No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients.

BACKGROUND: A recent study estimated that more than 1.5 million Americans have an indeterminate pulmonary nodule (IPN) identified on a chest computed tomography (CT) scan each year outside of lung cancer screening programs. However, the cost and pattern of subsequent IPN workup have not been described for real-world settings. OBJECTIVES: To examine the pattern and cost of IPN workup in real-world practice using insurer administrative claims data for commercially-insured individuals. METHODS: The primary source for this retrospective observational study was the MarketScan® 2013-2016 databases, which include information on 28 to 47 million insured lives. The newly diagnosed IPN study population consisted of members with an IPN diagnosis code on a claim in 2014 who did not have prior diagnosis of an IPN or lung cancer in 2013 and who had coverage from 2014 to 2016. Subsequent claims were examined for workups included in the American College of Chest Physicians (ACCP) guideline recommendations and the costs of workup were tabulated. RESULTS: Of the 15 064 patients in the study population, only 5471 (36%) received any subsequent workup. The average and median costs of workup for these patients were $3270 and $2068, respectively. Spread across the commercially-insured population, the workup is estimated to cost between $1 and $2 per member per year. CONCLUSIONS: The majority of commercially-insured members with newly identified IPNs do not appear to have any guideline-recommended workup, despite a low incremental cost of such workup services on a population basis.

The Prevalence and Payer Costs of Potentially Avoidable Emergent Care Visits for Suspected Amniotic Membrane Rupture in Pregnant Women.

BACKGROUND: Concern over amniotic fluid leakage is common among pregnant women. Uncertainty about prelabor rupture of amniotic membranes (PROM) can lead women to present to emergency departments or to labor and delivery units for medical evaluation. Many of such visits do not result in delivery, yet they carry significant, and potentially unnecessary, healthcare expenditures. OBJECTIVE: To estimate the prevalence and payer cost of potentially avoidable visits by pregnant women to an emergent care facility (including emergency departments, labor and delivery units, or observation units) for suspected PROM. METHODS: This study included 2 processes-an electronic medical records chart review and a commercial health insurance claims data analysis. The medical chart review included 843 scheduled and 1250 unscheduled pregnancy-related visits at Robert Wood Johnson University Hospital between January 4 and June 30, 2017, which was conducted to determine the rates of visits by pregnant women with suspected PROM and their results (ie, hospital admission or discharge). In addition, we performed a retrospective analysis of medical claims data from the Truven Health MarketScan Commercial Database to measure population-level incidence rates and the costs of pregnancy-related emergent care visits for suspected PROM. RESULTS: Of the 1250 unscheduled visits reviewed, 663 did not result in delivery; of these, 68 had a primary complaint of suspected PROM, and 55 (81%) of them were discharged with PROM ruled out. Of all scheduled and unscheduled nondelivery visits (N = 1069), 5.1% (N = 55) were associated with suspected PROM but were discharged home with PROM ruled out. In the commercial claims analysis, the average rate of emergent care visits by pregnant women was 436.69 per 1000 deliveries, with an estimated average cost of $1428 per visit (in 2018 dollars), or $0.58 per member per month. Applying the rates from our chart review to the claims data, we estimated that commercial insurers pay, on average, for approximately 22.47 facility visits per 1000 deliveries for suspected and ruled-out PROM. CONCLUSIONS: Our findings suggest that for most PROM cases that do not result in delivery, PROM is ruled out and patients are sent home. Reducing the number of PROM-related visits to emergent care facilities that result in ruled-out PROM could reduce healthcare costs and help patients and providers avoid these inconvenient visits.

Assessing Medicare's Approach To Covering New Drugs In Bundled Payments For Oncology.

