The impact of managed care on drug-dependent pregnant and postpartum women and their children

In the shift from fee-for-service (FFS) to managed care (MC), many drug user treatment programs have eliminated all but basic services, lessening short-term costs without considering long-term consequences. This study explored maternal and infant outcomes at an urban drug user treatment center for pregnant drug-dependent women under FFS (1995) vs. MC (2000) service periods. The two groups had similar birth parameters, but the MC group had more fetal and infant deaths, decreased immunization rates, and greater incidences of social services intervention. While these data are correlational and need to be interpreted with caution, they suggest poorer outcomes for drug-exposed children under MC and invite further study of short- and long-term consequences of such change.     

The impact of managed care on substance abuse treatment: a report of the American Society of Addiction Medicine

This report examines the impact of managed care (MC) and related developments on substance abuse treatment, and evaluates how it has been associated with a decline in the availability of proper treatment for many addicted patients. A trend toward carve-out and for-profit MC organizations is associated with lower financial incentives for intensive treatment than in earlier staff-model and not-for-profit MC organizations. The value of substance abuse insurance coverage has declined by 75% between 1988 and 1998 for employees of mid-to large-size companies, compared with only an 11.5% decline for general health insurance. The shift towards MC has also been associated with a drastic reduction in frequency and duration of inpatient hospitalization, and there is no clear evidence that this reduction has been offset by a corresponding increase in outpatient support. In a survey of physicians treating addiction, the majority felt that MC had a negative impact on detoxification and rehabilitation, and on their ethical practice of addiction medicine.     

The relevance to clinical care of recent research in neurobiology

Progress continues to be made in clarifying neurobiological factors in alcoholism and other chemical dependencies. Research in animal behavioral genetics and human genetics has revealed substantial genetic predispositions for some cases of alcoholism. Studies of neurotransmitters suggest that some alcoholics may have antecedent deficiencies in one or more important neurochemical systems. Cocaine dependence is considered to be related to biphasic change in sopaminergic neurons and receptor systems. Condensation products such as salsolinol, tetrahydropapaveroline, and beta carbolines can alter alcoholic preference and motivate heavy ethanol consumption in animals. However, hypothesized theoretical mechanisms underlying such increased drinking with infusions of condensation products are unclear and may require revision. New pharmacological treatments stemming from advances in neurobiological research have been applied successfully to treatment of withdrawal states, but none have been demonstrated to be appropriate for long-term maintenance of abstinence.     

The impact of non-concordant self-report of substance use in clinical trials research

BackgroundStudies comparing self-report substance use data to biochemical verification generally demonstrate high rates of concordance. We argue that these rates are due to the relatively high true negative rate in the general population, and high degree of honestly in treatment seeking individuals. We hypothesized that high risk individuals not seeking treatment would demonstrate low concordance and a high false negative rate of self-reported substance use.MethodsA sample of 500 individuals from a smoking cessation clinical trial was assessed over 1 year. Assessments included semi-structured interviews, questionnaires (e.g. Addiction Severity Index, etc.), and urine drug screen assays (UDS). Generalized estimating equations (GEEs) were used to predict false negative reports for various substances across the study and determine the influence of substance use on the primary study outcome of smoking cessation.ResultsParticipants demonstrated high false negative rates in reporting substances use, and the false negative rates increased as the study progressed. Established predictors of false negatives generalized to the current sample. High concordance and low false negative rates were found in self-report of nicotine use. A small but significant relationship was found in for effect of biochemically verified substance use on smoking cessation.ConclusionsBiochemical verification of substance use is needed in high risk populations involved in studies not directly related to the treatment of substance use, especially in populations with high threat of stigmatization. Testing should continue through the time period of the study for maximal identification of substance use.     

Economic impact of antidiabetic medications and glycemic control on managed care organizations: a review of the literature

OBJECTIVE: To review the recent literature (January 2000-November 2005) regarding the impact of antidiabetic medications and glycemic control on the overall costs of care for patients with diabetes in U.S. managed care organizations (MCOs). SUMMARY: The pharmacy component accounts for typically 20% to 30% (full range, 10%-65%) of overall costs for MCO patients with diabetes. About 30% of pharmacy expenses are directly related to glycemic control, while the balance is spent on the management of macrovascular and microvascular complications related to diabetes and other common comorbidities such as hypertension and hyperlipidemia. Cost offsets and/or cost savings have been shown with the initiation of insulin therapy, including the use of newer short-acting insulins. Increasing medication possession ratios for antidiabetic medications (including insulins) are correlated with reduced overall health care costs, particularly reductions in hospitalization rates. Patients with diagnosed diabetes not receiving medications have significantly increased health care resource utilization. We identified 8 studies that indicatred that improvements in glycemic control lower overall per-patient direct costs within MCOs. CONCLUSIONS: The literature to date suggests that improving glycemic control and antidiabetic medication persistence reduce overall medical costs for patients with diabetes in managed care plans. Continued expansion of antidiabetic medication options will place increasing pressure on MCOs to assess the return on investment for newer pharmacotherapies. Routine measurement of economic and quality-of-life outcomes alongside clinical outcomes will become necessary for assessing the total value that new antidiabetic medications provide and whether cost offsets to managed care exist. Appropriate use of antidiabetic medications, including medication compliance, is an important component in a strategy to achieve glycemic control and may improve outcomes for patients with diabetes.     

