Nearly 15% of insurance plans for sale via healthcare.gov lack in-network physicians for at least one specialty, according to an analysis published Oct. 27 in JAMA. Endocrinologists, rheumatologists, and psychiatrists were most commonly excluded.
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Of the 135 plans, 18 (13%) were specialist deficient in the 100-mile search, while 19 (14%) of plans lacked in-network specialists in the 50-mile search (JAMA. 2015;16:1749-50. doi. 101001/jama.2015.9375).
Patients in specialist-deficient plans had high out-of-network costs, Mr. Dorner and colleagues found. Of the 19 specialist-deficient plans, 5 did not cover out-of-network services, whereas 11 of the remaining 14 plans required cost-sharing of 50% or more. Nine of the 19 inadequate plans did not cover medications prescribed by out-of-network physicians.
The findings raise concerns about patient access to specialty care and suggest that a number of plans are violating network adequacy requirements, Mr. Dorner said, adding that such inadequate plans precipitate high out-of-pocket costs and may lead to adverse plan selection.
In 2011, after several unusual medical experiences and misdiagnoses, it was discovered that she had an autoimmune condition, scleroderma. In late 2012, her rheumatologist noticed that her chest X-rays and MRI scan revealed an enlarged heart. Her rheumatologist referred her to a cardiologist who suspected the scleroderma had led to PAH, which was confirmed by a RHC.
During the discussion that followed the presentation, session co-chair Franco Roviello, MD, professor of surgical oncology, University of Siena and Instituto Toscano Tumori, Siena, Italy, described the study as "very, very interesting."
Koechlin said she believes that it is important to "identify a sequence of events that would lead to higher risk and then give CT scans," adding: "I don't think we can prescribe this to all newly diagnosed patients."
Many connection behaviors can be controlled by cx_Oracle options. Othersettings can be configured in Optional Oracle Net Configuration Files or in Optional Oracle Client Configuration Files.These include limiting the amount of time that opening a connection can take, orenabling network encryption.
If you are using Oracle Client 19c, the latest Easy Connect Plus syntax allows the use ofmultiple hosts or ports, along with optional entries for the wallet location,the distinguished name of the database server, and even lets some networkconfiguration options be set. This means that a sqlnet.orafile is not needed for some common connection scenarios.
As an example, to ensure all connections to the database are checked forintegrity and are also encrypted, create or edit the Oracle Database$ORACLE_HOME/network/admin/sqlnet.ora file. Set the checksum negotiationto always validate a checksum and set the checksum type to your desired value.The network encryption settings can similarly be set. For example, to use theSHA512 checksum and AES256 encryption use:
For more information on Oracle Data Network Encryption and Integrity,configuring SSL network encryption and Transparent Data Encryption ofdata-at-rest in the database, see Oracle Database Security Guide.
From the Oracle Cloud console for the database, download the wallet zip file.It contains the wallet and network configuration files. Note: keep walletfiles in a secure location and share them only with authorized users.
Move the three files to the network/admin directory of the clientlibraries used by your application. For example if you are using InstantClient 19c and it is in $HOME/instantclient_19_11, then you would put thewallet files in $HOME/instantclient_19_11/network/admin/.
A common MRI-scanning guideline was implemented at six member sites of the U.S. Network of Pediatric MS Centers of Excellence. We included in this study the first ten scans performed at each site on patients meeting the following inclusion criteria: pediatric RRMS within 3 years of disease onset, examination within 1 month of MRI and no steroids 1 month prior to MRI. We quantified T2 number, T2-LV and individual lesion size in a total of 53 MRIs passing quality control procedures and assessed gadolinium-enhancing lesion number and LV in 55 scans. We studied MRI measures according to demographic features including age, race, ethnicity and disability scores, controlling for disease duration and treatment duration using negative binomial regression and linear regression.
MS patients were seen at one of the six U.S. Network of Pediatric MS Centers of Excellence located in San Francisco, CA (UCSF), Rochester, MN (Mayo), Birmingham, AL (UAB), Buffalo, NY (SUNY Buffalo), Stony Brook, NY (SUNY Stony Brook), and Boston, MA (MGH). In this pilot study, we obtained MRI scans from the first 10 subjects at each site (60 subjects total) who met the following inclusion criteria: 1) Diagnosis of RRMS and onset under 18 years using the International Pediatric MS Study Group diagnostic criteria [12]; 2) MRI performed using our standardized Network Pediatric MS MRI guidelines; 3) MRI performed less than 3 years from first symptom onset; 4) Clinical examination performed within 1 month of MRI (no acute relapse in between MRI and examination); and 5) No steroids administered 30 days prior to MRI scans. We collected MRI scans from ten patients at each site. Demographic data, including age at disease onset, EDSS, self-identified race and ethnicity and treatment history, were collected using a standardized database and are presented in Table 1. This study was conducted in compliance to the Helsinki Declaration. We obtained IRB approval for this study at all sites from the following ethics boards: Partners Human Research Committee (MGH), Health Sciences Institutional Review Board (SUNY-Buffalo), Stonybrook University IRB (SUNY-Stonybrook), University of Alabama IRB (UAB), UCSF Human Research Protection Program (UCSF), Mayo Clinic IRB (Mayo Clinic). Signed informed consent from a parent or guardian for children under the age of 18 was required by the IRB boards at all sites except MGH.
Calculation of the number, size and total volume of T2 lesions was performed on FLAIR images that were co-registered to PD/T2-WIs. The gadolinium-enhancing (GD+) lesion analysis was performed on SE-T1-WIs, whereas the 3D T1-SPGR images were used as a reference to confirm no presence of hyperintensities on corresponding pre-contrast scans. The analysis was based on a semi-automated tracing method using computer-displayed images, as previously described. [10, 13] For each individual lesion, the total number of voxels contained within the lesion was calculated using a fully automated connected-components algorithm [14]. The size for each lesion was then obtained by multiplying the number of voxels circumscribed within the lesion by the volume of the voxel. We recorded total volume of lesions as well as individual lesion size for each subject.
Limitations of this study include the small number of subjects and potential referral bias. In addition, the use of different MRI scanners and slightly different MR pulse sequence parameters across sites are limitations in multicenter studies. 2ff7e9595c
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