Implementing an advanced team-based care model in a federally qualified health center (FQHC): Assessing implementation facilitators and challenges.

OBJECTIVE: The objective of this paper is to assess implementation facilitators and challenges for advanced team-based care (aTBC) in a federally qualified health center (FQHC). In aTBC, care team coordinators room patients, perform vitals and agenda setting during patient intake, and remain present alongside providers during patient visits. METHODS: The authors conducted a qualitative post-hoc analysis of the aTBC implementation using data from several sources. They used content analysis to code items as facilitators or challenges and thematic analysis to group those into larger themes. Finally, they applied a priori codes from the revised consolidated framework for implementation research (CFIR) to organize the facilitators and barriers into subdomains. RESULTS: The existing evidence-base around aTBC, the FQHC's ability to pilot and adapt it, and strong implementation leads were key facilitating factors. Challenges included an external shock (i.e., the COVID-19 pandemic), aTBC complexity, and uncertainty about whether success required implementation of the full model versus easier-to-integrate smaller components. CONCLUSIONS: FQHCs that wish to implement aTBC models need strong champions and internal structures for piloting, adapting, and disseminating interventions. FQHC leaders must think strategically about how to build support and demonstrate success to improve an FQHC's chances of expanding and sustaining aTBC.

Cost-sharing With Medicaid Expansion in Michigan: Obligations and Propensity to Pay.

BACKGROUND: Six states expanding Medicaid under the Affordable Care Act have obtained waivers to incorporate cost-sharing. OBJECTIVE: We describe the magnitude and distribution of cost-sharing imposed by the Healthy Michigan Plan and enrollees' propensity to pay. RESEARCH DESIGN: Enrollees are followed for at least 18 months (6-mo baseline period for utilization and spending before receipt of first cost-sharing statement; ≥12 mo follow-up thereafter to ascertain obligations and payments). Analyses stratified by income, comparing enrollees with income less than Federal Poverty Level (FPL) who faced only utilization-based copayments and those greater than or equal to FPL who also faced premium contributions. SUBJECTS: A total of 158,322 enrollees aged 22-62 who initially enrolled during the first year of the program and remained continuously enrolled ≥18 months. RESULTS: Among those enrolled ≥18 months, 51.0% faced cost-sharing. Average quarterly invoices were $4.85 ($11.11 for those with positive invoices) for income less than FPL and $26.71 ($30.93 for those with positive invoices) for incomes greater than or equal to FPL. About half of enrollees with obligations made at least partial payments, with payments being more likely among those >100% FPL. Payment of the full obligation was highest in the initial 6 months. CONCLUSIONS: Many payment obligations go uncollected, suggesting that in a system without the threat of disenrollment, the impacts of cost-sharing may be muted. Similarly, the ability of cost-sharing to defray the program's budgetary impact may also be less than anticipated.

The Impact of Choosing Wisely Interventions on Low-Value Medical Services: A Systematic Review.

Policy Points Dissemination of Choosing Wisely guidelines alone is unlikely to reduce the use of low-value health services. Interventions by health systems to implement Choosing Wisely guidelines can reduce the use of low-value services. Multicomponent interventions targeting clinicians are currently the most effective types of interventions. CONTEXT: Choosing Wisely aims to reduce the use of unnecessary, low-value medical services through development of recommendations related to service utilization. Despite the creation and dissemination of these recommendations, evidence shows low-value services are still prevalent. This paper synthesizes literature on interventions designed to reduce medical care identified as low value by Choosing Wisely and evaluates which intervention characteristics are most effective. METHODS: We searched peer-reviewed and gray literature from the inception of Choosing Wisely in 2012 through June 2019 to identify interventions in the United States motivated by or using Choosing Wisely recommendations. We also included studies measuring the impact of Choosing Wisely on its own, without interventions. We developed a coding guide and established coding agreement. We coded all included articles for types of services targeted, components of each intervention, results of the intervention, study type, and, where applicable, study quality. We measured the success rate of interventions, using chi-squared tests or Wald tests to compare across interventions. FINDINGS: We reviewed 131 articles. Eighty-eight percent of interventions focused on clinicians only; 48% included multiple components. Compared with dissemination of Choosing Wisely recommendations only, active interventions were more likely to generate intended results (65% vs 13%, p < 0.001) and, among those, interventions with multiple components were more successful than those with one component (77% vs 47%, p = 0.002). The type of services targeted did not matter for success. Clinician-based interventions were more effective than consumer-based, though there is a dearth of studies on consumer-based interventions. Only 17% of studies included a control arm. CONCLUSIONS: Interventions built on the Choosing Wisely recommendations can be effective at changing practice patterns to reduce the use of low-value care. Interventions are more effective when targeting clinicians and using more than one component. There is a need for high-quality studies that include active controls.

