Collegial Courts: Panel Decision-Making and the U.S. Courts of Appeals

The three-judge panel mechanism by which the courts of appeals process almost all (though not quite all) of their cases affords scholars unique opportunities to explore how appellate court decision-making may transcend being merely the sum of its parts. Specifically, court of appeals judges pursue their decision-making responsibilities as part of a collegial group, and thus it is important to understand how being a member of a multimember court influences their behavior.

Tribunal troubles: an analysis of the potential effects of Bill 139 on housing affordability, and the transparency and efficiency of Ontario's land use planning and appeal system

This Major Research Paper (MRP) analyzes the potential effects of Bill 139 on housing affordability, and the transparency and efficiency of land use planning in the province of Ontario. Specifically, this MRP analyzes how changes to Ontario‘s Development and Land Use Appeals Process may impact the delivery of new housing supply to market, hence, impacting affordability. Additionally, this MRP evaluates changes in the appeals process in regards to increased transparency, an expected outcome of Bill 139. A qualitative analysis of the Bill 139 reforms finds that Ontario‘s land use planning and appeal systems require immediate assistance in regards to implementation, and further reform in terms of municipal autonomy, decision making power of the tribunal, and the nature of appeal hearings.

Tribunal troubles: an analysis of the potential effects of Bill 139 on housing affordability, and the transparency and efficiency of Ontario's land use planning and appeal system

This Major Research Paper (MRP) analyzes the potential effects of Bill 139 on housing affordability, and the transparency and efficiency of land use planning in the province of Ontario. Specifically, this MRP analyzes how changes to Ontario‘s Development and Land Use Appeals Process may impact the delivery of new housing supply to market, hence, impacting affordability. Additionally, this MRP evaluates changes in the appeals process in regards to increased transparency, an expected outcome of Bill 139. A qualitative analysis of the Bill 139 reforms finds that Ontario‘s land use planning and appeal systems require immediate assistance in regards to implementation, and further reform in terms of municipal autonomy, decision making power of the tribunal, and the nature of appeal hearings.

Doubly flawed: Canada's refugee determination system in a post 9/11 era

Canada’s refugee determination system not only remains vulnerable to terrorist exploitation but also fails to assist legitimate refugees in a post 9/11 era. Through conducting an analysis of the Immigration Act, this paper exemplifies how, historically, Canada has had difficulty in regulating refugee migration into the country. The Immigration and Refugee Protection Act was implemented as a means of overhauling the Immigration Act, making for a more secure Canada. Although this newer legislation is successful in maintaining the rights of refugees, especially with the verdict of Singh v. Minister of Employment and Immigration, it still lacks numerous safeguards. The lack of an adequate detainment policy, manifestly unfounded policy, the designated country of origin policy, the appeals process, and delayed deportation of foreign nationals leaves the system vulnerable to abuse by terrorists. Ultimately, Canada has become a potential base for terrorists who have access to the entire international community within the safety of Canadian borders.

Doubly flawed: Canada's refugee determination system in a post 9/11 era

Canada’s refugee determination system not only remains vulnerable to terrorist exploitation but also fails to assist legitimate refugees in a post 9/11 era. Through conducting an analysis of the Immigration Act, this paper exemplifies how, historically, Canada has had difficulty in regulating refugee migration into the country. The Immigration and Refugee Protection Act was implemented as a means of overhauling the Immigration Act, making for a more secure Canada. Although this newer legislation is successful in maintaining the rights of refugees, especially with the verdict of Singh v. Minister of Employment and Immigration, it still lacks numerous safeguards. The lack of an adequate detainment policy, manifestly unfounded policy, the designated country of origin policy, the appeals process, and delayed deportation of foreign nationals leaves the system vulnerable to abuse by terrorists. Ultimately, Canada has become a potential base for terrorists who have access to the entire international community within the safety of Canadian borders.

A review of evidence supporting NCCN category 2B off-label recommendations for determination of Medicare reimbursement eligibility.

