Time to button-mash with your favorite Android controller because we have another action RPG on the deck, and it's similar to Blizzard's Diablo Immortal. Line Games' newest release, Undecember, has made its way to Android. It's no secret that we've been hungry for some action RPG alternatives since Diablo Immortal, and luckily Undecember fits the bill.
Undecember will see you addictively hacking and slashing waves of enemies, looting to gear for challenging multiplayer content, and then navigating a plethora of skill trees to create your ultimate custom build. Of course, many systems accompany Undecember's core features and gameplay, so we've compiled a guide to show everyone how to get an early handle on these mechanics.
You'll have a few preliminary steps to follow before you can play. The first is selecting your primary login method; it's crucial to ensure you don't lose your data if you delete the app/swap your gaming device.
Next up, you'll fight multi-waves of enemies during the tutorial phase, letting you test out three weapon types, melee, bow, and staff. Every weapon unlocks a different palette of skills. We recommend using this as a baseline to decide which set of skills/weapon playstyle you prefer to build for your Rune Hunter.
The character customization tools for Undecember are limiting, but at least it is implemented.
Select between a male and female; you can choose a face type, skin tone, and hair style/hair color. Once you've finished customizing your character, tap on Create.
Enter your name and tap Create to finish the character creation process. Congratulations, you're now one step closer to beginning your heroic journey!
You have to manage your health (HP) and Mana. The HP and Mana bars are denoted as red and blue orbs at the bottom of your screen; once they empty, your bar reaches zero. Skills require using Mana, and HP is your survival measure; you can use potions to restore your HP and Mana.
The bread and butter of any ARPG game is tapping on your skills to perform actions, managing those cooldowns, and then reactively choosing how to begin your fight engagements/disengagements. Equipping a dodge skill (like roll and teleport) and playing to your weapon strengths is essential. Bow and magic wielders prefer to kite from monsters and spam skills, while melee builds will focus on crowd control and survival while in close contact.
See the gifs below for examples of the three available styles you'll encounter in the tutorial.
Melee prefers close-quarter fights and using slashes to control the incoming waves of enemies.
Bow classes prefer a mixture of powerful blows to defeat enemies and use skills to support this playstyle.
Magic wielders have to manage Mana, but the access to elemental skills can quickly turn the tides of a fight and enable a versatile build for both supporting and damage-dealing.
Adding link runes is how you'll enhance your skills; you can make your skills stronger or add effects.
To get started, you first equip skill runes on a hexagon grid. Essentially adding a skill rune to any empty slots effectively equips it, and you can add a link rune to the skill rune to enhance it. Link runes must match the skill rune's slot color; otherwise, you can't connect the runes.
Once you've finished customizing your skill runes, select a skill to register it under your equippable skill slots. You have two slot sets available, leaving you five equippable skills per slot. Mix and match to your heart's content; remember that some skills are locked behind which weapon you have equipped.
You can level up your runes by selecting elements as material. Experience points transfer to runes of the same color, but only 80% of experience points are transferred to ruins of different colors. You have five elements to select: red, green, blue, earth, and light. You gain bonus experience by transferring elements of the same color as your selected rune during rune growth. However, earth and light will still deliver a bonus experience for runes of any color.
Leveling up runes increases the potency behind skill runes and linked runes. Be sure to collect element material while looting and dissembling gear, all while progressing through ten acts.
As you make progress in Act I, you'll unlock Zodiac. Zodiac is where you'll first Boost the base stats of your character. You have the choice to invest in strength, dexterity, and intelligence.
To level up one of the base stats, tap on the plus sign by the stat of choice, then select Apply > Ok.
You only have so many free resets (removing all invested points) until Act II; otherwise, it will cost Gold or Stardust of Oblivion.
Once you have trait points, you can unlock specializations. Each specialization will have a separate constellation where you can add trait points for each starting node: moon, star, and sun. To access the other constellations, you need to meet the conditions of having spent a number of trait points in your previous Zodiac tree; for example, Leaf requires 15 trait points to access.
Similar to Zodiac stat points, you also have a limited number of resets with trait points; otherwise, it costs Gold or Stardust of Oblivion.
You'll acquire new equipment from loot. Visiting a blacksmith grants you the option to disassemble or enchant your gear. Enchanting gear requires essence; dissembling gear gives materials like essence used for enchanting your gear. You'll come across more essence from slaying monsters.
All your equipment has stat requirements (strength, dexterity, intelligence, and player-level checks). Your gear is separated into grades, normal, magic, rare, unique, and legendary; generally, the higher grade, the more enchantment options your gear has, but in some cases, it'll already have some pre-determined effects.
What Undecember brings to the table that Diablo Immortal and Torchlight: Infinite doesn't is a fully customizable build experience that isn't class-locked. In Undecember, you're playing as the Rune Hunter that has to stop the 13th God, but in this tale, you mold your hero based on skills you select, runes you customize, and skill loadouts you create. Undecember may not be the replacement for new players coming from Diablo Immortal, but it certainly has enough under its belt to warrant a try; any ARPG enthusiast looking for a fresh coat of paint when it comes to the fast-paced combat and character-building should deliver Undecember a shot.
For all the new investors that emerged in 2020 with their pandemic bankrolls and had a two-year free-for-all making money without really trying, 2022 has surely been a comeuppance. While most of the gamblers in the meme stock crowd have been pushed to the sidelines, either temporarily or for good, real investors are staring at account statements and are stunned at the carnage. They likely are wondering what to do now.
Technology dominates the American economy. While the sector is taking it in the chin now, it will be back. When it does return, it could dominate a market rally later this year or in 2023. While there is a good chance the market decline is not over, it likely is closer to the end than the beginning. Now might be a good time to nibble at some of the top stocks in the sector, especially if they pay a solid dividend.
We screened our 24/7 Wall St. technology research database looking for blue chip companies that pay a dependable dividend that have extremely high bounce-back potential. The following eight stocks hit our screens. While all are rated Buy by top Wall Street firms, it is important to remember that no single analyst report should be used as a sole basis for any buying or selling decision.Cisco
Investors who are more conservative may want to consider this mega-cap tech leader, which recently posted outstanding results. Cisco Systems Inc. (NASDAQ: CSCO) designs, manufactures and sells internet protocol (IP) based networking products and services related to the communications and information technology industry worldwide.
The company provides switching products, including fixed-configuration and modular switches, and storage products that provide connectivity to end users, workstations, IP phones, wireless access points and servers, as well as next-generation network routing products that interconnect public and private wireline and mobile networks for mobile, data, voice and video applications.
Its cybersecurity products deliver clients the scope, scale and capabilities to keep up with the complexity and volume of threats. Putting security above everything helps corporations innovate while keeping their assets safe.
Shareholders receive a 3.84% dividend. Evercore ISI has its target price for Cisco Systems stock set at $56. The consensus target is $54.78. Thursday's $40.61 closing share price was almost 4% higher on the day.Corning
This company continues to be a huge player in the fiber optic world. Corning Inc. (NYSE: GLW) is a technology pioneer that manufactures LCD glass for flat-panel displays for multiple product lines.
Telecommunications (30% of sales) produces optical fiber and cable, component hardware and equipment, and photonic components for the telecommunications, CATV and networking industry. In addition, the company’s Environmental Technologies division (12% of sales) produces specialized glass, glass ceramic and polymer-based products for the automotive industry.
Investors receive a 3.61% dividend. UBS's $40 price target compares to the $38.72 consensus target for Corning stock. The shares closed on Thursday at $30.58.Dell Technologies
This high-quality company pays a solid dividend and its shares have been hit hard. Dell Technologies Inc. (NYSE: DELL) designs, develops, manufactures, markets, sells and supports information technology (IT) hardware, software and services solutions worldwide. It operates through three segments.