Timely confirmation of gastro-esophageal reflux disease via pH monitoring: estimating budget impact on managed care organizations*

ABSTRACT

Background: Current guidelines recommend the use of pH monitoring to confirm the diagnosis of acid reflux in patients with a normal endoscopy. This analysis evaluated the financial impact of pH monitoring with the wireless pH capsule on a managed care organization (MCO) in the United States.

Methods: A decision model was constructed to project total 1-year costs to manage GERD symptoms with and without the adoption of wireless pH capsules in a hypo­thetical MCO with 10?000 eligible adult enrollees, of whom 600 presented with GERD-like symptoms. Costs of GERD diagnosis, treatment, and symptom management for those in whom a GERD diagnosis was ruled out by pH monitor­ing were assessed. The incremental per-member-per-month (PMPM) and per-treated-member-per-month (PTMPM) costs were the primary outcomes. Data sources included literature, expert input, and standardized fee schedules.

Results: An increase of 10 percentage points in the use of pH monitoring with wireless pH capsules yielded incremental PMPM and PTMPM costs of $0.029 and $0.481, respectively. The costs of proton pump inhibitor (PPI) therapy to the plan dropped to $236?363 from $238?086, while increases were observed in pH monitor­ing (from $16?739 to $21?973) and non-GERD therapy costs (from $1392 to $1740). The results were sensitive to the percentage of patients requiring repeat endoscopy before wireless pH monitoring and the cost of PPIs.

Conclusions: Timely and increased use of pH monitor­ing as recommended in published guidelines leads to less unnecessary use of PPIs with a modest budgetary impact on health plans.     

Lessons learned in managed care

Competition, reduction in health care premiums, rising health care costs, aging of the population, and technologic advances are several factors that create both challenges and opportunities for managed care organizations (MCOs). The demands to constantly improve quality of care and efficiency of operation while holding down costs are drivers meant to stimulate organizations to constantly strive to rethink their process of care provision. The most cost-effective program is one that maintains its health plan members who are active in the community and away from the institutional setting. This is optimally achieved through an accessible and comprehensive ambulatory practice. Innovation and paradigms of practice change in the acute, subacute, and long-term care arenas have allowed us to dramatically impact quality and utilization in these expensive areas, while at the same time freeing up additional time for MCO primary care practitioners to focus on their community-based patients. MCO primary care providers have not only supported but welcomed these changes in their organization, recognizing that these innovations represent a component of the continuum of health care needed to effectively serve their patients.     

The impact of thrombopoietin on clinical practice

Prevention of hemorrhage secondary to thrombocytopenia has generally been managed by the transfusion of platelets. The need for such transfusion is related to the depth and duration of "critical" thrombocytopenia, a level that until recently was hotly debated. However a number of clinical trials have established that transfusion at a platelet count greater than 10 x 10(9)/L was safe in the absence of factors associated with increased tendency to bleed. Trying to predict which patients are at risk of bleeding due to thrombocytopenia has proven difficult outside of those scenarios that inevitably cause severe thrombocytopenia, such as treatment of leukemia and myeloablative chemotherapy with stem cell support. Models have been proposed but have yet to be validated. Of greater importance is the need for proof that intensive treatment of solid tumours with growth tactor support leads to improved outcomes. The discovery of platelet growth factors raised expectations that an effective method for abrogating thrombocytopenia would be soon available in the clinic. The cytokines initially described were pleiotropic in nature, and stimulation of platelet production was generally modest. However, one of these agents, interleukin-11, was successfully shown to reduce the incidence of severe thrombocytopenia in patients receiving dose-intensive chemotherapy, and has now received approval from the FDA for this purpose. Initial clinical trials of thrombopoietin (TPO), the central regulator of megakaryocytopoiesis and thrombopoiesis, and its analogues showed these agents to be the most potent stimulators of thrombopoiesis and to be associated with few adverse effects. They have also been shown to enhance platelet recovery after chemotherapy, but early results from trials investigating their ability to prevent severe thrombocytopenia associated with the treatment of leukemia and bone marrow transplantation have been disappointing. In addition, subcutaneous administration of one of these agents, megakaryocyte growth and development factor, has been shown to induce the formation of antibodies that neutralize native TPO and cause thrombocytopenia. TPO remains a promising therapeutic agent, however its potential application is more limited than initially anticipated, and there are a number of obstacles to overcome before it finds an importance use in the clinic.     

A case of clozapine-induced tonic-clonic seizures managed with valproate: implications for clinical care

We describe a case of clozapine-induced seizures in a patient with treatment-resistant schizophrenia. She had previously been treated unsuccessfully with a number of atypical antipsychotic medications, before she was eventually started on clozapine. She experienced two separate episodes of observed fits whilst on an initial daily dose of 125 mg and, subsequently, on a daily dose of 237.5 mg. Following discontinuation of clozapine, she was rechallenged and again was observed to have seizures. Appropriate investigations ruled out any organic cause of the fits and clozapine was successfully restarted, together with sodium valproate. By the time of treatment stabilization, the patient had not experienced any further fits. These findings suggest that clozapine-induced seizures can be successfully treated, that gradual dose titration can reduce the likelihood of further episodes of seizures and that concomitant use of a suitable mood stabilizer/anti-epileptic medication can improve the outcome of treatment-resistant schizophrenia. Furthermore, the concomitant use of fluoxetine and clozapine is discouraged, with citalopram suggested as a suitable antidepressant in those depressed patients receiving clozapine.