann Chen Wu, Kathleen M. Mazor, Rachel Ceccarelli, Stephanie Loomer, Christine Y. Lu Dec 2018

The Implementation Process For Pharmacogenomic Testing For Cancer-Targeted Therapies, Ann Chen Wu, Kathleen M. Mazor, Rachel Ceccarelli, Stephanie Loomer, Christine Y. Lu

Kathleen M. Mazor

Recent advances in genomic medicine have led to the availability of genomic tests that have the potential to improve population health, yet the process for obtaining these tests and getting them reimbursed by insurers has not been described. The objective of this study was to describe the process of ordering pharmacogenomic tests by interviewing providers, patients, and laboratories about cancer-related pharmacogenomic tests. We interviewed patients who were prescribed, providers who prescribed medications that should be guided by pharmacogenomic testing, and individuals from diagnostic laboratories. A total of 10 providers, 16 patients, and eight diagnostic laboratories described logistical and insurance issues ...


Will Removing Rebates Really Lower Drug List Prices?, Stephanie Tran Dec 2018

Will Removing Rebates Really Lower Drug List Prices?, Stephanie Tran

Commonwealth Medicine Publications

The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs calls for incentives to lower drug list prices, including removing rebates. Our clinical consultant Stephanie Tran continues our pharmacy blog series with an assessment of this potential change & its impacts.


New Aca Waiver Directives Signal Changes For State Health Insurance Marketplaces, Rachel Gershon, Catherine Torri Dec 2018

New Aca Waiver Directives Signal Changes For State Health Insurance Marketplaces, Rachel Gershon, Catherine Torri

Commonwealth Medicine Publications

New Trump Administrations Section 1332 waiver guidance increases state ACA flexibility. Rachel Gershon & Catie Torri discuss what this could mean for health care policy.


Better Negotiations Between Payers And Manufacturers In An Effort To Reduce Drug Prices, Mckenzie Taylor Nov 2018

Better Negotiations Between Payers And Manufacturers In An Effort To Reduce Drug Prices, Mckenzie Taylor

Commonwealth Medicine Publications

Mckenzie Taylor continues our monthly conversation on the strategies presented in The Trump Administration Blueprint to Low Drug Prices and Reduce Out-of-Pocket Costs, discussing the ways new negotiations between payers and manufacturers are helping to reduce drug prices.


How Can Improved Competition Lead To Lower Drug Prices?, Youkavet Samih Oct 2018

How Can Improved Competition Lead To Lower Drug Prices?, Youkavet Samih

Commonwealth Medicine Publications

In this installment of our blog series on "President Trump's Blueprint to Lower Drug Prices and Reduce Out-Of-Pocket Costs," our pharmacy expert Youkavet Samih discusses how creating drug competition drives down prices for consumers.


The Implementation Process For Pharmacogenomic Testing For Cancer-Targeted Therapies, Ann Chen Wu, Kathleen M. Mazor, Rachel Ceccarelli, Stephanie Loomer, Christine Y. Lu Oct 2018

The Implementation Process For Pharmacogenomic Testing For Cancer-Targeted Therapies, Ann Chen Wu, Kathleen M. Mazor, Rachel Ceccarelli, Stephanie Loomer, Christine Y. Lu

Open Access Articles

Recent advances in genomic medicine have led to the availability of genomic tests that have the potential to improve population health, yet the process for obtaining these tests and getting them reimbursed by insurers has not been described. The objective of this study was to describe the process of ordering pharmacogenomic tests by interviewing providers, patients, and laboratories about cancer-related pharmacogenomic tests. We interviewed patients who were prescribed, providers who prescribed medications that should be guided by pharmacogenomic testing, and individuals from diagnostic laboratories. A total of 10 providers, 16 patients, and eight diagnostic laboratories described logistical and insurance issues ...