Infrastructure Solutions Group provides traditional and next-generation storage solutions, and rack, blade, tower and hyperscale servers. It also offers networking products and services that help its business customers to transform and modernize their infrastructure, mobilize and enrich end-user experiences and accelerate business applications and processes. It also offers attached software and peripherals, as well as support and deployment, configuration and extended warranty services.
Dell's The Client Solutions Group offers desktops, notebooks and workstations; displays and projectors; attached and third-party software and peripherals; as well as support and deployment, configuration and extended warranty services.
The VMware segment supports customers in the areas of hybrid and multi-cloud, modern applications, networking, security and digital workspaces, helping customers to manage IT resources across private clouds and complex multi-cloud, multi-device environments.
Dell also provides information security and cloud software and infrastructure-as-a-service solutions that enable customers to migrate, run, and manage mission-critical applications in cloud-based IT environments.
The dividend yield is 3.83%. The Credit Suisse price target is $60, while the consensus target is $55.21. The final Dell Technologies stock trade for Thursday was almost 4% higher at $34.99.HP
Legendary investor Warren Buffett stunned Wall Street earlier this year when Berkshire Hathaway reported a purchase of 121 million shares of the venerable tech giant. HP Inc. (NYSE: HPQ) provides personal computing and other access devices, imaging and printing products and related technologies, solutions and services in the United States and internationally. It serves individual consumers, small and medium-sized businesses and large enterprises, including customers in the government, health and education sectors.
HP's Personal Systems segment offers commercial and consumer desktop and notebook personal computers, workstations, thin clients, commercial mobility devices, retail point-of-sale systems, displays and other related accessories, software, support and services. The Printing segment provides consumer and commercial printer hardware, supplies, solutions and services, as well as scanning devices. And the Corporate Investments segment includes HP Labs and business incubation projects.
HP stock investors receive a 4.04% dividend. The $33 Credit Suisse target price is higher than the $30.49 consensus target. The stock closed 5% higher on Thursday at $26.02.IBM
This blue chip giant offers investors an incredibly solid entry point, a massive dividend and a degree of safety for investors who are more conservative. International Business Machines Corp. (NYSE: IBM) provides integrated solutions and services worldwide through these four business segments.
The Software segment offers hybrid cloud platform and software solutions, such as Red Hat, an enterprise open-source solutions; software for business automation, AIOps and management, integration, and application servers; data and artificial intelligence solutions; and security software and services for threat, data and identity. This segment also provides transaction processing software that supports clients' mission-critical and on-premise workloads in banking, airlines and retail industries.
The Consulting segment offers business transformation services, including strategy, business process design and operations, data and analytics, and system integration services; technology consulting services; and application and cloud platform services.
The Infrastructure segment provides on-premises and cloud-based server and storage solutions for its clients' mission-critical and regulated workloads; and support services and solutions for hybrid cloud infrastructure, as well as remanufacturing and remarketing services for used equipment.
The Financing segment offers lease, installment payment, loan financing and short-term working capital financing services.
IBM's second-quarter revenue of $15.5 billion was up sharply from a year ago and topped the consensus forecast. Profits also were ahead of analysts’ expectations.
Shareholders receive a 5.60% dividend. IBM stock has a $155 price target at BofA Securities. That is well above the $141.56 consensus target and Thursday’s closing print of $121.79, which was up close to 4% on the day.Juniper Networks
This is another familiar name that could offer among the best total return potential. Juniper Networks Inc. (NYSE: JNPR) designs, develops and sells network products and services worldwide. The company offers various routing products, such as ACX series universal access routers to deploy new high-bandwidth services; MX series Ethernet routers that function as a universal edge platform; PTX series packet transport routers; and NorthStar controllers.
Juniper Networks also provides switching products, including EX series Ethernet switches to address the access, aggregation and core layer switching requirements of micro branch, branch office, and campus environments; QFX series of core, spine and top-of-rack data center switches; and Juniper access points, which provide wireless access and performance.
In addition, the company offers security products including SRX series services gateways for the data center; Branch SRX family provides an integrated firewall and next-generation firewall; virtual firewall that delivers various features of physical firewalls; and advanced malware protection, a cloud-based service and Juniper ATP.
Juniper Networks stock comes with a 3.25% dividend. Wells Fargo's $32 price target is shy of the $32.71 consensus target. The shares closed at $26.32 on Thursday.Microsoft
This is a conservative way for investors to participate in the massive cloud growth, and the company posted stellar second-quarter results. Microsoft Inc. (NASDAQ: MSFT) manufactures, licenses and supports a wide range of software products. The company has transformed its business model from a component-driven model (personal computer, server) to one driven by the need for cloud capacity.
Many Wall Street analysts agree that Microsoft has become a clear number two in the public or hyper-scale cloud infrastructure market with Azure, which is the company’s cloud computing platform offerings, and which continues growing at triple-digit levels. Some have flagged Azure as the biggest rival to Amazon's AWS service.
Some analysts maintain that Microsoft is discounting Azure for large enterprises, so that Azure may be cheaper than AWS for larger users. The cloud was big in latest earnings reports and will remain a growing part of the software giant's earnings profile.
Investors receive a 1.20% dividend. The Jefferies team has a conservative $275 price target, compared with the $329.56 consensus target. Microsoft stock closed on Thursday at $234.24.Oracle
This top software stock has backed up recently and is offering an attractive entry point. Oracle Corp. (NYSE: ORCL) develops, manufactures, markets, sells, hosts and supports database and middleware software, application software, cloud infrastructure, hardware systems and related services worldwide.
The company licenses its Oracle Database software to customers, which is designed to enable reliable and secure storage, retrieval and manipulation of various forms of data. Its Oracle Fusion Middleware software aims to build, deploy, secure, access and integrate business applications, as well as automate their business processes.
Oracle recently announced that it would acquire Cerner, a leading provider of digital information systems used within hospitals and health systems to enable medical professionals to deliver better healthcare to individual patients and communities. The all-cash tender offer has approximately $28.3 billion in equity value.
The company pays a 2.05% dividend. The J.P. Morgan price objective is $84, though Oracle stock has a consensus target of $87.89. On Thursday, the closing share price was $65.20.
We avoided semiconductor stocks for the time being, as the new government restrictions on sales to Chinese companies could be putting a big dent in sales. While we are not ready to nibble in that space, we will be closely watching third-quarter results of the top names. The software, networking and information technology leaders we did focus on could be the first to take off when the selling reverses.
Originally posted at 24/7 Wall St.
For Beth (not her real name) living alone is a good thing. Over the years, she has grown accustomed to the single lifestyle. She’s satisfied with doing things on her own, even to take long bike rides. Just the other day, the cool weather motivated Beth to do exactly that — jump on the bicycle for a ride.
But this ride was different. As she glided down the driveway, and turned onto a busy street, nothing could have prepared her for what was about to happen. A few miles away from home, from nowhere, an 18-wheeler skirted a little too close, blowing Beth off balance. Stunned, she jerked the bike a bit too hard which sent her hurling over the handlebars, crashing on her hip. She stayed there until the ambulance showed up.
In the ER, the doctor reported: “Broken hip, you’ll be in rehab awhile. Who should we call?”
Having a trusted friend, family member or professional to call or text as an emergency contact should be the priority when compiling confidants for medical records, important documents and smartphones. The designation is I.C.E.: In Case of Emergency contact. And it should be labeled as such. Perhaps you rely on a close friend or family. But if you have no one nearby, you’re stuck.
