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Item Pilot study of reproductive health counseling in a pediatric rheumatology clinic(Wiley, 2014-04) Ronis, Tova; Frankovich, Jennifer; Yen, Sophia; Sandborg, Christy; Chira, Peter; Department of Pediatrics, Indiana University School of MedicineObjective: To assess perception and behavior after reproductive health counseling among adolescent patients in a tertiary care-based pediatric rheumatology clinic. Methods: Adolescent females seen at Stanford pediatric rheumatology clinic were prospectively enrolled during routine visits. At study start, standard clinic procedures for the following were reviewed with providers: 1) HEADSS (home, education, activities, drugs, sexual activity, and suicide/depression) assessment; 2) reproductive health counseling; and 3) medical record documentation. Patients were enrolled if providers indicated that they performed HEADSS assessment and reproductive health counseling. At enrollment, patients completed a survey to assess perceptions of reproductive health counseling. Chart review confirmed documented discussions. Follow-up survey 3-5 months after enrollment tracked reproductive health information seeking behavior. Results: Ninety females (ages 17 ± 2 years old) participated. Almost all patients (99%) agreed that reproductive health was discussed. Seventy-one percent reported that pregnancy risks were discussed, 42% had recent concerns about reproductive health, and 33% reported their provider recommended that they seek further reproductive health care. Eighty-four patients completed follow-up phone surveys, with 25% reporting seeking further information on reproductive health concerns but merely 9.5% actually sought further care. Only 18% reported having ever asked their rheumatology provider for guidance regarding reproductive health care concerns. Conclusion: Routine reproductive health discussion and counseling are necessary in a rheumatology clinic; as in our experience, a substantial number of adolescents have concerns and actively seek reproductive health information. Despite these discussions, teens rarely pursued further reproductive health care. Further work to bridge this gap is needed.Item Rebasing the Medicare payment for dialysis: rationale, challenges, and opportunities(American Society of Nephrology (ASN), 2014-12-05) Wish, Diane; Johnson, Doug; Wish, Jay; Department of Medicine, IU School of MedicineAfter Medicare's implementation of the bundled payment for dialysis in 2011, there has been a predictable decrease in the use of intravenous drugs included in the bundle. The change in use of erythropoiesis-stimulating agents, which decreased by 37% between 2007, when its allowance in the bundle was calculated, and 2012, was because of both changes in the Food and Drug Administration labeling for erythropoiesis-stimulating agents in 2011 and cost-containment efforts at the facility level. Legislation in 2012 required Medicare to decrease (rebase) the bundled payment for dialysis in 2014 to reflect this decrease in intravenous drug use, which amounted to a cut of 12% or $30 per treatment. Medicare subsequently decided to phase in this decrease in payment over several years to offset the increase in dialysis payment that would otherwise have occurred with inflation. A 3% reduction from the rebasing would offset an approximately 3% increase in the market basket that determines a facility's costs for 2014 and 2015. Legislation in March of 2014 provides that the rebasing will result in a 1.25% decrease in the market basket adjustment in 2016 and 2017 and a 1% decrease in the market basket adjustment in 2018 for an aggregate rebasing of 9.5% spread over 5 years. Adjusting to this payment decrease in inflation-adjusted dollars will be challenging for many dialysis providers in an industry that operates at an average 3%-4% margin. Closure of facilities, decreases in services, and increased consolidation of the industry are possible scenarios. Newer models of reimbursement, such as ESRD seamless care organizations, offer dialysis providers the opportunity to align incentives between themselves, nephrologists, hospitals, and other health care providers, potentially improving outcomes and saving money, which will be shared between Medicare and the participating providers.Item Understanding Care Linkage and Engagement Across 15 Adolescent Clinics: Provider Perspectives and Implications for Newly HIV-Infected Youth(International Society for AIDS Education, 2017-04) Philbin, Morgan M.; Tanner, Amanda E.; DuVal, Anna; Ellen, Jonathan M.; Kapogiannis, Bill; Fortenberry, J. Dennis; Pediatrics, School of MedicineThe National HIV/AIDS Strategy emphasizes rapid care linkage and engagement for HIV-infected individuals, though many adolescents are never tested, delay entering care, and frequently drop out. We conducted 183 staff interviews at 15 adolescent medicine clinics (baseline, n = 64; Year 1, n = 60; Year 2, = 59). We used a constant comparative thematic method to examine how providers approached and discussed care linkage/engagement. Qualitative analyses revealed differences in providers' conceptualizations of linkage and engagement. Providers saw linkage as mechanistic and health system driven. It was defined by number of clinic visits and involved relatively little youth agency. In contrast, providers defined engagement by youths' responsibility and participation in their own care. Linkage and engagement are related but distinct aspects of care that require different resources and levels of staff involvement. Integrating an understanding of these differences into future interventions will allow clinic staff to help youth improve long-term health outcomes.