Insurance Coverage Policies For Pharmacogenomic And Multi-Gene Testing For Cancer, Christine Y. Lu, Stephanie Loomer, Rachel Ceccarelli, Kathleen M. Mazor, James Sabin, Ellen Wright Clayton, Geoffrey S. Ginsburg, Ann Chen Wu Jul 2018

Insurance Coverage Policies For Pharmacogenomic And Multi-Gene Testing For Cancer, Christine Y. Lu, Stephanie Loomer, Rachel Ceccarelli, Kathleen M. Mazor, James Sabin, Ellen Wright Clayton, Geoffrey S. Ginsburg, Ann Chen Wu

Kathleen M. Mazor

Insurance coverage policies are a major determinant of patient access to genomic tests. The objective of this study was to examine differences in coverage policies for guideline-recommended pharmacogenomic tests that inform cancer treatment. We analyzed coverage policies from eight Medicare contractors and 10 private payers for 23 biomarkers (e.g., HER2 and EGFR) and multi-gene tests. We extracted policy coverage and criteria, prior authorization requirements, and an evidence basis for coverage. We reviewed professional society guidelines and their recommendations for use of pharmacogenomic tests. Coverage for KRAS, EGFR, and BRAF tests were common across Medicare contractors and private payers, but ...


The Role Of Clinical Guidelines In A Managed Long Term Services & Supports Framework, Jessica Carpenter, Jill Morrow-Gorton Jun 2018

The Role Of Clinical Guidelines In A Managed Long Term Services & Supports Framework, Jessica Carpenter, Jill Morrow-Gorton

Commonwealth Medicine Publications

This presentation describes the managed long-term services and supports (MLTSS) national landscape since 2012 as well as some LTSS utilization trends. A key part of the presentation is our MLTSS best practice framework and the role of LTSS clinical guidelines in that framework. The presentation includes a case study.

Experts from Disability Community Services and the Office of Clinical affairs gave the presentation during a webinar hosted by the Association for Community Affiliated Plans.


Insurance Coverage Policies For Pharmacogenomic And Multi-Gene Testing For Cancer, Christine Y. Lu, Stephanie Loomer, Rachel Ceccarelli, Kathleen M. Mazor, James Sabin, Ellen Wright Clayton, Geoffrey S. Ginsburg, Ann Chen Wu May 2018

Insurance Coverage Policies For Pharmacogenomic And Multi-Gene Testing For Cancer, Christine Y. Lu, Stephanie Loomer, Rachel Ceccarelli, Kathleen M. Mazor, James Sabin, Ellen Wright Clayton, Geoffrey S. Ginsburg, Ann Chen Wu

Open Access Articles

Insurance coverage policies are a major determinant of patient access to genomic tests. The objective of this study was to examine differences in coverage policies for guideline-recommended pharmacogenomic tests that inform cancer treatment. We analyzed coverage policies from eight Medicare contractors and 10 private payers for 23 biomarkers (e.g., HER2 and EGFR) and multi-gene tests. We extracted policy coverage and criteria, prior authorization requirements, and an evidence basis for coverage. We reviewed professional society guidelines and their recommendations for use of pharmacogenomic tests. Coverage for KRAS, EGFR, and BRAF tests were common across Medicare contractors and private payers, but ...


Accounting For Geographic Variation In Social Security Disability Program Participation, John Gettens, Pei-Pei Lei, Alexis D. Henry May 2018

Accounting For Geographic Variation In Social Security Disability Program Participation, John Gettens, Pei-Pei Lei, Alexis D. Henry

Commonwealth Medicine Publications

There is wide geographic variation in Social Security Disability Insurance and Supplementary Security Income participation across the United States. Some policymakers and members of the public may assume that interregional administrative inconsistencies are a major reason for the geographic variation. To test this assumption, and to reveal other potential explanations for the variation, we decompose the total variation into components by examining regional differences in disability prevalence and in program participation among persons with disabilities as well as the correlation between those two factors. We further decompose the variation in participation among persons with disabilities into socioeconomic components. Our findings ...


