Patient characteristics associated with enrolment under voluntary programs implemented within fee-for-service systems in British Columbia and Quebec: a cross-sectional study.

BACKGROUND: There is a paucity of information on patient characteristics associated with enrolment under voluntary programs (e.g. incentive payments) implemented within fee-for-service systems. We explored patient characteristics associated with enrolment under these programs in British Columbia and Quebec. METHODS: We used linked administrative data and a cross-sectional design to compare people aged 40 years or more enrolled under voluntary programs to those who were eligible but not enrolled. We examined 2 programs in Quebec (enrolment of vulnerable patients with qualifying conditions [implemented in 2003] and enrolment of the general population [2009]) and 3 in BC (Chronic disease incentive [2003], Complex care incentive [2007] and enrolment of the general population [A GP for Me, 2013]). We used logistic regression to estimate the odds of enrolment by neighbourhood income, rural versus urban residence, previous treatment for mental illness, previous treatment for substance use disorder and use of health care services before program implementation, controlling for characteristics linked to program eligibility. RESULTS: In Quebec, we identified 1 569 010 people eligible for the vulnerable enrolment program (of whom 505 869 [32.2%] were enrolled within the first 2 yr of program implementation) and 2 394 923 for the general enrolment program (of whom 352 380 [14.7%] were enrolled within the first 2 yr). In BC, we identified 133 589 people eligible for the Chronic disease incentive, 47 619 for the Complex care incentive and 1 349 428 for A GP for Me; of these, 60 764 (45.5%), 28 273 (59.4%) and 1 066 714 (79.0%), respectively, were enrolled within the first 2 years. The odds of enrolment were higher in higher-income neighbourhoods for programs without enrolment criteria (adjusted odds ratio [OR] comparing highest to lowest quintiles 1.21 [95% confidence interval (CI) 1.20-1.23] in Quebec and 1.67 [95% CI 1.64-1.69] in BC) but were similar across neighbourhood income quintiles for programs with health-related eligibility criteria. The odds of enrolment by urban versus rural location varied by program. People treated for substance use disorders had lower odds of enrolment in all programs (adjusted OR 0.60-0.72). Compared to people eligible but not enrolled, those enrolled had similar or higher numbers of primary care visits and longitudinal continuity of care in the year before enrolment. INTERPRETATION: People living in lower-income neighbourhoods and those treated for substance use disorders were less likely than people in higher-income neighbourhoods and those not treated for such disorders to be enrolled in programs without health-related eligibility criteria. Other strategies are needed to promote equitable access to primary care.

Changes in Hospital-acquired Conditions and Mortality Associated With the Hospital-acquired Condition Reduction Program.

IMPORTANCE: To improve patient safety, the Centers for Medicare and Medicaid Services announced the Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The program reduces Medicare payments by 1% for hospitals in the lowest performance quartile related to hospital-acquired conditions. Performance measures are focused on perioperative care. OBJECTIVE: To evaluate changes in HACs and 30-day mortality after the announcement of the HACRP. DESIGN: Interrupted time-series design using Medicare Provider and Analysis Review (MEDPAR) claims data. We estimated models with linear splines to test for changes in HACs and 30-day mortality before the Affordable Care Act (ACA), after the ACA, and after the HACRP. SETTING: Fee-for-service Medicare 2009-2015. PARTICIPANTS: Medicare beneficiaries undergoing surgery and discharged from an acute care hospital between January 2009 and August 2015 (N = 8,857,877). MAIN OUTCOME AND MEASURE: Changes in HACs and 30-day mortality after the announcement of the HACRP. RESULTS: Patients experienced HACs at a rate of 13.39 per 1000 discharges [95% confidence interval (CI), 13.10 to 13.68] in the pre-ACA period. This declined after the ACA was passed and declined further after the HACRP announcement [adjusted difference in annual slope, -1.34 (95% CI, -1.64 to -1.04)]. Adjusted 30-day mortality was 3.69 (95% CI, 3.64 to 3.74) in the pre-ACA period among patients receiving surgery. Thirty-day mortality continued to decline after the ACA [adjusted annual slope -0.04 (95% CI, -0.05 to -0.02)] but was flat after the HACRP [adjusted annual slope -0.01 (95% CI, -0.04 to 0.02)]. CONCLUSIONS AND RELEVANCE: Although hospital-acquired conditions targeted under the HACRP declined at a greater rate after the program was announced, 30-day mortality was unchanged.

