Billing and payment of commercial and Medicaid health plan adult vaccination claims in Michigan since the Affordable Care Act.

BACKGROUND: Provider concern regarding insurance non-payment for vaccines is a common barrier to provision of adult immunizations. We examined current adult vaccination billing and payment associated with two managed care populations to identify reasons for non-payment of immunization insurance claims. METHODS: We assessed administrative data from 2014 to 2015 from Blue Care Network of Michigan, a nonprofit health maintenance organization, and Blue Cross Complete of Michigan, a Medicaid managed care plan, to determine rates of and reasons for non-payment of adult vaccination claims across patient-care settings, insurance plans, and vaccine types. We compared commercial and Medicaid payment rates to Medicare payment rates and examined patient cost sharing. RESULTS: Pharmacy-submitted claims for adult vaccine doses were almost always paid (commercial 98.5%; Medicaid 100%). As the physician office accounted for the clear majority (79% commercial; 69% Medicaid) of medical (non-pharmacy) vaccination services, we limited further analyses of both commercial and Medicaid medical claims to the physician office setting. In the physician office setting, rates of payment were high with commercial rates of payment (97.9%) greater than Medicaid rates (91.6%). Reasons for non-payment varied, but generally related to the complexity of adult vaccine recommendations (patient diagnosis does not match recommendations) or insurance coverage (complex contracts, multiple insurance payers). Vaccine administration services were also generally paid. Commercial health plan payments were greater for both vaccine dose and vaccine administration than Medicare payments; Medicaid paid a higher amount for the vaccine dose, but less for vaccine administration than Medicare. Patients generally had very low (commercial) or no (Medicaid) cost-sharing for vaccination. CONCLUSIONS: Adult vaccine dose claims were usually paid. Medicaid generally had higher rates of non-payment than commercial insurance.

Western organizational change capacity theory and its application to public health organizations in China: A multiple case analysis.

As health reform becomes a crucial task for both Chinese and United States government, public health organizations are required to adopt changes based on reform policy. Organizational Change Capacity theory is a Western theory that indicates the capacities that organizations should possess when pursuing successful organizational change. This study seeks to understand the applicability of this theory to Chinese public health organizations by contrasting organizations that have achieved success or remained challenged in implementing organizational change to optimize health reform. The research questions are: Is the Organizational Change Capacity theory applicable in Chinese public health organizations? How should it be modified to best fit Chinese public health organizations? Seventy-two participants from 12 public health organizations in Beijing and Xi'an were recruited for interviews and follow-up questionnaires that asked for experiences during their organizational changes. During the analysis, a new Chinese Organizational Change Capacity theory with nine main themes emerged. This new framework provides a guideline for Chinese public health organizations to evaluate their change capacity, and offers a theoretical foundation for researchers to design interventions that increase these organizations' capacity in achieving successful change.

The Impact of Commercial Health Plan Prior Authorization Programs on the Utilization of Services for Low Back Pain.

STUDY DESIGN: An observational study. OBJECTIVE: The aim of this study was to evaluate the impact of a health plan's prior authorization (PA) programs for low back pain (LBP) in a non-Medicare population by assessing changes in pre-surgical nonoperative care; lumbar fusion trends; and overall back surgery rates compared with another health plan with a similar program and national benchmarks. The PA programs require mandatory physiatrist consultation before surgical evaluation, with subsequent additional LBP surgery PA. SUMMARY OF BACKGROUND DATA: LBP is prevalent and concern exists that spinal fusion is overutilized for LBP. METHODS: Annual rates of lumbar fusion trended over 6 years, and analysis of changes in standardized costs for LBP-related services among a 501-member subset who underwent lumbar fusion before and after program implementations, during the period January 1, 2008, through December 31, 2013, among commercial members aged 18 and 65 years enrolled in a health maintenance organization with commercial membership averaging >500,000 annually. RESULTS: After initiation of the physiatrist PA in December 2010, lumbar fusions decreased from 76.27/100,000 in 2010 to 62.63/100,000 in 2011 with subsequent increases to 64.24/100,000 and 73.84/100,000 in years 2012 and 2013. For members who had lumbar fusion, per-member, pre-surgical costs increased by $2,233 with the physiatrist PA and an additional $1,370 with implementation of the LBP surgery PA (March 2013). Spinal injections and inpatient admissions were the greatest contributors to the overall increase in costs. The physiatrist and LBP surgery PA programs were also associated with lengthening of LBP episodes ending in surgery by 309 and 198 days. CONCLUSION: Mandatory referral to a physiatrist before surgical evaluation did not result in persistent reduction in lumbar fusions. Instead, these programs were associated with the unintended consequence of increased costs from more nonoperative care for only a transitory change in the lumbar fusion rate, likely from delays due to the introduction of both PA programs. LEVEL OF EVIDENCE: 3.