6576 Background: Antineoplastic indications supported by a category 1 or 2A NCCN recommendation are reimbursed by insurance and Medicare, as are FDA-approved indications. While initial reimbursement requests for “off-label” NCCN category 2B indications may be denied, Medicare will reimburse off-label antineoplastic use supported by evidence from a peer-reviewed publication from one of 26 designated journals. Here, we evaluated the published clinical evidence supporting NCCN category 2B indications. Methods: Category 2B drug indications for the 10 most common solid tumor types were identified in the NCCN compendium (n=104). The results were then filtered to include drugs with only category 2B indications in a particular tumor type (n=14). Similarly, FDA-approved indications were excluded, resulting in a list of drugs with only a 2B indication that are not FDA approved in the specified cancer type (n=8). Published clinical studies supporting these category 2B indications were assessed for study type and journal name in PubMed, and journal names were cross-referenced with the CMS-supported list. Results: Among the 8 non-FDA-approved drug indications with only category 2B recommendations, 7 (87%) had at least one publication of a clinical trial in one of the 26 designated journals. The only 2B indication without supporting literature was single-agent gemcitabine hydrochloride in bladder cancer. For further details, see Table. Conclusions: These results suggest that clinicians should consider pursuing the appeals process and provide supporting evidence in cases of claim denial. While coverage is not guaranteed, the evidence supporting 2B indications frequently meets the criteria identified in the Medicare statute. Further studies will evaluate if these findings extrapolate to less common tumor types.[Table: see text]

Embedding an Advanced Pharmacy Technician in an Adult Specialty Pulmonary Clinic to Complete Prior Authorizations Improves Efficiency and Provider Satisfaction

Purpose: The purpose of this study is to assess the impact of a clinic embedded Medication Assistance Program (MAP) specialist on the prescription benefit prior authorization (PA) process and provider satisfaction in an adult pulmonary clinic. Methods: In this mixed methods study, a retrospective cohort analysis was done to determine the turnaround time for the PA process from initial referral to approval or final denial in an adult pulmonary clinic. Additionally, a pre- and post-implementation survey to providers was conducted to assess provider satisfaction and perceptions around the prescription benefit PA process. The first study aim assessed PA efficiency by summarizing PA approval rate and PA turnaround time using descriptive statistics. Any prescriptions written by a clinic provider requiring a PA during the timeframe of June 2018 through August 2018 were included. The second study aim assessed change in provider satisfaction, analyzed via the Mann-Whitney U test. Results: The MAP specialist completed 110 PAs over 3 months for 110 unique patients. Median turnaround time was 3 hours, with 76% of PAs approved in less than 24 hours. Initial approval rate was 82.7%, and overall approval rate following the appeals process was 87.3%. A significant difference between the pre- and post-survey responses were identified in 2 of the 17 questions. Conclusion: Implementation of a clinic embedded MAP specialist to complete PAs demonstrated an efficient process while also improving provider satisfaction.

Allocation of mental health resources

Resource allocation in mental health occurs at four levels. First, within the total allocation a society makes to health care, how much should go to mental health? In most societies, mental health services have been discriminated against. The quest for parity with medical and surgical services reflects the effort to undo this discrimination. In the Oregon priority-setting process, mental health conditions ranked high among community choices. Second, within the mental health sector, which conditions should receive priority? Some priority should be given to those with the most severe impairments, but no principles tell us just how much priority the sickest should receive. Third, within a particular area, such as schizophrenia, how much resource should be devoted to prevention, treatment of acute episodes, or rehabilitation of those with chronic conditions? Finally, in the care of individual patients, how much treatment is ‘enough’? Where and how is the line drawn between interventions regarded as ‘medically necessary’ versus interventions that are desirable but ‘optional’? In the absence of shared principles for making these allocational decisions, societies must establish fair decision-making processes, in which the rationales for policies and decisions are shared with the public, the rationales address meeting population needs in the context of available resources, and a robust appeals process allows patients, families, and clinicians to challenge decisions and policies. Because societies will develop their own distinctive approaches to resource allocation, progress requires looking at the allocation process in an international context.

