Examining the case for direct contracting: A multistakeholder case study

BACKGROUND

Employers and pharmacies are challenged by a complex system for prescription payment. Cost plus direct contracts for prescriptions and bundled services may yield benefits.

OBJECTIVES

This study aimed to (1) explore direct contracting using multistakeholder interviews, (2) compare employer costs and employee copays for 6 months of prescription charges under their pharmacy benefit manager (PBM) with projected costs under a pharmacy direct contract, (3) project pharmacy revenue, costs, and net profit had these prescriptions been processed through the direct contract, and (4) assess employee satisfaction under the direct contract.

METHODS

Semistructured stakeholder interviews were recorded transcribed and analyzed to identify different perspectives on direct contracting. Employer PBM invoices for 412 employee prescriptions over 6 months were analyzed to calculate employer and employee costs and reanalyzed for the invoice cost plus $12 professional fee direct contract. For the pharmacy financial analysis projection, invoice costs and a $9.82 cost of dispensing were subtracted from total revenue to yield an estimated profit had the parties been under the arrangement. A 34-item satisfaction survey was mailed using a 4-contact design with cash incentives to the 20 employees serviced by the direct contract that were analyzed descriptively.

RESULTS

Eight stakeholder interviews described the benefits and potential challenges of such direct contracts. The financial analysis suggested the employer costs would be $5664 lower and employee copays would have been $1918 lower had all prescriptions been paid using the direct contract. The estimated profit for the pharmacy was projected at $899. Survey respondents were generally satisfied with the direct contract, but few used the bundled services.

CONCLUSION

The direct contract may be financially beneficial for all parties. It also may offer more transparent pricing that may be desirable for the employer and pharmacy. Greater uptake of bundled services may increase the value to the employer.

Quantifying the Root-to-Shoot Transfer of 4,4'-Methylenedianiline Using Pressure Chamber and Intact Plant Methods

The high-production-volume chemical 4,4'-methylenedianiline (4,4'-MDA) is an aromatic amine used to manufacture 4,4'-methylenedianiline diisocyanate for polyurethane production. Based on 4,4'-MDA's octanol/water partition coefficient (K_OW ) and correlations with the transpiration stream concentration factor (TSCF), significant plant uptake and root-to-shoot transfer are predicted. However, most correlations between K_OW and TSCF were developed for neutral organics and may not be applicable for ionizable bases such as 4,4'-MDA. To investigate, TSCF values for 4,4'-MDA were measured using pressure chamber and intact plant approaches for tomato, soybean, and wheat (intact plants only). ¹⁴ C-labeled 4,4'-MDA was used to increase analytical sensitivity and facilitate measurement of distribution within plant tissues. The TSCF of ¹⁴ C-MDA determined using the pressure chamber method was 0.04 ± 0.00 for tomato and 0.17 ± 0.10 for soybean. These values were lower than predicted from log K_OW and within the range of values for ¹⁴ C-pyrene also measured in our study (0.14 ± 0.00 for tomato and 0.16 ± 0.09 for soybean). The TSCF values calculated from measurements made from intact plants grown to maturity were statistically equivalent to those obtained from the pressure chamber method for soybean and tomato. The distributions of ¹⁴ C within the three plants species were similar, with the roots > leaves ≈ stems > fruit. The log root concentration factors for 4,4'-MDA ranged from 3.68 to 4.33 for the three plant species. This finding indicates that the aromatic amine sorption to root materials is much greater than would be predicted based on its log K_OW and may be the reason for the limited root-to-shoot transfer observed in the pressure chamber and intact plant studies. Environ Toxicol Chem 2023;42:655-662. © 2023 SETAC.

A conceptual framework for evaluation of community pharmacy pay-for-performance programs

BACKGROUND

Recent interest in initiating pay-for-performance (P4P) programs indicates an underlying belief that economic incentives will have a direct impact on health care quality and efficiency. Evaluations of the impact of P4P programs on health care organizations and providers have been presented in the literature; however, none have focused on the impact of an incentive targeting community pharmacies.

OBJECTIVE

To propose a theory-derived conceptual framework of how a financial incentive might work in a community pharmacy.

