Trends in low-value cancer care during the COVID-19 pandemic.

OBJECTIVE: To assess the association between the onset of the COVID-19 pandemic and change in low-value cancer services. STUDY DESIGN: In this retrospective cohort study, we used administrative claims from the HealthCore Integrated Research Environment, a repository of medical and pharmacy data from US health plans representing more than 80 million members, between January 1, 2016, and March 31, 2021. METHODS: We used linear probability models to investigate the relation between the onset of the COVID-19 pandemic and 4 guideline-based metrics of low-value cancer care: (1) conventional fractionation radiotherapy instead of hypofractionated radiotherapy for early-stage breast cancer; (2) non-guideline-based antiemetic use for minimal-, low-, or moderate- to high-risk chemotherapies; (3) off-pathway systemic therapy; and (4) aggressive end-of-life care. We identified patients with new diagnoses of breast, colorectal, and/or lung cancer. We excluded members who did not have at least 6 months of continuous insurance coverage and members with prevalent cancers. RESULTS: Among 117,116 members (median [IQR] age, 60 [53-69] years; 72.4% women), 59,729 (51.0%) had breast cancer, 25,751 (22.0%) had colorectal cancer, and 31,862 (27.2%) had lung cancer. The payer mix was 18.7% Medicare Advantage or Medicare supplemental and 81.2% commercial non-Medicare. Rates of low-value cancer services exhibited minimal changes during the pandemic, as adjusted percentage-point differences were 3.93 (95% CI, 1.50-6.36) for conventional radiotherapy, 0.82 (95% CI, -0.62 to 2.25) for off-pathway systemic therapy, -3.62 (95% CI, -4.97 to -2.27) for non-guideline-based antiemetics, and 2.71 (95% CI, -0.59 to 6.02) for aggressive end-of-life care. CONCLUSIONS: Low-value cancer care remained prevalent throughout the pandemic. Policy makers should consider changes to payment and incentive design to turn the tide against low-value cancer care.

The U.S. COVID-19 County Policy Database: a novel resource to support pandemic-related research.

BACKGROUND: It is increasingly recognized that policies have played a role in both alleviating and exacerbating the health and economic consequences of the COVID-19 pandemic. There has been limited systematic evaluation of variation in U.S. local COVID-19-related policies. This study introduces the U.S. COVID-19 County Policy (UCCP) Database, whose objective is to systematically gather, characterize, and assess variation in U.S. county-level COVID-19-related policies. METHODS: In January-March 2021, we collected an initial wave of cross-sectional data from government and media websites for 171 counties in 7 states on 22 county-level COVID-19-related policies within 3 policy domains that are likely to affect health: (1) containment/closure, (2) economic support, and (3) public health. We characterized the presence and comprehensiveness of policies using univariate analyses. We also examined the correlation of policies with one another using bivariate Spearman's correlations. Finally, we examined geographical variation in policies across and within states. RESULTS: There was substantial variation in the presence and comprehensiveness of county policies during January-March 2021. For containment and closure policies, the percent of counties with no restrictions ranged from 0% (for public events) to more than half for public transportation (67.8%), hair salons (52.6%), and religious gatherings (52.0%). For economic policies, 76.6% of counties had housing support, while 64.9% had utility relief. For public health policies, most were comprehensive, with 70.8% of counties having coordinated public information campaigns, and 66.7% requiring masks outside the home at all times. Correlations between containment and closure policies tended to be positive and moderate (i.e., coefficients 0.4-0.59). There was variation within and across states in the number and comprehensiveness of policies. CONCLUSIONS: This study introduces the UCCP Database, presenting granular data on local governments' responses to the COVID-19 pandemic. We documented substantial variation within and across states on a wide range of policies at a single point in time. By making these data publicly available, this study supports future research that can leverage this database to examine how policies contributed to and continue to influence pandemic-related health and socioeconomic outcomes and disparities. The UCCP database is available online and will include additional time points for 2020-2021 and additional counties nationwide.

Trends in Medically Integrated Dispensing Among Oncology Practices.

