Pub Date : 2024-01-16eCollection Date: 2024-01-01DOI: 10.1093/haschl/qxad089
Mara A G Hollander, Alexandra Patton, Morgan C Shields
State Medicaid programs are prohibited from using federal dollars to pay institutions for mental diseases (IMDs)-freestanding psychiatric facilities with more than 16 beds. Increasingly, regulatory mechanisms have made payment of treatment in these settings substantially more feasible. This study evaluates if changing financial incentives are associated with increases in for-profit ownership among IMD facilities relative to non-IMD facilities, as well as greater increases in Medicaid acceptance among for-profit IMD facilities relative to for-profit non-IMD facilities. We used data from the 2014-2020 National Mental Health Services Surveys and examined 11 945 facility-years. Relative to non-IMDs, the increase in for-profit ownership among IMDs was 6.6 percentage points greater. The largest proportional change in Medicaid acceptance occurred among for-profit IMD facilities relative to for-profit non-IMDs (18.5 percentage points). Existing research is mixed on the quality of inpatient and residential psychiatric care provided in for-profit vs nonprofit and public facilities, as well as in IMD relative to non-IMD facilities. As payment policy increasingly incentivizes for-profit facilities to enter the psychiatric care space, we should be mindful of the impact of these decisions on patient safety.
{"title":"Changes in institution for mental diseases (IMD) ownership status and insurance acceptance over time.","authors":"Mara A G Hollander, Alexandra Patton, Morgan C Shields","doi":"10.1093/haschl/qxad089","DOIUrl":"10.1093/haschl/qxad089","url":null,"abstract":"<p><p>State Medicaid programs are prohibited from using federal dollars to pay institutions for mental diseases (IMDs)-freestanding psychiatric facilities with more than 16 beds. Increasingly, regulatory mechanisms have made payment of treatment in these settings substantially more feasible. This study evaluates if changing financial incentives are associated with increases in for-profit ownership among IMD facilities relative to non-IMD facilities, as well as greater increases in Medicaid acceptance among for-profit IMD facilities relative to for-profit non-IMD facilities. We used data from the 2014-2020 National Mental Health Services Surveys and examined 11 945 facility-years. Relative to non-IMDs, the increase in for-profit ownership among IMDs was 6.6 percentage points greater. The largest proportional change in Medicaid acceptance occurred among for-profit IMD facilities relative to for-profit non-IMDs (18.5 percentage points). Existing research is mixed on the quality of inpatient and residential psychiatric care provided in for-profit vs nonprofit and public facilities, as well as in IMD relative to non-IMD facilities. As payment policy increasingly incentivizes for-profit facilities to enter the psychiatric care space, we should be mindful of the impact of these decisions on patient safety.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10790904/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139486414","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jun Soo Lee, Ami Bhatt, Lisa M Pollack, Sandra L. Jackson, Ji Eun Chang, Xin Tong, Feijun Luo
Telehealth utilization increased during the COVID-19 pandemic, yet few studies have documented associations of telehealth use with subsequent medical costs and health care utilization. We examined associations of telehealth use during the early COVID-19 public health emergency (March–June 2020) with subsequent total medical costs and health care utilization among people with heart disease (HD). We created a longitudinal cohort of individuals with HD using MarketScan Commercial Claims data (2018–2022). We used difference-in-difference methodology adjusting for patients’ characteristics, comorbidities, COVID-19 infection status, and number of in-person visits. We found that using telehealth during the stay-at-home order period was associated with a reduction in total medical costs (by -$1814 per person), number of emergency department visits (by -88.6 per 1,000 persons), and inpatient admissions (by -32.4 per 1,000 persons). Telehealth use increased per-person per-year pharmacy prescription claims (by 0.514) and average number of days’ drug supply (by.773 days). These associated benefits of telehealth use can inform decision makers, insurance companies, and health care professionals, especially in the context of disrupted health care access.