Out-Of-Pocket Cost For Individuals Being Treated For Opioid Dependence In Rutland County, Vermont, Christopher T. Veal Jan 2018

Out-Of-Pocket Cost For Individuals Being Treated For Opioid Dependence In Rutland County, Vermont, Christopher T. Veal

Family Medicine Clerkship Student Projects

Each day more than 140 Americans die from drug overdoses, 91 specifically due to opioids. In Vermont, more than 50 people die each year from opioid poisoning. With insurance coverage being a critical component of Opioid Dependence Recovery, many people seeking treatment are unaware of the financial barriers to recovery- namely the out-of-pocket costs associated with treatment. This study sought to provide insight on the financial impact of Opioid Dependence Treatment on the patient, and provide financial assistance information to the Rutland County community.


Narrow Networks On The Individual Marketplace In 2017, Daniel Polsky, Janet Weiner, Yuehan Zhang Sep 2017

Narrow Networks On The Individual Marketplace In 2017, Daniel Polsky, Janet Weiner, Yuehan Zhang

Issue Briefs

This Issue Brief describes the breadth of physician networks on the ACA marketplaces in 2017. We find that the overall rate of narrow networks is 21%, which is a decline since 2014 (31%) and 2016 (25%). Narrow networks are concentrated in plans sold on state-based marketplaces, at 42%, compared to 10% of plans on federally-facilitated marketplaces. Issuers that have traditionally offered Medicaid coverage have the highest prevalence of narrow network plans at 36%, with regional/local plans and provider-based plans close behind at 27% and 30%. We also find large differences in narrow networks by state and by plan type.


Stabilizing Individual Health Insurance Markets With Subsidized Reinsurance, Scott E. Harrington Sep 2017

Stabilizing Individual Health Insurance Markets With Subsidized Reinsurance, Scott E. Harrington

Issue Briefs

Subsidized reinsurance represents a potentially important tool to help stabilize individual health insurance markets. This brief describes alternative forms of subsidized reinsurance and the mechanisms by which they spread risk and reduce premiums. It summarizes specific state initiatives and Congressional proposals that include subsidized reinsurance. It compares approaches to each other and to more direct subsidies of individual market enrollment. For a given amount of funding, a particular program’s efficacy will depend on how it affects insurers’ risk and the risk margins built into premiums, incentives for selecting or avoiding risks, incentives for coordinating and managing care, and the ...


Equity And Community-Based Health Insurance: How Does Insurance Coverage Affect Health Seeking Behavior Among Disadvantaged Groups In India?, Hazel Hering Apr 2017

Equity And Community-Based Health Insurance: How Does Insurance Coverage Affect Health Seeking Behavior Among Disadvantaged Groups In India?, Hazel Hering

Independent Study Project (ISP) Collection

The objective of this study is to examine how Community-Based Health Insurance (CBHI) can promote equity by improving health seeking behavior across gender and geography. Using a CBHI scheme from the Self-Employed Women’s Association (SEWA) as a case study, trends in claims filed between October 2016 and March 2017 are compared to the distribution of memberships in order to investigate whether health insurance coverage positively impacts health seeking behavior among disadvantaged groups, and what barriers to access exist when the burden of medical costs are reduced. This study concludes that the number of male and female claims in the ...


Social Health Insurance Coverage And Financial Protection Among Rural-To-Urban Internal Migrants In China: Evidence From A Nationally Representative Cross-Sectional Study, Wen Chen, Qi Zhang, Andre M. N. Renzaho, Fangjing Zhou, Hui Zhang, Li Ling Jan 2017

Social Health Insurance Coverage And Financial Protection Among Rural-To-Urban Internal Migrants In China: Evidence From A Nationally Representative Cross-Sectional Study, Wen Chen, Qi Zhang, Andre M. N. Renzaho, Fangjing Zhou, Hui Zhang, Li Ling

Community & Environmental Health Faculty Publications

INTRODUCTION: Migrants are a vulnerable population and could experience various challenges and barriers to accessing health insurance. Health insurance coverage protects migrants from financial loss related to illness and death. We assessed social health insurance (SHI) coverage and its financial protection effect among rural-to-urban internal migrants (IMs) in China.