In 2019, the Institute of Healthcare Policy and Innovation claimed 22% of the 50 to 80 age group had an emergency or disaster such as a power outage lasting more than a day, severe weather, evacuation or lockdown, while 73% reported experiencing at least one such event during their lifetime.
Although more than half of older adults believe they will experience some type of crisis, the majority feel confident in their ability to manage. And when living alone, it’s critical to prepare and develop a support network of friends.
Create a group of people for social interactions and relationships, as well as a group that will look out for one another. What’s important is that you’re comfortable with one another and you actively participate in the relationships. If you enjoy their company and conversation, they are part of your network.
Alison Arnett, geriatric care manager at PremierCMGA in Atlanta, suggests developing a purpose-driven network. “No one lives alone — there are people all around. To feel secure and connected, develop a team of people who can support you,” she says. “Many times, people are stuck because they have no one to look out for their welfare.”Where to find people to support you
Caryn Issacs of New York, a patient advocate with GetHealthHelp.com, advises, “When selecting people to care for you in time of need, pick those who know your preferences, and who are strong enough to lift things like shopping bags and even walkers. It’s vital they know how to access transportation and other services. It’s better if they’re active listeners and efficient note takers. And you must trust them.”
Here are several types of emergencies you should prepare for:Power outages
For a power outage lasting over 24 hours, two in three older adults felt very confident that they were prepared, 27% were somewhat confident, and only 4% were not confident at all, according to the Institute of Healthcare Policy and Innovation.
In July, my high rise building in Texas lost power for 17 hours. The temperature hit 100 degrees outside. The outage was not citywide; however, a year earlier during a winter storm, power failed throughout the metroplex. From that, I learned to be better prepared.
Arnett suggests, “Learn the locations of the city-sponsored shelters in case of lost power and situations like a snowmageddon.” People need to know where to go and have a plan to get there in case of a weather-related crisis. Finding shelter is critical. Visit a Disaster Recovery Center (DRC) to receive guidance or information. Additionally, make sure to know when to evacuate an area.
No one expects to slice one’s finger while preparing food, which I experienced. When it happened, there were neighbors who I knew could help out. I grabbed a towel, wrapped the finger and walked down the hall to a friend’s apartment.
And if the crisis is more traumatic than a cut finger like a bicycle accident or a broken hip, Nancy Ruffner, a patient advocate in North Carolina, encourages third-person thinking which removes you from the situation. If you land in the hospital, who could step in and do what needs to be done?
“When making a plan, remove the emotions and focus on the tasks — who could get mail/find or assemble bills and pay them? Who will watch your home; water plants, check for security, turn lights off and on, move things around outside to create the appearance of someone there?” says Ruffner. “If you have a pet, who will care for it?”
Have a hospital go-to bag filled and ready to grab. Include an I.C.E. list (in case of emergency contact list) of medications and medical conditions, a photocopy of a health insurance card, Medicare card (blackout the last four digits of the Social Security number,) toiletries, pen and notebook, puzzle books, lip balm, hand sanitizer, personal grooming items, a copy of the Healthcare Power of Attorney documents. Identify a key contact person. Make an extra copy of the contents of each folder and leave it with a friend or relative at home.
Create a spreadsheet listing your support contacts and information such as who will look after your home, pet, vehicle, food in the refrigerator, etc. Also list who will check on you in the hospital, gather necessities and bring them to you.
Mountain regions aren’t the only areas affected by winter storms. Even low altitude regions get hit. Blankets of snow snarls traffic and keep people indoors. In 2016, winter storm Jonas crushed the Northeast with up to 31 inches of snow.
During winter storms, the priority is staying warm and safe. Here are some tips for planning ahead:
Home: Keep the cold out with insulation, caulking and weather stripping. Keep pipes from freezing. Install and test smoke alarms and carbon monoxide detectors with battery backups. Install storm or thermal-pane windows or cover windows with plastic from the inside. If you’re without power, have a power outage emergency kit on hand.
Car: jumper cables, sand, flashlight, warm clothes, blankets, bottled water and nonperishable snacks. Keep a full tank. Ready.gov offers a full guide for car preparation.
As has been observed in the wake of Hurricane Ian in Florida and the Carolinas, it’s important to be prepared for an emergency, knowing that internet access could be impacted by major storms. Ready.gov offers options for emergency messages from authorized federal, state, local, tribal and territorial public alerting authorities that broadcast warnings.
Colleen Tressler, Bureau of Consumer Protection, Federal Trade Commission, warns, “In addition to preparing for weather disasters, protect yourself from scammers. These criminals use emergencies to cheat consumers.”
Be alert, stay safe, and prepare for emergencies. Do it now before you’re taken by surprise and build a support team of nearby peers and friends.
Carol Marak, author of “SOLO AND SMART: The Roadmap for a Supportive and Secure Future,” is a former family caregiver and an avid writer and advocate for the solo community. Carol lives alone and has created a safe and confident lifestyle. She plans to continue to thrive well into her 90s. Follow her work at carolmarak.com.
This article is reprinted by permission from NextAvenue.org, © 2022 Twin Cities Public Television, Inc. All rights reserved.
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HP laptops offer something for you, whether you're a creative looking to edit photos, a gamer in search of aor a student in need of a small, lightweight laptop.
Many of the best HP laptops have features designed for remote or hybrid work such asand microphones, , longer battery life, and the .
Like other PC makers such as Dell, Lenovo, Acer and Asus, HP is in the midst of updating the processors in its laptops and two-in-ones. That means Intel-based models are moving from 11th-gen to 12th-gen CPUs, while AMD Ryzen systems are switching from 5000-series chips to 6000-series. It also means it's generally a good time to look for deals on older models of the best HP laptops. However, we've also seen big performance improvements with the new processors. An updated model might cost a little more but will add to the overall longevity.
Spectre is HP's top consumer laptop line so you're getting the best of the best with this 16-inch two-in-one.
Of course, a premium two-in-one like the Spectre x360 comes at a relatively high price; it starts at around $1,200. The top-end configuration we reviewed was good but not great considering its $2,030 price. This is definitely one we recommend getting with the 12th-gen Intel processors and Intel Arc graphics if you're going to go all-in. Read our HP Spectre x360 16 review.
HP's Victus 16 is a surprisingly robust and powerful gaming laptop that keeps up with the latest games at a more affordable price. Compared to HP's high-end Omen gaming laptop line, the Victus is more of an all-purpose laptop but still configured for gaming with a price starting at less than $1,000. HP offers several configurations with graphics chip options ranging from Nvidia's entry-level GeForce GTX 1650 up to a midrange RTX 3060 or AMD Radeon RX 6500M. We like almost everything about it except for its flimsy display hinge and underwhelming speakers. Read our HP Victus 16 review.
There are plenty of convertible Chromebooks, where the screen flips around to the back of the keyboard so you can use it as a tablet. But Chrome tablets with removable keyboards like the HP Chromebook x2 11 are still a rarity. It offers long battery life and performance that rises (slightly) above the competition. The main downside is that it's expensive; the model we reviewed is $599. However, that price did include both the keyboard cover and USI pen and it's regularly on sale for $200. If you're interested make sure to wait for one of those deals. Read our HP Chromebook x2 11 review.
If you're making a laptop aimed at creatives, it's not enough to just put discrete graphics and a strong processor in a slim body. The extra performance really should be paired with a good screen, and that's what you get with the HP Envy 14. The laptop's 16:10 14-inch 1,920x1,200-pixel display not only gives you more vertical room to work, but is color-calibrated at the factory and covers 100% of the sRGB color gamut. The result: a well-rounded option for creatives looking for on-the-go performance at a reasonable price. This model is due for a refresh, though, so keep an eye out for updated models. Read our HP Envy 14 review.