Emergency department use associated with primary care office management.

OBJECTIVES: The goal of this pilot study is to demonstrate whether revisiting and focusing on simple and generally known primary care office management practices has a meaningful impact on emergency department (ED) utilization for conditions that likely could have been treated in the primary care office setting (primary care physician [PCP] treatable). STUDY DESIGN: Cohort study using health plan administrative data from 2007 to 2010 involving primary care physicians (PCPs) affiliated with both Blue Care Network of Michigan, a nonprofit health maintenance organization, and Oakland Southfield Physicians PC, a Metropolitan Detroit independent practice association. PCPs were assigned to cohorts according to pre-intervention increasing or decreasing temporal trends in annual ED visit rates for PCP-treatable conditions by 12-month continuously enrolled commercial members with the same emergency care copay. METHODS: A difference-in-difference approach measuring control and intervention PCPs for the same 4 months (September-December) during 3 years (2007-2009) pre-intervention, and the available same 4-month period post-intervention, to determine if the pilot was associated with decreased ED utilization for PCP-treatable conditions. RESULTS: A substantive reversal of a worsening 2007 to 2009 trend (peak of 49.2 visits per 1000 in 2009 decreased to 7.3 visits/1000 in 2010) in ED use for PCP-treatable conditions at intervention sites, with the 2010 rate also lower than control sites (23.8 visits per 1000) during the same postintervention period. CONCLUSIONS: Simple and effective practice management techniques, while generally known, require revisiting and focused attention by PCPs to limit rates of PCP-treatable ED visits.

A meta-analysis of social capital and health: a case for needed research.

Social capital refers to various levels of social relationships formed through social networks. Measurement differences have lead to imprecise measurement. A meta-analysis of eligible studies assessing the bivariate association between social capital and self-reported health and all-cause mortality was performed. Thirty-nine studies met inclusion criteria, showing social capital increased odds of good health by 27 percent (95% confidence intervals [CI] =21%, 34%). Social capital variables, reciprocity increased odds of good health by 39 percent (95% CI = 21%, 60%) and trust by 32 percent (95% CI =19%, 46%). Future research suggests operationalizing measures by assessing differences by race/ethnicity, gender and socioeconomic status.

Updating the FORECAST formative evaluation approach and some implications for ameliorating theory failure, implementation failure, and evaluation failure.

Historically, there has been considerable variability in how formative evaluation has been conceptualized and practiced. FORmative Evaluation Consultation And Systems Technique (FORECAST) is a formative evaluation approach that develops a set of models and processes that can be used across settings and times, while allowing for local adaptations and innovations. FORECAST integrates specific models and tools to improve limitations in program theory, implementation, and evaluation. In the period since its initial use in a federally funded community prevention project in the early 1990s, evaluators have incorporated important formative evaluation innovations into FORECAST, including the integration of feedback loops and proximal outcome evaluation. In addition, FORECAST has been applied in a randomized community research trial. In this article, we describe updates to FORECAST and the implications of FORECAST for ameliorating failures in program theory, implementation, and evaluation.

Using the interactive systems framework to support a quality improvement approach to dissemination of evidence-based strategies to promote early detection of breast cancer: planning a comprehensive dynamic trial.

Dissemination efforts must optimize interventions for new settings and populations. As such, dissemination research should incorporate principles of quality improvement. Comprehensive Dynamic Trial (CDT) designs examine how information gained during dissemination may be used to modify interventions and improve performance. Although CDT may offer distinct advantages over static designs, organizing the many necessary roles and activities is a significant challenge. In this article, we discuss use of the Interactive Systems Framework for Dissemination and Implementation to systematically implement a CDT. Specifically, we describe "Bronx ACCESS", a program designed to disseminate evidence-based strategies to promote adherence to mammography guidelines. In Bronx ACCESS, the Intervention Delivery System will elicit information needed to adapt strategies to specific settings and circumstances. The Intervention Synthesis and Translation System will use this information to test changes to strategies through "embedded experiments". The Intervention Support System will build local capacities found to be necessary for intervention institutionalization. Simulation modeling will be used to integrate findings across systems. Results will inform on-going policy debate about interventions needed to promote population-level screening. More generally, this project is intended to advance understanding of research paradigms necessary to study dissemination.

Effect of cost efficiency reporting on utilization by physician specialists: a difference-in-difference study.