PURPOSE: The integration of pharmacies with oncology practices-known as medically integrated dispensing or in-office dispensing-could improve care coordination but may incentivize overprescribing or inappropriate prescribing. Because little is known about this emerging phenomenon, we analyzed historical trends in medically integrated dispensing. METHODS: Annual IQVIA data on oncologists were linked to 2010-2019 National Council for Prescription Drug Programs pharmacy data; data on commercially insured patients diagnosed with any of six common cancer types; and summary data on providers' Medicare billing. We calculated the national prevalence of medically integrated dispensing among community and hospital-based oncologists. We also analyzed the characteristics of the oncologists and patients affected by this care model. RESULTS: Between 2010 and 2019, the percentage of oncologists in practices with medically integrated dispensing increased from 12.8% to 32.1%. The share of community oncologists in dispensing practices increased from 7.6% to 28.3%, whereas the share of hospital-based oncologists in dispensing practices increased from 18.3% to 33.4%. Rates of medically integrated dispensing varied considerably across states. Oncologists who dispensed had higher patient volumes (P < .001) and a smaller share of Medicare beneficiaries (P < .001) than physicians who did not dispense. Patients treated by dispensing oncologists had higher risk and comorbidity scores (P < .001) and lived in areas with a higher % Black population (P < .001) than patients treated by nondispensing oncologists. CONCLUSION: Medically integrated dispensing has increased significantly among oncology practices over the past 10 years. The reach, clinical impact, and economic implications of medically integrated dispensing should be evaluated on an ongoing basis.

Disparities in health care use among low-salary and high-salary employees.

OBJECTIVES: To examine how health care utilization and spending vary for low-income employees compared with high-income employees enrolled in an employer-sponsored high-deductible health plan (HDHP). STUDY DESIGN: We use commercial medical claims data and administrative human resource data from a large employer between 2014 and 2018. We link the administrative data, which include details on salary and other benefit choices, to each employee in each year with medical claims. Our variables of interest include medical spending and utilization outcomes grouped into different care settings. METHODS: Using multivariate regressions, we estimate the association between salary buckets and health care utilization and spending, controlling for demographic characteristics, comorbidities of employees, human resource health plan benefits, and geography. RESULTS: Employees earning less than $75,000 show lower rates of utilization and spending on preventive measures, such as outpatient visits and prescription drugs, while having higher rates of utilization of preventable and avoidable emergency department visits and inpatient stays, resulting in lower overall health care spending among lower-salary employees. CONCLUSIONS: Low-salary employees enrolled in HDHPs have higher rates of acute care utilization and spending but lower rates of primary care spending compared with high-salary employees. Results suggest that HDHPs discourage routine physician-patient care among low-salary employees.

Trends in Disenrollment and Reenrollment Within US Commercial Health Insurance Plans, 2006-2018.

Importance: The commercial health insurance market is characterized by consistently high enrollee turnover. Turnover can disrupt care continuity for patients and create challenges for insurers in managing the health of their enrollee populations. Yet the extent to which enrollees reenroll is not widely known. Objective: To characterize rates of disenrollment (hereafter, external turnover) and reenrollment in commercial health plans. Design, Setting, and Participants: In this retrospective longitudinal cohort study, trends in turnover and reenrollment in commercial health plans between January 1, 2006, and August 31, 2018, were analyzed. Data analysis was conducted from January 21, 2020, through December 23, 2021. Participants included 3 018 633 primary members and their dependents with employer-sponsored coverage. Main Outcomes and Measures: Primary outcomes included external turnover from commercial coverage and subsequent reenrollment into any line of business with the insurer (commercial, Medicaid Managed Care, and Medicare Advantage). Within commercial coverage, external turnover was analyzed separately for group (ie, employer-sponsored) and individual markets. Results: In the sample of 3 018 633 members, 50.2% were men; mean (SD) age, including dependents, was 30.68 (19.05) years. A total of 2.2% of members experienced external turnover each month and 21.5% experienced external turnover each year. The individual market had the highest average monthly turnover rate of 3.4% compared with 2.1% in the group market. December had the highest rate of external turnover, with 13.8% experiencing external turnover in the individual market and 6.9% of members experiencing external turnover in the group market. Fourteen percent of the members who left the insurer from an individual plan reenrolled with the insurer after 1 year, and 34% had reenrolled after 5 years. Among members who left the insurer from a group plan, 12% reenrolled after 1 year and 32% reenrolled after 5 years. After 10 years, reenrollment reached 47% in the 2 markets. More than 80% of enrollees returned to the same line of business and within the same state, suggesting findings may generalize to smaller insurers. Conclusions and Relevance: The findings of this cohort study suggest that insurers may benefit from investing in members' long-term health outcomes despite substantial short-term turnover rates.