New oncology therapies can contribute to survival or quality of life, but payers and policy makers have raised concerns about the cost of these therapies. Similar concerns extend beyond cancer. In seeking a solution, payers are increasingly turning toward value-based payment models in which providers take financial risk for costs and outcomes. These models, including episode payment and bundled payment, create financial gains for providers who reduce cost, but they also create concerns about potential stinting on necessary treatments. One approach, which the Centers for Medicare and Medicaid Services adopted in the Oncology Care Model (OCM), is to partially adjust medical practices' budgets for their use of novel therapies, defined in this case as new oncology drugs or new indications for existing drugs approved after December 31, 2014. In an analysis of the OCM novel therapies adjustment using historical Medicare claims data, we found that the adjustment may provide important financial protection for practices. In a simulation we performed, the adjustment reduced the average loss per treatment episode by $758 (from $807 to $49) for large practices that use novel therapies often. Lessons from the OCM can have implications for other alternative payment models.

Newly Diagnosed Hepatitis C in the US Commercially Insured Population Before and After the 2012 Implementation of Expanded Screening Guidelines.

BACKGROUND: In the United States in 2014, more than 3 million individuals were estimated to have chronic hepatitis C virus (HCV) infection, including many undiagnosed individuals. In 2012, the Centers for Disease Control and Prevention expanded its HCV testing recommendations to target all adults born between 1945 and 1965, in addition to at-risk individuals, which has led to an increase in newly diagnosed patients. Few studies have explored the medical cost or clinical status of patients who are newly diagnosed with HCV. OBJECTIVE: To compare the demographics, comorbidities, and medical costs of patients who are newly diagnosed and those who were previously diagnosed with HCV infection. METHOD: We conducted a retrospective study using 2013 claims data from the Truven Health MarketScan Commercial database to compare patients newly diagnosed with HCV infection in 2013 and patients who were diagnosed before 2013. The patients were divided into 2 cohorts based on the time of diagnosis before and after 2013. All patients were classified by disease stage and by comorbidities, and were required to have continuous health plan enrollment between January 2010 and December 2013. The full-year costs were tabulated for every patient, regardless of the date of diagnosis. RESULTS: Of the 9193 patients with an HCV diagnosis in 2013 in the database, approximately 26% (N = 2428) were newly diagnosed in 2013, of whom 12% (N = 299) had advanced-stage HCV. The average age of the newly diagnosed patients was 49.5 years versus 54.1 years for previously diagnosed patients. Patients who were previously diagnosed had a higher prevalence of HIV, diabetes, and more severe cancers than patients who were newly diagnosed with HCV. Patients who were newly diagnosed with HCV had a higher prevalence of acute liver failure and drug-induced psychosis. The average annual per-patient per-month (PPPM) medical costs for both groups was approximately $2200 in 2013. The annual medical cost for a patient who was newly diagnosed increased sharply in the year before diagnosis, from approximately $588 PPPM for the 3 years before the diagnosis to approximately $854 PPPM in the year before diagnosis. CONCLUSION: In 2013, the healthcare costs of patients who were newly diagnosed with HCV were similar in their first year of diagnosis to the costs of patients who had been diagnosed previously, although patients who were previously diagnosed had more advanced-stage disease. Patients who were newly diagnosed had 3-fold the healthcare costs in their first year of diagnosis versus the costs in the 3 years before their diagnosis.

Computed Tomography Colonography Less Costly Than Colonoscopy for Colorectal Cancer Screening of Commercially Insured Patients.

BACKGROUND: Computed tomography (CT) colonography's effectiveness, its associated patient advantages, and its potential role to increase colorectal cancer (CRC) screening rates have been demonstrated in previous research, but whether CT colonography has a cost advantage relative to optical colonoscopy for the commercially insured US population has not been assessed. OBJECTIVE: To compare the costs of CRC screening using CT colonography or optical colonoscopy for commercially insured people in the United States. METHODS: Using retrospective commercial healthcare claims data and peer-reviewed studies, we performed a simulated multiyear, matched-case comparison of the costs of CT and optical colonoscopies for CRC screening. We estimated commercial optical colonoscopy costs per screening based on the 2016 Truven Health MarketScan Commercial Database and ancillary services, such as bowel preparation, anesthesia, pathology, and complication costs. We developed 4 scenarios for CT colonography cost per screening using the ratio of commercial to Medicare fees, and calculated ancillary service and follow-up costs from payers' costs for these services when associated with optical colonoscopies. For comparison, we converted the costs per screening to the costs per screening year per person using real-world screening intervals that were obtained from peer-reviewed studies. RESULTS: In 2016, the average optical colonoscopy screening cost for commercial payers was $2033 (N = 406,068), or $340 per screening year per person. With our highest-cost CT colonography scenario, CT colonography costs 22% less, or $265 per screening year, than optical colonoscopy, mostly because of the advantages for patients of no anesthesia and the greatly reduced use of pathology services. CONCLUSIONS: The use of CT colonography for CRC testing offers effective screening, patient-centered advantages, and lower costs compared with optical colonoscopy, and may be particularly appealing to the currently unscreened population with commercial health insurance. If the availability of CT colonography expands to meet the increased demand for it, CT colonography could cost up to 50% less than optical colonoscopy per screening year.

