Out-of-Pocket Costs and Prescription Filling Behavior of Commercially Insured Individuals With Chronic Obstructive Pulmonary Disease.

This cohort study uses a longitudinal access and adjudication data set to evaluate prescription out-of-pocket costs and filling behaviors of commercially insured individuals with chronic obstructive pulmonary disease (COPD).

The Physician and Administrator-Reported Cost of Drug Utilization Management to Physician Practices: A Cross-Sectional Survey.

BACKGROUND: The use of drug utilization management techniques such as formulary exclusions, prior authorizations, and step edits has risen sharply during the last decade, contributing to growing administrative costs for physician practices. However, limited data exist on the extent of these administrative costs, with previous studies relying on data from over a decade ago. OBJECTIVE: The aim of this study was to assess physician and practice administrator experiences with drug utilization management. METHODS: A national survey was conducted between 9 February and 30 March 2021, targeting 925 physicians and administrators working at medical practices in the US. Time spent by physicians and their staff on tasks related to drug utilization management for prescription medications was collected and used to calculate the dollar value of that time. RESULTS: We estimated that physicians spent a median of 4.0 h per week on drug utilization management, while nurses spent 15.0 h and other staff spent between 3.6 and 10.0 h on drug utilization management per physician per week. This time was associated with a calculated median dollar value of $75,927 per physician per year. Extrapolating this estimate to a national scale suggests that time spent annually by physician practices on drug utilization management could be valued at more than $43 billion. CONCLUSIONS: Drug utilization management results in significant time spent by US physician practices, which in turn, results in meaningful costs to these practices. As the prevalence of drug utilization management continues to grow, the impact on physician practices will remain an important topic.

Teledentistry for Patient-centered Screening and Assessment.

Teledentistry is a powerful tool for connecting oral health providers with patients who cannot easily visit a dental office, such as patients with special health care needs. Teledentistry is a skill that must be learned and this article will review key concepts that will allow providers to be better prepared to use it within their practices. These concepts include considerations for data collection and information that is necessary for a successful teledentistry visit. The authors also provide different examples of teledentistry in action, such as guided oral hygiene or dental screenings. Lastly, the authors review some unique challenges related to teledentistry and recommendations for overcoming those challenges.

Population-based return on investment of deploying transient elastography.

OBJECTIVES: To evaluate the cost savings outcomes, from the payer's perspective, of deploying vibration-controlled transient elastography/controlled attenuation parameter (VCTE/CAP) machines for detecting and monitoring fatty liver disease (FLD). STUDY DESIGN: We modeled disease transitions and costs under the current observed pathway and under an alternative pathway in which VCTE/CAP devices are adopted. Marginal savings (or costs) due to implementing the device are derived by comparing the aggregate costs between the 2 pathways. Sources of potential savings are 2-fold. First, VCTE/CAP tests result in early identification of patients with FLD (the majority are currently undiagnosed), allowing for proactive intervention and behavior change to slow the progression of disease in these patients. Second, VCTE/CAP tests can reduce the aggregate volume of some current diagnosis methods, such as liver biopsy, imaging, and laboratory work. METHODS: Our model relied on administrative claims data consisting of 5 million commercial members and 3 million Medicare members to inform baseline statistics on disease prevalence, health care cost and utilization, and disease progression associated with different severities of liver disease. We consulted expert clinical opinion and medical literature to inform our assumptions related to device adoption and use. RESULTS: Scenario testing demonstrated positive net savings within 2 to 3 years after device deployment. Across a 5-year time span, we estimate net savings up to $2.64 per member per month (PMPM) for Medicare payers and up to $1.91 PMPM for commercial payers. CONCLUSIONS: We conclude that deploying VCTE/CAP devices is a financially advantageous solution to address the epidemic of FLD.

Quantifying The Economic Burden Of Drug Utilization Management On Payers, Manufacturers, Physicians, And Patients.

The continuing launch of innovative but high-price drugs has intensified efforts by payers to manage use and spending and by pharmaceutical manufacturers to support patient access and sales. Payers are restricting drug formularies, requiring more stringent prior authorizations, and raising patient cost-sharing requirements. Manufacturers are investing in programs that help patients and physician practices navigate administrative controls and help patients meet cost-sharing obligations. Based on a compilation and analysis of the existing peer-reviewed and professional literature, this article estimates that payers, manufacturers, physicians, and patients together incur approximately $93.3 billion in costs annually on implementing, contesting, and navigating utilization management. Payers spend approximately $6.0 billion annually administering drug utilization management, and manufacturers spend approximately $24.8 billion supporting patient access in response. Physicians devote approximately $26.7 billion in time spent navigating utilization management, whereas patients spend approximately $35.8 billion annually in drug cost sharing, even after taking advantage of manufacturer and philanthropic sources of financial support. All stakeholders in the US pharmaceutical system would benefit from a deescalation of utilization management, combining lower drug prices with lower barriers to patient access.

