Healthcare spending for non-fatal falls among older adults, USA.

BACKGROUND: The older adult (65+) population in the USA is increasing and with it the number of medically treated falls. In 2015, healthcare spending attributable to older adult falls was approximately US$50 billion. We aim to update the estimated medical expenditures attributable to older adult non-fatal falls. METHODS: Generalised linear models using 2017, 2019 and 2021 Medicare Current Beneficiary Survey and cost supplement files were used to estimate the association of falls with healthcare expenditures while adjusting for demographic characteristics and health conditions in the model. To portion out the share of total healthcare spending attributable to falls versus not, we adjusted for demographic characteristics and health conditions, including self-reported health status and certain comorbidities associated with increased risk of falling or higher healthcare expenditure. We calculated a fall-attributable fraction of expenditure as total expenditures minus total expenditures with no falls divided by total expenditures. We applied the fall-attributable fraction of expenditure from the regression model to the 2020 total expenditures from the National Health Expenditure Data to calculate total healthcare spending attributable to older adult falls. RESULTS: In 2020, healthcare expenditure for non-fatal falls was US$80.0 billion, with the majority paid by Medicare. CONCLUSION: Healthcare spending for non-fatal older adult falls was substantially higher than previously reported estimates. This highlights the growing economic burden attributable to older adult falls and these findings can be used to inform policies on fall prevention efforts in the USA.

Cost Drivers of Elective Colon and Rectal Surgery: A Retrospective Cohort Analysis.

BACKGROUND: Colorectal surgery is expensive. Few studies have evaluated complications as an economic cost driver, and there is little evidence comparing multiple cost drivers of colorectal surgery to determine the most effective means of reducing total cost. OBJECTIVE: This study aimed to determine the effects of surgical techniques, use of enhanced recovery protocols, and presence or absence of complications on the total cost of hospitalization for elective colorectal surgery. DESIGN: A retrospective cohort analysis using data from 2011 to 2018 was performed. The primary end point was a mean cost per hospitalization. The cost was compared between patients who experienced minimally invasive versus open surgeries, enhanced recovery after surgery protocols versus not, and complications versus none. SETTINGS: This study was conducted at a university-affiliated teaching hospital in the Northeastern United States. PATIENTS: Adult patients who have undergone elective colorectal surgery were included. MAIN OUTCOME MEASURES: The primary outcome for this study was the mean cost per hospitalization calculated using inpatient cost based on the total cost of the episode of care. RESULTS: A total of 1039 patients met the criteria for inclusion. The average cost of all hospitalizations was $19,801. Multivariate analysis demonstrated that enhanced recovery protocols substantially lowered the cost of care by $6392 ( p = 0.001), whereas complications increased the cost of care by $16,780 per episode ( p < 0.001). When complications occurred, enhanced recovery protocols reduced the cost by $17,963 ( p = 0.010). LIMITATIONS: This retrospective cohort study performed at a single institution has inherent limitations, including confounding and selection bias. CONCLUSIONS: For elective colorectal surgery, complications are associated with significantly increased costs. Avoiding complications should be a priority to reduce costs. Enhanced recovery protocols are associated with significantly reduced costs. Surgeons should focus future research efforts on improving protocols and processes that decrease postoperative complications to improve patient outcomes and to reduce costs associated with elective colorectal hospitalizations. See Video Abstract at http://links.lww.com/DCR/B927 . FACTORES DE COSTO DE LA CIRUGA ELECTIVA DE COLON Y RECTO UN ANLISIS DE COHORTE RETROSPECTIVE: ANTECEDENTES:La cirugía colorrectal es costosa. Pocos estudios han examinado las complicaciones como un factor de costo económico, y hay poca evidencia que compare múltiples factores de costo de la cirugía colorrectal para determinar los medios más efectivos para reducir el costo total.OBJETIVO:Este estudio tiene como objetivo determinar los efectos de las técnicas quirúrgicas, el uso de protocolos de enhanced recovery y la presencia o ausencia de complicaciones en el costo total de hospitalización por cirugía colorrectal electiva.DISEÑO:Se realizó un análisis retrospectivo de cohortes utilizando data del 2011-2018. El punto principal fue el costo medio por hospitalización. Se comparó el costo entre los pacientes que experimentaron: cirugías mínimamente invasivas versus abiertas, protocolos de enhanced recovery después de la cirugía versus no, y complicaciones versus no.FUENTE DE DATOS:Se consultó la base de datos financiera y contable del hospital y el registro médico electrónico para la obtencion de datos.ENTORNO CLINICO:Este estudio se realizó en un hospital docente afiliado a una universidad en el noreste de los Estados Unidos.PACIENTES:Se incluyeron pacientes adultos sometidos a cirugía colorrectal electiva.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal de este estudio fue el costo medio por hospitalización calculado utilizando el costo de hospitalización basado en el costo total del episodio de atención.RESULTADOS:Un total de 1.039 pacientes cumplieron los criterios de inclusión. El costo promedio de todas las hospitalizaciones fue de $19801. El análisis multivariante demostró que los protocolos de enhanced recovery redujeron sustancialmente el costo de la atención en $6392 ( p = 0,001), mientras que las complicaciones aumentaron el costo en $16780 por episodio ( p < 0,001). Cuando ocurrieron complicaciones, los protocolos de enhanced recovery redujeron el costo en $17963 ( p = 0,010).LIMITACIONES:Este es un estudio de cohorte retrospectivo realizado en una sola institución y tiene limitaciones inherentes que incluyen confusión y sesgo de selección.CONCLUSIONES:Video Resumen en http://links.lww.com/DCR/B927 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Community Health Teams: a qualitative study about the factors influencing the decision-making process.

