Is a ‘guideline-compliant’ primary cesarean delivery associated with a modified risk for maternal and neonatal morbidity?: a clinical evaluation of the 2014 ACOG/SMFM obstetric care consensus statement

Background It is currently unknown whether primary CDs performed in compliance with the 2014 ACOG/SMFM Obstetric Care Consensus Statement guidelines (“guideline-compliant”) are associated with a modified risk of maternal and neonatal morbidity, when compared to primary CDs performed outside the guidelines (“guideline-noncompliant”). Our primary objective was to determine if a guideline-compliant primary CD is associated with a modified risk for maternal or neonatal morbidity, when compared to guideline-noncompliant primary CD. Methods A retrospective cohort study of all primary CDs at one tertiary referral center in the calendar year following publication of the Consensus Statement. Logistic regression was performed to calculate the risk of adverse maternal and neonatal outcomes for guideline-compliant primary CDs, when compared to guideline-noncompliant and guideline-not addressed, and when adjusted for maternal age, BMI, hypertension, gestational age at delivery, insurance carrier, and provider practice. Results Eight hundred twenty-seven primary CDs were included during the study period, of which 34.8, 26.0, and 39.2% were guideline compliant, guideline-noncompliant, and guideline-not addressed. No statistically significant differences in the frequency of adverse maternal outcomes across these three groups were observed with the exception of maternal ICU admission, which was significantly associated with a guideline-not addressed primary CD (p = 0.0002). No statistical difference in rates of NICU admissions, 5 min APGAR < 5, or umbilical artery cord pH < 7 were observed between guideline-compliant and guideline-noncompliant primary CDs. Conclusion Women undergoing guideline-compliant primary CDs were not significantly more likely to experience a maternal or neonatal morbidity when compared to guideline-noncompliant primary CDs.

Asbestos Exposure and Ovarian Cancer – a Gynaecological Occupational Disease. Background, Mandatory Notification, Practical Approach

In 2017, ovarian cancer due to asbestos exposure was designated a new, and thereby the first, gynaecological occupational disease in Germany. Asbestos is a naturally occurring mineral fibre with an annual usage in Germany of 160 000 – 180 000 metric tonnes in the 1960s and 1970s. The carcinogenicity of asbestos for the target organs lungs, larynx, pleura including pericardium, and peritoneum including tunica vaginalis testis has been clearly established for many years. Recent meta-analyses of data from cohort studies have demonstrated that the risk of ovarian cancer roughly doubles in women with occupational exposure to asbestos. Since the group of people with double the risk of developing lung cancer due to work-related asbestos exposure has a 2.25-fold increased risk of mortality from ovarian cancer on average, work-related ovarian cancer has been assigned the same recognition requirements as in occupational lung (and laryngeal) cancer. Thus, gynaecologists must obtain a thorough history of occupational exposure to asbestos, even if it may have taken place long in the past. The law mandates that suspected such cases must be reported to the Statutory Accident Insurance carrier or the State Occupational Safety and Health Agency.

Understanding Consumer Experiences and Insurance Outcomes Following Plan Disenrollment in the Nongroup Insurance Market

Disenrollment from health plans purchased on Affordable Care Act (ACA) Marketplaces is frequent; little is known whether disenrollment from off-Marketplace plans is as common or about the experiences and consequences of disenrollment. Using longitudinal administrative data on 2017-2018 nongroup plan enrollment linked with survey data, we analyze plan disenrollment in one regional insurance carrier servicing three states. Overall, 71% of enrollees disenrolled from their 2017 plan. Disenrollment was associated with purchasing through an ACA Marketplace, the carrier making significant changes to an enrollee’s plan benefit design, being healthier, being younger, and paying a higher premium for their 2017 plan in 2018. Experiencing financial burden or poor access to preferred providers was not associated with disenrollment. Most disenrollees (93.2%) enrolled in other coverage, often at a lower premium, but lacked confidence that they could afford needed care. These results can inform policy to support enrollees through coverage transitions and foster stability in the nongroup market.

Prescribing patterns in patients with metastatic castrate-sensitive prostate cancer (mCSPC).