METHODS

Studies from the fields of economics (agency theory), psychology (intrinsic and extrinsic motivators; expectancy theory), and organizational theory (ownership, institutional layers, organizational culture, and change management; quality improvement) were reviewed to inform the framework's components. This proposed conceptual framework also integrated and expanded on previous health care-related P4P models.

RESULTS

P4P programs inherently use financial incentives to catalyze change; however, elements from psychology and organizational theories along with economic theory were identified as important considerations in how a financial incentive may operate when targeting a community pharmacy. Through the incorporation of these theories along with other P4P frameworks in health care, a conceptual framework was derived comprising 4 domains: incentive, pharmacy, other influencing factors, and P4P program measures. Hypothesized relationships among these domains were depicted.

CONCLUSION

As focus on improving the quality of health care provision develops, opportunities for pharmacists to provide patient care services beyond dispensing will continue to advance, along with expanded reimbursement mechanisms extending beyond traditional product dispensing. The proposed theory-derived conceptual framework serves to depict how the integration of P4P and other factors may affect the pharmacy environment and subsequently affect a pharmacy's capability to perform well on medication-related quality measures. This framework may be used as a foundation on which to design studies to investigate the association between community pharmacy factors and performance in a P4P program.

The Initial Use of the Home Medication Experience Questionnaire (HOME-Q) in Community-Based Pharmacy

The Home Medication Experience Questionnaire (HOME-Q) was developed to systematically gather information on the medication experience of patients. The objectives of this study were to (1) assess the frequencies of medication experience issues for a sample of patients and (2) report pharmacist recommendations to address issues and patient implementation of recommendations. This study used a single-group design with 3-month follow-up. A convenience sample of patients aged 55 years and older and taking 4 or more chronic medications self-administered the HOME-Q and discussed responses with a pharmacist from 2 community pharmacies. A researcher called or visited participants at 3 months to readminister the HOME-Q and inquire about recommendations. Thirty-three patients completed questionnaires, and 30 participated in the follow-up. At 3 months, the HOME-Q median did not decrease (4 at both administrations). There were 51 pharmacist interventions/recommendations, and 47% were reported adopted. The HOME-Q prompted pharmacists to respond to medication experience issues that may not have been identified otherwise. More work is needed to test the impact of the HOME-Q and better understand medication experience discussions between patients and pharmacists.

Pharmacist Segments Identified from 2009, 2014, and 2019 National Pharmacist Workforce Surveys: Implications for Pharmacy Organizations and Personnel

Background/Objective: Findings from the 2009 and 2014 National Pharmacist Workforce Surveys showed that approximately 40% of U.S. pharmacists devoted their time primarily to medication providing, 40% contributed a significant portion of their time to patient care service provision, and the remaining 20% contributed most of their time to other health-system improvement activities. The objective of this study was to characterize the U.S. pharmacist workforce into segments based on the proportion of time they spend in medication providing and patient care services and compare changes in these segments between 2009, 2014, and 2019. Methods: Data from 2009, 2014, and 2019 National Pharmacist Workforce Surveys were analyzed. Responses from 1200 pharmacists in 2009, 1382 in 2014, and 4766 in 2019 were used for analysis. Respondents working in the pharmacy or pharmacy-related fields reported both their percent time devoted to medication providing and to patient care services. Medication providing included preparing, distributing, and administering medication products, including associated professional services. Patient care services were professional services designed for assessing and evaluating medication-related needs, monitoring and adjusting patient's treatments, and other services designed for patient care. For each year of data, pharmacist segments were identified using a two-step cluster analysis. Descriptive statistics were used for describing the characteristics of the segments. Results: For each year, five segments of pharmacists were identified. The proportions of pharmacists in each segment for the three surveys (2009, 2014, 2019) were: (1) medication providers (41%, 40%, 34%), (2) medication providers who also provide patient care (25%, 22%, 25%), (3) other activity pharmacists (16%, 18%, 14%), (4) patient care providers who also provide medication (12%, 13%, 15%), and (5) patient care providers (6%, 7%, 12%). In 2019, other activity pharmacists worked over 45 hours per week, on average, with 12 of these hours worked remotely. Patient care providers worked 41 hours per week, on average, with six of these hours worked remotely. Medication providers worked less than 40 hours per week, on average, with just one of these hours worked remotely. Regarding the number of patients with whom a respondent interacted on a typical day, medication providers reported 18 per day, patient care providers reported 11 per day, and other activity pharmacists reported 6 per day. In 2009, 8% of patient care providers worked in a setting that was not licensed as a pharmacy. In 2019, this grew to 17%. Implications/Conclusions: The 2019 findings showed that 34% of U.S. pharmacists devoted their time primarily to medication providing (compared to 40% in 2009 and 2014), 52% contributed a significant portion of their time to patient care service provision (compared to 40% in 2009 and 2014), and the remaining 14% contributed most of their time to other health-system improvement activities. Distinguishing characteristics of the segments suggested that recent growth in the pharmacist workforce has been in the patient care services, with more being provided through remote means in organizations that are not licensed as pharmacies. The findings have implications for pharmacist training, continuing education, labor monitoring, regulations, work systems, and process designs. These changes will create new roles and tasks for pharmacy organizations and personnel that will be needed to support emerging patient care services provided by pharmacists.