{"title":"Telehealth Use During the Early COVID-19 Public Health Emergency and Subsequent Health Care Costs and Utilization","authors":"Jun Soo Lee, Ami Bhatt, Lisa M Pollack, Sandra L. Jackson, Ji Eun Chang, Xin Tong, Feijun Luo","doi":"10.1093/haschl/qxae001","DOIUrl":"https://doi.org/10.1093/haschl/qxae001","url":null,"abstract":"\u0000 Telehealth utilization increased during the COVID-19 pandemic, yet few studies have documented associations of telehealth use with subsequent medical costs and health care utilization. We examined associations of telehealth use during the early COVID-19 public health emergency (March–June 2020) with subsequent total medical costs and health care utilization among people with heart disease (HD). We created a longitudinal cohort of individuals with HD using MarketScan Commercial Claims data (2018–2022). We used difference-in-difference methodology adjusting for patients’ characteristics, comorbidities, COVID-19 infection status, and number of in-person visits. We found that using telehealth during the stay-at-home order period was associated with a reduction in total medical costs (by -$1814 per person), number of emergency department visits (by -88.6 per 1,000 persons), and inpatient admissions (by -32.4 per 1,000 persons). Telehealth use increased per-person per-year pharmacy prescription claims (by 0.514) and average number of days’ drug supply (by.773 days). These associated benefits of telehealth use can inform decision makers, insurance companies, and health care professionals, especially in the context of disrupted health care access.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139528304","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Meiling Ying, Jane H Forman, Sitara Murali, Lauren E Gauntlett, Sarah L Krein, Brent K Hollenbeck, John M Hollingsworth
The Medicare Shared Savings Program (MSSP) is an alternative payment model launched in 2012, creating accountable care organizations (ACOs) to improve quality and lower costs for Traditional Medicare patients. Most MSSP participants were expected to shift from bearing no financial risk to a two-sided risk model (i.e., bonus if spending reduced below historical benchmarks, penalty if not), yet fewer than 20% did. Therefore, in 2019 the Centers for Medicare and Medicaid Services (CMS) launched the Pathways to Success program, which required shifting to a two-sided model within 12 months. For the first time, more ACOs exited than entered the MSSP. To understand these participation decisions, we conducted qualitative interviews with ACO leaders. Pathways caused ACOs to: reassess their potential shared savings versus losses, particularly in light of benchmarking methodology changes, reconsider perceived non-revenue benefits, and reassess participation in the MSSP vs. other programs. As ACOs, particularly those assuming downside risk, have contained costs and enhanced care quality, policymakers should strive to improve MSSP enrollment rates in downside-risk models through strategies that allow ACOs to achieve shared-savings and deliver accountable care.
{"title":"Factors affecting ACOs’ decisions to remain in or exit the Medicare Shared Savings Program following Pathways to Success","authors":"Meiling Ying, Jane H Forman, Sitara Murali, Lauren E Gauntlett, Sarah L Krein, Brent K Hollenbeck, John M Hollingsworth","doi":"10.1093/haschl/qxad093","DOIUrl":"https://doi.org/10.1093/haschl/qxad093","url":null,"abstract":"\u0000 The Medicare Shared Savings Program (MSSP) is an alternative payment model launched in 2012, creating accountable care organizations (ACOs) to improve quality and lower costs for Traditional Medicare patients. Most MSSP participants were expected to shift from bearing no financial risk to a two-sided risk model (i.e., bonus if spending reduced below historical benchmarks, penalty if not), yet fewer than 20% did. Therefore, in 2019 the Centers for Medicare and Medicaid Services (CMS) launched the Pathways to Success program, which required shifting to a two-sided model within 12 months. For the first time, more ACOs exited than entered the MSSP. To understand these participation decisions, we conducted qualitative interviews with ACO leaders. Pathways caused ACOs to: reassess their potential shared savings versus losses, particularly in light of benchmarking methodology changes, reconsider perceived non-revenue benefits, and reassess participation in the MSSP vs. other programs. As ACOs, particularly those assuming downside risk, have contained costs and enhanced care quality, policymakers should strive to improve MSSP enrollment rates in downside-risk models through strategies that allow ACOs to achieve shared-savings and deliver accountable care.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139383925","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Xane Peters, Jill Sage, Courtney Collins, Frank Opelka, Clifford Ko
Healthcare performance metrics are offered predominantly in terms of outcomes, processes, or structural components of healthcare delivery. However, measurement is limited by variability in data sources, definitions, and workarounds. The American College of Surgeons has recently developed a new type of performance metric known as a programmatic measure. These metrics align structures, processes, and outcomes to better coordinate quality measurement with support of frontline care teams. In this multifaceted way, these measures differ from current ‘single’ measures such as targeting surgical site infection (SSI). The thematic focus of these measures and alignment of structure-resource components to support processes and outcomes also sets these measures apart from contemporary composite measures. Importantly, structural elements of these measures reflect minimum resources required for patient care, addressing staffing and resource barriers felt by local institutions in addressing numerous existing quality metrics. These metrics will streamline quality reporting to improve care navigation for patients. Clinicians will find more appropriately aligned goals and responsibilities, resulting in increased teamwork and communication. These measures are designed to address the current burdens of overabundant metrics, priority misalignment, and low resources in a patient centric fashion to better align healthcare quality and measurement.