BACKGROUND: The purpose of this study was to explore the factors influencing how individual Community Health Teams (CHTs) make decisions about what services to offer and how to allocate their resources. METHODS: We conducted thirteen semi-structured interviews with all 13 CHTs program managers between January and March, 2021. We analyzed interviewees descriptions of their service offerings, resources allocation, and decision-making process to identify themes. RESULTS: Four major themes emerged from the interview data as factors influencing community health team program managers' decision-making process: commitment to offering high-quality care coordination, Blueprint's stable and flexible structure, use of data in priority setting, and leveraging community partnerships and local resources. CONCLUSIONS: Community-based CHTs with flexible funding allowed programs to tailor service offerings in response to community needs. It is important for teams to have access to community-level data. Teams are cultivating and leveraging community partners to increase their care coordination capacity, which is focus of their work. CHTs are a model for leveraging community partnerships to increase service capacity and pubic engagement in health services for other states to replicate.

The effect of medical innovation on the cost-effectiveness of Covid 19-related policies in the United States using a SIR model.

BACKGROUND: During 2020-21, the United States used a multifaceted approach to control SARS-CoV-2 (Covid-19) and reduce mortality and morbidity. This included non-medical interventions (NMIs), aggressive vaccine development and deployment, and research into more effective approaches to medically treat Covid-19. Each approach had both costs and benefits. The objective of this study was to calculate the Incremental Cost Effectiveness Ratio (ICER) for three major Covid-19 policies: NMIs, vaccine development and deployment (Vaccines), and therapeutics and care improvements within the hospital setting (HTCI). METHODS: To simulate the number of QALYs lost per scenario, we developed a multi-risk Susceptible-Infected-Recovered (SIR) model where infection and fatality rates vary between regions. We use a two equation SIR model. The first equation represents changes in the number of infections and is a function of the susceptible population, the infection rate and the recovery rate. The second equation shows the changes in the susceptible population as people recover. Key costs included loss of economic productivity, reduced future earnings due to educational closures, inpatient spending and the cost of vaccine development. Benefits included reductions in Covid-19 related deaths, which were offset in some models by additional cancer deaths due to care delays. RESULTS: The largest cost is the reduction in economic output associated with NMI ($1.7 trillion); the second most significant cost is the educational shutdowns, with estimated reduced lifetime earnings of $523B. The total estimated cost of vaccine development is $55B. HTCI had the lowest cost per QALY gained vs "do nothing" with a cost of $2,089 per QALY gained. Vaccines cost $34,777 per QALY gained in isolation, while NMIs alone were dominated by other options. HTCI alone dominated most alternatives, except the combination of HTCI and Vaccines ($58,528 per QALY gained) and HTCI, Vaccines and NMIs ($3.4 m per QALY gained). CONCLUSIONS: HTCI was the most cost effective and was well justified under any standard cost effectiveness threshold. The cost per QALY gained for vaccine development, either alone or in concert with other approaches, is well within the standard for cost effectiveness. NMIs reduced deaths and saved QALYs, but the cost per QALY gained is well outside the usual accepted limits.