The cost of unintended pregnancies for employer-sponsored health insurance plans.

BACKGROUND: Pregnancy is associated with a significant cost for employers providing health insurance benefits to their employees. The latest study on the topic was published in 2002, estimating the unintended pregnancy rate for women covered by employer-sponsored insurance benefits to be approximately 29%. OBJECTIVES: The primary objective of this study was to update the cost of unintended pregnancy to employer-sponsored health insurance plans with current data. The secondary objective was to develop a regression model to identify the factors and associated magnitude that contribute to unintended pregnancies in the employee benefits population. METHODS: We developed stepwise multinomial logistic regression models using data from a national survey on maternal attitudes about pregnancy before and shortly after giving birth. The survey was conducted by the Centers for Disease Control and Prevention through mail and via telephone interviews between 2009 and 2011 of women who had had a live birth. The regression models were then applied to a large commercial health claims database from the Truven Health MarketScan to retrospectively assign the probability of pregnancy intention to each delivery. RESULTS: Based on the MarketScan database, we estimate that among employer-sponsored health insurance plans, 28.8% of pregnancies are unintended, which is consistent with national findings of 29% in a survey by the Centers for Disease Control and Prevention. These unintended pregnancies account for 27.4% of the annual delivery costs to employers in the United States, or approximately 1% of the typical employer's health benefits spending for 1 year. Using these findings, we present a regression model that employers could apply to their claims data to identify the risk for unintended pregnancies in their health insurance population. CONCLUSION: The availability of coverage for contraception without employee cost-sharing, as was required by the Affordable Care Act in 2012, combined with the ability to identify women who are at high risk for an unintended pregnancy, can help employers address the costs of unintended pregnancies in their employee benefits population. This can also help to bring contraception efforts into the mainstream of other preventive and wellness programs, such as smoking cessation, obesity management, and diabetes control programs.

Offering lung cancer screening to high-risk medicare beneficiaries saves lives and is cost-effective: an actuarial analysis.

BACKGROUND: By a wide margin, lung cancer is the most significant cause of cancer death in the United States and worldwide. The incidence of lung cancer increases with age, and Medicare beneficiaries are often at increased risk. Because of its demonstrated effectiveness in reducing mortality, lung cancer screening with low-dose computed tomography (LDCT) imaging will be covered without cost-sharing starting January 1, 2015, by nongrandfathered commercial plans. Medicare is considering coverage for lung cancer screening. OBJECTIVE: To estimate the cost and cost-effectiveness (ie, cost per life-year saved) of LDCT lung cancer screening of the Medicare population at high risk for lung cancer. METHODS: Medicare costs, enrollment, and demographics were used for this study; they were derived from the 2012 Centers for Medicare & Medicaid Services (CMS) beneficiary files and were forecast to 2014 based on CMS and US Census Bureau projections. Standard life and health actuarial techniques were used to calculate the cost and cost-effectiveness of lung cancer screening. The cost, incidence rates, mortality rates, and other parameters chosen by the authors were taken from actual Medicare data, and the modeled screenings are consistent with Medicare processes and procedures. RESULTS: Approximately 4.9 million high-risk Medicare beneficiaries would meet criteria for lung cancer screening in 2014. Without screening, Medicare patients newly diagnosed with lung cancer have an average life expectancy of approximately 3 years. Based on our analysis, the average annual cost of LDCT lung cancer screening in Medicare is estimated to be $241 per person screened. LDCT screening for lung cancer in Medicare beneficiaries aged 55 to 80 years with a history of ≥30 pack-years of smoking and who had smoked within 15 years is low cost, at approximately $1 per member per month. This assumes that 50% of these patients were screened. Such screening is also highly cost-effective, at <$19,000 per life-year saved. CONCLUSION: If all eligible Medicare beneficiaries had been screened and treated consistently from age 55 years, approximately 358,134 additional individuals with current or past lung cancer would be alive in 2014. LDCT screening is a low-cost and cost-effective strategy that fits well within the standard Medicare benefit, including its claims payment and quality monitoring.