21 Background: Recent advances and approvals in mCSPC treatment offer improved outcomes. Docetaxel chemotherapy as well as novel hormonal therapies (NHT) including abiraterone, apalutamide and enzalumide are preferred regimens in addition to androgen deprivation therapy (ADT), with category 1 evidence supporting their use. Despite lack of consensus regarding use of first-generation anti-androgens (fgAI) aside from tumor flare prevention, they are still frequently prescribed. This multitude of options may lead to disparities in prescribing patterns. Methods: Retrospective analysis of pharmacy and medical claims data from the IQVIA database was performed. Patients were aged >18 years and had an ICD 9/10 diagnosis of metastatic prostate cancer (PCa) with >1 treatment claim. Patients on active therapy for another primary malignancy as well as those with <12 months of data pre- and <9 months post-first PCa-related event were excluded. Data was collected from 1/1/2015 to 6/30/2020. Treatment categories were classified as NHT, fgAI, chemotherapy, or ADT monotherapy. Results: National (N) and state of California (S) prescribing patterns are provided in Table. Nationally, Medicare reimbursed 16% NHT, 30% fgAI, 2% chemotherapy and 52% ADT, while third-party payers reimbursed 18% NHT, 20% fgAI, 3% chemotherapy and 59% ADT in 2020. State of California 2020 data yielded similar reimbursement patterns. In Southern California, academic centers prescribed 31% NHT, 23% fgAI and 46% ADT, while community-based practices prescribed 7% NHT, 36% fgAI and 57% ADT in 2020. In Southern California, community oncology practices prescribed 12% NHT, 40% fgAI, 2% chemotherapy and 44% ADT, while community urology practices prescribed 2% NHT, 38% fgAI, and 59% ADT in 2020. Data from 2015-2019 was similar. Conclusions: Although NHT utilization is increasing while chemotherapy utilization is declining, only a minority of mCSPC men received these therapies in 2020. Most of mCSPC men still receive ADT monotherapy or fgAI. Type of insurance carrier does not appear to affect prescribing patterns. Dramatic variations across treatment settings and different specialties exist, with academic centers prescribing more NHT than community-based practices and oncology practices prescribing more NHT than urology practices. These disparities should be addressed with provider education to standardize care delivery for mCSPC patients. [Table: see text]

Gender X and auto insurance: is gender rating unfairly discriminatory?

There are three goals of insurance rate regulation. Rates must be: 1) adequate; 2) not excessive; and 3) not unfairly discriminatory. Rates that are adequate yet not excessive are overall high enough to pay claims and expenses, yet not so high overall that they result in unreasonable profiteering by insurers. The third regulatory goal—that rates are not unfairly discriminatory—is the topic of interest in our research. The concept of unfair discrimination in an insurance context—determining what constitutes fairness in pricing—can differ substantially from the thinking on fairness in a societal context. As a result, the term “discrimination” may be used quite differently in these two contexts. Discrimination, with negative societal connotations, is endemic in our world broadly and largely unjustifiable, yet in the narrower world of insurance, it is the basis for the entire industry’s viability and sustainability. In the insurance context, we can receive the term “discrimination” in a neutral manner, simply taking it to mean different treatment for different groups having different characteristics, without it necessarily connoting any negative intent or outcome. Indeed, the purpose in insurance for engaging in “fair discrimination” —that is, discrimination that price differentiates between discernibly different levels of risk—is itself rooted in economic fairness. An insurance carrier charges differential prices for its products based on differentials in risk. Nevertheless, when risk transfer to an insurer is priced based on uncontrollable and/or immutable classifications such as race and gender, there can be profoundly different views of what constitutes fairness. In many areas of U.S. law, discrimination on either the basis of gender or sexual identity is prohibited in a number of jurisdictions for a number of consumer situations. Yet the broad concept of societal fairness and the much narrower concept of actuarial fairness differ, and so within insurance markets, U.S. law has historically set insurance apart from other products in speaking to issues of fairness and discrimination (West, 2013). Within the last year, several states have enhanced their recognition of nonbinary or genderqueer identities by implementing a Gender X option on driver’s licenses. Insurance carriers are left with minimal direction on how to appropriately price this emerging class within the three goals of rate regulation. Additionally, as diversity and inclusion continue to be a strategic initiative within the insurance market, the insurance industry and its regulatory environment have to navigate carefully between the business imperatives for adequate pricing and inclusion efforts. This paper addresses the potential for unfair discrimination in some lines of business—with special focus on auto insurance—should gender-based rating be continued into the future. It also explores an immediate opportunity to enhance the insurance industry’s social compact with its insureds via recognition of the Gender X identity. Part I gives a primer on nonbinary and trans-identity followed by a brief history of the role of gender in insurance pricing, Part II discusses nonbinary, transgender, and the introduction of Gender X as an additional categorical level of the gender identify rating factor as used in insurance pricing. Part III and Part IV dive into the economic and social implications of movement in U.S. law toward more gender inclusivity.