New Jersey, NJ -- (SBWIRE) -- 10/09/2022 -- Latest Study on Industrial Growth of Worldwide Health Insurance Exchange Market 2022-2028. A detailed study accumulated to offer Latest insights about acute features of the Worldwide Health Insurance Exchange market. The report contains different market predictions related to revenue size, production, CAGR, Consumption, gross margin, price, and other substantial factors. While emphasizing the key driving and restraining forces for this market, the report also offers a complete study of the future trends and developments of the market. It also examines the role of the leading market players involved in the industry including their corporate overview, financial summary and SWOT analysis.
The Major Players Covered in this Report: Accenture, CGI, Deloitte, IBM, Infosys, MAXIMUS, Oracle, Xerox, Connecture, Cognosante, HCentive, Hexaware Technologies, HP, Inovalon, Inc., KPMG, Microsoft, Noridian Healthcare Solutions, Tata Consultancy Services (TCS), Wipro, Health Insurance Exchange markets by :, In North America, In Latin America, Europe, The Asia-pacific & Middle East and Africa (MEA)
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The titled segments and sub-section of the market are illuminated below:
In-depth analysis of Worldwide Health Insurance Exchange market segments by Types: Software & Hardware
Detailed analysis of Worldwide Health Insurance Exchange market segments by Applications: Government Agencies, Third Party Administrators (TPAs) & Health Plans or Payers
Major Key Players of the Market: Accenture, CGI, Deloitte, IBM, Infosys, MAXIMUS, Oracle, Xerox, Connecture, Cognosante, HCentive, Hexaware Technologies, HP, Inovalon, Inc., KPMG, Microsoft, Noridian Healthcare Solutions, Tata Consultancy Services (TCS), Wipro, Health Insurance Exchange markets by : In North America, In Latin America, Europe, The Asia-pacific & Middle East and Africa (MEA)
Regional Analysis for Worldwide Health Insurance Exchange Market:
- APAC (Japan, China, South Korea, Australia, India, and Rest of APAC; Rest of APAC is further segmented into Malaysia, Singapore, Indonesia, Thailand, New Zealand, Vietnam, and Sri Lanka)
- Europe (Germany, UK, France, Spain, Italy, Russia, Rest of Europe; Rest of Europe is further segmented into Belgium, Denmark, Austria, Norway, Sweden, The Netherlands, Poland, Czech Republic, Slovakia, Hungary, and Romania)
- North America (U.S., Canada, and Mexico)
- South America (Brazil, Chile, Argentina, Rest of South America)
- MEA (Saudi Arabia, UAE, South Africa)
Furthermore, the years considered for the study are as follows:
Historical year – 2016-2021
Base year – 2021
Forecast period** – 2022 to 2027 [** unless otherwise stated]
**Moreover, it will also include the opportunities available in micro markets for stakeholders to invest, detailed analysis of competitive landscape and product services of key players.
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Detailed TOC of Worldwide Health Insurance Exchange Market Research Report-
– Worldwide Health Insurance Exchange Introduction and Market Overview
– Worldwide Health Insurance Exchange Market, by Application [Government Agencies, Third Party Administrators (TPAs) & Health Plans or Payers]
– Worldwide Health Insurance Exchange Industry Chain Analysis
– Worldwide Health Insurance Exchange Market, by Type [Services, Software & Hardware]
– Industry Manufacture, Consumption, Export, Import by Regions (2016-2021)
– Industry Value ($) by Region (2016-2021)
– Worldwide Health Insurance Exchange Market Status and SWOT Analysis by Regions
– Major Region of Worldwide Health Insurance Exchange Market
i) Worldwide Health Insurance Exchange Sales
ii) Worldwide Health Insurance Exchange Revenue & market share
– Major Companies List
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Hello and welcome to another episode of Health Affairs This Week, the podcast where Health Affairs editors go beyond the headlines to explore some of the most notable health policy news of the week. I'm Kathleen Haddad.
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And I'm Chris Fleming.
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Today, we've decided to take a look at latest health policy litigation. We'll look at three issues which have been prominent in the past weeks and months. In one set of cases, providers are challenging federal rules governing their payments under the No Surprises Act. The law enacted last year to ban surprise medical bills. Another conflict also concerns provider payment.
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Specifically, whether and when consumers can count the value of drug manufacturer coupons towards their deductibles and out-of-pocket maximums. A third issue involves a challenge to ACA's preventive services coverage mandate. So Chris, let's start with the litigation around the No Surprises Act or the NSA. Last week, the Texas Medical Association sued the Biden administration again over the NSA's independent dispute resolution process.
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And this came after a string of lawsuits about the same topic. Let's recall that the NSA prohibits out-of-network doctors and other providers from, in most circumstances, billing patients at rates higher than in network amounts. It seems, however, that surgeons and anesthesiologists among other providers are not happy with the process set up by the government to resolve disputes over what insurers should pay these providers when there's no network fees SCO to go by.
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Chris, what's happening with this litigation?
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Well, it's as they as I think it was Yogi Berra used to say it's déjà vu all over again, Kathleen. As you mentioned, the previous like the previous case brought by the Texas Medical Association, this current lawsuit focuses on the NSA's independent dispute resolution or IDR. It focuses on that framework, which, as you alluded to, is the arbitration mechanism that decides how much a payer, like an insurer or an employer plan, will pay an out-of-network provider.
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And the IDR in the No Surprises Act is what's known as baseball style arbitration, which means that both sides pick a number. The arbitrator picks one or the other. There's no compromising or averaging or that sort of thing.
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So I get the Yogi Berra reference, Chris.
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I wish I could claim that I was that clever. It was accidental. But anyway, more specifically and also like the earlier case, this current suit focuses on something called the qualifying payment amount or QPA, and that's roughly what the payers median rate is for in-network for the service involved in the same geographic area, in the same market.
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Now, there was a interim rule previously that the Biden administration had issued to implement the NSA that established a, quote, rebuttable presumption, unquote, in favor of the QPA. And all that meant was that the arbitrator should choose the number closest to the QPA as the payment amount, unless one of the parties and usually the provider offered good evidence that the QPA was not the appropriate out-of-network amount.
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So in that earlier case, Texas Federal District Court Judge Jeremy Kernodle agreed with the Texas Medical Association that the rebuttable presumption gave too much of a privileged position to the QPA more than the statute, more than the NSA intended. Now, in response to that decision, the Biden administration issued a new rule, a new final rule that eliminated the rebuttable presumption.
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But the TMA sued again, claiming the new rule still gives too much prominence to the QPA. And the suit is not only back in federal district court in Texas, but it's in fact back in front of Judge Kernodle. Now, one thing I want to emphasize, however this turns out it's important to know consumers will still be protected by the NSA from surprise medical bills.
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But what could happen if the Texas Medical Association is ultimately successful in this new litigation? What that could mean is higher awards from IDR cases and thus higher health care costs.
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So Chris, what you're saying is, if I understand this, is that the government did what the plaintiffs wanted, but the plaintiffs are still not happy. Do you know what they're asking for now?
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Well, they're basically asking for the any sort of privileged position for the QPA to be eliminated. They basically want an unbiased, they view the QPA as biased towards insurers and payers, and they want what they think of as an even playing field where the QPA is not given any sort of preference.