Use of a comprehensive program to review religious and personal seasonal influenza vaccination exemption requests by healthcare personnel

Objective: Vanderbilt University Medical Center (VUMC) requires that all faculty and staff receive the seasonal influenza vaccine annually or receive an approved vaccine exemption, either for a medical or deeply held religious or personal belief. We sought to understand the underlying principles behind these exemption requests and their interaction with a multidisciplinary exemption review process. Design: All of the personal and religious exemption requests at VUMC for 3 consecutive influenza seasons from 2015 to 2018 were analyzed, categorizing these requests by 1 of 12 standardized employee categories and 1 of 18 unique reasons for vaccine exemption. Setting: Tertiary-care academic medical center. Participants: Healthcare personnel (HCP). Results: Among the 3 influenza seasons, 1.1%–2.1% of all VUMC HCP requested religious or personal exemption from vaccination. The frequency of religious and personal exemption approval increased annually from 296 of 452 (65.5%) to 196 of 248 (80.2%) to 283 of 323 (87.6%) over the 3 seasons, representing a statistically significant increase each year. Of the 5 most common reasons against vaccination, 4 were explicitly religious in nature; the most common reason was that the “body is a temple or sacred.” Nonclinical staff submitted the most religious and personal exemption requests of any job category, submitting approximately one-third of all requests every year. Conclusions: These results demonstrate how detailed the personal or religious convictions behind vaccine avoidance can be among HCP and how vaccine avoidance stems from much more than simple misinformation regarding vaccination. The intersection between misinformation and personal or religious beliefs provides a unique opportunity to address HCP opinions toward vaccination in an exemption and appeals process like the one described here.

Adolescent and young adult cancer patients' health insurance experiences, expectations, and literacy.

65 Background: Adolescent and young adult (AYA) cancer patients (15-39 years of age) often report health insurance concerns and financial toxicity due to their life-saving treatment. AYAs often have limited experience with healthcare prior to their diagnosis, which may limit their understanding of health insurance concepts, coverage, and costs. To describe AYA health insurance experiences, expectations, and literacy, we conducted semi-structured interviews with AYA cancer patients and survivors. Methods: Eligible participants were 18-39 years, diagnosed with cancer, and insured. Participants were recruited through an AYA cancer navigation program in Utah from 10/2019-03/2020. Participants were purposively sampled to achieve equal age strata (18-25 vs. 26-39), as patients under 26 often remain on their parents policy. Individual interviews were recorded, transcribed, and analyzed. Inductive qualitative analysis was conducted to describe their experiences with and understanding of their insurance. We calculated descriptive statistics of demographics and the Health Insurance Literacy Measure (HILM), a continuous measure ranging from 0-84 (higher scores indicate higher comfortability and literacy). Associations of age (18-25 vs. 26-39) and policy holder (yes vs. no) with HILM score were evaluated with t-tests. Results: AYAs (N = 24) were nearly even by gender, female (58%), primarily heterosexual (92%), Non-Hispanic White (79%), and had at least some college (92%). Less than half of participants were policy holders (41.7%). Three themes emerged from analysis: 1) Lack of knowledge and experiential learning throughout treatment, 2) Unclear expectations of health insurance, and 3) Difficulties navigating coverage and the complex systems. Most AYAs were unaware of the specifics of their coverage and how their insurance plan impacted their costs. Most AYAs were surprised at the lack of coverage and high costs they encountered during treatment. Most AYAs experienced substantial difficulty navigating coverage issues, particularly the appeals process. The mean HILM score was 55.63 (SD = 10.06), no differences by age group or policy holder status. Conclusions: AYAs with cancer report substantial difficulty navigating the complex health insurance system and demonstrate low levels of health insurance literacy. Health insurance education focusing on insurance concepts (e.g., cost-sharing mechanisms) may help AYAs better manage costs and enable them to make informed health insurance decisions despite being at higher risk for financial toxicity.