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.

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.

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.

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.

Relationship between primary care physician financial risk and member emergency department use in a commercial HMO population.

OBJECTIVE: To demonstrate whether, despite factors beyond the control of primary care physicians (PCPs), health maintenance organization (HMO) members under the care of PCPs with greater financial risk for the cost of emergency care have lower rates of emergency department use. STUDY DESIGN: Cohort study using calendar year 2000 administrative data on 217 298 commercial members enrolled in a nonprofit statewide HMO (Blue Care Network of Michigan) under the care of non-staff-model PCPs with varying levels of financial risk for emergency care. METHODS: Ordinary least squares (OLS) and binary logistic regression models were developed to assess the influence of PCP financial risk, net effects of member and PCP demographics, and emergency care accessibility on use of emergency treat-and-release services by members. RESULTS: OLS results indicated emergency use was lower by 33 visits per 1000 (P < .001) and 51 visits per 1000 (P < .001) for members with PCPs who had medium and high financial risk, respectively, compared with members whose PCPs had low financial risk for emergency care. Emergency care availability, member copayment and demographics, and the number of all Blue Care Network members assigned to the PCP also were significant predictors of emergency use. CONCLUSIONS: PCPs do have the ability to influence their patients' emergency department use if financially motivated to do so. Ensuring that the PCP has a large enough number of patients under a specific contractual arrangement also is an important component of the success of an associated financial incentive.