Attitudes About Consumer Strategies Among Americans in High-deductible Health Plans.

BACKGROUND: More than 70 million Americans are enrolled in a high-deductible health plan (HDHP), with high upfront cost-sharing to encourage strategies such as price shopping to mitigate out-of-pocket spending. Recent research suggests HDHP enrollees are reluctant to engage in these consumer strategies, but there is little information on why. OBJECTIVES: To describe associations between HDHP enrollees' attitudes about and intent to engage in consumer strategies. RESEARCH DESIGN: We conducted a nationally representative web survey of 1637 HDHP enrollees that included 2 hypothetical scenarios amenable to consumer strategies. For each scenario, we asked participants whether they would compare price or quality information, discuss cost with a provider, or try to negotiate a service price. We measured participants' ratings of the difficulty of each strategy, its effectiveness at reducing cost or increasing the likelihood of getting care, and how likely participants would be to actually engage in each strategy. RESULTS: Fewer than half of HDHP enrollees intended to engage in any of the surveyed strategies. Enrollees who viewed a consumer strategy as helpful were more likely to engage in that strategy; no associations were found with perceived difficulty of a strategy and intent to engage in it. CONCLUSIONS: HDHP enrollees may not pursue consumer strategies because they believe they are not helpful for getting care or lowering costs. Providers and payers should ensure these strategies are actually helpful to HDHP enrollees and that enrollees understand how they could use these strategies to reduce their out-of-pocket costs.

Deductible imputation in administrative medical claims datasets.

OBJECTIVE: To validate imputation methods used to infer plan-level deductibles and determine which enrollees are in high-deductible health plans (HDHPs) in administrative claims datasets. DATA SOURCES AND STUDY SETTING: 2017 medical and pharmaceutical claims from OptumLabs Data Warehouse for US individuals <65 continuously enrolled in an employer-sponsored plan. Data include enrollee and plan characteristics, deductible spending, plan spending, and actual plan-level deductibles. STUDY DESIGN: We impute plan deductibles using four methods: (1) parametric prediction using individual-level spending; (2) parametric prediction with imputation and plan characteristics; (3) highest plan-specific mode of individual annual deductible spending; and (4) deductible spending at the 80th percentile among individuals meeting their deductible. We compare deductibles' levels and categories for imputed versus actual deductibles. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: All methods had a positive predictive value (PPV) for determining high- versus low-deductible plans of ≥87%; negative predictive values (NPV) were lower. The method imputing plan-specific deductible spending modes was most accurate and least computationally intensive (PPV: 95%; NPV: 91%). This method also best correlated with actual deductible levels; 69% of imputed deductibles were within $250 of the true deductible. CONCLUSIONS: In the absence of plan structure data, imputing plan-specific modes of individual annual deductible spending best correlates with true deductibles and best predicts enrollees in HDHPs.

Do high-deductible health plans affect price paid for childbirth?

OBJECTIVE: To test whether out-of-pocket costs and negotiated hospital prices for childbirth change after enrollment in high-deductible health plans (HDHPs) and whether price effects differ in markets with more hospitals. DATA SOURCES: Administrative medical claims data from 2010 to 2014 from three large commercial insurers with plans in all U.S. states provided by the Health Care Cost Institute (HCCI). STUDY DESIGN: I identify employer groups that switched from non-HDHPs in 1 year to HDHPs in a subsequent year. I estimate enrollees' change in out-of-pocket costs and negotiated hospital prices for childbirth after HDHP switch, relative to a comparison group of employers that do not switch plans. I use a triple-difference design to estimate price changes for enrollees in markets with more hospital choices. Finally, I re-estimate models with hospital-fixed effects. DATA COLLECTION: From the HCCI sample, childbearing women enrolled in an employer-sponsored plan with at least 10 people. PRINCIPAL FINDINGS: Switching to an HDHP increases out-of-pocket cost $227 (p < 0.001; comparison group base $790) and has no meaningful effect on hospital-negotiated prices (-$26, p = 0.756; comparison group base $5821). HDHP switch is associated with a marginally statistically significant price increase in markets with three or fewer hospitals ($343, p = 0.096; comparison group base $5806) and, relative to those markets, with a price decrease in markets with more than three hospitals (-$512; p = 0.028). Predicted prices decrease from $5702 to $5551 after HDHP switch in markets with more than three hospitals due primarily to lower prices conditional on using the same hospital. CONCLUSIONS: Prices for childbirth in markets with more hospitals decrease after HDHP switch due to lower hospital prices for HDHPs relative to prices at those same hospitals for non-HDHPs. These results reinforce previous findings that HDHPs do not promote price shopping but suggest negotiated prices may be lower for HDHP enrollees.