Cost and Utilization Impacts of a Medicaid Managed Care Organization's Behavioral Health Wraparound Program.

Wraparound programs that provide comprehensive evidence-based outpatient treatment, transportation, social services, and housing supports have shown promise for improving clinical behavioral health-related outcomes to reduce the need for institutionalized care; however, the majority of evidence is based on wraparound programs for children. This study examined the impact of a wraparound program for adult Medicaid managed care organization members with serious mental health or substance use disorders on health care costs and utilization. This retrospective observational study used 2013-2018 claims data collected from a large Medicaid managed care organization operating in multiple states. We used an intention-to-treat difference-in-difference study design to examine the association of the wraparound with costs and utilization. Adult Medicaid members with an emergency department (ED) or inpatient visit for a behavioral health condition (index visit) were eligible for the study. Outcomes included all-cause and behavioral health-related costs and utilization during follow-up after the index visit's admission date. Outcomes were calculated overall, as well as separately by inpatient, ED, and outpatient/wraparound settings. We found that during the first post-admission month, the wraparound program was associated with 27.6 percentage points (PP) and 27.2 PP reductions in the number of behavioral health-related inpatient nights and costs, respectively. However, during subsequent months (median follow-up ranging from 7 to 10 months) there were no associations with per-member-per-month total all-cause or behavioral health-related costs. Nonetheless, the wraparound program was associated with 12.3 PP reduction in all-cause cost during the entire study period among a subset of members who were high cost at the baseline. Reduced hospital utilization and costs during the first month of wraparound services were fully counteracted by outpatient, housing, and other wraparound services costs during the following months. This indicates the importance of proper payment arrangements with value-based contracting or performance targets with wraparound services providers to align the objective of reducing inpatient use. Future wraparound programs may consider a more focused recruitment from high-cost members with complex care needs. However, our estimates were conservative given that it's from a single Medicaid managed care organization's perspective and some benefit from investing in addressing social needs may be realized in longer term (beyond our study period). States' Medicaid programs may consider the longer-term cost and broader, societal benefit of wraparound investment.

Alcohol-Attributable Medical Costs in Commercially Insured and Medicaid Populations.

Introduction: Despite its social acceptance, excessive alcohol use remains among the top causes of preventable deaths in the U.S. Although there is a recognition of alcohol-related health and social costs, there are no current studies quantifying the medical costs incurred under health plans. Methods: This study estimates the direct medical costs attributable to excessive alcohol use using claims records from a large national insurer. The sample consists of adults with commercial insurance and Medicaid between 2008 and 2019. A case-control matched study design is used to compare individuals with a condition considered 100% attributable to alcohol by the Centers for Disease Control and Prevention with similar individuals. Medical care use and costs are examined over a 12-month follow-up. Costs are broken down by healthcare setting and health conditions as defined by the Centers for Disease Control and Prevention's Alcohol-Related Disease Impact diagnoses codes. Results: We find that having a diagnosis attributable to alcohol is associated with higher annual per-person healthcare expenditures in both commercially insured and Medicaid-insured participants by $14,918 (95% CI=$14,540, $15,297) and $4,823 (95% CI=$4,489, $5,158), respectively. We find that 60%‒75% of the additional costs of excessive alcohol use are driven by heart disease and stroke; conditions of the liver, gallbladder, and pancreas; and certain cancers as well as acute conditions that may be attributable to alcohol. Conclusions: The findings suggest that public and private initiatives to target people vulnerable to the harms of excessive alcohol use may potentially help to cut down significant costs on the already strained healthcare system in the U.S.

Association Between a National Insurer's Pay-for-Performance Program for Oncology and Changes in Prescribing of Evidence-Based Cancer Drugs and Spending.