Carving Out Financial Success: The Power of Insurance Carve-Outs in a Private Plastic Surgery Practice.

BACKGROUND: Since the Patient Protection and Affordable Care Act was signed into law, there has been a push away from fee-for-service payment models. The rise of bundled payments has drastically impacted plastic surgeons' incomes, especially nonsalaried surgeons in private practice. As a result, physicians must now attempt to optimize contractual reimbursement agreements (carve-outs) with insurance providers. The aim of this article is to explain the economics behind negotiating carve-outs and to offer a how-to guide for plastic surgeons to use in such negotiations. METHODS: Based on work relative value units, Medicare reimbursement, overhead expenses, physician workload, and desired income, the authors present an approach that allows surgeons to evaluate the reimbursement they receive for various procedures. The authors then review factors that influence whether a carve-out can be pursued. Finally, the authors consider relevant nuances of negotiating with insurance companies. RESULTS: Using tissue expander insertion (CPT 19357) as an example, the authors review the mathematics, thought process required, and necessary steps in determining whether a carve-out should be pursued. Strategies for negotiation with insurance companies were identified. The presented approach can be used to potentially negotiate a carve-out for any reconstructive procedure that meets appropriate financial criteria. CONCLUSIONS: Understanding practice costs will allow plastic surgeons to evaluate the true value of insurance reimbursements and determine whether a carve-out is worth pursuing. Plastic surgeons must be prepared to negotiate adequate reimbursement carve-outs whenever possible. Ultimately, by aligning the best quality patient care with insurance companies' financial motivations, plastic surgeons have the opportunity to improve reimbursement for some reconstructive procedures.

Improving Payment for Collaborative Mental Health Care in Primary Care.

BACKGROUND: There is strong evidence supporting implementation of the Collaborative Care Model within primary care. Fee-for-service payment codes, published by Current Procedural Terminology in 2018, have made collaborative care separately reimbursable for the first time. These codes (ie, 99492-99494) reimburse for time spent per month by any member of the care team engaged in Collaborative Care, including behavioral care managers, primary care providers, and consulting psychiatrists. Time-based billing for these codes presents challenges for providers delivering Collaborative Care services. OBJECTIVES: Based on experience from multiple health care organizations, we reflect on these challenges and provide suggestions for implementation and future refinement of the codes. CONCLUSIONS: Further refinements to the codes are encouraged, including moving from a calendar month to a 30-day reimbursement cycle. In addition, we recommend payers adopt the new code proposed by the Centers for Medicare and Medicaid Services to account for smaller increments of time.

Fee-for-service payment is not the (main) problem.

OBJECTIVE: To understand the effect of physician payment incentives on the allocation of health care resources. DATA SOURCES/STUDY SETTING: Review and analysis of the literature on physician payment incentives. STUDY DESIGN: Analysis of current physician payment incentives and several ways to modify those incentives to encourage increased efficiency. PRINCIPAL FINDINGS: Fee-for-service payments can be incorporated into systems that encourage efficient pricing - prices that are close to the provider's marginal cost - by giving consumers information on provider-specific prices and a strong incentive to choose lower cost providers. However, efficient pricing of services ultimately will need to be supplemented by incentives for efficient production of health and functional status. CONCLUSIONS: The problem with current FFS payment is not paying a fee for each service, per se, but the way in which the fees are determined.

Ethical Issues in Physician Billing Under Fee-For-Service Plans.