Implementation of teledentistry for orthodontic practices.

Recent advances in technology, growing patient demand, and the need for social distancing due to Coronavirus Disease 2019 has expedited adoption of teledentistry in orthodontics as a means of consulting and monitoring a patient without an in-office visit. However, a lack of computer literacy and knowledge of software choices, and concerns regarding patient safety and potential infringement of regulations can make venturing into this new technology intimidating. In this article, various types of teledentistry systems for orthodontic practices, implementation guidelines, and important regulatory considerations on the use of teledentistry for orthodontic purposes are discussed. A thorough evaluation of the intended use of the software should precede commitment to a service. Selected service should be Health Insurance Portability and Accountability Act compliant at minimum and a Business Associate Agreement should be in place for protection of privacy. Ensuring the compatibility of the designated clinic computer with the system's requirements and installation of all safeguards must follow. Appointments should be documented in the same manner as in-office visits and teledentistry patients must be located within the clinician's statutory license boundary. Informed consent forms should include teledentistry or a supplemental teledentistry consent form should be used. Malpractice insurance covers everything usual and customary under the provider's license but the need for cyber liability insurance increases with teledentistry.

Value-based contracting innovated Medicare advantage healthcare delivery and improved survival.

OBJECTIVES: In Medicare Advantage (MA) with its CMS Hierarchical Condition Categories (CMS-HCC) payment model, CMS reimburses private plans (Medicare Advantage Organizations [MAOs]) with prospective, monthly, health-based or risk-adjusted, capitated payments. The effect of this payment methodology on healthcare delivery remains debatable. How value-based contracting generates cost efficiencies and improves clinical outcomes in MA is studied. STUDY DESIGN: A difference in contracting arrangements between an MAO and 2 provider groups facilitated an intervention-control, preintervention-postintervention, difference-in-differences approach among statistically similar, elderly, community-dwelling MA enrollees within one metropolitan statistical area. METHODS: Starting in 2009, for intervention-group MA enrollees, the MAO and a provider group agreed to full-risk capitation combined with a revenue gainshare. The gainshare was based on increases in the Risk Adjustment Factor (RAF), which modified the CMS-HCC payments. For the control group, the MAO continued to reimburse another provider group through fee-for-service. RAF, utilization, and survival were followed until December 31, 2012. RESULTS: The intervention group's mean RAF increased significantly (P <.001), estimating $2,519,544 per 1000 members of additional revenue. The intervention increased office-based visits (P <.001). Emergency department visits (P <.001) and inpatient hospital admissions (P = .002) decreased. This change in utilization saved $2,071,293 per 1000 enrollees. By intensifying office-based care for these MA enrollees with multiple comorbidities, a 6% survival benefit with a 32.8% lower hazard of death (P <.001) was achieved. CONCLUSIONS: Value-based contracting can drive utilization patterns and improve clinical outcomes among chronically ill, elderly MA members.

Protocols for treating patients with end-stage renal disease: a survey of nephrology fellowships.

RATIONALE/BACKGROUND: Approximately 14% of Americans are living with chronic kidney disease (CKD). The prevalence of end-stage renal disease (ESRD), the result of progressing CKD continues to rise by 21,000 per year. Currently, the only antibiotic prophylaxis guidelines for patients with ESRD undergoing dental treatment were published by the AHA in 2003. Presented in three parts, the first and second parts of this study found no consistent protocols amongst U.S. dental schools and U.S. GPRs and AEGDs, respectively. The goal of the third part of the project was to determine the current protocol being used to treat ESRD patients at U.S. nephrology fellowship programs. METHODS AND MATERIALS: An 18 multiple-choice question survey was e-mailed to 130 directors of nephrology fellowships within the U.S. regarding renal treatment protocol details and antibiotic prophylaxis for patients with renal disease. RESULTS: Note that, 34.6% of respondents reported having an established renal treatment protocol. For programs with a protocol, 69% of programs reported following AHA guidelines. CONCLUSION: There is a lack of consistent, established protocols amongst U.S. nephrology fellowships. It is suggested that updated and evidence based guidelines for the safe treatment of patients be developed.

Specialty pharmaceuticals: policy initiatives to improve assessment, pricing, prescription, and use.

The value of "specialty pharmaceuticals" for cancer and other complex conditions depends not merely on their molecular structures but also on the manner in which the drugs are assessed, insured, priced, prescribed, and used. This article analyzes the five principal stages through which a specialty drug must pass on its journey from the laboratory to the bedside. These include regulatory approval by the Food and Drug Administration for market access, insurance coverage, pricing and payment, physician prescription, and patient engagement. If structured appropriately, each stage improves performance and supports continued research and development. If structured inappropriately, however, each stage adds to administrative burdens, distorts clinical decision making, and weakens incentives for innovation. Cautious optimism is in order, but neither the continued development of breakthrough products nor their use according to evidence-based guidelines can be taken for granted.