METHODS: Data from the '2014 National Internal Migrant Dynamic Monitoring Survey' were used. We categorised 170 904 rural-to-urban IMs according to their SHI status, namely uninsured by SHI, insured by the rural SHI scheme (new rural cooperative medical scheme (NCMS)) or the urban SHI schemes (urban employee-based basic medical insurance (UEBMI ...


Health Insurance Co-Ops: Product Availability And Premiums In Rural Counties, Erika C. Ziller Phd, Zach T. Croll Ba, Andrew F. Coburn Phd Oct 2016

Health Insurance Co-Ops: Product Availability And Premiums In Rural Counties, Erika C. Ziller Phd, Zach T. Croll Ba, Andrew F. Coburn Phd

Access / Insurance

Created by the Affordable Care Act (ACA), Consumer Operated and Oriented Plans (CO-OPs) are private, non-profit health insurers that were designed to increase insurance plan choice and lower premiums in the Health Insurance Marketplaces. Early analyses of the ACA suggested that CO-OPs may be particularly beneficial for rural communities, where fewer individual and small group health insurance options have traditionally been available.

This Research and Policy Brief, authored by research staff at the Maine Rural Health Research Center, explores the early availability and role of CO-OPs in rural and urban counties. We describe the regional distribution and market prevalence of ...


Why Not Fix It?, William H. Lane May 2016

Why Not Fix It?, William H. Lane

English Faculty Publications

Have you felt the pinch of rising health care costs this year? If not, maybe you haven't actually needed to see a doctor or pay for a prescription. Even those of us who are lucky enough to be "covered" at work have noticed rapidly rising deductibles and copays - and shrinking networks of providers. Employers, facing a big, one-year increase in insurance costs, naturally enough go shopping for a new plan. But the big savings with a new plan often mean a big effective pay cut for everyone who's covered under it when employee contributions, deductibles and copays all ...


Essays On Household Health Expenditures, National Health Insurance And Universal Access To Health Care In Ghana, Evelyn Kwakye Jan 2016

Essays On Household Health Expenditures, National Health Insurance And Universal Access To Health Care In Ghana, Evelyn Kwakye

Doctoral Dissertations

Access to quality health services is essential for maintaining a healthy population and economic development hence the growing global consensus that universal health coverage is necessary. Ghana attempts to expand access by making basic health services free at the point of delivery through its National Health Insurance Scheme (NHIS). Prior studies indicate NHIS increases demand for health services, but questions remain about its impact on out of pocket payments, quality of services, and the financial viability of the program. Hence, this dissertation analyzes the financial risk in health care seeking, the effect of NHIS on out of pocket payments and ...


Rural Disabled Medicare Beneficiaries Spend More Out-Of-Pocket Than Their Urban Counterparts, Erika C. Ziller Phd, Jennifer D. Lenardson Mhs, Andrew F. Coburn Phd Nov 2015

Rural Disabled Medicare Beneficiaries Spend More Out-Of-Pocket Than Their Urban Counterparts, Erika C. Ziller Phd, Jennifer D. Lenardson Mhs, Andrew F. Coburn Phd

Access / Insurance

The majority of Medicare beneficiaries experience gaps between the care they need and costs covered by Medicare and seek supplemental coverage to meet this gap, including private plans offered by former employers or purchased individually, or public coverage through Medicaid. Since rural beneficiaries are more likely to purchase supplemental indemnity coverage individually, to participate in Medicaid, or to go without supplemental coverage altogether, it is likely that their out-of-pocket spending differs from that of urban residents, although the magnitude and direction of these differences may vary for individual beneficiaries. This study used data from the 2006-2010 Medical Expenditure Panel Survey ...