Characterization of actions taken during the delivery of medication therapy management: A time-and-motion approach

OBJECTIVES

To characterize actions performed by pharmacists and support staff during provision of medication therapy management (MTM) and to compare actions performed according to practice characteristics.

METHODS

A purposeful sample of 7 MTM practices (2 call centers and 5 community practices) was identified and visited by investigators. Pharmacists and support staff were observed during their routine provision of MTM. Investigators characterized "major" (e.g., preparation for a comprehensive medication review) and "minor" (i.e., specific steps in overarching major action) actions with the use of a time-and-motion approach.

RESULTS

A total of 32 major and 469 minor actions were observed. Practices were characterized as Later Maturity Level or Early Maturity Level on the basis of their self-reported MTM appointment volume, self-assessment of the extent of integration of chronic care model principles, and payer mix. Later Maturity Level practices were more likely to deliver follow-up medication therapy reviews and comprehensive medication reviews (CMRs) as opposed to targeted medication reviews (TMRs) and to receive physician referrals for MTM. Later Maturity Level practices were also more likely to use paid interns than pharmacy rotation students. CMR activities observed at Later Maturity Level practices lasted a median of 30.8 minutes versus 20.3 minutes for CMR activities at Early Maturity Level practices. Similarly, TMR activities observed at Later Maturity Level practices were longer: a median of 31.0 minutes versus 12.3 minutes. At Later Maturity Level practices, pharmacists spent a greater proportion of time providing patient education, while support staff spent a greater proportion of time on tasks such as capturing demographics and introducing or explaining MTM.

CONCLUSION

MTM activities were longer at Later Maturity Level practices, and these practices were more likely to use paid pharmacy interns and to receive physician referrals for MTM. This work provides a foundation for future research.

Factors influencing the degree of physician-pharmacist collaboration within Iraqi public healthcare settings

OBJECTIVES

Medication safety and effectiveness can be improved through interprofessional collaboration. The goals of this study were to measure the degree of physician-pharmacist collaboration within Iraqi governmental healthcare settings and to investigate factors influencing this collaboration.

METHODS

This cross-sectional study was conducted in Al-Najaf Province using the Collaborative Working Relationship Model and Physician-Pharmacist Collaborative Instrument (PPCI). Four pharmacists distributed paper surveys with a 7-point Likert scale to a convenience sample of physicians and pharmacists working in seven public hospitals and two outpatient clinics. The questionnaire (in English) covered individual (demographics, practising years and academic affiliation), context (practice setting) and PPCI characteristics (trustworthiness, role specification and relationship initiation) in addition to collaborative care items: one for pharmacists and one for physicians. Separate multiple regressions were used to assess the association of the factors with collaborative care for physicians and for pharmacists.

KEY FINDINGS

Seventy-seven physicians and 86 pharmacists returned usable surveys (81.5% response rate). The majority of physicians were male (84%), while the majority of pharmacists were female (58%). The mean age of the physicians was (37.99 years) older than that of the pharmacists (30.35 years). The physicians had a longer period of practice (11.32 years) than pharmacists (5.45 years). Most (90%) of the providers were practising in hospitals. Pharmacist academic affiliation was significantly associated with collaborative care. The pharmacist and physician regressions indicated significant (P < 0.05) associations between collaborative care and two PPCI domains (role specification and relationship initiation for physicians; role specification and trustworthiness for pharmacists).