Relationship between Insurance Type and Delays in Tympanostomy Tube Placement

Objective: To investigate the role of insurance carriers and changes in insurance on rates of cancelation and rescheduling of tympanostomy tube surgery. Methods: Retrospective cohort study between January 1, 2013 and December 31, 2018 at a single tertiary care academic pediatric otolaryngology practice of pediatric patients (≤18 years) who underwent tympanostomy tube placement for any indication. Patients had to have insurance providers recorded both at clinic visit and at the time of surgery. Rates of cancelation and postponement of tympanostomy tube placement were assessed. Logistic regression was performed to determine factors associated with cancelation or postponement of surgery. Results: Of the 5080 patients, 2961 patients had Medicaid and 2012 patients had private insurance at the time of surgery. A total of 197 (3.96%) patients switched insurance between clinic appointment and date of surgery. Time to surgery was nearly 2 weeks more for those who had a change in insurance vs. those who did not (33 vs. 20 days, P < .001). Those who switched insurance were nearly twice as likely to have to reschedule surgery than those who did not (OR 1.95, CI 1.42-2.67). Patients who had Medicaid as the primary payer also had increased odds of needing to reschedule and postpone surgery (OR 1.39, 95% CI 1.17-1.63). Conclusion: Difference in insurance carrier and loss/change of insurance appear to be associated with delays in tympanostomy tube placement. Standardization of re-enrollment schedules across insurance providers or a single payer model may be useful in addressing these delays in care.

Combined in-person and tele-delivered mobile school clinic: A novel approach for improving access to healthcare during school hours

Aims We report a novel pilot project that allows access to healthcare for children and staff at school via a mobile clinic or telemedicine portal connected to the mobile clinic. The objectives of this pilot project were (a) to perform physicals for children not attached to a primary care physician; (b) to provide medical consultations and treatment for acute illnesses of students and staff, and (c) to lower absenteeism rates among students and staff. Methods In 2013, Ronald McDonald House Charities, a non-profit organization, partnered with Children’s Hospital of Erlanger to provide a mobile clinic trademarked Ronald McDonald Care Mobile utilising a large, box-style truck equipped with examination rooms and a telemedicine portal. Initially, starting with three elementary schools in Bradley County, Tennessee, USA, the programme rapidly expanded to include schools in five other participating Tennessee counties. Only three schools in Bradley County have the option of in-person visits. All other schools access care via telemedicine portals. Funding is provided through multiple grants and community partners. If a student does have insurance, the insurance carrier is billed for the visit, but students without insurance are treated free of charge. Prior to the 2018–2019 school year, only limited data were collected. Results Our first goal was to perform physicals for children not attached to a primary care physician. During the 2018–2019 school year, 28 patients presented for a well-child check. However, 16 of these (57%) did not have a primary care physician. Of note, 19% of students presenting for any complaint did not have a primary care physician on file (172 students). All well-child checks were performed in-person on the Care Mobile. Our second goal was to provide medical consultations and treatment for acute illnesses. A total of 1446 persons were seen for sick visits. Of these, 424 were telemedicine visits (352 students and 72 staff), while 1022 were in-person visits. The five most common diagnoses that the nurse practitioner managed during the 2018–2019 school year included acute pharyngitis, acute upper respiratory infection, streptococcal pharyngitis, fever and acute maxillary sinusitis. Finally, our third goal was to lower absenteeism rates. There were 1446 sick person visits (1253 students and 193 staff). Twenty-two per cent of the students (276 persons) returned to class while 74% (142 persons) of staff returned to work. Conclusion The mobile/telemedicine health clinic is a novel innovation to increase access to acute care and reduce school absenteeism among both students and staff, potentially saving schools hundreds to thousands of dollars.