OBJECTIVE: To assess whether health plan implementation of specialist profile reports not associated with any health plan administered reward or consequence that measured physician cost efficiency relative to peers, and shared with specialists and primary care referral sources only, were associated with changes in specialist behaviour. DATA SOURCE/STUDY SETTING: Blue Care Network of Michigan is a non-profit statewide Health Maintenance Organization and wholly owned subsidiary of Blue Cross Blue Shield of Michigan. This study used administrative data from 2002 to 2006 and included only providers and adult (ages 18-65) commercial membership located in Southeastern Michigan. STUDY DESIGN: A difference-in-difference study design of before and after specialist cost efficiency reporting on six specialties to both specialists and primary care referral sources, but not health plan members, to determine whether specialists who performed worse than peers changed the level of utilization of their own physician services without any direct health plan reward or consequence. PRINCIPAL FINDINGS: Substantive changes were noted for interventional cardiology (-32.3%, P ≤ 0.01), orthopaedics (-13.3%, P ≤ 0.01) and otolaryngology (-15.9%, P ≤ 0.02). Less established, yet negative changes were noted for ophthalmology (-11.9%, P ≤ 0.01), gastroenterology (-3.2%, P = 0.23) and urology (-3.1%, P = 0.52). CONCLUSIONS: Simple and transparent reports on specialist cost efficiency distributed to referral sources and specialists using a more laissez-faire style reporting only health plan programme can engage providers and be associated with reductions in utilization. Possible mechanisms include explicit pressure from referral sources or self-motivated change by specialists.

Polyketide synthase pathways identified from a metagenomic library are derived from soil Acidobacteria.

Polyketides are structurally diverse secondary metabolites, many of which have antibiotic or anticancer activity. Type I modular polyketide synthase (PKS) genes are typically large and encode repeating enzymatic domains that elongate and modify the nascent polyketide chain. A fosmid metagenomic library constructed from an agricultural soil was arrayed and the macroarray was screened for the presence of conserved ketosynthase [ß-ketoacyl synthase (KS)] domains, enzymatic domains present in PKSs. Thirty-four clones containing KS domains were identified by Southern hybridization. Many of the KS domains contained within metagenomic clones shared significant similarity to PKS or nonribosomal peptide synthesis genes from members of the Cyanobacteria or the Proteobacteria phyla. However, analysis of complete clone insert sequences indicated that the blast analysis for KS domains did not reflect the true phylogenetic origin of many of these metagenomic clones that had a %G+C content and significant sequence similarity to genes from members of the phylum Acidobacteria. This conclusion of an Acidobacteria origin for several clones was further supported by evidence that cultured soil Acidobacteria from different subdivisions have genetic loci closely related to PKS domains contained within metagenomic clones, suggesting that Acidobacteria may be a source of novel polyketides. This study also demonstrates the utility of combining data from culture-dependent and -independent investigations in expanding our collective knowledge of microbial genomic diversity.

Gram negative shuttle BAC vector for heterologous expression of metagenomic libraries.

Bacterial artificial chromosome (BAC) vectors enable stable cloning of large DNA fragments from single genomes or microbial assemblages. A novel shuttle BAC vector was constructed that permits replication of BAC clones in diverse Gram-negative species. The "Gram-negative shuttle BAC" vector (pGNS-BAC) uses the F replicon for stable single-copy replication in E. coli and the broad-host-range RK2 mini-replicon for high-copy replication in diverse Gram-negative bacteria. As with other BAC vectors containing the oriV origin, this vector is capable of an arabinose-inducible increase in plasmid copy number. Resistance to both gentamicin and chloramphenicol is encoded on pGNS-BAC, permitting selection for the plasmid in diverse bacterial species. The oriT from an IncP plasmid was cloned into pGNS-BAC to enable conjugal transfer, thereby allowing both electroporation and conjugation of pGNS-BAC DNA into bacterial hosts. A soil metagenomic library was constructed in pGNS-BAC-1 (the first version of the vector, lacking gentamicin resistance and oriT), and recombinant clones were demonstrated to replicate in diverse Gram-negative hosts, including Escherichia coli, Pseudomonas spp., Salmonella enterica, Serratia marcescens, Vibrio vulnificus and Enterobacter nimipressuralis. This shuttle BAC vector can be utilized to clone genomic DNA from diverse sources, and then transfer it into diverse Gram-negative bacterial species to facilitate heterologous expression of recombinant pathways.

Comparison of midgut bacterial diversity in tropical caterpillars (Lepidoptera: Saturniidae) fed on different diets.