CONCLUSIONS

This study focused on physician-pharmacist collaboration within hospitals, and it was the first study measuring interprofessional collaboration in Iraq. The results showed there is physician-pharmacist collaboration within Iraqi hospitals and exchange characteristics had significant influence on this collaboration.

Personal health records: a randomized trial of effects on elder medication safety

PURPOSE

To examine the impact of a personal health record (PHR) on medication-use safety among older adults.

BACKGROUND

Online PHRs have potential as tools to manage health information. We know little about how to make PHRs accessible for older adults and what effects this will have.

METHODS

A PHR was designed and pretested with older adults and tested in a 6-month randomized controlled trial. After completing mailed baseline questionnaires, eligible computer users aged 65 and over were randomized 3:1 to be given access to a PHR (n=802) or serve as a standard care control group (n=273). Follow-up questionnaires measured change from baseline medication use, medication reconciliation behaviors, and medication management problems.

RESULTS

Older adults were interested in keeping track of their health and medication information. A majority (55.2%) logged into the PHR and used it, but only 16.1% used it frequently. At follow-up, those randomized to the PHR group were significantly less likely to use multiple non-steroidal anti-inflammatory drugs-the most common warning generated by the system (viewed by 23% of participants). Compared with low/non-users, high users reported significantly more changes in medication use and improved medication reconciliation behaviors, and recognized significantly more side effects, but there was no difference in use of inappropriate medications or adherence measures.

CONCLUSIONS

PHRs can engage older adults for better medication self-management; however, features that motivate continued use will be needed. Longer-term studies of continued users will be required to evaluate the impact of these changes in behavior on patient health outcomes.

Medication therapy management and complex patients with disability: a randomized controlled trial

BACKGROUND

Drug therapy problems, adverse drug events (ADEs), and symptom burden are high among adults with disabilities.

OBJECTIVE

To compare the effects of a modified medication therapy management (MTM) program within a self-efficacy workshop versus the workshop alone or usual care on symptom burden among adults with activity limitations.

METHODS

Three-group randomized controlled trial among adults (age 40 and older) with self-reported activity limitations in community practice.

INTERVENTIONS

8 weekly Living Well With a Disability (LWD) 2-hour workshop sessions with and without a collaborative medication management (CMM) module.

PRIMARY OUTCOME

mean number of moderate to very severe symptoms from a list of 11 physical and mental symptoms. Process measures: changes in medication regimens and self-reported ADEs.

ANALYSIS

general linear mixed models (continuous outcomes) and generalized estimating equations (categorical outcomes).

RESULTS

Participants had high symptom burden, low physical health, and took many medications. There was a significant increase in ADE reporting in the LWD + CMM group relative to the other 2 groups (Study group × Time P = .014), and there were significantly more changes in medication regimens in the LWD + CMM group (P = .013 LWD only vs LWD + CMM). The oldest third of participants had significantly fewer mean symptoms but received more intense CMM. There was no difference between the LWD-only, LWD + CMM, and usual care groups in symptom burden over time.

CONCLUSION

Pharmacist MTM practices and MTM guidelines may need to be modified to affect symptom burden in a population with physical activity limitations.

Volatilization of trichloroethylene from trees and soil: measurement and scaling approaches

Trichloroethylene (TCE) volatilization from leaves, trunk, and soil was measured to assess the significance of these pathways from phytoremediation sites at Travis and Fairchild Air Force Bases. Measurements were scaled temporally and spatially to estimate the annual volatilization of TCE at the Travis (0.82 ± 0.51 kg/yr) and Fairchild sites (0.014 ± 0.008 kg/yr). Volatilization was primarily through the leaf (0.34 ± 0.16 kg/yr at Travis and 0.01 ± 0.06 kg/yr at Fairchild) and soil (0.48 ± 0.36 kg/yr at Travis, 0.003 ± 0.002 kg/yr at Fairchild) pathways. The larger volatilization estimate at Travis was expected because of the site's higher TCE groundwater concentrations. Using groundwater data collected in 2004 and 2009, calculations show that over the 5 year period, 1.7 and 0.015 kg of TCE were removed each year at the Travis and Fairchild sites, respectively. On the basis of the scaled field measurements, volatilization from the leaves and soil may play a significant role in TCE removal at both sites. Daily and seasonal variations were not addressed during the limited daytime sampling events, but the methods described here provide a novel and practical framework for evaluating the potential importance of volatilization of TCE and similar compounds at phytoremediation sites.