Changes in healthcare spending attributable to obesity and overweight: payer- and service-specific estimates.

BACKGROUND: National efforts to control US healthcare spending are potentially undermined by changes in patient characteristics, and in particular increases in rates of obesity and overweight. The objective of this study was to provide current estimates of the effect of obesity and overweight on healthcare spending overall, by service line and by payer using the National Institutes of Health classifications for BMI. METHODS: We used a quasi-experimental design and analyzed the data using generalized linear models and two-part models to estimate obesity- and overweight-attributable spending. Data was drawn from the 2006 and 2016 Medical Expenditures Panel Survey. We identified individuals in the different BMI classes based on self-reported height and weight. RESULTS: Total medical costs attributable to obesity rose to $126 billion per year by 2016, although the marginal cost of obesity declined for all obesity classes. The overall spending increase was due to an increase in obesity prevalence and a population shift to higher obesity classes. Obesity related spending between 2006 and 2016 was relatively constant due to decreases in inpatient spending, which were only partially offset by increases in outpatient spending. CONCLUSIONS: While total obesity related spending between 2006 and 2016 was relatively constant, by examining the effect of different obesity classes and overweight, it provides insight into spend for each level of obesity and overweight across service line and payer mix. Obesity class 2 and 3 were the main factors driving spending increases, suggesting that persons over BMI of 35 should be the focus for policies focused on controlling spending, such as prevention.

The impact of care management for high-risk pediatric asthmatics on healthcare utilization.

INTRODUCTION: From 2011 to 2015, a series of quality improvement interventions were developed that targeted pediatric persistent asthmatics that included recalls for those overdue for care and access to specialist care. The objective of this study was to assess the impact on urgent care and emergency department visits and hospitalizations from enrollment into at least one intervention during the time period. METHODS: Persistent asthmatics were identified through electronic medical records, with patients having an asthma designation containing "persistent," asthma control containing "poor", and asthma risk being "high risk." Asthma utilization events were identified for these patients between January 1, 2011, and June 30, 2015 using ICD-9 diagnosis codes. Evaluation focused on differences in utilization for patients before and after receiving interventions through the use of logistic regression for each utilization outcome. RESULTS: The interventions were delivered to 1060 children out of a total of 2046 identified as having the persistent asthmatic criteria. The intervention group consisted of 389 (36.7%) moderate persistent asthmatics and 643 (60.7%) mild persistent asthmatics, with 976 (92.1%) identifying as a minority. Analysis of 60692 months of data showed patients who received the intervention were less likely to visit the urgent care (OR [0.80, 0.96]) or be hospitalized (OR [0.37, 0.75]) than those who did not receive any interventions. Adjustment for provider referral into the interventions resulted in slight changes for both hospitalizations (OR [0.38, 0.79]) and urgent care (OR [0.68, 0.94]). CONCLUSION: Children receiving interventions were less likely to be hospitalized or visit urgent care clinics.

Understanding the factors that affect the appropriateness of rheumatology referrals.

BACKGROUND: Reducing inappropriate referrals to specialists is a challenge for the healthcare system as it seeks to transition from volume to value-based healthcare. Given the projection of a severe shortage of rheumatologists in the near future, innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. Efforts to increase appropriate utilization through reductions in capacity may have the unintended consequence of reducing appropriate care as well. This highlights the challenges in increasing the appropriate use of high cost services as the health system transitions to value based care. The objective of this study was to analyze factors affecting appropriateness of rheumatology services. METHODS: This was a cross-sectional study of patients receiving Rheumatology services between November 2013 and October 2019. We used a proxy for "appropriateness": whether or not there was any follow-up care after the first appointment. Results from regression analysis and physicians' chart reviews were compared using an inter-rater reliability measure (kappa). Data was drawn from the EHR 2013-2019. RESULTS: We found that inappropriate referrals increased 14.3% when a new rheumatologist was hired, which increased to 14.8% after wash-out period of 6 months; 15.7% after 12 months; 15.5% after 18 months and 16.7% after 18 months. Other factors influencing appropriateness of referrals included severity of disease, gender and insurance type, but not specialty of referring provider. CONCLUSIONS: Given the projection of a severe shortage of rheumatologists in the near future, innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. Innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. These findings may apply to other specialties as well. This study is relevant for health care systems that are implementing value-based payment models aimed at reducing inappropriate care.

Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study.

BACKGROUND: Armenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health. METHODS: This was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services. RESULTS: The mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government's reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers' concern. CONCLUSION: The study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.

Cost-effectiveness of a statewide public health intervention to reduce cardiovascular disease risk.

BACKGROUND: The cost-effectiveness of community health worker (CHW)-based cardiovascular disease (CVD) risk-reduction interventions is not well established. Colorado Heart Healthy Solutions is a CHW-based intervention designed to reduce modifiable CVD risk factors. This program has previously demonstrated success, but the cost-effectiveness is unknown. CHW-based interventions are potentially attractive complements to healthcare delivery because laypersons implement the intervention at a lower cost relative to medical care and may be attractive in rural settings with limited clinical resources. METHODS: CHWs performed screenings and provided ongoing participant support within predominantly rural communities. A point-of-service software tool was used to generate 10-year Framingham CVD risk scores and assist CHWs to make medical referrals and provide ongoing individualized support for lifestyle changes. A sample of program participants returned for reassessment of risk factors. We calculated quality-adjusted life years (QALYs) gained and program costs using a Markov model. Transition probabilities were calculated using Framingham risk equations or derived from the literature using the observed mean reduction in 10-year CVD risk score over of 37- months follow-up. Program cost-effectiveness was calculated for both at-risk (abnormal baseline CVD risk factors) and overall program populations. RESULTS: The base-case scenario evaluating a 52-year-old male participant revealed an incremental cost savings of $3576 and a gain of 0.16 QALYs associated with the intervention. Cost savings were greater in at-risk populations. The economic dominance of the model was robust in multiple sensitivity analyses. CONCLUSIONS: A community-based CVD intervention demonstrated to reduce CVD risk is cost-effective. This suggests that population-based public health programs may have the potential to complement primary care preventative services to improve health and reduce the burden of traditional medical care.

Apoyo con Cariño (support with caring): RCT protocol to improve palliative care outcomes for Latinos with advanced medical illness.

Latinos are more likely to experience uncontrolled pain, and institutional death, and are less likely to engage in advance care planning. Efforts to increase access to palliative care must maximize primary palliative care and community based models to meet the ever-growing need in a culturally sensitive and congruent manner. Patient navigator interventions are community-based, culturally tailored models of care that have been successfully implemented to improve disease prevention, early diagnosis, and treatment. We have developed a patient navigation intervention to improve palliative care outcomes for seriously ill Latinos. We describe the protocol for a National Institute of Nursing Research-funded randomized controlled trial designed to determine the effectiveness of the manualized patient navigator intervention. We aim to enroll 240 Latino adults with non-cancer, advanced medical illness from both urban and rural clinical sites. Participants will be randomized to the intervention group (five palliative care patient navigator visits plus bilingual educational materials) or control group (usual care plus bilingual educational materials). Outcomes include quality of life (Functional Assessment of Chronic Illness Therapy), advance care planning (Advance Care Planning Engagement survey), pain (Brief Pain Inventory), symptom management (Edmonton Symptom Assessment Scale-revised), hospice utilization, and cost and utilization of healthcare resources. This culturally tailored, evidence-based, theory-driven, innovative patient navigation intervention has significant potential to improve palliative care for Latinos, and facilitate health equity in palliative and end-of-life care.

Recommendations for Methicillin-Resistant Staphylococcus aureus Prevention in Adult ICUs: A Cost-Effectiveness Analysis.