Medical claim cost impact of improved diabetes control for medicare and commercially insured patients with type 2 diabetes.

BACKGROUND: Diabetes prevalence is increasing in the United States, yet the control of critical clinical metrics (e.g., hemoglobin A1c [A1c], blood pressure, and lipids) remains suboptimal. Lower A1c levels have been shown to be associated with lower diabetes complication rates, and reduced medical costs have been reported in individuals with diabetes who have improved glycemic control. While many studies have quantified the impact of A1c control on medical claim costs, this article provides new information on the cost and event impact of better control for all 3 metrics for the commercial population and Medicare population separately. OBJECTIVES: To (a) quantify current type 2 diabetes control rates for A1c, blood pressure, and lipids and (b) model the impact of scenarios for better control of these metrics on diabetes complication rates and complication costs in people with diabetes in commercially insured and Medicare populations. METHODS: 858 adults with commercial (n = 392) or Medicare (n = 466) coverage and type 2 diabetes were identified from approximately 10,000 individuals in the National Health and Nutrition Examination Survey (NHANES; combined series 2005-2006 and 2007-2008). Based on each individual's risk factors, the United Kingdom Prospective Diabetes Study modeling tool was used to project rates of 7 diabetes complications under status quo A1c, blood pressure, and lipid levels and complication rates under better management. Three improved management scenarios were created to model the impact of better control in all commercially insured and Medicare individuals with type 2 diabetes who had A1c, blood pressure, or lipids not at goal and in a subset of individuals whose A1c levels were ≥ 7%, with or without blood pressure or lipids not at goal. Thomson Reuters MarketScan Commercial Claims and Encounters Database (2006-2009) and Medicare 5% sample data (2006-2009), including the eligibility data for each, were used to develop both the average annual costs and per-patient-per-month (PPPM) costs, adjusted to 2012 dollars, in commercially insured and Medicare fee-for-service patients with diabetes and the cost of diabetes-related complications to monetize the impact of reducing complications. RESULTS: Analysis of NHANES data showed that type 2 diabetes prevalence is 6.1% in commercially insured individuals aged 20 to 64 years and 19.4% in Medicare beneficiaries aged 65 years and older. Of patients with type 2 diabetes, 47% of commercially insured patients and 38% of Medicare patients were found to have A1c ≥ 7%. With improved control of A1c, blood pressure, and lipid levels that were not at goal, as modeled in 3 management scenarios, reductions in the probability of complications across all patients with diabetes ranged from 43% to 67% in the commercial population and 28% to 49% in the Medicare population. The cost savings effect from reduced complications across all patients with diabetes ranged from $67 to $105 PPPM in the commercial population and $99 to $158 in the Medicare population. The high end of this savings range yielded a reduction of about 10% in total costs when compared with an average of $1,090 PPPM in commercially insured patients with diabetes and an average of $1,565 PPPM in Medicare patients with diabetes derived from large claims databases, both in projected 2012 dollars. CONCLUSION: Results of this analysis suggest that better control of A1c, blood pressure, and lipids is associated with savings opportunities in commercially insured and Medicare patients with type 2 diabetes. A focus on only patients with uncontrolled A1c offers a somewhat higher per-patient cost reduction than for all uncontrolled diabetes patients but greatly diminishes the number of targeted patients.

A cost-utility analysis of lung cancer screening and the additional benefits of incorporating smoking cessation interventions.