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Okay. So let's move on to another payment issue in the courts. Several weeks ago, a coalition led by the HIV and Hepatitis Policy Institute, consumer advocates filed suit here in D.C. Federal District Court against pharmacy benefit managers. They said the PBM's won't count the value of their coupons for expensive drugs, such as HIV prophylactic treatment. They won't count it toward a consumer's deductible or annual out-of-pocket maximum.
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So that means, as I understand it, that patients get help paying for the drugs, but they can end up paying huge amounts in the long run anyway, and deductibles until they reach their annual maximum, which is often tens of thousands of dollars. So what's this legal conflict about, Chris?
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Ah yes this can get complex even by health policy standards. So these programs that are involved here that are controversial are known as accumulator adjustment programs or sometimes copay accumulator programs. As you note that drug companies sometimes provide coupons or cards to help consumers pay cost sharing requirements for brand name drugs. Now, on the plus side, what that can do, helping with cost sharing can make it more probable that consumers will take the drugs as intended, and that could be particularly a big deal when you're talking about chronic conditions.
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On the flip side, these programs can also undermine incentives in formularies to use cheaper generic drugs, and that encourages consumers to use the more expensive brand name drugs, which in turn can increase health care costs.
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So Chris, let me just say the other flip side that I'm aware of is that once these coupon programs end they're often time limited, then consumers or patients may stop using their medication or try to spread it out. But that's not a legal issue. So let's get back to that.
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Well, but that is true, that sometimes these assistance, the amount of assistance from the drug companies are capped. And if the consumer hits that cap, what you're talking about happens that they all of a sudden are hit with these huge bills and that can impact compliance at that point. So there's a little bit of a checkered history here that in the final 2020 payment rule, the Trump administration basically banned accumulated adjustment programs for brand name drugs where there wasn't a generic version available.
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But then a few months later, they delayed enforcement of that policy. And then the next payment roll, the 2021 payment rule, they reversed course completely and allowed accumulator adjustment programs in all cases. Now, states some states, though, have actually banned these programs for the fully insured health plans that are under their jurisdiction. Now, in this litigation, Kathleen, the plaintiffs are arguing that the co-pay accumulator policy are included in the 2021 payment notice, which basically allowed them that that's unlawful on a number of grounds.
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It conflicts with the ACA and agency regulations. They also claim it's arbitrary and capricious under the Administrative Procedure Act.
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So this is becoming clear to me. I hope it is to our listeners as well. There is another court case, a latest significant decision affecting the ACA's preventive services coverage mandate. Right. Chris, can you tell us about that?
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I can. Now, the mandate is in section 2713. It requires health plans to cover without consumer cost sharing, preventive services that are approved by various bodies, including the most relevant to this case, the United States Preventive Services Task Force. Most of the litigation regarding Section 2713 has involved challenges to the contraceptive coverage mandates that have arisen from that, and those challenges have been based on religious freedom claims.
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This latest case, however, offers a little bit of a different take. The plaintiffs, among other claims, and the plaintiffs, a group of companies and individuals, argued that the task force and other bodies charged by the ACA with approving preventive services, that they violate the appointment's clause of the Constitution. Now, that doesn't come up all that often compared to some of the other provisions in the Constitution.
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It requires officers of the United States to be appointed by the president and confirmed by the Senate. Judge Reed O'Connor, who is a repeat player in the ACA litigation world and once famously held the entire ACA unconstitutional, he agreed in the case of the Preventive Services Task Force. He found that the power granted by 2713 to the task force to determine what preventive services must be covered that make the task force members officers of the U.S..
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Since the members were appointed by the head of AHRQ, the Agency for Health Care Research and Quality, and not the President. He held that the appointment's clause was, in fact, violated. Now, he didn't find constitutional violations for the other bodies, like the Advisory Committee on Immunization Practices, because there were slightly different circumstances there.
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Okay. So, Chris, you mentioned there was a religious freedom aspect in this case or some related cases. Is there one in this case specifically?
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There is, indeed. Now, one of the plaintiffs argued that requiring him to cover Prep, which is a daily antiviral medication that helps prevent high risk individuals from getting HIV, that violated his rights under the something called the Religious Freedom Restoration Act. He claimed that the covering this drug or he claimed that this drug facilitate sex, same sex, sexual relations and sexual activity outside marriage, and that violated his religious beliefs.
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And again, Judge O'Connor agreed. He said that the Prep coverage mandate did not meet the referral requirement, that if you're going to substantially burden someone's religious practice and belief, that meant that you had to have choose the least restrictive means of achieving a compelling government objective. So he cited a statement by Justice Alito in the Supreme Court case of Hobby Lobby a few years back, where Justice Alito had said in that case that the government, if it wanted to, could directly fund contraceptives.
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And in this case, Judge O'Connor said the government could have just directly funded Prep. Now, it's not clear how far Judge O'Connor's rulings will extend, whether they'll go beyond the parties in the case and maybe apply in a national basis. And if so, whether he'll stay as ruling pending appeal. So Kathleen, we've, of course, covered these cases very quickly.
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We left out a lot of details. I would really encourage listeners to read the full Health Affairs Forefront write ups of the lawsuits, if they haven't already. And of course, these three cases we've talked about, they're only a smattering of the usual smorgasbord of health policy litigation that's out there. Just one more example I'll point listeners to in its upcoming term, the Supreme Court will consider the case of Health and Hospital Corp V. Talevski and that's a huge case that could determine whether Medicaid enrollees can continue accessing the courts when they believe states have violated their constitutional rights.
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Chris, thank you for your legal clarity on these issues. These are all complicated legal matters. So let's wrap up for now and deliver our listeners some time to absorb it. Thanks for tuning in. Please leave us a review. And if you like this episode, please tell a friend and subscribe to Health Affairs This Week wherever you get your podcasts.
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Thanks, Kathleen. And thanks to everyone.
Health Affairs Editor-in-Chief Alan Weil interviews Northwestern University's Tara Lagu on the paper she published in the October 2022 issue of Health Affairs examining physicians attitudes toward patients with disabilities.
Order the October 2022 issue of Health Affairs on disability and health.
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Hello and welcome to A Health Podyssey. I'm your host, Alan Weil. About one in four adults in the United States has a disability. People with disabilities face persistent inequities in health status and in access to health care services. Despite laws such as the Americans with Disabilities Act that require equal access and reasonable accommodation, many people with disability face barriers to obtaining the care they need.
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How do physicians view their willingness and ability to care for people with disabilities? That is the subject of today's episode of A Health Podyssey. I'm here with Tara Lagu, Professor of medicine at Northwestern University's Feinberg School of Medicine. Dr. Lagu, who in coauthors published a paper in the October 2022 issue of Health Affairs, examining physicians attitudes toward patients with disabilities.
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They found, through focus group style interviews that many physicians have negative attitudes toward people with disabilities, and many physicians feel unprepared to handle some of the challenges they face or expect to face meeting the needs of patients with disability. These findings have significant implications for efforts to close the gaps in health status between people with and without disabilities will discuss these attitudes and beliefs in today's episode.
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Dr. Lagu, welcome to the program.
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Thank you so much, Alan. Happy to be here.
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I find this a fascinating and somewhat disturbing paper. Before we get into the findings, which we'll do very soon, I just want to make sure people understand how you collected the data. This is not sort of your multi-thousand person physician survey where people are checking boxes about what they will and won't do. You actually talk to people. Can you just say a little bit about what methods you use to collect the data that we're going to discuss in much more detail over the next few minutes?
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Yeah, absolutely. So we did, we used qualitative methods, which is, you know, common actually in the marketing world, in the business world, when you really want to get the opinions of people who are living the experience you're talking about. You get six or eight of them into a room and you ask them questions about how it is to care for people with disabilities or, you know, pick out a cereal in the grocery store, depending on what your question is.