Variations in surgeon treatment recommendations for lobectomy in early-stage non-small-cell lung cancer by patient age and comorbidity

BACKGROUND

Prior research suggests that older patients are less likely to undergo resection of early-stage non-small-cell lung carcinomas (NSCLCs). We surveyed surgeons to understand how their recommendations for lobectomy were influenced by age, the presence and severity of smoking-related lung disease, or by characteristics of the surgeons and their practices.

METHODS

We surveyed surgeons caring for NSCLC patients regarding whether they would recommend lobectomy for hypothetical patients with early-stage NSCLC who varied by age (55 vs. 80 years) and comorbid illness (none, moderate, severe chronic obstructive pulmonary disease [COPD]). Ordinal logistic regression was used to identify the importance of patient, surgeon, and practice characteristics on surgery recommendations.

RESULTS

Surgeons recommended lobectomy for nearly all patients who were 55 years old with no comorbidity (adjusted proportion 98.6%), 55 years old with moderate COPD (adjusted proportion 97.8%), or 80 years old with no comorbidity (adjusted proportion 98.1%). Fewer recommended lobectomy for 80-year-old patients with moderate COPD (adjusted proportion 82.3%), and far fewer recommended lobectomy for severe COPD, irrespective of age (adjusted rate 18.7% for the 55-year-old patient and 6.1% for the 80-year-old patient) (P < 0.002). Surgeons who enroll patients onto clinical trials (P = 0.03) were more likely than others to recommend lobectomy, but no other surgeon characteristic predicted recommendations.

CONCLUSIONS

Lower rates of lobectomy among older patients do not seem to be explained by age-related biases among surgeons for otherwise healthy patients.

Changes in crested wheatgrass root exudation caused by flood, drought, and nutrient stress

Root exudates can chelate inorganic soil contaminants, change rhizosphere pH, and may increase degradation of organic contaminants by microbial cometabolism. Root-zone stress may increase exudation and enhance phytoremediation. We studied the effects of low K+, high NH4+/NO3- ratio, drought, and flooding on the quantity and composition of exudates. Crested wheatgrass (Agropyron cristatum) was grown in Ottawa sand in sealed, flow-through glass columns under axenic conditions for 70 d. Root exudates were collected and analyzed for total organic carbon (TOC) and organic acid content to compare treatment effects. Plants in the low K+ treatment exuded 60% more TOC per plant per day (p = 0.01) than the unstressed control. Drought stress increased cumulative TOC exuded per gram dry plant by 71% (p = 0.05). The flooded treatment increased TOC exuded per gram dry plant by 45%, although this was not statistically significant based on the two replicate plants in this treatment. Exudation from the high NH4+/NO3- ratio treatment was 10% less than the control. Exudation rates in this study ranged from 8 to 50% of rates in four other published studies. Gas chromatography-mass spectrometry (GC-MS) analysis indicated that malic acid was the predominant organic acid exuded. Fumaric, malonic, succinic, and oxalic acids were also detected in the exudates of all treatments. These results demonstrate that nutrient and water stress have significant effects on the quantity and composition of root exudates. Cultural manipulations to induce stress may change the quantity of root exudates and thus increase the effectiveness of phytoremediation.

Workplace-Based Cardiovascular Risk Management by Community Pharmacists: Impact on Blood Pressure, Lipid Levels, and Weight

STUDY OBJECTIVE

To assess the effectiveness of a community pharmacist-delivered cardiovascular case-management program by comparing body mass index (weight), systolic and diastolic blood pressure, and full lipid profile at the beginning of the program with these outcome measures at the end of the program.

DESIGN

Retrospective data analysis using billing data submitted between July 1, 2001, and October 31, 2004, with a pre-post design in which subjects served as their own controls.

SETTING

Manufacturing workplace in rural Iowa.

PARTICIPANTS

Fifty-six workers with risk factors for cardiovascular disease (mean age 40.67 yrs), 37 had diabetes mellitus and 19 did not.