BACKGROUND: A 2011 report from the National Lung Screening Trial indicates that three annual low-dose computed tomography (LDCT) screenings for lung cancer reduced lung cancer mortality by 20% compared to chest X-ray among older individuals at high risk for lung cancer. Discussion has shifted from clinical proof to financial feasibility. The goal of this study was to determine whether LDCT screening for lung cancer in a commercially-insured population (aged 50-64) at high risk for lung cancer is cost-effective and to quantify the additional benefits of incorporating smoking cessation interventions in a lung cancer screening program. METHODS AND FINDINGS: The current study builds upon a previous simulation model to estimate the cost-utility of annual, repeated LDCT screenings over 15 years in a high risk hypothetical cohort of 18 million adults between age 50 and 64 with 30+ pack-years of smoking history. In the base case, the lung cancer screening intervention cost $27.8 billion over 15 years and yielded 985,284 quality-adjusted life years (QALYs) gained for a cost-utility ratio of $28,240 per QALY gained. Adding smoking cessation to these annual screenings resulted in increases in both the costs and QALYs saved, reflected in cost-utility ratios ranging from $16,198 per QALY gained to $23,185 per QALY gained. Annual LDCT lung cancer screening in this high risk population remained cost-effective across all sensitivity analyses. CONCLUSIONS: The findings of this study indicate that repeat annual lung cancer screening in a high risk cohort of adults aged 50-64 is highly cost-effective. Offering smoking cessation interventions with the annual screening program improved the cost-effectiveness of lung cancer screening between 20% and 45%. The cost-utility ratios estimated in this study were in line with other accepted cancer screening interventions and support inclusion of annual LDCT screening for lung cancer in a high risk population in clinical recommendations.

An actuarial analysis shows that offering lung cancer screening as an insurance benefit would save lives at relatively low cost.

Lung cancer screening is not established as a public health practice, yet the results of a recent large randomized controlled trial showed that screening with low-dose spiral computed tomography reduces lung cancer mortality. Using actuarial models, this study estimated the costs and benefits of annual lung cancer screening offered as a commercial insurance benefit in the high-risk US population ages 50-64. Assuming current commercial reimbursement rates for treatment, we found that screening would cost about $1 per insured member per month in 2012 dollars. The cost per life-year saved would be below $19,000, an amount that compares favorably with screening for cervical, breast, and colorectal cancers. Our results suggest that commercial insurers should consider lung cancer screening of high-risk individuals to be high-value coverage and provide it as a benefit to people who are at least fifty years old and have a smoking history of thirty pack-years or more. We also believe that payers and patients should demand screening from high-quality, low-cost providers, thus helping set an example of efficient system innovation.

An actuarial approach to comparing early stage and late stage lung cancer mortality and survival.

Comparing the mortality characteristics of different cohorts is an essential process in the life insurance industry. Pseudodisease, lead-time bias, and length bias, which are critical to determining the value of cancer screening, have close analogues in life insurance company management, including the temporal impact of underwriting. Ratios of all-cause mortality rates for cancer cohorts relative to standard population mortality rates can provide insights into early stage and late stage mortality differences, differences by age, sex, race, and histology, and allow modeling of biases associated with early stage detection or screening protocols. The Surveillance, Epidemiology and End Results (SEER) data set has characteristics that allow efficient application of actuarial techniques. We show the mortality burden associated with treated early stage lung cancer and that identifying all lung cancers at early stage could reduce US lung cancer deaths by over 70,000 per year.

Medical care cost of Medicare/Medicaid beneficiaries with vision loss.

PURPOSE: To assess the impact of vision loss on healthcare cost for patients with Medicaid and Medicare and whether these costs are adequately captured by Medicare hierarchical condition categories (HCC) risk adjustment methodology. DATA SOURCES: The public use data set of the Program of All-Inclusive Care for the Elderly (PACE) for 1994-1998, and the Medicare 5% Sample datasets for 2003 and 2004. METHODS: For the first analysis, up to five years of PACE data for each individual was used to calculate HCC scores (n = 3,459). For the second analysis, claim or encounter data from Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) were used to estimate the cost for each beneficiary in the upcoming payment year (n = 2,108). RESULTS: The increase in medical cost risk overall for visually impaired PACE participants was 10%, increasing to 13% for the non-institutionalized, community-based cohort, but PACE participants in nursing homes with vision loss did not generally result in increased costs. In the Medicare 5% sample, the HCC model under-predicts costs by about 17%. CONCLUSION: Our analyses provide evidence that healthcare cost risk attributable to vision loss is not adequately captured by Medicare HCC risk adjustment methodology. We hypothesize this is due to additional morbidity and treatment patterns associated with visual impairment.