Open doors to primary care should add a "screen" to reduce low-value care.

For primary care to fulfill its promise of promoting a healthier population and more efficient spending, deliberate efforts to curtail the use of low-value services are warranted.

Examining Household Changes in Produce Purchases Among New Parents.

OBJECTIVE: To measure whether parenthood is associated with changes in produce purchasing behavior, overall and stratified by income. DESIGN: Retrospective examination of retail grocery purchases in the Nielsen Consumer Panel, a nationally representative sample of US households, 2007-2015. PARTICIPANTS AND SETTING: A total of 21,939 households in the US, aged 25-49 years, observed ≤ 8 years; 508 households initiated parenthood during the study period. MAIN OUTCOME MEASURE: Percentage of household grocery budget spent on produce each year. ANALYSIS: Difference-in-differences design was used to measure change in the percentage of the grocery budget spent on produce after becoming a parent, relative to households that did not become parents, overall and stratified by income level. Ordinary least-squares regressions was used to adjust for confounders. RESULTS: Percentage of the grocery budget spent on produce increased by 1.7 percentage points (15.7%) after initiating parenthood. Among higher-income households, produce purchases increased by 1.9 percentage points; no detectable change was found among low-income households. CONCLUSIONS AND IMPLICATIONS: Initiation of parenthood increased grocery expenditures on produce. Because new parenthood is a critical time in a person's life, this behavior change could create the opportunity for interventions with long-term effects. However, heterogeneous impacts by income indicated that lower-income households need more support and reveal 1 mechanism for income-related disparities in childhood nutrition.

Spillover Effects From A Consumer-Based Intervention To Increase High-Value Preventive Care.

Increasing the use of high-value medical services and reducing the use of services with little or no clinical value are key goals for efficient health systems. Yet encouraging the use of high-value services may unintentionally affect the use of low-value services. We examined the likelihood of high- and low-value service use in the first two years after an insurance benefit change in 2011 for one state's employees that promoted use of high-value preventive services. In the intervention group, compared to a control sample with stable benefit plans, in year 1 the likelihood of high-value service use increased 11.0 percentage points, and the likelihood of low-value service use increased 7.9 percentage points. For that year we associated 74 percent of the increase in high-value services and 57 percent of the increase in low-value services with greater use of preventive visits. Our results imply that interventions aimed at increasing receipt of high-value preventive services can cause spillovers to low-value services and should include deterrents to low-value care as implemented in later years of this program.

A Survey Of Americans With High-Deductible Health Plans Identifies Opportunities To Enhance Consumer Behaviors.

Most high-deductible health plan (HDHP) enrollees do not engage in consumer behaviors such as price shopping. Why not? We surveyed 1,637 Americans in HDHPs-which can be linked to health savings accounts (HSAs) but usually are not-about factors that may predict, facilitate, or impede HDHP enrollees' engagement in consumer behaviors. We found that having an HSA was associated with saving for future care, high financial literacy was associated with comparing prices and quality, and high confidence in talking with providers about costs and trying to negotiate prices was associated with engaging in these behaviors. Employer HSA contributions were the most frequent facilitator of saving, websites were the most frequent facilitators of comparing prices and quality, and "someone at the doctor's office" was the most frequent facilitator of discussing costs with providers and trying to negotiate prices. The most frequent impediment to all of these behaviors was not having considered them when making decisions. These results suggest strategies that health plans, employers, and health systems should explore to promote greater engagement in consumer behaviors among patients in HDHPs.