INTERVENTION

During visits to the workers, pharmacists provided education about cardiovascular disease, identification of drug therapy problems, and importance of routine blood pressure, pulse, and weight measurements; they communicated with participants' physicians as needed.

MEASUREMENTS AND MAIN RESULTS

The number of pharmacist visits/participant ranged from 1-13 (mean +/- SD 6.97 +/- 3.05). Outcome measures were weight, systolic and diastolic blood pressures, full lipid profiles (in patients with diabetes), and percentage of patients achieving treatment goal by the end of the 3 years. Statistically significant differences between the first and last visits were achieved for both systolic (124.12 +/- 11.07 and 120.36 +/- 14.39 mm Hg, respectively, p=0.016) and diastolic (80.4 +/- 9.01 and 77.43 +/- 9.14 mm Hg, respectively, p=0.019) blood pressure. The 19 patients without diabetes showed a statistically significant improvement in diastolic blood pressure (p=0.039), but the 37 patients with diabetes did not show a significant difference. A nonsignificant increase was seen in the percentage of patients with diabetes achieving low-density lipoprotein cholesterol (LDL) level goal between the first and last visits (p=0.06).

CONCLUSION

A cardiovascular case-management program delivered in the workplace to middle-aged working adults by community pharmacists improved blood pressure and reduced LDL levels. The program was not effective, however, in weight reduction.

An axenic plant culture system for optimal growth in long-term studies

The symbiotic co-evolution of plants and microbes leads to difficulties in understanding which of the two components is responsible for a given environmental response. Plant-microbe studies greatly benefit from the ability to grow plants in axenic (sterile) culture. Several studies have used axenic plant culture systems, but experimental procedures are often poorly documented, the plant growth environment is not optimal, and axenic conditions are not rigorously verified. We developed a unique axenic system using inert components that promotes plant health and can be kept sterile for at least 70 d. Crested wheatgrass (Agropyron cristatum cv. CDII) plants were grown in sand within flow-through glass columns that were positively pressured with filtered air. Plant health was optimized by regulating temperature, light level, CO2 concentration, humidity, and nutrients. The design incorporates several novel aspects, such as pretreatment of the sand with Fe, graduated sand layers to optimize the air-water balance of the root zone, and modification of a laminar flow hood to serve as a plant growth chamber. Adaptations of several sterile techniques were necessary for maintenance of axenic conditions. Axenic conditions were verified by plating and staining leachates as well as a rhizoplane stain. This system was designed to study nutrient and water stress effects on root exudates, but is useful for assessing a broad range of plant-microbe-environment interactions. Based on total organic C analysis, 74% of exudates was recovered in the leachate, 6% was recovered in the bulk sand, and 17% was recovered in the rhizosphere sand. Carbon in the leachate after 70 d reached 255 microg d(-1). Fumaric, malic, malonic, oxalic, and succinic acids were measured as components of the root exudates.

Wild-type nonneuronal cells extend survival of SOD1 mutant motor neurons in ALS mice

The most common inherited [correct] form of amyotrophic lateral sclerosis (ALS), a neurodegenerative disease affecting adult motor neurons, is caused by dominant mutations in the ubiquitously expressed Cu-Zn superoxide dismutase (SOD1). In chimeric mice that are mixtures of normal and SOD1 mutant-expressing cells, toxicity to motor neurons is shown to require damage from mutant SOD1 acting within nonneuronal cells. Normal motor neurons in SOD1 mutant chimeras develop aspects of ALS pathology. Most important, nonneuronal cells that do not express mutant SOD1 delay degeneration and significantly extend survival of mutant-expressing motor neurons.

Factors affecting bargaining outcomes between pharmacies and insurers

OBJECTIVE

To model the bargaining power of pharmacies and insurers in price negotiations and test whether it varies with characteristics of the pharmacy, insurer, and pharmacy market.

DATA SOURCES/STUDY SETTING

Data from four sources. Pharmacy/insurer transactions were taken from Medstat's universe of 6.8 million pharmacy claims in their 1994 Marketscan database. Sources Informatics, Inc. supplied a three-digit zip code-level summary database containing pharmacy payments and self-reported costs for retail (cash-paying) customers for the top 200 pharmaceutical products by prescription size in 1994. The National Council of Prescription Drug Programs supplied their 1994 pharmacy database. Zip code-level socioeconomic and commercial information was taken from Bureau of the Census' 1990 Summary Tape File 3B and 1994 Zip Code Business Patterns database.