{"title":"Programmatic Quality Measures: A new model to promote surgical quality","authors":"Xane Peters, Jill Sage, Courtney Collins, Frank Opelka, Clifford Ko","doi":"10.1093/haschl/qxad094","DOIUrl":"https://doi.org/10.1093/haschl/qxad094","url":null,"abstract":"\u0000 Healthcare performance metrics are offered predominantly in terms of outcomes, processes, or structural components of healthcare delivery. However, measurement is limited by variability in data sources, definitions, and workarounds. The American College of Surgeons has recently developed a new type of performance metric known as a programmatic measure. These metrics align structures, processes, and outcomes to better coordinate quality measurement with support of frontline care teams. In this multifaceted way, these measures differ from current ‘single’ measures such as targeting surgical site infection (SSI). The thematic focus of these measures and alignment of structure-resource components to support processes and outcomes also sets these measures apart from contemporary composite measures. Importantly, structural elements of these measures reflect minimum resources required for patient care, addressing staffing and resource barriers felt by local institutions in addressing numerous existing quality metrics. These metrics will streamline quality reporting to improve care navigation for patients. Clinicians will find more appropriately aligned goals and responsibilities, resulting in increased teamwork and communication. These measures are designed to address the current burdens of overabundant metrics, priority misalignment, and low resources in a patient centric fashion to better align healthcare quality and measurement.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139389651","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Richard Pulvera, Kaitlyn Jackson, Wendi Gosliner, Rita Hamad, Lia Fernald
Safety net programs in the United States offered critical support to counter food insecurity and poverty during the first year of the COVID-19 pandemic. The Supplemental Nutrition Assistance Program (SNAP) and the Earned Income Tax Credit (EITC) are both means-tested programs with significant benefits. Take-up of SNAP and EITC is lower in California than nationwide and reasons for this difference are unclear. We examined associations of participation in SNAP and receipt of the EITC and perceptions of the US government, two types of welfare stigma (program stigma and social stigma), and perceived discrimination. We interviewed a sample of 497 caregivers of young children from families with low income in California between August 2020 and May 2021. We found that participation in SNAP (OR = 1.24 [1.05, 1.47]) and receiving the EITC (OR = 1.39 [1.05, 1.84]) were both associated with greater reported perceptions of social stigma, but not with perceptions of government, program stigma, or discrimination. Among food insecure respondents, we found that participation in SNAP was additionally associated with program stigma and discrimination. These findings suggest that perceived social stigma may be a reason that people with low income may not participate in programs for which they are eligible.