As primary consumers of foliage, caterpillars play essential roles in shaping the trophic structure of tropical forests. The caterpillar midgut is specialized in plant tissue processing; its pH is exceptionally alkaline and contains high concentrations of toxic compounds derived from the ingested plant material (secondary compounds or allelochemicals) and from the insect itself. The midgut, therefore, represents an extreme environment for microbial life. Isolates from different bacterial taxa have been recovered from caterpillar midguts, but little is known about the impact of these microorganisms on caterpillar biology. Our long-term goals are to identify midgut symbionts and to investigate their functions. As a first step, different diet formulations were evaluated for rearing two species of tropical saturniid caterpillars. Using the polymerase chain reaction (PCR) with primers hybridizing broadly to sequences from the bacterial domain, 16S rRNA gene libraries were constructed with midgut DNA extracted from caterpillars reared on different diets. Amplified rDNA restriction analysis indicated that bacterial sequences recovered from the midguts of caterpillars fed on foliage were more diverse than those from caterpillars fed on artificial diet. Sequences related to Methylobacterium sp., Bradyrhizobium sp., and Propionibacterium sp. were detected in all caterpillar libraries regardless of diet, but were not detected in a library constructed from the diet itself. Furthermore, libraries constructed with DNA recovered from surface-sterilized eggs indicated potential for vertical transmission of midgut symbionts. Taken together, these results suggest that microorganisms associated with the tropical caterpillar midgut may engage in symbiotic interactions with these ecologically important insects.

Changes in soil Acidobacteria communities after 2,4,6-trinitrotoluene contamination.

Despite their widespread occurrence in soils, the ecology of Acidobacteria and their response to environmental perturbations due to human activities remain very poorly documented. This study was aimed at assessing changes in the diversity and abundance of Acidobacteria in soils contaminated with 2,4,6-trinitrotoluene (TNT) compared with nonpolluted soils. The analysis of Acidobacteria communities at two sites with long-term and short-term contamination revealed that TNT has a drastic impact on the relative abundance of Acidobacteria in soil bacterial 16S rRNA gene libraries. The disappearance of most Acidobacteria from these soils was concomitant with a shift in Acidobacteria community composition and a loss of diversity, although the extent of diversity erosion depended on the sampling site.

A construct for building the capacity of community-based initiatives in racial and ethnic communities: a qualitative cross-case analysis.

This article reports on a qualitative cross-case study that compares patterns of implementation across community-based public health initiatives resulting in a construct for building the capacity of such initiatives in racial and ethnic communities. By specifying which capacities provide optimum leverage, community initiatives may increase precision in developing intervention strategies that focus on those pivotal capacities that are necessary for producing desired outcomes. First, community capacity is defined and briefly contrasted with social capital. Then the research method is described from which the capacity construct is derived. The study reveals several capacities of community-based initiatives that are crucial in distinguishing highly successful initiatives from those that had greater difficulty in realizing their goals. Leadership was the most important capacity that distinguished highly and less successful initiatives. Organizing capacity, or the propensity to provide structure, operational procedures, oversight, and activity formation were also critical in leveraging community action and desired outcomes. The study concludes that developing high levels of community capacity where it can produce the most strategic advantage is a promising pathway for mitigating antagonistic social factors.

Empowerment evaluation for violence prevention public health programs.

The formative evaluation consultation and systems technique (FORECAST) approach to evaluating complex community programs is described as an empowerment evaluation strategy. First, empowerment evaluation is defined and contrasted with more-traditional approaches, such as experimental and quasi-experimental designs. Then FORECAST is described, illustrating how it was applied in four community projects. One of the projects is used to demonstrate the application of FORECAST evaluation in programs addressing the prevention of first-time male perpetration of sexual violence.

The 6-step model for community empowerment: revisited in public housing communities for low-income senior citizens.

The 6-step community empowerment model was replicated in communities with different geographical, racial, and age backgrounds from the original application. Resident groups of Blue Ribbon Health Panels (BRHPs) in federally funded senior housing in Pennsylvania followed the 6 steps to identify community health issues, to develop strategies to address priority issues, and to implement the strategies in collaboration with partner agencies. The 6-step model served as an operationalization strategy of community empowerment by facilitating quick accomplishments of communities' desired outcomes, legitimizing and motivating BRHP efforts. Community capacities to actively participate and collaborate influenced the model's progress in this replication study, as did partner agencies' capacities to adhere to the community-based participatory and collaborative orientation of the project. Community capacity development and partnership facilitation would be important for a community empowerment project, as well as consistent and clear communication among everyone involved in the process.

A construct for building the capacity of community-based initiatives in racial and ethnic communities: a qualitative cross-case analysis.

OBJECTIVE: This article reports on a qualitative study that contrasts implementation patterns across community-based public health initiatives, resulting in a construct for building the capacity of such initiatives in racial and ethnic communities. By specifying which capacities provide optimum leverage, community initiatives may increase precision in developing intervention strategies that are pivotal in producing desired outcomes. METHOD: Cross-case comparisons were made on the basis of intensive interviews with key initiative leaders. RESULTS: Several capacities distinguish highly successful initiatives from those that had greater difficulty in realizing their goals. Leadership was the most important distinguishing capacity. Organizing capacity, or the propensity to provide structure, operational procedures, oversight, and activity formation, was also critical in leveraging community action and desired outcomes. CONCLUSION: The study concludes that developing high levels of community capacity where it can produce the most strategic advantage is a promising pathway for mitigating antagonistic social factors.