Estimates of commercial population at high risk for cardiovascular events: impact of aggressive cholesterol reduction.

OBJECTIVES: To model the financial and health outcomes impact of intensive statin therapy compared with usual care in a high-risk working-age population (actively employed, commercially insured health plan members and their adult dependents). The target population consists of working-age people who are considered high-risk for cardiovascular disease events because of a history of coronary heart disease. STUDY DESIGN: Three-year event forecast for a sample population generated from the National Health and Nutrition Examination Survey data. METHODS: Using Framingham risk scoring system, the probability of myocardial infarction or stroke events was calculated for a representative sample population, ages 35 to 69 years, of people at high risk for cardiovascular disease, with a history of coronary heart disease. The probability of events for each individual was used to project the number of events expected to be generated for this population. Reductions in cardiovascular and stroke events reported in clinical trials with aggressive statin therapy were applied to these cohorts. We used medical claims data to model the cohorts' event costs. All results are adjusted to reflect the demographics of a typical working-age population. RESULTS: The high-risk cohort (those with coronary heart disease) comprises 4% of the 35- to 69-year-old commercially insured population but generates 22% of the risk for coronary heart disease and stroke. Reduced event rates associated with intensive statin therapy yielded a $58 mean medical cost reduction per treated person per month; a typical payer cost for a 30-day supply of intensive statin therapy is approximately $57. CONCLUSIONS: Aggressive low-density lipoprotein cholesterol-lowering therapy for working-age people at high risk for cardiovascular events and with a history of heart disease appears to have a significant potential to reduce the rate of clinical events and is cost-neutral for payers.

Cancer chemoprevention and cancer preventive vaccines--a call to action: leaders of diverse stakeholder groups present strategies for overcoming multiple barriers to meet an urgent need.

The emerging field of cancer prevention through chemoprevention agents and cancer vaccines offers significant promise for reducing suffering and death from cancer. However, that promise may not be kept unless major barriers to progress are lowered or eliminated. Among the most significant barriers are the relatively small investment from government and industry in research and development of cancer preventive agents; a predominant emphasis of translational cancer research on therapeutic interventions for metastatic or advanced cancer; complexities of prevention trial design; a relatively uncharted Food and Drug Administration (FDA) approval process for preventive agents; insufficient public and patient understanding of the importance and potential for cancer preventive measures, with consequent unpredictable public and patient willingness to take preventive agents; an uncertain reimbursement from payors; and limitations in patent law, liability protection, and data package exclusivity that undermine the opportunity for recouping investment. Viewed individually or collectively, each of these barriers serves as a substantial deterrent to intellectual and financial investment by all sectors of the cancer community. In an effort to ultimately overcome these barriers, a Cancer Prevention Research Summit was assembled June 12-13, 2006 in Bethesda, Maryland, organized by C-Change with support from the AACR. The Summit brought together some 120 leaders from private, public, and not-for-profit entities, including cancer researchers and clinicians; federal health officials; regulatory agency representatives; pharmaceutical, biotech, and food industry leaders; patent attorneys; economists; public and private provider group executives; and advocates. Participants engaged in a detailed process to more carefully define the major barriers, identify potential solutions, and formulate initial priorities and recommendations for action. At the conclusion of this dialogue among experts, the following recommended actions were outlined: define policy solutions to patent, intellectual property, and liability law barriers; create an advisory document about the approval process for cancer chemopreventive agents and vaccines for the FDA; develop new design models for cancer chemopreventive clinical trials; outline the business case for chemopreventive agents and vaccines for federal research agencies, payors and investors; and implement a communications strategy to increase public awareness about the importance of chemoprevention and cancer preventive vaccines.