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Ours was, do patients do physicians have difficulties when they're caring for people with disabilities? What are those difficulties? How does that impact their ability to serve people with disabilities? How does that impact their ability to provide high quality care for people with disabilities? And so to do that, to get those physicians, I will say we had some additional criteria that we wanted to meet.
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We didn't just want any physicians and in several focus groups, we wanted a real mix of different kinds of physicians from different subspecialties. We wanted men and women. We wanted people of different races. We wanted people from both rural and urban areas. And we really wanted to focus more on community settings than academic settings. There have been studies in a lot of academic settings and our senior author, Dr. Lisa Iezzoni, has actually done a lot of work in academic settings, but there haven't been as many studies asking physicians who work in the community.
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You know, how do you serve people with disabilities? What are the barriers? Tell us what you're experiencing. And so to identify those people, we actually used a very popular social networking site for physicians called Sermo. There are more than 800,000 physicians across specialties who use Sermo, and there are many opportunities within Sermo to participate in research. And so people who say who are physicians and were on the site who say they want to participate in research, are then can be invited to participate in studies.
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And that's what we did. We asked her to recruit three focus groups of physicians from this variety of backgrounds. And we actually decided and it was it was a very careful decision that we were not going to identify the physicians who participated beyond their first name and being visible in what is a video conference, like a Zoom or another kind of video conference room.
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And so this gave the people who participated the ability to be relatively anonymous. They could, you could see their faces. We knew their first names, but we didn't know who they were. We didn't have a lot of details on where they practiced. And as a result, I think we got some brutally honest answers from physicians about some of the challenges they face and some of their attitudes about people with disability.
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Well, we're going to dove into those brutally honest answers. But before you deliver us the detail, why don't you just say what was your main takeaway from the work that you did with these physicians?
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Yeah, absolutely. So after speaking with doctors who practice in a variety of settings, mostly community settings, from a variety of subspecialties and a mix of races and ages and genders, we asked physicians about their attitudes towards people with disability, and overall, physicians reported that there are many barriers to caring for people with disability. Some expressed what we called explicit bias towards people with disability, and we can get into that a little more because I think that's a confusing term in some ways.
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And then perhaps the most disturbing finding was that some physicians in a couple of different focus groups reported that they used specific strategies to attempt to get people with disability to leave their practices to deny care to people with disability.
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Well, that is quite concerning. We're going to go into more depth on all of these. As you noted at the outset, this is qualitative work and you're trying to draw out themes. These aren't necessarily representative of all physicians. They're just the themes of what you learned in these focus groups. In the paper, you identify six themes. I know, just sort of studying themes, isn't that interesting?
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But I think to introduce a subject, it would be helpful if you just said what were the thematic areas of your conclusions?
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Absolutely. And some of these themes have come out in earlier research, and I should definitely reference that. Our senior author, Dr. Lisa Iezzoni, has really identified some of these themes before. As a group, we've actually done surveys and some of these themes have emerged from surveys as well. And I've also done and led research that identified that some of these issues exist.
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So we sort of knew that these six themes were going to emerge. And we actually based our interview guide to really get at some of these questions, which is perhaps why some of the themes emerge the way they did. But to tell you about them. So physicians described physical barriers to providing care for people with disabilities so they can't weigh patients with disability if they use a wheelchair.
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If they are in a wheelchair, they can't examine them. They can't sometimes get them into their building. There was one physician that said, our building is not accessible to wheelchairs and was very honest about it. We identified communication barriers so people who are deaf or hard of hearing, many of the physicians reported that they can't or won't hire sign language interpreters.
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Almost none of the physicians asked about communication accommodations if they need them, you know, and many said that if the person had hearing difficulties, they would just talk to the caregiver as opposed to talking to the patient themselves, or would use sort of suboptimal strategies for communicating with the patient, like pen and paper as opposed to using, you know, assistive devices.
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There were big knowledge gaps. So really physicians reported that they don't have the knowledge. They don't really understand what patients with disability need to receive high quality care and they don't really know how to provide it. And that was a very common theme. There's what I would call structural problems, and this encompasses a lot, but it's sort of that there are problems with the health care system generally, and that includes procedures, policies, the way we pay physicians that provide, you know, real obstruction to getting people with disability, good care.
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There were attitudinal questions and attitudinal themes that emerged. So physicians reported that they felt that people with disabilities were entitled, that they sometimes asked for things they didn't need. And there were also real gaps around knowledge of the Americans with Disabilities Act. And this includes that physicians said they don't have any knowledge of the Americans with Disabilities Act.
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They don't know what they're required to provide. And many said they don't seek out more information even when they don't know what to give.
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Well, those are really important themes and a broad range of courses that you covered. So we only have time probably to go into a few of them. I'll do that as we start our discussion here. But as we do, I guess I want to sort of ask you to help us understand the difference between what seem like, you know, reasonable, normal.
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This is my job is hard. These are the challenges they face. And people are being honest about that relative to things that sound like maybe excuses or barriers that they really should be expected to overcome. Because even in the six themes you just described, I can hear a combination of ah, that makes sense and eh, that sounds terrible. So let's take the fourth one you mentioned here.
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These so-called structural barriers just deliver me a little more detail about what physician said, what it tells you about their willingness to meet the needs of people disability and their ability to meet those needs.
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Absolutely. So anybody who's been a patient in a doctor's office knows that it can be a very rushed process and in some some cases unpleasant for the patient. So you're expected to get pretty much all of that. You need to get out of that appointment and in 10 minutes or 15 minutes, tops. And that was one of the big pieces that came out of that structural barrier.
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Physicians said, we have 15 minutes with patients if they need accommodations, if they need communication assistance, if they have to be transferred to a table, it's just impossible. And we find it a barrier to providing care that was very common. It came across in every focus group. And I think this is true. But this is also paired with another structural barrier around finances, which is that for some patients, when you need a longer time, you can just say you had a longer appointment in a more complex patient.
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There isn't built into the payment structure a way to say I provided accommodations and therefore I should be paid a higher level of care. And so that's an additional structural barrier that is really intertwined with the first one about the limited time in appointments. Additionally, there were barriers around and it's hard to think about, but a lot of times when you walk into a doctor's office, the physician knows a lot about you before you come in.
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They know all your past history. They know their medications, and they know that from the electronic health record. But it was pretty clear from these focus groups that there is very few places that capture in their electronic health record whether a person has a disability, whether they need accommodations, and as a result, the person shows up and it's chaos because we didn't know they were coming.
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And I think that was another big theme. And again, it's intertwined with all the other ones. But they'll say, you know, I have no idea the patient's coming. I have no idea what their accommodation needs are. And on some level, you understand how that happens because it's not built into the system. On another level, we never learn. It's totally unacceptable that we do this to people with disability again and again and again.
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So a person who uses a wheelchair and this is from examples from my own patients may call ahead, make sure the doctor's office has an adjustable table, will say, I'm coming, I need these accommodations. I need someone who's trained to help me transfer or I need a lift. They may talk to the office manager and half the time they show up.
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And that is there's no preparation. The room's not available. The staff aren't there. And so I think that some of that is reasonable and some of that is how can we just keep making the same mistake over and over and over?
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I guess that is a bit of the theme of this work, is that the first time these problems emerge, it's kind of reasonable. But if there are systemic problems and no one's overcoming them, that really isn't reasonable. And it may not be reasonable to expect every individual physician or physician practice to solve every single problem. But it's also not realistic to say that the entire burden of solving these problems or experiencing the problems just falls to the patient who has nothing to bring to this role in terms of resources.