Medical ethics has become an important and recognized component of physician training. There is one area, however, in which medical students receive little guidance. There is practically no discussion of the financial aspects of medical practice. My objective in this paper is to initiate a discussion about the moral dimension of physician billing practices. I argue that physicians should expand their conception of professional responsibility in order to recognize that their moral obligations toward patients include a commitment to honest and forthright billing practices. I argue that physicians should aspire to a standard of clinical accuracy-not legal adequacy-in describing their activities. More generally, physicians should strive to promote an integrity-based professional culture, first and foremost by stigmatizing rather than celebrating creative billing practices, as well as condemning the misguided sense of solidarity that currently makes it taboo for physicians to criticize each other on this score.

Financial Sustainability of an Oregon Rural Health, Primary Care, and Pharmacist-Run Comprehensive Medication Management Program Through Direct Medical Billing.

BACKGROUND: Although several states recognize pharmacists as providers and allow credentialing, this practice is not recognized nationwide. Following adoption of Oregon House Bill 2028, pharmacists are recognized as providers, allowing "health insurers to provide payment or reimbursement for their services to patients." Before this law, and in several instances currently, pharmacist-run programs were financially justified through soft dollars saved by improving patient outcomes, reducing emergency department use, and decreasing readmission rates. OBJECTIVE: To determine if direct billing of third-party payers covers the direct cost of a comprehensive medication management (CMM) program in an ambulatory rural health adult population with uncontrolled diabetes or hypertension. METHODS: This study of a population derived from 2 Oregon rural health primary care clinics was a retrospective chart review of adults (aged ≥18 years) with a primary diagnosis of diabetes mellitus or hypertension who completed a CMM visit with a clinical pharmacist from March 2017 to June 2018. In determining the financial sustainability of a pharmacist-run CMM program, the following primary outcomes were evaluated: (a) percentage of visits completed per insurance type; (b) median reimbursement rate (dollars per visit) per insurance type; and (c) the estimated number of visits per day to cover 100% of the total CMM cost annually. The secondary outcome was the percentage of the major third-party payers that allowed credentialing of pharmacists. All outcomes were evaluated using descriptive statistics. RESULTS: 664 CMM visits were included. Visits per insurance type comprised Medicare Advantage (34%), traditional Medicare (25%), Oregon State Medicaid (20.9%), commercial (17.8%), and self-pay (cash; 1.4%). Median reimbursement rate (dollars per visit) was highest from Oregon Medicaid, followed by Medicare Advantage, and lowest among commercial, self-pay (cash), and traditional Medicare. Total reimbursement received throughout the duration of this pilot project covered 14.1% of the total CMM program cost. It was estimated that approximately 17 visits per day are needed to cover 100% of the total CMM cost annually per pharmacist relying solely on direct revenue within these clinics. Currently, of the 18 contracted insurance companies, only 50% recognize and allow credentialing of pharmacists as providers. CONCLUSIONS: Pharmacist-run services within the 2 rural health primary care clinics were not financially justifiable via direct billing of third-party payers alone. The lack of credentialing, recognition of pharmacists as providers, and reimbursement is inadequate for program expansion and sustainability without relying on additional revenue streams or benefits from improved patient outcomes. Currently, federal insurance significantly contributes to this lack of funding. DISCLOSURES: No outside funding provided support for this research; however, funding from Willamette Valley Community Health was given in the form of a grant to partially fund the comprehensive medication management pilot program. Pharmacists were paid from this grant, while Sublimity Pharmacy compensated pharmacists in the form of benefits. The authors have nothing to disclose. This work was presented in part as a poster at the ASHP Midyear Clinical Meeting; December 4, 2018; Anaheim, CA, and as a peer-reviewed podium presentation at the Northwestern States Residency Conference; May 4, 2019; Portland, OR.

Aggregating Claims Data Across Payers: Approaches, Challenges, and Lessons Learned From the Comprehensive Primary Care Initiative.

The Comprehensive Primary Care (CPC) initiative fueled the emergence of new organizational alliances and financial commitments among payers and primary care practices to use data for performance improvement. In most regions of the country, practices received separate confidential feedback reports of claims-based measures from multiple payers, which varied in content and provided an incomplete picture of a practice's patient panel. Over CPC's last few years, participating payers in several regions resisted the tendency to guard data as a proprietary asset, instead working collaboratively to produce aggregated performance feedback for practices. Aggregating claims data across payers is a potential game changer in improving practice performance because doing so potentially makes the data more accessible, comprehensive, and useful. Understanding lessons learned and key challenges can help other initiatives that are aggregating claims or clinical data across payers for primary care practices or other types of providers.