PURPOSE: Cancer drug prescribing by medical oncologists accounts for the greatest variation in practice and the largest portion of spending on cancer care. We evaluated the association between a national commercial insurer's ongoing pay-for-performance (P4P) program for oncology and changes in the prescribing of evidence-based cancer drugs and spending. METHODS: We conducted an observational difference-in-differences study using administrative claims data covering 6.7% of US adults. We leveraged the geographically staggered, time-varying rollout of the P4P program to simulate a stepped-wedge study design. We included patients age 18 years or older with breast, colon, or lung cancer who were prescribed cancer drug regimens by 1,867 participating oncologists between 2013 and 2017. The exposure was a time-varying dichotomous variable equal to 1 for patients who were prescribed a cancer drug regimen after the P4P program was offered. The primary outcome was whether a patient's drug regimen was a program-endorsed, evidence-based regimen. We also evaluated spending over a 6-month episode period. RESULTS: The P4P program was associated with an increase in evidence-based regimen prescribing from 57.1% of patients in the preintervention period to 62.2% in the intervention period, for a difference of +5.1 percentage point (95% CI, 3.0 percentage points to 7.2 percentage points; P < .001). The P4P program was also associated with a differential $3,339 (95% CI, $1,121 to $5,557; P = .003) increase in cancer drug spending and a differential $253 (95% CI, $100 to $406; P = .001) increase in patient out-of-pocket spending, but no significant changes in total health care spending ($2,772; 95% CI, -$181 to $5,725; P = .07) over the 6-month episode period. CONCLUSION: P4P programs may be effective in increasing evidence-based cancer drug prescribing, but may not yield cost savings.

Association of Utilization Management Policy With Uptake of Hypofractionated Radiotherapy Among Patients With Early-Stage Breast Cancer.

Importance: Breast cancer accounts for the largest portion of cancer-related spending in the United States. Although hypofractionated radiotherapy after breast-conserving surgery is a cost-effective and convenient treatment strategy for patients with early-stage breast cancer, less than 40% of eligible women received hypofractionated radiotherapy in 2013. Objective: To assess the association of a large commercial payer's utilization management policy with the use of hypofractionated radiotherapy among women with early-stage breast cancer and its associated cost. Design, Setting, and Participants: A retrospective, adjusted difference-in-differences economic analysis was conducted using administrative claims data from January 1, 2012, to June 1, 2018, of women 18 years or older with early-stage breast cancer who were eligible for hypofractionated radiotherapy according to 2011 guidelines from the American Society for Radiation Oncology and were continuously enrolled in 14 geographically diverse commercial health plans covering 6.9% of US adult women. Women who received mastectomy, brachytherapy, or less than 11 or more than 40 external beam fractions of radiotherapy were excluded. A utilization management policy was used to encourage the use of hypofractionated radiotherapy among women in fully insured and Medicare Advantage (fully insured) plans. Under the new policy, claims for extended-course radiotherapy were not reimbursed for fully insured women who were eligible for hypofractionated radiotherapy. This policy did not apply to women in self-insured or Medicare supplemental insurance (self-insured) plans, allowing these groups to serve as a comparison group. Main Outcomes and Measures: The primary outcome was use of hypofractionated radiotherapy, and the secondary outcome was the cost of this type of radiotherapy. Results: Of 10 540 eligible women, 3619 (34.3%) were in fully insured plans and thus subject to the policy. There were no meaningful differences between the fully insured and self-insured groups in mean (SD) age at the start of radiotherapy (63.8 [8.6] vs 65.0 [8.9] years), mean (SD) Charlson Comorbidity Index score (3.0 [1.5] vs 3.2 [1.6]), or practice setting (outpatient hospital setting, 2982 of 3619 [82.4%] vs 5600 of 6921 [80.9%]). The policy was associated with an increase in use of hypofractionated radiotherapy among fully insured patients subject to the policy (adjusted percentage point difference-in-difference, 4.2%; 95% CI, 0.0%-8.4%; P = .05) and a nonsignificant decrease in radiotherapy-associated expenditures (-$2275 relative to self-insured patients; P = .09). Spillover analyses revealed a significantly higher uptake of hypofractionated radiotherapy among self-insured patients who were indirectly exposed to the policy (adjusted percentage point difference-in-difference, 8.5%; 95% CI, 3.6%-13.5%; P < .001) compared with those who were not exposed. Conclusions and Relevance: This study suggests that a payer's utilization management policy was associated with direct and spillover increases in the use of hypofractionated radiotherapy, even after accounting for a long-term secular trend in the uptake of hypofractionated radiotherapy in the control groups. Utilization management may promote evidence-based cancer care.

Use of Optimal Evidence-Based Anticancer Drug Regimens in Physician Offices Versus Hospital Outpatient Facilities.

