Payer Coverage of Valley Fever Diagnostic Tests

Background The nonspecific symptoms of Valley fever, or coccidioidomycosis, hinders its proper diagnosis. This results in unnecessary health care costs and antibiotic usage. Thus, this study seeks to determine the coverage of the Valley fever diagnostic test as provided by Arizona insurance companies to increase early diagnosis rates. Methods Through scripted messaging and telephone communications, we contacted 40 health insurance companies in Arizona about their coverage of CPT 86635 (antibody diagnostic assay for Coccidioides) without prior authorization under all plan types provided in both primary and urgent care settings. If prior authorization was required, we discussed the coverage of ICD-10 codes J18.9 (pneumonia, unspecified organism), J18.1 (lobar pneumonia, unspecified organism), or L52 (erythema nodosum). Results Of the 40 health insurance companies contacted, 25 did not answer our inquiries, most requiring member-specific information to share coverage data. The remaining 15 companies covered Valley fever testing, of which 4 required prior authorization for the ICD-10 codes of interest. Of these 15 companies, 14 provided coverage in primary and urgent care settings, and 13 provided coverage for all available plans. Conclusion All payers that provided information covered Valley Fever testing. Most of the insurance companies that were unable to answer our inquiry likely cover Valley fever testing, but were unable to share information with third party inquiries. Obtaining general coverage information is difficult, which can potentially impact patient care.

Nursing home-sensitive conditions: analysis of routine health insurance data and modified Delphi analysis of potentially avoidable hospitalizations

Background: Hospitalizations of nursing home residents are associated with various health risks. Previous research indicates that, to some extent, hospitalizations of this vulnerable population may be inappropriate and even avoidable. This study aimed to develop a consensus list of hospital discharge diagnoses considered to be nursing home-sensitive, i.e., avoidable. Methods: The study combined analyses of routine data from six statutory health insurance companies in Germany and a two-stage Delphi panel, enhanced by expert workshop discussions, to identify and corroborate relevant diagnoses. Experts from four different disciplines estimated the proportion of hospitalizations that could potentially have been prevented under optimal conditions. Results: We analyzed frequencies and costs of data for hospital admissions from 242,236 nursing home residents provided by statutory health insurance companies. We identified 117 hospital discharge diagnoses, which had a frequency of at least 0.1%. We recruited experts (primary care physicians, hospital specialists, nursing home professionals and researchers) to estimate the proportion of potentially avoidable hospitalizations for the 117 diagnoses deemed avoidable in two Delphi rounds (n=107 in Delphi Round 1 and n=96 in Delphi Round 2, effective response rate=91%). A total of 35 diagnoses with high and consistent estimates of the proportion of potentially avoidable hospitalizations were identified as nursing home-sensitive. In an expert workshop (n=16), a further 25 diagnoses were discussed that had not reached the criteria, of which another 23 were consented to be nursing home-sensitive conditions. Extrapolating the frequency and mean costs of these 58 diagnoses to the national German context yielded total potentially avoidable care costs of €768,304,547, associated with 219,955 nursing home-sensitive hospital admissions. Conclusion: A total of 58 nursing home-relevant diagnoses (ICD-10-GM three-digit level) were classified as nursing home-sensitive using an adapted Delphi procedure. Interventions should be developed to avoid hospital admission from nursing homes for these diagnoses.

Availability and accessibility of opioids for pain and palliative care in Colombia: a survey study

Introduction: Access to essential medicines, including opioids, is a component of the right to health. Objective: To identify barriers to opioid availability and accessibility for pain and palliative care. Methods: Online survey with Colombian prescribers. Availability barriers were analyzed for each facility (distribution and/or dispensing). Accessibility barriers were analyzed by type. Descriptive analyses were conducted using relative frequencies. Significance within categories and regions was measured using Fisher's exact test. Results: Out of 1,208 prescribers invited, 806 (66.7%) completed the survey. Availability: 76.43% reported barriers. The most cited barrier was “Pharmacies authorized by health insurance companies”, where opioids are frequently unavailable. Accessibility: 74.6% reported barriers. Most frequently cited was “Difficulty securing payment authorization for medication from health insurance companies”. Significant differences were observed in terms of regions and “Cost” (p=0.02). Lack of coordination among procuring and distributing agencies affects availability. Limited awareness and bureaucratic procedures affect accessibility. Conclusions: There are barriers to opioid availability and access in Colombia, related to the existing structure for guaranteeing equitable supply. From the perspective of healthcare providers, problems related to pharmacy availability, prescription and cost of medicines hinder pain treatment.