Claims-based cardiovascular outcome identification for clinical research: Results from 7 large randomized cardiovascular clinical trials.

BACKGROUND: Medicare insurance claims may provide an efficient means to ascertain follow-up of older participants in clinical research. We sought to determine the accuracy and completeness of claims- versus site-based follow-up with clinical event committee (+CEC) adjudication of cardiovascular outcomes. METHODS: We performed a retrospective study using linked Medicare and Duke Database of Clinical Trials data. Medicare claims were linked to clinical data from 7 randomized cardiovascular clinical trials. Of 52,476 trial participants, linking resulted in 5,839 (of 10,497 linkage-eligible) Medicare-linked trial participants with fee-for-service A and B coverage. Death, myocardial infarction (MI), stroke, and revascularization incidences were compared using Medicare inpatient claims only, site-reported events (+CEC) only, or a combination of the 2. Randomized treatment effects were compared as a function of whether claims-based, site-based (+CEC), or a combined system was used for event detection. RESULTS: Among the 5,839 study participants, the annual event rates were similar between claims- and site-based (+CEC) follow-up: death (overall rate 5.2% vs 5.2%; adjusted κ 0.99), MI (2.2% vs 2.3%; adjusted κ 0.96), stroke (0.7% vs 0.7%; adjusted κ 0.99), and any revascularization (7.4% vs 7.9%; adjusted κ 0.95). Of events detected by claims yet not reported by CEC, a minority were reported by sites but negatively adjudicated by CEC (39% of MIs and 18% of strokes). Differences in individual case concordance led to higher event rates when claims- and site-based (+CEC) systems were combined. Randomized treatment effects were similar among the 3 approaches for each outcome of interest. CONCLUSIONS: Claims- versus site-based (+CEC) follow-up identified similar overall cardiovascular event rates despite meaningful differences in the events detected. Randomized treatment effects were similar using the 2 methods, suggesting claims data could be used to support clinical research leveraging routinely collected data. This approach may lead to more effective evidence generation, synthesis, and appraisal of medical products and inform the strategic approaches toward the National Evaluation System for Health Technology.

Multi-Payer Advanced Primary Care Practice Demonstration on quality of care.

OBJECTIVES: We evaluated whether primary care practices in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration improved the quality of care and patient outcomes for beneficiaries. STUDY DESIGN: For our quantitative analyses, we employed a pre-post study design with a comparison group using enrollment data, Medicare fee-for-service claims data, and Medicaid managed care and fee-for-service claims data, covering the period 2 to 4 years before Medicare joined the state patient-centered medical home initiatives through December 2014. We used difference-in-differences (DID) regression analysis to compare quality and outcomes in the period before and after the demonstration began. METHODS: We examined the extent to which MAPCP and comparison group beneficiaries received up to 11 process and preventive care measures, as well as 4 measures of potentially avoidable hospitalizations to assess patient outcomes. RESULTS: Analyses of Medicare and Medicaid data did not consistently reflect the positive impacts intended by the demonstration. Our descriptive and DID analysis found an inconsistent pattern among the process-of-care results, and there were some significant unfavorable associations between participation in MAPCP and avoidable hospitalizations. CONCLUSIONS: Our analyses showed few statistically significant, favorable impacts on quality metrics among Medicare or Medicaid beneficiaries receiving care from MAPCP practices.