Disparities In Hospital Services Utilization Among Patients With Mental Health Issues: A Statewide Example Examining Insurance Status And Race Factors From 1999-2010, Viann N. Nguyen-Feng, Hind A. Beydoun, Michael K. Mcshane, James D. Blando Jul 2015

Disparities In Hospital Services Utilization Among Patients With Mental Health Issues: A Statewide Example Examining Insurance Status And Race Factors From 1999-2010, Viann N. Nguyen-Feng, Hind A. Beydoun, Michael K. Mcshane, James D. Blando

Community & Environmental Health Faculty Publications

There exist many disconnects between the mental and general health care sectors. However, a goal of the Affordable Care Act (ACA) of 2010 is to change this by improving insurance access and the intersection of mental and general health care. As insurance status intersects with race, the present study examines how race, insurance status, and hospital mental health services utilization differ across groups within the state of New Jersey. The present study aims to determine trends in hospital mental health care utilization by insurance status and race from 1999 to 2010. The rate of self-pay for mental health disorders in ...


Value-Based Differential Pricing: Efficient Prices For Drugs In A Global Context, Patricia. M. Danzon, Adrian Towse, Jorge Mestre-Ferrandiz Mar 2015

Value-Based Differential Pricing: Efficient Prices For Drugs In A Global Context, Patricia. M. Danzon, Adrian Towse, Jorge Mestre-Ferrandiz

Health Care Management Papers

This paper analyzes pharmaceutical pricing between and within countries to achieve second-best static and dynamic efficiency. We distinguish countries with and without universal insurance, because insurance undermines patients' price sensitivity, potentially leading to prices above second-best efficient levels. In countries with universal insurance, if each payer unilaterally sets an incremental cost-effectiveness ratio (ICER) threshold based on its citizens' willingness-to-pay for health; manufacturers price to that ICER threshold; and payers limit reimbursement to patients for whom a drug is cost-effective at that price and ICER, then the resulting price levels and use within each country and price differentials across countries are ...


Workplace Wellness Programs: Are They Part Of The Answer To The U.S.’S Growing Healthcare Crisis?, Maria C. Grillo Dec 2014

Workplace Wellness Programs: Are They Part Of The Answer To The U.S.’S Growing Healthcare Crisis?, Maria C. Grillo

Cornell HR Review

[Excerpt] Of the $2.8 trillion that the United States has spent on healthcare in recent years, the majority of it (75%) is spent treating chronic disease. Chronic disease is “a long-standing condition that can be controlled but not cured… It is the leading cause of death and disability in the U.S., which is 1.7 million lives each year.” To make matters worse, chronic disease indicators in the U.S. have been on the increase recently. And, even though chronic disease is commonly thought to be more prevalent among the elderly, in the past 10 years, it has ...


Navigating The Health Care Labyrinth: Portraits Of The Socioeconomically Disadvantaged, Thomas C. Crawford Phd Jan 2014

Navigating The Health Care Labyrinth: Portraits Of The Socioeconomically Disadvantaged, Thomas C. Crawford Phd

Dissertations & Theses

In 2010, an estimated population of the 311,212,863 Americans generated approximately 1,014,688,290 physician office encounters (Moore, 2010). The frequency and number of professional interactions between caregivers and patients/family members in medical office settings equated to a staggering 1,931 visits per minute. Based on the massive volume of interactions that occurred between patients of different races, ethnicities, genders, sexual orientations, and socioeconomic standings that generated an average household income of $49,445 in 2010 (United States Census Bureau, 2010a) with a physician workforce that the Association of American Medical Colleges (2010) captured as being ...


Want More Value From Prescription Drugs? We Need To Let Prices Rise And Fall, Dana. P. Goldman, Adam Leive, Darius Lakdawalla Dec 2013

Want More Value From Prescription Drugs? We Need To Let Prices Rise And Fall, Dana. P. Goldman, Adam Leive, Darius Lakdawalla

Health Care Management Papers

The high price of some cancer drugs has recently come under attack by the medical profession. We examine the reasons behind the pricing strategies of cancer drugs. On the one hand, prices should reflect value and research demonstrates that the health benefits from novel cancer drugs have been enormous in terms of additional years of life patients can now enjoy. This provides some justification for the high price tag of these drugs. On the other hand, drug pricing is also a product of a hidebound reimbursement system that does a poor job in letting prices adjust to new information about ...