OBJECTIVE: Patients in the ICU are at the greatest risk of contracting healthcare-associated infections like methicillin-resistant Staphylococcus aureus. This study calculates the cost-effectiveness of methicillin-resistant S aureus prevention strategies and recommends specific strategies based on screening test implementation. DESIGN: A cost-effectiveness analysis using a Markov model from the hospital perspective was conducted to determine if the implementation costs of methicillin-resistant S aureus prevention strategies are justified by associated reductions in methicillin-resistant S aureus infections and improvements in quality-adjusted life years. Univariate and probabilistic sensitivity analyses determined the influence of input variation on the cost-effectiveness. SETTING: ICU. PATIENTS: Hypothetical cohort of adults admitted to the ICU. INTERVENTIONS: Three prevention strategies were evaluated, including universal decolonization, targeted decolonization, and screening and isolation. Because prevention strategies have a screening component, the screening test in the model was varied to reflect commonly used screening test categories, including conventional culture, chromogenic agar, and polymerase chain reaction. MEASUREMENTS AND MAIN RESULTS: Universal and targeted decolonization are less costly and more effective than screening and isolation. This is consistent for all screening tests. When compared with targeted decolonization, universal decolonization is cost-saving to cost-effective, with maximum cost savings occurring when a hospital uses more expensive screening tests like polymerase chain reaction. Results were robust to sensitivity analyses. CONCLUSIONS: As compared with screening and isolation, the current standard practice in ICUs, targeted decolonization, and universal decolonization are less costly and more effective. This supports updating the standard practice to a decolonization approach.

Value of Public Health Funding in Preventing Hospital Bloodstream Infections in the United States.

OBJECTIVES: To estimate the association of 1 activity of the Prevention and Public Health Fund with hospital bloodstream infections and calculate the return on investment (ROI). METHODS: The activity was funded for 1 year (2013). A difference-in-differences specification evaluated hospital standardized infection ratios (SIRs) before funding allocation (years 2011 and 2012) and after funding allocation (years 2013 and 2014) in the 15 US states that received the funding compared with hospital SIRs in states that did not receive the funding. We estimated the association of the funded public health activity with SIRs for bloodstream infections. We calculated the ROI by dividing cost offsets from infections averted by the amount invested. RESULTS: The funding was associated with a 33% (P < .05) reduction in SIRs and an ROI of $1.10 to $11.20 per $1 invested in the year of funding allocation (2013). In 2014, after the funding stopped, significant reductions were no longer evident. CONCLUSIONS: This activity was associated with a reduction in bloodstream infections large enough to recoup the investment. Public health funding of carefully targeted areas may improve health and reduce health care costs.

Health risk factors as predictors of workers' compensation claim occurrence and cost.

OBJECTIVE: The objective of this study was to examine the predictive relationships between employee health risk factors (HRFs) and workers' compensation (WC) claim occurrence and costs. METHODS: Logistic regression and generalised linear models were used to estimate the predictive association between HRFs and claim occurrence and cost among a cohort of 16 926 employees from 314 large, medium and small businesses across multiple industries. First, unadjusted (HRFs only) models were estimated, and second, adjusted (HRFs plus demographic and work organisation variables) were estimated. RESULTS: Unadjusted models demonstrated that several HRFs were predictive of WC claim occurrence and cost. After adjusting for demographic and work organisation differences between employees, many of the relationships previously established did not achieve statistical significance. Stress was the only HRF to display a consistent relationship with claim occurrence, though the type of stress mattered. Stress at work was marginally predictive of a higher odds of incurring a WC claim (p<0.10). Stress at home and stress over finances were predictive of higher and lower costs of claims, respectively (p<0.05). CONCLUSIONS: The unadjusted model results indicate that HRFs are predictive of future WC claims. However, the disparate findings between unadjusted and adjusted models indicate that future research is needed to examine the multilevel relationship between employee demographics, organisational factors, HRFs and WC claims.

Strategic Methodologies in Public Health Cost Analyses.

CONTEXT: The National Research Agenda for Public Health Services and Systems Research states the need for research to determine the cost of delivering public health services in order to assist the public health system in communicating financial needs to decision makers, partners, and health reform leaders. OBJECTIVE: The objective of this analysis is to compare 2 cost estimation methodologies, public health manager estimates of employee time spent and activity logs completed by public health workers, to understand to what degree manager surveys could be used in lieu of more time-consuming and burdensome activity logs. DESIGN: Employees recorded their time spent on communicable disease surveillance for a 2-week period using an activity log. Managers then estimated time spent by each employee on a manager survey. Robust and ordinary least squares regression was used to measure the agreement between the time estimated by the manager and the time recorded by the employee. MAIN OUTCOME MEASURES: The 2 outcomes for this study included time recorded by the employee on the activity log and time estimated by the manager on the manager survey. SETTING: This study was conducted in local health departments in Colorado. PARTICIPANTS: Forty-one Colorado local health departments (82%) agreed to participate. RESULTS: Seven of the 8 models showed that managers underestimate their employees' time, especially for activities on which an employee spent little time. Manager surveys can best estimate time for time-intensive activities, such as total time spent on a core service or broad public health activity, and yet are less precise when estimating discrete activities. CONCLUSIONS: When Public Health Services and Systems Research researchers and health departments are conducting studies to determine the cost of public health services, there are many situations in which managers can closely approximate the time required and produce a relatively precise approximation of cost without as much time investment by practitioners.

