Universiẗat der Bundeswehr München, Diss.--Neubiberg, 2006.

Research supports the clinical and societal benefits of antiretroviral treatment (ART) for people living with HIV or AIDS (PLWHA). However, factors associated with ART adherence and the relationship of ART adherence to total healthcare expenditures are not well understood. The research data included Florida Medicaid claims for five years (July 2006 through June 2011). All subjects (n=514) were HIV-positive, adult, non-pregnant, and ART naïve for at least 12 months prior to their 24 month measurement period. Each subject was categorized as adherent (>90%#37;) or non-adherent (<90%#37;) based upon medication possession ratios (MPR). Total expenditures were payments Medicaid made to providers and pharmacies. Objective 1 modeled the logit probability of a subject being non-adherent to ART (versus adherent). Certain factors were expected to have significant negative associations with non-adherence to ART, including females, older age group, AIDS diagnosis, adherence to antidepressants, severe mental illness, meeting the minimum recommended number of outpatient visits, ART regimen type, number of medications in the ART regimen, residing in a county with a high median income, and residing in a county with an urban population density. The variables expected to have significant positive associations included race/ethnicity, substance or alcohol abuse diagnosis, depression or anxiety diagnoses, disease progression from HIV to AIDS, discontinuous Medicaid coverage, Medicaid eligibility type, and co-morbidity count levels. The Objective 1 results showed that all non-white race/ethnicity categories had at least twice the odds of being classified as non-adherent. Also, increasing numbers of concurrent ART medications significantly predicted non-adherence; the odds ratio for three to five ART medications was 2.04 (95%#37; CI=1.04-4.01, p<.05), and six or more prescriptions category odds ratio was 4.58 (95%#37; CI=1.82-11.56, p<.01), as compared to a single medication. Finally, a chronic diseases diagnosis was protective against non-adherence (OR=.46, 95%#37; CI=.26-.84, p<.01), as was adherence to antidepressants (OR=.28, 95%#37; CI=.14-.54, p<.01). In Objective 2, it was expected that the ART adherence group, the explanatory variable, would have significantly less monthly mean total healthcare expenditures, the outcome variable. For each of the HIV-positive (n=232) and the AIDS-diagnosed (n=270) groups, a generalized linear model predicted the mean total expenditures for the ART non-adherence group (<90%#37; MPR) versus the ART adherence group, controlling for other factors. For the HIV-positive subjects, the predicted mean total healthcare expenditures for the ART non-adherent group was $1,291 (95%#37; CL $840-$2,004); the predicted mean for the adherent group was $1,926 (95%#37; CL $1,157-$3,231). The difference was statistically significant, but the hypothesis was not supported. The non-adherent group mean was less than the adherent group (-40%#37;, p<.001). However, for the AIDS-diagnosed subjects, there was no statistical difference between the non-adherent and adherent groups. The predicted mean for the non-adherent group was $2,279 (95%#37; CL $1,572-$3,322), and $2,005 (95%#37; CL $1,387-$2,913) for the adherent group. The findings of this research support the need for translating evidence on racial/ethnic disparities in ART adherence, along with behavioral, social, or cultural barriers and effective interventions, into policy and practice. Also, certain medication management strategies should be implemented to reduce the number of medications in ART regimen. Finally, the results of the present study underscores the necessity for appropriate financial incentives and purposeful risk-adjusted capitation payment structures that would support ART adherence among Medicaid-insured PLWHA.

Pharmaceutical manufacturers’ use of prescription brand-name drugs coupons and vouchers to subsidize patients’ cost-sharing obligations such as co-pays has increased. The co-pays are used by managed care organizations (MCOs) to give their plan members an appreciation of drug costs as well as to offer incentives to use available equivalent generic alternatives due to lower co-pays. With higher tiered co-pays for brand-name drugs being offset by coupons, little is known about MCO representatives’ perceptions about use of co-pay subsidy coupons for brand-name prescription drugs. The objective of this study was to assess health plan managers and pharmacy benefit managers (PBMs) perceptions on the use of prescription drug co-pay subsidy coupons. An online survey instrument was used to collect data. A convenience sample of 834 MCO representatives was selected from the Academy of Managed Care Pharmacy (AMCP) membership directory. A total of 122 surveys were returned of which 105 were usable surveys, giving a response rate of 13.7%. A five-point, 11-item Likert scale ranging from 1 through 5, (1 = ‘Strong Disagree’ and 5 = ‘Strongly Agree’) was used to measure respondents’perceptions. Some items referred to coupons used to get co-pay discounts repeatedly over a year (i.e., long-term use coupons) while some items referred to coupons distributed for trial purposes (i.e., short-term use coupons). Of the 105 respondents, 42 (40%) “agreed,” while 58 (55.2%) “strongly agreed” that co-pay subsidy coupons encouraged non-preferred brand-name drugs over preferred brand-name drugs. A total of 78 respondents (74.3%) reported that brand-name drug coupons undermined tiered formulary structure. Sixty respondents (57.1%) “strongly agreed” that short-term use coupons increased plan sponsor’s costs and 72 respondents (68.6%) “agreed” that sponsor cost increased with long-term use coupons. A total of 42 (40%) reported to “strongly agree” that short-term use coupons should be eliminated whereas 49 (46.7%) respondents reported “strongly agreed” that long-term use coupons should be eliminated. In summary, MCO representatives believe that brand-name drug utilization is increasing due to prescription drug incentives such as coupons which undermines their formulary controls and in turn, increases health care costs. / text

Medicaid provides coverage to approximately 60 million individuals and is the largest single payer of healthcare for children. Given this scope of the program and the concentration of low-income and minority recipients, improvements to the quality of care delivered to Medicaid members represents a significant opportunity to reduce health care disparities and improve the overall delivery and quality of healthcare within the U.S. The current study sought to evaluate the various approaches that state Medicaid agencies are taking to assess and improve the quality of care to their managed care enrollees and the degree to which they have implemented recommendations of various policy experts. A survey was distributed to the Medicaid Directors of all 50 states. A total of 23 states with risk based managed care programs responded, representing 62% of the states that have managed care programs. The results indicated that nearly all states are utilizing standard performance measures as one method to assess quality, with virtually all relying on HEDIS measures for this purpose. Additional strategies that are being used include public reporting of quality data and the use of pay-for-performance incentives; few states are currently focusing on health information technology. Recommendations are made for steps that the Medicaid program could take at both the state and federal level to further develop quality improvement programs.

Thesis (Ph.D.)--University of Adelaide, Dept. of Clinical Nursing, 2003. / Includes bibliographical references. Also available in a print form.

Thesis (Ph.D.)--University of Adelaide, Dept. of Clinical Nursing, 2003. / "March 2003." Includes bibliographical references (leaves 340-350). Also available electronically.

Calif., California Inst. of Technology, Diss.--Pasadena, 2003. / Kopie, ersch. im Verl. UMI, Ann Arbor, Mich.

Thesis (Ph. D.)--University of Washington, 1998. / Vita. Includes bibliographical references (p. [84]-89).

Thesis (Ph. D.)--University of Missouri-Columbia, 1996. / Typescript. Vita. Includes bibliographical references (leaves 99-105). Also available on the Internet.

Thesis (M.A. (Publishing))--University of Pretoria, 2000. / Summaries in English and Afrikaans.