Rights of Insurance Holders to the Compensation Damage in Bosnia and Herzegovina // Pravo nosilaca osiguranja na naknadu štete u Bosni i Hercegovini

The importance of the pension system in a society requires finding an optimal legal solution tailored to the needs, possibilities, and new changes in that system and society in general. Transition processes that Bosnia and Herzegovina has to adapt to in all spheres of life, the specificity of state regulation, the entity autonomy in the field of pension insurance, during one period the lack of a model for creating or reforming their own model of the pension system is the cause of slow reforms in this area . Thus, the Law on Pension and Disability Insurance of the Federation of Bosnia and Herzegovina was passed in 1998., applied for 20 years, despite its many shortcomings and overcrowding. This particularly refers to the fact that this Law did not provide protection to the Pension Fund of the Federation of Bosnia and Herzegovina, the insurance carrier in the Federation of Bosnia and Herzegovina, in terms of the right to compensation for damages that should have been exercised in court proceedings under general regulations, i.e. the Law on Obligations, and the case law did not “allow” it. Due to the lack of norms that would prescribe these rights, has caused the Pension Fund of the Federation of Bosnia and Herzegovina over the course of the last 20 years unbelievable damage. This situation lasted until the adoption of the new Law on Pension and Disability Insurance Fund of the Federation of Bosnia and Herzegovina (New Law on Pension and Disability Insurance Fund of BiH), which came to power on March 1, 2018. Finally, this law prescribes the right of the insurance carrier to compensation of damages.

Alterssicherungssystem und Reichsversicherungsanstalt für Angestellte (RfA) in der „Volksgemeinschaft“. Zur Geschichte der Rentenversicherung in der NS-Zeit

Zusammenfassung Der Beitrag untersucht die Entwicklung der RfA, dem Versicherungsträger der Angestellten, als Teil des NS-Herrschaftssystems und im Kontext der nationalsozialistischen Rentenpolitik. Dabei geht es zum einen um die RfA als Behörde und den Prozess ihrer Transformation zu einem Teil des NS-Verwaltungsstaates, zum anderen um die Probleme der Umsetzung von Rentengesetzen aus der Perspektive der RfA am Beispiel des Handwerker-Versorgungsgesetz, und drittens schließlich wird die Diskriminierung und Exklusion von jüdischen Versicherten und Rentnern aus der Angestelltenversicherung thematisiert. Abstract History of the Pension Insurance of the Nazi regime: RfA as an insurance carrier for employees in the context of the National Socialist public pension policy The article examines the development of the RfA as an insurance carrier for employees as part of the Nazi regime and in the context of the National Socialist public pension policy. On the one hand it concerns the RfA as authority and the process of its transformation to a part of the NS administrative state, on the other hand the problems of the implementation of pension laws from the perspective of the RfA on the example of the craftsman supply law, and thirdly finally the discrimination and exclusion of Jewish insured and pensioners from the employee insurance.

Alterssicherungssystem und Reichsversicherungsanstalt für Angestellte (RfA) in der „Volksgemeinschaft“. Zur Geschichte der Rentenversicherung in der NS-Zeit

Zusammenfassung Der Beitrag untersucht die Entwicklung der RfA, dem Versicherungsträger der Angestellten, als Teil des NS-Herrschaftssystems und im Kontext der nationalsozialistischen Rentenpolitik. Dabei geht es zum einen um die RfA als Behörde und den Prozess ihrer Transformation zu einem Teil des NS-Verwaltungsstaates, zum anderen um die Probleme der Umsetzung von Rentengesetzen aus der Perspektive der RfA am Beispiel des Handwerker-Versorgungsgesetz, und drittens schließlich wird die Diskriminierung und Exklusion von jüdischen Versicherten und Rentnern aus der Angestelltenversicherung thematisiert. Abstract History of the Pension Insurance of the Nazi regime: RfA as an insurance carrier for employees in the context of the National Socialist public pension policy The article examines the development of the RfA as an insurance carrier for employees as part of the Nazi regime and in the context of the National Socialist public pension policy. On the one hand it concerns the RfA as authority and the process of its transformation to a part of the NS administrative state, on the other hand the problems of the implementation of pension laws from the perspective of the RfA on the example of the craftsman supply law, and thirdly finally the discrimination and exclusion of Jewish insured and pensioners from the employee insurance.