Dispositivo estructurado de intervenciones psicosociales en atención primaria: serie de casos retrospectiva / Structured psychosocial interventions in primary care: retrospective case series

Antecedentes: Más allá del pago por cápita, desde 2009 el Plan de Salud del Hospital Italiano de Buenos Aires reconoció a los médicos de familia el pago por prestación de intervenciones psicosociales de cuarenta minutos de duración realizadas para promover el bienestar y la autonomía de sus pacientes. Objetivos: Describir los problemas que motivaron estas intervenciones y las redefiniciones diagnósticas que realizaron estos profesionales. Métodos: Fueron revisadas las fichas estructuradas de registro de 482 intervenciones psicosociales realizadas durante 2011 y codificadas mediante la Clasificación Internacional de la Atención Primaria (CIAP-2). Resultados: Los motivos de consulta más frecuentes fueron los sentimientos depresivos y/o de ansiedad (33,25 %), problemas familiares y/o vinculados a crisis vitales (16 %), dolor (9,56 %) y cansancio (2,91 %). Entre las redefiniciones diagnósticas predominaron las crisis vitales (15,45 %), los problemas de la relación conyugal o con hijos (14,61 %), y los trastornos depresivos y/o de ansiedad (27 %). Conclusiones: nuestro modelo de trabajo contribuyó a que en una gran proporción de pacientes que había consultado por dolor u otros síntomas generales, detectáramos, abordáramos y documentáramos el proceso de atención de problemas de la esfera psicosocial, que suele ser subregistrado con el abordaje biomédico clásico. (AU)

Background: Beyond capitation payment, since 2009 Hospital Italiano de Buenos Aires Health Maintenance Organization incorporated "structured primary care psychosocial interventions" as a fee for service practice. They last 40 minutes and are undertaken by family physicians with the aim of improving the wellbeing of their patients and helping them to strengtheningtheir autonomy. Objectives: To identify chief complaints and problems (re)definitions carried out by family physicians. Methodology: 482 medical records written during 2011 were reviewed and coded according to the International Classification of Primary Care (ICPC-2). Results: Most frequent chief complaints were depressive and/or anxious feelings (33.25 %), family problems and/or phasesof adult life problems (16 %), pain (9.56 %) and fatigue (2.91 %). Most common problem (re)definitions were life events(15.45 %), followed by marital or childrelated problems (14.61 %), and depressive and/or anxiety disorders (27 %). Conclusions: Our working model enabled us to identify, address and document psychosocial problems which are often underreported within the classical biomedical approach in a large proportion of patients whose chief complaint were painor other general symptoms. (AU)

Health provider networks with private contracts: Is there under-treatment in narrow networks?

Contracts between health insurers and providers are private. By modelling this explicitly, we find the following. Insurers with bigger provider networks, pay providers higher fee-for-service rates. This makes it more likely that a patient is treated and hence health care costs and utilization increase with provider network size. Although providers are homogeneous, the welfare maximizing provider network can consist of two or more providers. Provider profits are positive whereas they would be zero with public contracts. Increasing transparency of provider prices increases welfare only if consumers can "mentally process" the prices of all treatments involved in an insurance contract. If not, it tends to reduce welfare.

Early Health System Experiences with Collaborative Care (CoCM) Billing Codes: a Qualitative Study of Leadership and Support Staff.

BACKGROUND: Although collaborative care (CoCM) is an evidence-based and widely adopted model, reimbursement challenges have limited implementation efforts nationwide. In recent years, Medicare and other payers have activated CoCM-specific codes with the primary aim of facilitating financial sustainability. OBJECTIVE: To investigate and describe the experiences of early adopters and explorers of Medicare's CoCM codes. DESIGN AND PARTICIPANTS: Fifteen interviews were conducted between October 2017 and May 2018 with 25 respondents representing 12 health care organizations and 2 payers. Respondents included dually boarded medicine/psychiatry physicians, psychiatrists, primary care physicians (PCPs), psychologists, a registered nurse, administrative staff, and billing staff. APPROACH: A semi-structured interview guide was used to address health care organization characteristics, CoCM services, patient consent, CoCM operational components, and CoCM billing processes. All interviews were recorded, transcribed, coded, and analyzed using a content analysis approach conducted jointly by the research team. KEY RESULTS: Successful billing required buy-in from key, interdisciplinary stakeholders. In planning for CoCM billing implementation, several organizations hired licensed clinical social workers (LICSWs) as behavioral health care managers to maximize billing flexibility. Respondents reported a number of consent-related difficulties, but these were not primary barriers. Workflow changes required for billing the CoCM codes (e.g., tracking cumulative treatment minutes, once-monthly code entry) were described as arduous, but also stimulated creative solutions. Since CoCM codes incorporate the work of the psychiatric consultant into one payment to primary care, organizations employed strategies such as inter-departmental ledger transfers. When challenges arose from variations in the local payer mix, some organizations billed CoCM codes exclusively, while others elected to use a mixture of CoCM and traditional fee-for-service (FFS) codes. For most organizations, it was important to demonstrate financial sustainability from the CoCM codes. CONCLUSIONS: With deliberate planning, persistence, and widespread organizational buy-in, successful utilization of newly available FFS CoCM billing codes is achievable.