Earnings management by health insurance companies in Brazil

PurposeThis study examines whether Brazilian health insurance companies (HICs) engage in earnings management through discretionary accruals or operational decisions by refraining from reporting a low indicator of sustainability in the market (IDSM).Design/methodology/approachThe study used the Jones and Modified Jones models to identify earnings management through discretionary accruals and used the model described by Roychowdhury to estimate the abnormal behaviors of operational decisions. Data covering 2012 to 2018 were collected from the ANS website.FindingsThe results show that HICs engaged in earnings management to avoid reporting a low IDSM. The findings should help health insurance clients make decisions regarding the purchase or change of health insurance. The findings should also encourage regulators to improve their evaluation of the economic and financial risks around HICs.Originality/valueThe National Agency of Supplementary Health (ANS) established a qualification program for HICs, monitoring them based on a set of indicators. Managers may have an incentive to use earnings management to obtain indices that meet the requirements of the ANS qualification program in order to avoid showing signs of abnormality.

Economic and Social Aspects of Secondary Lymphedema following Treatment of Breast Cancer

Introduction The quality of life of female patients who have undergone mentally and physically demanding treatment of cancer is often affected by the emergence of secondary lymphedema. The purpose of our work is to evaluate this complexity not only from an objective but also subjective point of view. Methods Qualitative focusstudy in 18 patients under 60 years of age conducted by way of a structured interview during 2019 at the lymphological workplace. Results The economic burden for patients is on the average CZK 683 per month (about $360 USD per year), the treatment is paid for fully by health insurance companies. Lymphedema is a significant barrier in an occupation, more in women after treatment of the second grade of cancer than the first one. Lymphedema is a bigger obstacle for women with lower education, physically working. Family status does not have a significant effect on the treatment of cancer. Conclusions The study has confirmed the difficulty of treatment ofsecondary lymphedema after the treatment of breast cancer, both from financial and professional points of view. The medical staff should take into account these factors or expand the rehabilitation team and thus ensure better compliance in therapy.

Preventing drug vial wastage and reducing expenditure associated with injectable cancer drugs: International oncology pharmacy survey

Purpose Our objective was to determine what vial sharing techniques and other strategies were being used globally to reduce wastage from partially used single-use drug vials, what barriers are preventing these strategies being employed, and what savings are being achieved. Methods A survey, comprising 19 questions, was distributed to the membership of the International Society of Oncology Pharmacy Practitioners and British Oncology Pharmacy Association. Questions asked included how parenteral cancer drugs are obtained and prepared, what vial sharing strategies are used, what means are employed to extend stability, how prepared products are reused and what cost savings are achieved. Results In all, 74 responses were received from 20 countries, most from the United Kingdom. Some manufacturing is done by 60.8% of institution, with 41.9% making all products. Vial sharing strategies, for frequently used drugs, were employed in 53% of cases. Barriers preventing vial sharing being used included government legislation, USP 797 guidelines, and health insurance companies. Extension of stability was possible for 70.2% of centres. Most respondents reported reduction in cytotoxic and biological waste, and alleviation of drug shortages from vial sharing utilisation. Cost savings were achieved in 74% of cases and was significant in one third. Conclusions The survey has determined that drug vial wastage and expenditure can be reduced, and vial sharing facilitates this. International collaboration plus the assistance of governments and the pharmaceutical industry is vital in achieving this aim. These findings can hopefully guide oncology pharmacy in establishing appropriate strategies to reduce wastage internationally.

IoT Based Accident Detection and Life Guard System

In an enormous population, people make vehicles for their needs, leading to heavy traffic. Every day, thousands of people die in road accidents across the world, creating a global hazard. In the existing system, when an accident occurs, information only is sending to emergency services through GSM, but there is no prospect for an insurance claim. This research paper describes the detection of the crash using a piezoelectric device by the observation of vibration caused by fatal crashes. There are two types of accidents: major accidents and minor accidents. These will be determined by establishing new crash pressure threshold values. Depending on the nature of the accident, official announcements can decide to make to eitherlocal emergency services and vehicle insurance companies, or both vehicle insurance and health insurance companies, as well as local emergency services.

Brain Tumors Presumed Malignant without Biopsy-Evaluation and Treatment Problems

Patients with brain tumors may have the following issues: tumors are in deep or vital regions; they refuse the biopsy; the neurosurgeon does not reach the tumoral tissue and the biopsy is irrelevant; advanced cases, considered “outside the surgical and oncological therapeutic resources”. These patients cannot receive oncological treatment or radiotherapy because of the restrictive indications of the insurers (health insurance companies) or because of the risk of allegations of malpractice. Patients will not receive some social security rights (short term sick leave, disability pension) in the same way as cancer patients, but only as a patient with a common illness. Patients can receive palliative treatment, can be hospitalized in oncology departments. We propose to discuss a separate diagnostic and treatment protocol for this group of patients, based on laboratory (ctDNA) and imagistic criteria. Assistive technologies using Computer Vision Model combined with Convolutional Neural Network may help classificate and diagnose these tumors.