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In comparison, I shouldn't say they have nothing to bring. It's not fair to put the full burden on the patient who has a lot fewer resources to solve these problems than the physician does.
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Well, that's right. And we're also talking about a huge power differential. So, I mean, if you've been in a gown and a doctor's office, you know what it feels like and how vulnerable you can be. So if you add to that that you have a spinal cord injury and you're afraid of being dropped when transferred, and the strategy for transferring you is to bring in the parking attendant or something, you can imagine how scary and vulnerable that it feels.
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And I think we've gotten that from our prior work in focus groups with patients in in studies that we've done of doctors. We know that these things are happening. I think what was shocking was that when we got these groups of physicians into our video conference room, I didn't think they would be so honest about the failures that they have committed when trying to provide care for people with disability.
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And yet they were very honest. And I think some of it stems from just the frustration of working in a broken system. And of course, the bigger implication here is that we know that there are problems in the health system. It's interesting how caring for people with disabilities becomes this model for all the things that are wrong with the system.
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But I think additionally there was a powerlessness on the part of the physicians. That was surprising to me that it was this is how it is. I can't change it. And, you know, I'm powerless to do something different. And that was disheartening to me. And I really I think it's a product of a lot of different things which we can talk about.
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But it really feels to me like as physicians, we should do better.
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Well, we're going to talk about some of the things that could be done better and a few more of the themes you identified. We'll have that conversation after we take a short break. And we're back, I'm speaking with Dr. Tara Lagu about physicians attitudes about caring for people with disabilities. Before the break, we spoke of one of the themes that her work identified having to do with structural barriers.
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But now we're going to talk about another one. I'd like to ask you about attitudes. And you did mention at the beginning of our conversation that you use this term in the paper about explicit bias and that that probably needs a little explanation. So tell me what you heard about attitudes and what that makes you or what conclusions you draw from that with respect to physicians caring for people with disability?
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Absolutely. You know, we've become increasingly familiar with the term implicit bias. And if you've read, you know, the papers in the last couple of years that we have kind of baked in as a result of our culture biases against different groups of people. And you don't always express it when asked. But if you're given a test, sometimes it will reveal that you have preferences for different kinds of people.
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So I sort of expected that there would be some of this implicit bias towards people with disability. What I didn't expect was that physicians flat out said things like people with disabilities are entitled. People with disabilities ask for too much. I can't serve this population, they just want too much from me. And so, you know, and this led to another theme in this attitude section, which is that in a couple of the focus groups, those discussions about attitudes, what we called explicit bias, this sort of demonstration of real sort of negative attitudes about people with disability devolved into a discussion of how they discharge people with disabilities from their practice.
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But even before I get to that, I guess I'll say again, I was just surprised that people didn't have an internal check on saying negative things about a group of people. You know, one of the reasons we do the implicit bias test when we're thinking about if there are racial preferences, for example, is that we think that people will not express their negative attitudes about groups of people in focus groups.
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But in this case, the people in the focus groups had no problem saying, I don't like this population, I don't like to care for this population. I think they're entitled. And we were just floored. And the only thing I can say is that there is something different about people with disabilities, than there is about other minority groups.
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And I think some of our next work is going to have to be figuring out what that's all about.
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Well, it also sounds like they were sort of trying to justify or rationalize their behavior, which they felt was defensible. It's sort of it's not so much that I don't want to. It's that I can't. And I need to explain why I can't. And then if you understand why I can't, that you'll be okay with that, which is something you would never hear said about other groups, that they might at least in this day and age, you wouldn't hear people say that.
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I'm not trying to make excuses. I'm just trying to understand, as you say, the willingness to be so explicit about the the bias here.
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Well, and, you know, and it went beyond that because it was first it was saying negative things about the population. And we were all very surprised at that. And then within a couple of the focus groups without the moderator really necessarily intervening much that the participants started talking to one another about their strategies for discharging people from their practice.
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And so it became this conversation where one says, well, no, because of all these problems, because of this population and being difficult, I now just I've thought about this and I just say if a person with disabilities tries to come to my practice, I just say, I don't take your insurance. And another one says like, oh, no, no, you can't refuse them outright.
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That puts you at risk for lawsuits. What actually I say is that you don't need this care that you're seeking out. And then another person said something like, you know, I no, no, no. I just say, I can't provide the specialized care you need. You need to be cared for in another facility. And so it became this really surprising conversation between doctors about how they plan to get rid of people with disabilities from their practice.
00;19;29;09 - 00;19;55;10
And again, it's indefensible. It's people. But I think when I think about the context, it's people who have previously in the hour or 2 hours said the system is so difficult to navigate. I'm overwhelmed by seeing people every 15 minutes. I don't know how to provide care for these people. And I feel like there's there's some something about this population which is different and difficult.
00;19;56;04 - 00;20;17;04
But so then you have people who are in what I would say, okay, those people are in a terrible situation. But in the setting of a terrible situation, you have kind of a right decision and a wrong decision. And there was a group of people who definitely made a wrong decision. They said, okay, I can't do this, so I'm just going to discharge patients with disabilities from my practice.
00;20;17;17 - 00;20;47;29
There were others in another focus group who said, I can't. Even as hard as it is, I can't think of a rationale for doing that or behaving that way. And it was really interesting the differences in the focus groups and how the participants sort of differed on that. But the fact that anyone would say that out loud as a physician who, you know, under the Americans with Disabilities Act is required to provide care, it was surprising, it was disheartening.
00;20;47;29 - 00;21;00;09
And honestly, like I feel somewhat discouraged about the culture of medicine generally and some of the choices that participants in the study made.
00;21;00;29 - 00;21;19;12
Well, you just alluded to the ADA, and of course, we've published quantitative research indicating very low levels of understanding of the provisions of the ADA among physicians. But I wonder if you could say a little about the themes that came out in these discussions as they relate to knowledge of the ADA.
00;21;20;03 - 00;21;45;15
Right? No, absolutely. There was, this is a very important part of this. And I mean, just as a little bit of background, the Americans with Disabilities Act and the Rehabilitation Act for it are considered civil rights legislation. So it's a little bit complicated because physicians fall under this public accommodations lens part of it. And so physicians do have the right to make discretionary choices about who their patients are and what care they provide.
00;21;46;03 - 00;22;19;11
They just can't make discriminatory discretionary choices. And so what it seems like and I don't know for sure because I don't know the whole situation, but what it seemed like some of the physicians in our study were describing was discriminatory discretionary decisions about who to provide care for. And so it becomes tricky, right? Because for that person to bring a lawsuit, they have to prove that the physician made a discriminatory choice.
00;22;19;11 - 00;22;57;11
And it's very hard to know that because any one of us could call physician and say, can I see you? And they could say, I'm not taking new patients, or I don't take your insurance. And we would have no context to know whether that was true or not. And this is why this study is in some ways even more frustrating for me, because it means that we have this law that exists to protect people with disabilities, a vulnerable population that we know experiences poor care, and we can't enforce it because it relies on lawsuits that it's very hard to prove that were not about the physician's discretion.
00;22;57;23 - 00;23;17;04
And I think this is where lawyers can talk about this more. But it seems to me that there's a lot of places that we have to make changes so that this happens less. And I think that is about we have to change the culture of medicine. We have to educate physicians about how to care for people with disabilities.
00;23;17;13 - 00;23;41;21
We have to teach physicians about their responsibilities under the ADA. And I think in addition, we have to do all the pieces with practicing physicians around making accommodations available, getting information to the electronic health record, collecting information on people with disability, changing payment structures so that we actually reimburse when physicians spend more time taking care of people with disabilities.