{"title":"The association of safety net program participation with government perceptions, welfare stigma, and discrimination","authors":"Richard Pulvera, Kaitlyn Jackson, Wendi Gosliner, Rita Hamad, Lia Fernald","doi":"10.1093/haschl/qxad084","DOIUrl":"https://doi.org/10.1093/haschl/qxad084","url":null,"abstract":"\u0000 Safety net programs in the United States offered critical support to counter food insecurity and poverty during the first year of the COVID-19 pandemic. The Supplemental Nutrition Assistance Program (SNAP) and the Earned Income Tax Credit (EITC) are both means-tested programs with significant benefits. Take-up of SNAP and EITC is lower in California than nationwide and reasons for this difference are unclear. We examined associations of participation in SNAP and receipt of the EITC and perceptions of the US government, two types of welfare stigma (program stigma and social stigma), and perceived discrimination. We interviewed a sample of 497 caregivers of young children from families with low income in California between August 2020 and May 2021. We found that participation in SNAP (OR = 1.24 [1.05, 1.47]) and receiving the EITC (OR = 1.39 [1.05, 1.84]) were both associated with greater reported perceptions of social stigma, but not with perceptions of government, program stigma, or discrimination. Among food insecure respondents, we found that participation in SNAP was additionally associated with program stigma and discrimination. These findings suggest that perceived social stigma may be a reason that people with low income may not participate in programs for which they are eligible.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138950377","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ji E Chang, Nate Smith, Zoe Lindenfeld, William B Weeks
Recognizing the impact of the social determinants of health (SDOH) on health outcomes, in 2016, the Centers for Medicare and Medicaid Services recommended use of ICD-10 Z-Codes to capture patients’ health related social needs. We examined changes in Z-Code utilization to document health related social needs for Medicare Fee for Service recipients among U.S. hospitals between 2017 to 2021 across five common SDOH domains. We found that while 56.9 percent of hospitals had at least one Z-Code recorded in at least one patient per year, apart from those referring to housing needs, rates of Z-Code adoption were low. Additionally, hospitals that were general medical, part of a teaching institution, affiliated with larger health systems, and of medium to large size had greater odds of utilizing Z-Codes. Findings from this study highlight the need for continued efforts in promoting the consistent use of standardized SDOH capturing methods like Z-Code documentation, such as provider training.
认识到健康的社会决定因素（SDOH）对健康结果的影响，美国医疗保险和医疗补助服务中心于 2016 年建议使用 ICD-10 Z 代码来记录患者与健康相关的社会需求。我们研究了 2017 年至 2021 年期间，美国医院在五个常见 SDOH 领域使用 Z 代码记录医疗保险收费服务受助者健康相关社会需求的变化情况。我们发现，虽然 56.9% 的医院每年至少为一名患者记录了一个 Z 代码，但除了那些提及住房需求的医院外，Z 代码的采用率很低。此外，全科医院、教学机构的一部分、大型医疗系统的附属医院以及大中型医院使用 Z 代码的几率更大。这项研究的结果突出表明，有必要继续努力促进标准化 SDOH 采集方法（如 Z 代码文档）的持续使用，例如对医疗服务提供者进行培训。
{"title":"Hospital Use of Common Z-Codes for Medicare Fee-for-Service Beneficiaries 2017-2021","authors":"Ji E Chang, Nate Smith, Zoe Lindenfeld, William B Weeks","doi":"10.1093/haschl/qxad086","DOIUrl":"https://doi.org/10.1093/haschl/qxad086","url":null,"abstract":"\u0000 Recognizing the impact of the social determinants of health (SDOH) on health outcomes, in 2016, the Centers for Medicare and Medicaid Services recommended use of ICD-10 Z-Codes to capture patients’ health related social needs. We examined changes in Z-Code utilization to document health related social needs for Medicare Fee for Service recipients among U.S. hospitals between 2017 to 2021 across five common SDOH domains. We found that while 56.9 percent of hospitals had at least one Z-Code recorded in at least one patient per year, apart from those referring to housing needs, rates of Z-Code adoption were low. Additionally, hospitals that were general medical, part of a teaching institution, affiliated with larger health systems, and of medium to large size had greater odds of utilizing Z-Codes. Findings from this study highlight the need for continued efforts in promoting the consistent use of standardized SDOH capturing methods like Z-Code documentation, such as provider training.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138971465","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hospital quality ratings are widely available to help Medicare beneficiaries make an informed choice about where to receive care. However, how beneficiaries trade-off between different quality domains (clinical outcomes, patient experience, safety, efficiency) and other considerations (out of pocket cost, travel distance) is not well understood. We sought to study how beneficiaries make trade-offs when choosing a hypothetical hospital. We administered an online survey that included a discrete choice experiment to a nationally representative sample of one thousand and twenty-five Medicare beneficiaries. On average, beneficiaries were willing to pay $1,698 more for a hospital with a one-star higher rating on clinical outcomes. This was over twice the value of the patient experience ($691) and safety domains ($615) and nearly eight times the value of the efficiency domain ($218). We also found that the value of a one-star improvement depends not only on the quality domain, but also the baseline level of performance of the hospital. Generally, it is more valuable for low performing hospitals to achieve average performance than for average hospitals to achieve excellence.