[Risk adjusted capitation is the basis for general practitioners' renumeration]. / A korkorrigált fejkvóta (kapitáció) a háziorvosi (alapellátási) finanszírozás alapja.

The health care renumeration poses a great challenge for both politicians and policymakers. During the beginning of the 1990s, following the end of communism in Hungary, the reform of health care began with the introduction of the primary health care (PHC), specifically with general practitioner (GPP)/family medicine (FM) care. The basis of the renumeration was the age-adjusted capitation built upon the free choice of doctors, while social security renumeration was built on a mixed system. Several pros and cons have been highlighted, but the underlying principle has proved to be simple and effective. Comparison of the European and Hungarian characteristics, analysis of data in the present patient care report as well as in the years preceding the release of the aforementioned document, these confirm that the method of capitation-based remuneration is a fundamental, easy, and unmanipulable method. It places minimal weight on social security and comes with little costs. Orv Hetil. 2019; 160(27): 1057-1063.

The impact of the adoption of a patient rostering model on primary care access and continuity of care in urban family practices in Ontario, Canada.

BACKGROUND: Greater continuity and access to primary care results in improved patient health, satisfaction, and reduced healthcare costs. Although patient rostering is considered to be a cornerstone of a high performing primary care system and is believed to improve continuity and access, few studies have examined these relationships. This study examined the impact of the adoption of a patient rostering enhanced fee-for-service model (eFFS) on continuity, coordination of specialized care, and access. METHOD: A population-based longitudinal study was conducted using health administrative data from urban family practices in Ontario, Canada. Family physicians that transitioned from traditional FFS (tFFS) to eFFS between 2004 and 2013 were followed overtime. Physicians providing comprehensive primary care that had at least 4 years of pre-transition and 2 years of post-transition data were eligible. Patients were attributed to physicians on an annual basis by determining the provider that billed the largest dollar amount over a 2 year period. Outcomes of interest were the usual provider of care index (UPC), a referral index (RI) (% of total primary care referrals for a physician's roster made by the main provider), and emergency department (ED) visits for family practice sensitive conditions (FPSCs). Mixed-effects segmented linear and logistic regressions were used to examine changes in outcomes while controlling for patient and provider contextual factors. RESULTS: Prior to transitioning, UPC was decreasing at a rate of 0.27%/year (95% CI: -0.34 to - 0.21, p < 0.0001). Following the transition, UPC began decreasing by an additional 0.59%/year (95% CI: -0.69 to - 0.49, p < 0.0001) relative to the pre-transition rate. RI decreased by an additional 0.34%/year (95% CI: -0.43 to - 0.24, p < 0.0001) relative to the pre-transition period, where it had been stable. The transition had minimal impact on FPSC ED visits. CONCLUSION: Continuity and coordination of specialized care slightly decreased upon transition from tFFS to eFFS. This is likely due to physicians working in groups and sharing patients following the transition to the eFFS model. Adoption of an enrolment model with after-hours care did not decrease non-urgent ED use, which may reflect the small impact that primary care access has on these types of ED visits.

"Primary care is primary care": Use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario.