00;23;42;05 - 00;23;58;01
And I think all of these pieces are critical. But at the end of the day, the fact that most of the physicians in our study said that they don't have any knowledge of the ADA sets us way back in terms of being able to make any strides in this area.
00;23;59;04 - 00;24;25;10
Well, those last comments really lead to the thoughts and questions I have as our conversation comes to an end, because you've painted a pretty stark picture here, maybe a dark picture, some might say, well, you know, you only talked to a few dozen people and this isn't that prevalent. I think that would be a lot of denial, but I'm sure some will have that response.
00;24;25;10 - 00;24;54;14
You indicate the limits of legal provisions, and I think that's appropriate. All civil rights laws are faced challenges we're in a world where people exercise discretion all the time in proving that someone did something that violates those laws is often very difficult. You listed of really nice collection of policy interventions around payment in education and resources, but I don't see anyone stepping up and actually making those happen.
00;24;55;06 - 00;25;12;24
And the question is what priority would the health system place on putting all of those provisions in place for people with disability relative to all of the other places they could put their resources? And if you have the answer to that question, I'd love to hear it, but I don't know that you do.
00;25;13;05 - 00;25;36;17
Well, I mean, I think we have an aging population, right? There are 60 million people with a disability. 18% of middle age adults have mobility impairment, 30% of older adults have mobility impairment. We have similar large numbers around people with communication disabilities. A huge percentage of older adults are hard of hearing. So these problems are only getting bigger.
00;25;36;17 - 00;25;56;19
And one of the things I always say when asked about this is the thing about disability is if even if it doesn't affect you today, it could affect you tomorrow. And so we should all have a motivation to correct these problems because at any point we could have a spinal cord injury, we could suffer from osteoarthritis. I mean, it doesn't take much.
00;25;57;03 - 00;26;30;01
And so I think there is there needs to be a motivation in part because it is a problem that affects all of us. I think there's an additional motivation and it's affecting a larger percentage of the population. And in a way, the reason we do this research is to raise awareness about the need for these kinds of policy interventions, and I will continue doing this work, as depressing as it is, because I'm hoping that eventually someone will listen, that we will think about some of these policy fixes, changes to medical education, changes to residency training.
00;26;30;08 - 00;26;50;27
There's so many potential opportunities. And I, I really will continue to advocate for people in the medical establishment and the policy establishment, people who run health systems to take this seriously. It's not just because we're at risk for lawsuits, and it's not just because it's the right thing to do. It's some combination of it's the right thing to do.
00;26;50;27 - 00;26;56;27
We're at risk for lawsuits. It's more and more people. And tomorrow it could be you that we should take this seriously.
00;26;57;14 - 00;27;23;01
Well, that's how I knew. I couldn't come up with a good question to follow up on that. So I'm going to say you've you've laid out the situation beautifully. You've shown the importance of this kind of work in framing the problem, in enabling us to come up with some ideas for solutions. And unfortunately, the hard work continues of actually getting those solutions implemented.
00;27;23;01 - 00;27;37;01
But I really appreciate the attention you've paid to this issue, the methods you brought to it that enable you to tell stories and have a perspective on the data that we just wouldn't have any other way. And thank you so much for being my guest on A Health Podyssey.
00;27;37;18 - 00;27;56;28
Thank you so much. I mean, I think I owe you all a huge thank you for taking this issue seriously, for having a special issue devoted to disability. I think this is the kind of attention that this population deserves because I think they've been getting poor care for far too long. So thank you so much for your commitment to this issue.
00;28;00;11 - 00;28;13;20
And thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about A Health Podyssey.
Healthcare in America is not getting high grades, and that’s putting it mildly.
More than two years since the pandemic highlighted the varied and acute challenges surrounding medical care in the U.S., a new survey reveals persistent challenges and stubbornly high costs.
Nearly half — 44% — assigned an overall grade of poor, a D grade, or failing, an F grade. That averages to a C minus.
That’s according to a poll from company Gallup and researchers at West Health, a family of non-profit organizations in Washington, D.C. They asked more than 5,500 people to grade the healthcare system on its costs, it capacity to equally deliver care to all patients, the quality of the care and more.
There were no High Marks to be found anywhere in the new findings, but the research shows that lack of affordability is pulling down the grade-point average.
Three-quarters of people assigned either a D or an F to the cost of care. That’s a D minus average. Whether making less than $24,000 annually or more than $180,000, roughly three-quarters in all income demographics gave the D or F grade.
“Some 13% of people surveyed said they couldn’t pay for needed medication, up from 7% in June 2021.”
“When members of my family have needed surgeries or medications [they] have to really consider how much medical debt they’re willing to go into,” said one survey participant, a 28-year-old Pennsylvania woman. “Our healthcare system forces us to try and make calculations between financial security and health just because of how expensive things are.”
During June, more than one-quarter of people (26%) said they or a family member skipped a treatment in the past three months because they couldn’t afford the cost, nearly double the 14% who said the same in June 2021.
Some 13% of people said they couldn’t pay for needed medication, up from 7% in June 2021.
Women, Hispanic and Black survey participants were the most likely to say they’ve cut back on medical care and medication during the past 12 months in order to meet other costs, the authors noted.
When people delay or avoid treatment, the are most likely to skip a trip to the dentist, followed by a doctor’s visit.
“The inability to afford care, resulting in skipped treatments, could have a lasting impact on Americans’ health — a growing concern as rising inflation continues to force Americans to tighten their expenses,” Gallup and West Health researchers wrote. West Health is comprised of non-profit, non-partisan organizations focused on improving care and lowering patient costs.
“The ‘No Surprises’ act launched this year, banning unexpected medical bills for out-of-network care. ”
At a time when all costs are rising, medical costs are no exception. The cost of living increased 8.3% in August, outpacing expectations. Within that overall number, the combined expenses comprising “medical care costs” increased 5.6% year over year. Within that category, health-insurance costs climbed more than 24% from the same point last year.
The Bureau of Labor Statistics’ September inflation data release is due next week, Oct. 13.
Problems with cost and patient access to medical care stretch back for years, but Thursday’s research comes as more laws, rules and initiatives attempt to reduce costs.
For example, the “No Surprises” act launched this year, banning unexpected medical bills for out-of-network care. The country’s three major credit reporting companies, Equifax EFX, -3.54%, Experian EXPGY, -1.48% and TransUnion TRU, -4.02%, are wiping away paid medical collection debt on consumers’ credit reports.
Meanwhile, the recently-passed Inflation Reduction Act has cost-containing provisions for beneficiaries of Medicare, and federal health insurance for people over age 65. For example, the law, starting next year, will link drug prices to the Consumer Price Index, and companies that raise prices faster than the index will have to pay rebates.
“Many survey participants thinking whether Medicare and Social Security will be available for them when they become eligible. ”
Starting in 2025, out-of-pocket costs are limited at $2,000 for Medicare beneficiaries.
Many survey participants, however, thinking whether Medicare and Social Security will be available for them when they become eligible. Generally, Medicare coverage can start at age 65 and Social Security retirement benefits can start as early as age 62.
Two-thirds of people under age 64 said they were “worried” or “extremely worried” about whether Medicare would be available for them, and three-quarters of people age 62 and younger said the same about Social Security.
The worries, particularly about Social Security, are shared by many people. The projected depletion date for the Social Security trust fund is 2035.
Depletion would mean the capacity to cover 75% of the currently legislated benefit, explained MarketWatch columnist Alicia H. Munnell, director of Boston College’s Center for Retirement Research at Boston College.