PURPOSE: Cancer care has increasingly shifted from physician offices (MDOs) to hospital-based outpatient departments (HOPDs). This study compared the proportion of patients receiving optimal, evidence-based anticancer drug regimens and the cost of care when administered in these sites. METHODS: Patients with breast, lung, or colorectal cancer were identified from a large health insurance database. Anticancer drug regimens were considered on pathway when they were on the payer's program list of optimal regimens when administered. Anticancer drug-related costs included all patient- and plan-paid costs on claims for anticancer drugs over the 6-month postindex period; total per-patient costs were summed over all claims in that period. RESULTS: A total of 38,140 patients (MDO, n = 18,998; HOPD, n = 19,142) were included. On-pathway status was similar in HOPDs (59.5%; 95% CI, 58.6% to 60.4%) versus MDOs (60.8%; 95% CI, 59.8% to 61.8%; P = .069). HOPDs had substantially higher costs. Adjusted cancer drug-related costs were $63,763 (95% CI, $62,301 to $65,224) for HOPDs versus $36,500 (95% CI, $35,729 to $37,271) for MDOs (P < .001); adjusted total costs were $115,843 (95% CI, $113,642 to $118,044) for HOPDs versus $77,346 (95% CI, $76,072 to $78,620) for MDOs (P < .001). For Medicare Advantage, adjusted total costs were $61,812 for HOPDs compared with $62,769 for MDOs; adjusted drug-related costs were $31,610 for HOPDs compared with $33,168 for MDOs. For commercial insurance, total costs were $119,288 for HOPDs compared with $77,613 for MDOs; drug-related costs were $65,930 for HOPDs compared with $36,366 for MDOs. CONCLUSION: Total and cancer drug-related per-patient costs were higher in HOPDs versus MDOs, but on-pathway status was similar. The cost differential between HOPDs and MDOs was driven by commercially insured members rather than Medicare Advantage members.

Evaluation of value-based insurance design for primary care.

OBJECTIVES: To evaluate the impact of value-based insurance design (VBID), which removed patient cost sharing for primary care visits, on healthcare spending in a large, geographically diverse employer. STUDY DESIGN: Quasi-experimental, difference-in-differences (DID) design, administrative claims-based study. METHODS: Healthcare spending during the preintervention period (2008 and 2009) was compared with the postintervention period (2011 through 2014) to measure the impact of removing primary care cost sharing. The study population included Anthem commercially insured enrollees with continuous medical eligibility from 2008 to 2014 who were younger than 65 years. The VBID cohort included health plan enrollees from a national large employer that implemented the benefit change. The comparison cohort included other Anthem enrollees who did not have a similar benefit change and were propensity score-matched to the VBID cohort. Utilization of various types of healthcare services was also examined. RESULTS: The VBID cohort experienced a $12.0 per member per month relative reduction in overall spending compared with the comparison cohort (P = .02). The trend was driven by reductions in expenditures for emergency department (ED) visits ($1.3 relative reduction; DID, -10.0%; P = .03) and other outpatient services ($7.6 relative reduction; DID, -5.8%; P = .02), which aligned with reduced utilization of ED visits (DID, -4.5%; P = .07) and other outpatient services (DID, -4.1%; P = .004). For physician office visits, the VBID cohort did not experience a significant relative increase compared with the comparison cohort (DID, 0.9%; P = .25). CONCLUSIONS: The attempt to increase primary care access by reducing cost sharing did not produce a negative outcome in terms of total spending for healthcare.

Comparison of Specialty Medication Use for Common Chronic Inflammatory Diseases Among Health Exchange and Other Commercially Insured Members.

