Rationing just medical care

Tracheostomy-related durable medical equipment: Insurance coverage, gaps, and barriers

PURPOSE

Tracheostomy care is supply- and resource-intensive, and airway-related adverse events in community settings have high rates of readmission and mortality. Devices are often implicated in harm, but little is known about insurance coverage, gaps, and barriers to obtaining tracheostomy-related medically necessary durable medical equipment. We aimed to identify barriers patients may encounter in procuring tracheostomy-related durable medical equipment through insurance plan coverage.

MATERIALS AND METHODS

Tracheostomy-related durable medical equipment provisions were evaluated across insurers, extracting data via structured telephone interviews and web-based searches. Each insurance company was contacted four times and queried iteratively regarding the range of coverage and co-pay policies. Outcome measures include call duration, consistency of explanation of benefits, and the number of transfers and disconnects. We also identified six qualitative themes from patient interviews.

RESULTS

Tracheostomy-related durable medical equipment coverage was offered in some form by 98.1 % (53/54) of plans across 11 insurers studied. Co-pays or deductibles were required in 42.6 % (23/54). There was significant variability in out-of-pocket expenditures. Fixed co-pays ranged from $0-30, and floating co-pays ranged from 0 to 40 %. During phone interviews, mean call duration was 19 ± 10 min, with an average of 2 ± 1 transfers between agents. Repeated calls revealed high information variability (mean score 2.4 ± 1.5). Insurance sites proved challenging to navigate, scoring poorly on usability, literacy, and information quality.

CONCLUSIONS

Several factors may limit access to potentially life-saving durable medical equipment for patients with tracheostomy. Barriers include out-of-pocket expenditures, lack of transparency on coverage, and low-quality information. Further research is necessary to evaluate patient outcomes.

"Professionalism, Physicianhood, and Psychiatric Practice": Conceptualizing and Implementing a Senior Psychiatry Resident Seminar in Reflective and Inspired Doctoring

BACKGROUND

Professionalism, although broadly acknowledged to be an important goal of medical education, needs to be taught well.

OBJECTIVE

We describe the content selection and structure of an elective professionalism seminar for advanced trainees in psychiatry at the Massachusetts General Hospital.

METHOD

We critically evaluate the curriculum content based on participant feedback.

RESULTS

We successfully implemented and sustained for 8 years a monthly, 10-session professionalism seminar for advanced trainees in psychiatry. The average number of participants was 4-8 residents or fellows out of a possible 12-16. The curriculum covers 3 broad domains: physicianhood, bioethics, and medical/psychiatric practice. Participants felt that they were more reflective of their practice and that were given a vocabulary to do so. Physician burnout emerged as a key professional concern.

CONCLUSION

Professionalism can be taught in a seminar but requires reaching to other disciplines (history of medicine, philosophy, and sociology) to make it meaningful and utile. Consultation-liaison psychiatrists through their interdisciplinary and team-based work are ideally situated to teach professionalism that emphasizes commonalities of psychiatry with the other medical specialties and fosters leadership.