Minimum package of public health services: the adoption of core services in local public health agencies in Colorado.

OBJECTIVES: We examined the effect of a state law in Colorado that required local public health agencies to deliver a minimum package of public health services. METHODS: We used a longitudinal, pre-post study design, with baseline data collected in 2011 and follow-up data collected in 2013. We conducted means testing to analyze the change in service delivery and activities. We conducted linear regression to test for system structure effects on the implementation of core services. RESULTS: We observed statistically significant increases in several service areas within communicable disease, prevention and population health promotion, and environmental health. In addition to service and program areas, specific activities had significant increases. The significant activity increases were all in population- and systems-based services. CONCLUSIONS: This project provided insight into the likely effect of national adoption of a minimum package as recommended by the Institute of Medicine. The implementation of a minimum package showed significant changes in service delivery, with specific service delivery measurement over a short period of time. Our research sets up a research framework to further explore core service delivery measure development.

Examining alignment of community health teams' preferences for health, equity, and spending with state all-payer waiver priorities: A discrete choice experiment.

OBJECTIVE: The state of Vermont has a statewide waiver from the centers for medicare and medicaid services to allow all-payer Accountable Care Organizations (ACOs). The Vermont all-payer model (VAPM) waiver is layered upon previous reforms establishing regional community health teams (CHTs) and medical homes. The waiver is intended to incentivize healthcare value and quality and create alignment between health system payers, providers, and CHTs. The objective of this study was to examine CHT's trade-offs and preferences for health, equity, and spending and the alignment with VAPM priorities. DATA SOURCES/STUDY SETTING: Data were gathered from a survey and discrete choice experiment among CHT leadership and CHT team members of the 13 CHTs in Vermont. STUDY DESIGN: We used conditional logit models to model the choice as a function of its characteristics (attributes) and mixed logit models to analyze whether preferences for programs varied by persons and roles within CHTs. DATA COLLECTION/EXTRACTION METHODS: There were 60 respondents who completed the survey online with 14 choice tasks, with three program options in each task, for a total sample size of 2520. PRINCIPAL FINDINGS: We found that CHTs prioritized programs in the community health plan and those with quantitative evidence of effectiveness. They were less likely to choose either programs targeting racial and ethnic minorities or programs having a small effect on a large population. Preferences did not vary across individual or community attributes. Program priorities of the VAPM, especially healthcare spending, were not prioritized. CONCLUSIONS: The results suggest that the new VAPM does not automatically create system alignment: CHTs tended to prioritize local needs and voices. The statewide priorities are less important to CHTs, which have excellent internal alignment. This creates potential disconnection between state and community health goals. However, CHTs and the VAPM prioritize similar populations, indicating an opportunity to increase alignment by allowing flexible programs tailored to local needs. CHTs also prioritized programs with a strong evidence base, suggesting another potential avenue to create system alignment.

Efforts by commercial health plans to increase Chlamydia trachomatis screening among their members.

BACKGROUND: The screening rate for Chlamydia trachomatis (Ct) is below 38% nationally, despite the high prevalence of Ct nationally and the low cost of both the screening test and the treatment. The purposes of this study are (a) to ascertain what activities commercial health plans have attempted (if any) to increase their Ct screening rates and (b) to identify barriers to improving Ct screening rates in commercial health plans. METHODS: Qualitative research methods were used, including structured interviews. In-depth telephone interviews with commercial health plans were conducted to identify health plan activities that led to high Ct screening rates by providers. Plans were selected, which were either in the top or in the bottom quarter of all plans or had either an increase or decrease in Ct screening rates of at least 3 percentage points over the previous 2 to 3 years. Interviews were restricted to plans reporting Ct screening rates to the National Committee for Quality Assurance for at least 3 years, plans with enrollment of at least 500 commercially insured women aged 15 to 26 years, and plans that were not staff model-managed care plans. A total of 35 structured interviews were completed with a response rate of 64%. RESULTS: Overall Ct screening rates in commercial health plans are quite low, with a median rate of 35%. All interviewed plans-both successful and not successful-reimbursed for Ct screening and used clinical guidelines. All but 3 plans had some type of intervention in place designed to improve Ct screening rats. The interventions varied-some aimed at providers, others at patients, and others at data collection-but the health plans were actively trying to improve screening rates. Health plans identified several barriers to improving screening rates in the commercially insured population. These include difficulties in identifying sexually active members for screening, limited health plan resources to target the problem, concerns about contacting minors, and cultural barriers to discussing sexually transmitted diseases. CONCLUSIONS: Both high- and low-performing plans are actively trying to increase the Ct screening rates. However, efforts to date have not been successful, suggesting the need for alternative approaches to address existing barriers.