STUDY DESIGN

The provider/insurer bargaining model first employed in Brooks, Dor, and Wong (1997, 1998) was adapted to the circumstances surrounding pharmacy and insurer bargaining.

DATA COLLECTION/EXTRACTION METHODS

The units of observation in this study were single Medstat claims for each unique insurer/pharmacy combination in the database for selected pharmaceutical products. The four products selected varied in the conditions they treat, whether they are used to treat chronic or acute conditions, and by their sales volume. Used in the analysis were 9,758 Zantac, 2,681 Humulin, 3,437 Mevacor, and 1,860 Dilantin observations.

PRINCIPAL FINDINGS

We find statistically significant variation in pharmacy bargaining power. Pharmacy bargaining power varies significantly across markets, insurers, and pharmacy types. With respect to market structure, pharmacy bargaining power is negatively related to pharmacies per capita and pharmacies per employer and positively related to pharmacy concentration at higher concentration levels. In addition, the higher the percentage of independent pharmacies in an area, the lower the pharmacy bargaining power. With respect to socioeconomic conditions, pharmacy bargaining power is higher in areas with lower per capita income and higher rates of public assistance.

CONCLUSIONS

The bargaining power of pharmacies in contract negotiations with insurers varies considerably with exogenous factors. Local area pharmacy ownership concentration enhances pharmacy bargaining. As a result, anti-trust law prohibiting the collective bargaining of independent pharmacies with insurers leaves independents at a disadvantage with respect to chains.

Varying health care provider objectives and cost-shifting: the case of retail pharmacy in the US

In this paper we investigate the relationship between health care provider objectives, cost-shifting, and prices by exploring the relationship between state Medicaid pharmacy reimbursements and average prices paid by pharmacy retail customers for four distinct pharmaceutical products across the US in 1994. We develop a more general theory than past researchers to enable provider objectives to vary with Medicaid pharmacy reimbursement levels. We find that provider objectives and the direction of relationship between Medicaid pharmacy reimbursements and retail prices vary with Medicaid pharmacy reimbursement levels. At high Medicaid pharmacy reimbursement levels we find a consistent negative relationship across products. At low Medicaid pharmacy reimbursement levels, the direction of the relationship is product-specific. As a result, policy-makers should be aware that policies affecting reimbursements from government-sponsored health insurance will also affect retail customers that include the uninsured. Paradoxically, for certain products if a state cuts a generous Medicaid reimbursement level this could hurt uninsured patients, whereas cuts in a stingy Medicaid reimbursement rate may help uninsured patients.

Extraction of polycyclic aromatic hydrocarbons from spiked soil

A homogenization method was evaluated for extracting polycyclic aromatic hydrocarbons (PAHs) from soils. Fifteen PAHs were spiked and recovered from 2 soils at concentrations ranging from 1 to 1000 micrograms/g, using the homogenization method and a Soxhlet extraction method. Each extraction method performed well in removing the 15 PAHs from both soils over a broad range of concentrations. In general, Soxhlet extraction yielded slightly but significantly (P less than 0.05) higher recoveries than did the homogenization method. The homogenization method, however, was easy to use, and the extraction step turnaround time was less than 15 min/sample. The method should be suitable for other applications requiring the extraction of hydrophobic organic compounds from soils.

Extraction of Polycyclic Aromatic Hydrocarbons from Spiked Soil

A homogenization method was evaluated for extracting polycyclic aromatic hydrocarbons (PAHs) from soils. Fifteen PAHs were spiked and recovered from 2 soils at concentrations ranging from 1 to 1000 Mg/g. using the homogenization method and a Soxhlet extraction method. Each extraction method performed well in removing the 15 PAHs from both soils over a broad range of concentrations. In general, Soxhlet extraction yielded slightly but significantly (P &lt;0.05) higher recoveries than did the homogenization method. The homogenization method, however, was easy to use, and the extraction step turnaround time was less than 15 min/sample. The method should be suitable for other applications requiring the extraction of hydrophobic organic compounds from soils.