{"title":"What is a star worth to Medicare beneficiaries? A discrete choice experiment of hospital quality ratings","authors":"L. Trenaman, Mark Harrison, Jeffrey S Hoch","doi":"10.1093/haschl/qxad085","DOIUrl":"https://doi.org/10.1093/haschl/qxad085","url":null,"abstract":"\u0000 Hospital quality ratings are widely available to help Medicare beneficiaries make an informed choice about where to receive care. However, how beneficiaries trade-off between different quality domains (clinical outcomes, patient experience, safety, efficiency) and other considerations (out of pocket cost, travel distance) is not well understood. We sought to study how beneficiaries make trade-offs when choosing a hypothetical hospital. We administered an online survey that included a discrete choice experiment to a nationally representative sample of one thousand and twenty-five Medicare beneficiaries. On average, beneficiaries were willing to pay $1,698 more for a hospital with a one-star higher rating on clinical outcomes. This was over twice the value of the patient experience ($691) and safety domains ($615) and nearly eight times the value of the efficiency domain ($218). We also found that the value of a one-star improvement depends not only on the quality domain, but also the baseline level of performance of the hospital. Generally, it is more valuable for low performing hospitals to achieve average performance than for average hospitals to achieve excellence.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139008550","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Claire McGlave, John P Bruno, Elizabeth Watts, S. Nikpay
The 340B program grants eligible healthcare providers (“covered entities”) access to discounted prices for outpatient prescription drugs. Covered entities frequently rely on retail pharmacies (“contract pharmacies”) to dispense discounted drugs. This analysis describes contract pharmacy participation by ownership: the top four chains, grocery chains, small chains, and institutional independent pharmacies. We find that 71% of pharmacies in the top 4 chains were contract pharmacies, 41% of institutional pharmacies, 38% of grocery store pharmacies, and 22% of independent pharmacies participated in 340B in 2022. The median number of contracts per pharmacy was 2 among the top four chains and grocery store pharmacies, versus 1 for all other pharmacy types. The median farthest distance in miles from contracting covered entities was largest for the top-four chains (19 miles) and small chains (18 miles) and smallest for independent and institutional pharmacies (10 miles). The top four chains held the highest proportion of contracts with core safety-net providers (75%, compared to 61% of institutional pharmacies).
{"title":"340B Contract Pharmacy Growth by Pharmacy Ownership: 2009-2022","authors":"Claire McGlave, John P Bruno, Elizabeth Watts, S. Nikpay","doi":"10.1093/haschl/qxad075","DOIUrl":"https://doi.org/10.1093/haschl/qxad075","url":null,"abstract":"\u0000 The 340B program grants eligible healthcare providers (“covered entities”) access to discounted prices for outpatient prescription drugs. Covered entities frequently rely on retail pharmacies (“contract pharmacies”) to dispense discounted drugs. This analysis describes contract pharmacy participation by ownership: the top four chains, grocery chains, small chains, and institutional independent pharmacies. We find that 71% of pharmacies in the top 4 chains were contract pharmacies, 41% of institutional pharmacies, 38% of grocery store pharmacies, and 22% of independent pharmacies participated in 340B in 2022. The median number of contracts per pharmacy was 2 among the top four chains and grocery store pharmacies, versus 1 for all other pharmacy types. The median farthest distance in miles from contracting covered entities was largest for the top-four chains (19 miles) and small chains (18 miles) and smallest for independent and institutional pharmacies (10 miles). The top four chains held the highest proportion of contracts with core safety-net providers (75%, compared to 61% of institutional pharmacies).","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138585456","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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