Understanding factors associated with increases in Medicare Advantage enrollment, 2007-2018.

OBJECTIVES: Private managed care plans in the Medicare Advantage (MA) program have been gaining market share relative to traditional fee-for-service Medicare (TM), yet there are no obvious structural changes to Medicare that would explain this growth. Our goal is to explain the growth in MA market share during a period when it increased dramatically. STUDY DESIGN: Data are drawn from a representative sample of the Medicare population from 2007 to 2018. METHODS: We decomposed MA growth into changes in the values of explanatory variables that influence MA enrollment (eg, income and payment rate) and changes in preferences for MA vs TM (estimated coefficients) using a nonlinear version of the Blinder-Oaxaca decomposition to distinguish the sources of MA growth. We find that the relatively smooth growth in MA market share masks 2 distinct growth periods. RESULTS: From 2007 to 2012, 73% of the increase was due to changes in the values of the explanatory variables, and only 27% was due to changes in coefficients. In contrast, from 2012 to 2018, changes in explanatory variables, particularly MA payment levels, would have led to a decline in MA market share if that effect had not been offset by changes in the coefficients. CONCLUSIONS: Overall, we find that MA is becoming more appealing to more educated and nonminority beneficiaries than in the past, although minority and lower-income beneficiaries are still more likely to pick the program. Over time, if preferences continue to shift, the nature of the MA program will change as it moves more toward the middle of the Medicare distribution.

Public and private health insurance premiums: how do they affect the health insurance status of low-income childless adults?

The Patient Protection and Affordable Care Act (ACA) will substantially increase public health insurance eligibility and alter the costs of insurance coverage. Using Current Population Survey (CPS) data from the period 2000-2008, we examine the effects of public and private health insurance premiums on the insurance status of low-income childless adults, a population substantially affected by the ACA. Results show higher public premiums to be associated with a decrease in the probability of having public insurance and an increase in the probability of being uninsured, while increased private premiums decrease the probability of having private insurance. Eligibility for premium assistance programs and increased subsidy levels are associated with lower rates of uninsurance. The magnitudes of the effects are quite modest and provide important implications for insurance expansions for childless adults under the ACA.

Lives saved and lost in the first six month of the US COVID-19 pandemic: A retrospective cost-benefit analysis.

In the beginning of the COVID-19 US epidemic in March 2020, sweeping lockdowns and other aggressive measures were put in place and retained in many states until end of August of 2020; the ensuing economic downturn has led many to question the wisdom of the early COVID-19 policy measures in the US. This study's objective was to evaluate the cost and benefit of the US COVID-19-mitigating policy intervention during the first six month of the pandemic in terms of COVID-19 mortality potentially averted, versus mortality potentially attributable to the economic downturn. We conducted a synthesis-based retrospective cost-benefit analysis of the full complex of US federal, state, and local COVID-19-mitigating measures, including lockdowns and all other COVID-19-mitigating measures, against the counterfactual scenario involving no public health intervention. We derived parameter estimates from a rapid review and synthesis of recent epidemiologic studies and economic literature on regulation-attributable mortality. According to our estimates, the policy intervention saved 866,350-1,711,150 lives (4,886,214-9,650,886 quality-adjusted life-years), while mortality attributable to the economic downturn was 57,922-245,055 lives (2,093,811-8,858,444 life-years). We conclude that the number of lives saved by the spring-summer lockdowns and other COVID-19-mitigation was greater than the number of lives potentially lost due to the economic downturn. However, the net impact on quality-adjusted life expectancy is ambiguous.