BACKGROUND: The Affordable Care Act of 2010 allows the purchase of health insurance through special marketplaces called "health exchanges." The majority of individuals enrolling in the exchanges were previously uninsured, older, and sicker than other commercially insured members. Early evidence also suggests that exchange plan members use more costly specialty drugs compared with other commercially insured members. OBJECTIVES: To (a) examine patient characteristics and specialty drug use for common chronic inflammatory diseases (CIDs) among exchange plan members compared with other commercially insured members and (b) explore variations in specialty drug use within exchange plans by metal tiers (bronze, silver, gold, and platinum), as well as across local markets. METHODS: This analysis included adults aged ≥ 18 years who were enrolled in exchange plans (exchange population) and other commercial health plans (nonexchange population). The primary outcome was the likelihood of using specialty drugs prescribed to treat common CIDs, such as rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, psoriatic arthritis, and psoriasis. The adjusted likelihood of using CID specialty drugs was calculated from logistic regression controlling for prevalence of CIDs and other health risk factors. RESULTS: A total of 931,384 exchange plan members and 2,682,855 nonexchange plan members were included in the analysis. Compared with the nonexchange population, the exchange population was older, more likely to be female, had more comorbid conditions, but filled fewer prescriptions. The 2 groups were similar in terms of CID prevalence. The observed likelihood of CID specialty drug use was 20.0% lower in the exchange versus the nonexchange populations (341 users per 100,000 exchange members vs. 427 users per 100,000 nonexchange members; P < 0.001). Within the exchange population, the observed likelihood of CID specialty drug use was 132 per 100,000 bronze plan members (69.1% lower than nonexchange); 326 per 100,000 silver plan members (23.5% lower than nonexchange); 579 per 100,000 gold plan members (35.6% higher than nonexchange); and 672 per 100,000 platinum plan members (57.5% higher than nonexchange). All differences were statistically significant at P < 0.001. There were also large differences by local market, ranging from 49.1% lower to 75.8% higher CID use in the exchange population than in the nonexchange population. After adjustment, the exchange population was 16.6% less likely to use CID specialty drugs than the nonexchange population (P < 0.001). Large variation in specialty drug use within the exchange plan metal tiers was reduced. After adjustment, the higher use of CID specialty drugs among the exchange population in certain local plans was no longer statistically significant. CONCLUSIONS: Members insured through exchange plans were older and sicker than those with nonexchange plans, but they did not use more CID specialty drugs compared with the nonexchange population. Large variations were seen among the exchange plan metal tiers and by local markets, which were often related to the risk profiles of exchange plan enrollees. DISCLOSURES: Funding for this study was provided by Anthem. Anthem had no role in study design, data interpretation, manuscript development, or the decision to publish. Chen, Gautam, DeVries, and Sylwestrzak are employees of HealthCore, a wholly owned subsidiary of Anthem. Richards is an employee of Anthem. Ruggieri is a former employee of Anthem and a current employee of MedImpact Healthcare Systems. Study concept and design were contributed by Ruggieri, Richards, DeVries, and Sylwestrzak. Chen took the lead in data collection, along with Gautam. Data interpretation was performed by Chen, along with the other authors. The manuscript was written by Chen, Gautam, Sylwestrzak, and DeVries and revised by Chen, Gautam, and Sylwestrzak, along with the other authors.

Uptake and costs of hypofractionated vs conventional whole breast irradiation after breast conserving surgery in the United States, 2008-2013.

IMPORTANCE: Based on randomized evidence, expert guidelines in 2011 endorsed shorter, hypofractionated whole breast irradiation (WBI) for selected patients with early-stage breast cancer and permitted hypofractionated WBI for other patients. OBJECTIVES: To examine the uptake and costs of hypofractionated WBI among commercially insured patients in the United States. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, observational cohort study, using administrative claims data from 14 commercial health care plans covering 7.4% of US adult women in 2013, we classified patients with incident early-stage breast cancer treated with lumpectomy and WBI from 2008 and 2013 into 2 cohorts: (1) the hypofractionation-endorsed cohort (n = 8924) included patients aged 50 years or older without prior chemotherapy or axillary lymph node involvement and (2) the hypofractionation-permitted cohort (n = 6719) included patients younger than 50 years or those with prior chemotherapy or axillary lymph node involvement. EXPOSURES: Hypofractionated WBI (3-5 weeks of treatment) vs conventional WBI (5-7 weeks of treatment). MAIN OUTCOMES AND MEASURES: Use of hypofractionated and conventional WBI, total and radiotherapy-related health care expenditures, and patient out-of-pocket expenses. Patient and clinical characteristics included year of treatment, age, comorbid disease, prior chemotherapy, axillary lymph node involvement, intensity-modulated radiotherapy, practice setting, and other contextual variables. RESULTS: Hypofractionated WBI increased from 10.6% (95% CI, 8.8%-12.5%) in 2008 to 34.5% (95% CI, 32.2%-36.8%) in 2013 in the hypofractionation-endorsed cohort and from 8.1% (95% CI, 6.0%-10.2%) in 2008 to 21.2% (95% CI, 18.9%-23.6%) in 2013 in the hypofractionation-permitted cohort. Adjusted mean total health care expenditures in the 1 year after diagnosis were $28,747 for hypofractionated and $31,641 for conventional WBI in the hypofractionation-endorsed cohort (difference, $2894; 95% CI, $1610-$4234; P < .001) and $64,273 for hypofractionated and $72,860 for conventional WBI in the hypofractionation-permitted cohort (difference, $8587; 95% CI, $5316-$12,017; P < .001). Adjusted mean total 1-year patient out-of-pocket expenses were not significantly different between hypofractionated vs conventional WBI in either cohort. CONCLUSIONS AND RELEVANCE: Hypofractionated WBI after breast conserving surgery increased among women with early-stage breast cancer in 14 US commercial health care plans between 2008 and 2013. However, only 34.5% of patients with hypofractionation-endorsed and 21.2% with hypofractionation-permitted early-stage breast cancer received hypofractionated WBI in 2013.