Plan Selection In Medicare Part D: Evidence From Administrative Data, Florian Heiss, Adam Leive, Daniel Mcfadden, Joachim Winter Dec 2013

Plan Selection In Medicare Part D: Evidence From Administrative Data, Florian Heiss, Adam Leive, Daniel Mcfadden, Joachim Winter

Health Care Management Papers

We study the Medicare Part D prescription drug insurance program as a bellwether for designs of private, non-mandatory health insurance markets, focusing on the ability of consumers to evaluate and optimize their choices of plans. Our analysis of administrative data on medical claims in Medicare Part D suggests that fewer than 25% of individuals enroll in plans that are ex ante as good as the least cost plan specified by the Plan Finder tool made available to seniors by the Medicare administration, and that consumers on average have expected excess spending of about $300 per year, or about 15% of ...


Consumers' Misunderstanding Of Health Insurance., George Loewenstein, Joelle Y Friedman, Barbara Mcgill, Sarah Ahmad, Suzanne Linck, Stacey Sinkula, John Beshears, James J Choi, Jonathan Kolstad, David Laibson, Brigitte C Madrian, John A List, Kevin. G. Volpp Sep 2013

Consumers' Misunderstanding Of Health Insurance., George Loewenstein, Joelle Y Friedman, Barbara Mcgill, Sarah Ahmad, Suzanne Linck, Stacey Sinkula, John Beshears, James J Choi, Jonathan Kolstad, David Laibson, Brigitte C Madrian, John A List, Kevin. G. Volpp

Health Care Management Papers

We report results from two surveys of representative samples of Americans with private health insurance. The first examines how well Americans understand, and believe they understand, traditional health insurance coverage. The second examines whether those insured under a simplified all-copay insurance plan will be more likely to engage in cost-reducing behaviors relative to those insured under a traditional plan with deductibles and coinsurance, and measures consumer preferences between the two plans. The surveys provide strong evidence that consumers do not understand traditional plans and would better understand a simplified plan, but weaker evidence that a simplified plan would have strong ...


Improving Health Outcomes For Children (Ihoc): Summary Of Pediatric Quality Measures For Children Enrolled In Mainecare Ffy 2009 - Ffy 2012, Nathaniel J. Anderson Ms, Mph, Tracey Meagher Apr 2013

Improving Health Outcomes For Children (Ihoc): Summary Of Pediatric Quality Measures For Children Enrolled In Mainecare Ffy 2009 - Ffy 2012, Nathaniel J. Anderson Ms, Mph, Tracey Meagher

Population Health & Health Policy

his report, authored by USM Muskie School research staff, presents the results of the 16 CHIPRA Core Measures that were collected using MaineCare claims or Vital Statistics data and reported in the State of Maine’s FFY 2012 CHIP Annual Report to the Centers for Medicare and Medicaid Services (CMS). Also included in this report are an additional three measures from the Improving Health Outcomes for Children (IHOC) project’s Master List of Pediatric Measures. In addition to presenting results in graphs and narrative, this report also provides measure definitions and background information about each measure topic.

The goal of ...


Examining Mainecare’S Coverage Options Under The Affordable Care Act, Erika C. Ziller Phd, Trish Riley Mar 2013

Examining Mainecare’S Coverage Options Under The Affordable Care Act, Erika C. Ziller Phd, Trish Riley

Population Health & Health Policy

The Affordable Care Act (ACA) was designed to achieve nearly universal access to health coverage in the United States—in part by standardizing Medicaid eligibility across the country so that each state’s program would cover individuals with incomes below 138% of the federal poverty level (FPL), or $15,856 for an individual and $32,499 for a family of four in 2013 (see Figure 1).i However, in June 2012, the U.S. Supreme Court determined that states could not be required to broaden Medicaid and retained the decision as a state option. States that choose to participate may ...