BACKGROUND: In Ontario, Canada, healthcare for transgender individuals is accessed through primary care; however, there are a limited number of practitioners providing transgender care, and patients are often on waiting lists and/or traveling great distances to receive care. Understanding how primary care is implemented and delivered to transgender individuals is key to improving access and eliminating healthcare barriers. The purpose of this study is to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario. METHODS: A qualitative, exploratory, multiple-case study guided by Normalization Process Theory (NPT) was used to compare transgender care delivery and implementation across three primary care models. Three cases known to provide transgender primary care and represent different primary care models in Ontario, Canada (i.e., family health team, community health centre, fee-for service physician) were explored. The NoMAD survey, a tool to measure implementation processes, and qualitative interviews with primary care practitioners and allied healthcare staff were administered. RESULTS: Using the NPT framework to guide analysis, key themes emerged about successful implementation of primary care services for transgender individuals. These themes include creating a safe space for patients, identifying gaps in services, understanding practitioners' roles, and the need for more training and education in transgender care for practitioners. CONCLUSIONS: Primary care services for transgender individuals can and should be delivered in all models of primary care. Training and awareness for healthcare practitioners are needed to develop capacity in providing primary care to transgender individuals. A greater number of practitioners and organizations are needed to take on this work, embedding and normalizing transgender care into routine practice to address barriers to access and improve quality of care for transgender individuals.

Comparison of treatment of early-stage breast cancer among Nurses' Health Study participants and other Medicare beneficiaries.

PURPOSE: Increasingly epidemiological cohorts are being linked to claims data to provide rich data for healthcare research. These cohorts tend to be different than the general United States (US) population. We will analyze healthcare utilization of Nurses' Health Study (NHS) participants to determine if studies of newly diagnosed incident early-stage breast cancer can be generalized to the broader US Medicare population. METHODS: Analytic cohorts of fee-for-service NHS-Medicare-linked participants and a 1:13 propensity-matched SEER-Medicare cohort (SEER) with incident breast cancer in the years 2007-2011 were considered. Screening leading to, treatment-related, and general utilization in the year following early-stage breast cancer diagnosis were determined using Medicare claims data. RESULTS: After propensity matching, NHS and SEER were statistically balanced on all demographics. NHS and SEER had statistically similar rates of treatments including chemotherapy, breast-conserving surgery, mastectomy, and overall radiation use. Rates of general utilization include those related to hospitalizations, total visits, and emergency department visits were also balanced between the two groups. Total spending in the year following diagnosis were statistically equivalent for NHS and SEER ($36,180 vs. $35,399, p = 0.70). CONCLUSIONS: NHS and the general female population had comparable treatment and utilization patterns following diagnosis of early-stage incident breast cancers with the exception of type of radiation therapy received. This study provides support for the larger value of population-based cohorts in research on healthcare costs and utilization in breast cancer.

Impacts of an Integrated Medicaid Managed Care Program for Adults with Behavioral Health Conditions: The Experience of Illinois.

This study assessed the impact of the Integrated Care Program (ICP), a new Medicaid managed care model in Illinois, on health services utilization and costs for adults with behavioral health conditions. Data sources included Medicaid claims, encounter records, and state payment data for 28,127 persons with a behavioral health diagnosis. Difference-in-differences models, in conjunction with propensity score weighting, were used to compare utilization and costs between ICP enrollees and a fee-for-service (FFS) comparison group. The model considered the impact of the SMART Act, which restricted access to care for the comparison group. Before the SMART Act, ICP was associated with 2.8 fewer all-cause primary care visits, 34.6 fewer behavioral health-specific outpatient visits, and 2.5 fewer all-cause inpatient admissions per 100 persons per month, and $228 lower total costs per member per month relative to the FFS group. After the SMART Act, ICP enrollees had increased outpatient and dental services utilization without significantly higher costs. The relative increase in utilization was due primarily to decreased utilization in the restricted FFS group after the SMART Act. By the end of the study period, the ICP group had 13.3 more all-cause primary care visits, 1.5 more emergency department visits, and 1.4 more dental visits per 100 persons per month relative to the FFS program. A fully-capitated, integrated managed care program has the potential to reduce overall Medicaid costs for people with behavioral health conditions without negative effects on service utilization.