Price transparency for MRIs increased use of less costly providers and triggered provider competition.

To encourage patients to select high-value providers, an insurer-initiated price transparency program that focused on elective advanced imaging procedures was implemented. Patients having at least one outpatient magnetic resonance imaging (MRI) scan in 2010 or 2012 were divided according to their membership in commercial health plans participating in the program (the intervention group) or in nonparticipating commercial health plans (the reference group) in similar US geographic regions. Patients in the intervention group were informed of price differences among available MRI facilities and given the option of selecting different providers. For those patients, the program resulted in a $220 cost reduction (18.7 percent) per test and a decrease in use of hospital-based facilities from 53 percent in 2010 to 45 percent in 2012. Price variation between hospital and nonhospital facilities for the intervention group was reduced by 30 percent after implementation. Nonparticipating members residing in intervention areas also observed price reductions, which indicates increased price competition among providers. The program significantly reduced imaging costs. This suggests that patients select lower-price facilities when informed about available alternatives.

Evaluation of practice patterns in the treatment of atrial fibrillation among the commercially insured.

OBJECTIVE: The management of atrial fibrillation (AF) involves two choices: (1) rate control versus rhythm control, and (2) anticoagulation treatment based upon risk of stroke. The objective of the study was to describe practice patterns in both of these treatment areas in patients with newly diagnosed AF among a commercially insured population. METHODS: This retrospective administrative claims analysis included patients with ≥2 AF claims between 1 January 2008 and 30 September 2010. Patients with AF claims within a year prior to the index date (i.e., the first AF diagnosis date) were excluded. The primary outcome was the proportion of patients treated with rate control (i.e., beta blockers, calcium channel blockers, digoxin) versus rhythm control (i.e., electrical cardioversion, left atrial catheter ablation [LACA], and/or surgical ablation) and the use of anticoagulants stratified by risk of stroke based on CHADS2 score. RESULTS: Of 48,814 patients with a diagnosis of AF, 38,502 (78.9%) received treatment. Of those treated, the majority received only pharmacologic treatment (73.4%), of which beta blockers were predominantly used in the initial regimen (66.7%). Antiarrhythmic drugs were used in 23.9% of patients, but within the initial regimen in only 11.7% of patients. Direct current cardioversion occurred in 18.2% of patients, with the majority being either first-line (8.5%) or second-line (9.1%) therapy. LACA was used in only 5.2% of patients and was typically reserved for use after pharmacologic treatment or direct current cardioversion. Of 1924 patients who received LACA, 14.6% received a repeat procedure and 53.4% of the repeat procedures occurred within 6 months of the initial one. A little more than half of all patients (57.0%) received anticoagulant therapy (predominantly warfarin); of those at high risk for stroke, 63.8% with a CHADS2 score ≥2 received anticoagulants. KEY LIMITATIONS: It is a retrospective analysis using administrative claims data from a commercially insured population only. Identification of the first episode of AF may be inaccurate, and we cannot differentiate between paroxysmal and persistent AF. CONCLUSIONS: Debate continues regarding whether the preferred management of most patients with AF is through rate control or restoration of normal sinus rhythm. Our retrospective study found that treatments to restore normal heart rhythm, including LACA, which could be considered aggressive initial treatment, were typically reserved as second- or third-line alternatives. Initial standard of care for the majority patients was beta blockers. Though use of anticoagulation may be higher than other observational studies, opportunities exist to increase treatment in high risk patients.