Variation in spending associated with primary care practices.

OBJECTIVES: To measure variation in spending and inpatient prices associated with the primary care physician (PCP) practice to which patients are attributed. STUDY DESIGN: Cross-sectional analysis of claims data. METHODS: We used random effect models to estimate case mix-adjusted spending across large PCP practices within 3-digit zip codes. We compare inpatient prices for patients in high-spending practices with those in low-spending practices. RESULTS: The physician practice to which a patient was attributed is associated with significant differences in spending after controlling for patient comorbidities and geography. Patients attributed to practices in the top quartile of total medical expenses have about 30% higher spending than patients attributed to practices in the bottom quartile of adjusted spending in their 3-digit zip code. If patients attributed to practices in the top 2 quartiles had spending equivalent to those in the median practice, total spending would drop by 8%. Price variation accounts for a meaningful amount of the variation, with inpatient prices 17% higher in top-quartile vs bottom-quartile practices. We cannot disaggregate the large variation in utilization into practice patterns and unmeasured case mix (including unmeasured differences in patients' socioeconomic status) vs random health shocks, but correlation in spending patterns across years suggests that some persistent differences in spending patterns exist. CONCLUSIONS: There are meaningful opportunities to reduce spending by changing patient PCP selection, encouraging patients to use lower-priced specialists and hospitals, and eliminating wasteful care. Attention must be paid to the best ways to reap these savings.

Resilient Aging: Psychological Well-Being and Social Well-Being as Targets for the Promotion of Healthy Aging.

Population aging is one of the most important social trends of the 21st century and in the United States, the number of people aged ≥65 is projected to increase by nearly 50% in the next 15 years. Most biomedical and public health efforts have focused on reducing harmful risk factors when targeting chronic disease-an approach that has contributed greatly to prevention and treatment programs. However, evidence suggests that the number of years lost to disability is increasing and historic gains we have made in life expectancy are eroding, and even reversing in some groups. As our society ages and grapples with these issues, expanding the focus to include resilience, as well as psychosocial assets in our prevention and treatment programs might help inform the multidisciplinary response effort we need. Here we synthesize research evaluating associations between different dimensions of psychological well-being (e.g., purpose in life, optimism, life satisfaction) and social well-being (e.g., structural, functional, quality) with chronic conditions. We also evaluate evidence around three biopsychosocial pathways hypothesized to underlie these associations. These factors are meaningful, measurable, and potentially modifiable; thus, further pursuing this line of inquiry might unveil innovative paths to enhancing the health of our rapidly aging society.

Workforce planning-going beyond the count.

Every country struggles with how best to meet the demand for health care services with the available resources. This commentary offers a perspective on the Israeli physician workforce and the analyses of Horowitz et al., which found age and gender differences in physician productivity and career longevity, differences across specialties, and a sizeable fraction of licensed Israeli physicians living abroad. Workforce planning can be subject to data collection and statistical uncertainties, but even more important are the assumptions and forecasts related to demand for services and organizational arrangements for care delivery. Readers should be cautious in analyzing productivity just by counting hours or years worked, and comparisons across countries may not account for differences in the nature of physician work. The question of whether Israel has enough physicians for the future has to go "beyond the count" to looking at the roles of other health professionals, the use of new technologies and new team configurations, and the overall efficiency and effectiveness of health care delivery systems such as hospitals, ambulatory care clinics, and community-based care.

Comparative effectiveness and costs of insulin pump therapy for diabetes.

OBJECTIVES: Continuous subcutaneous insulin infusion (CSII), or "insulin pump" therapy, is an alternative to multiple daily insulin injections (MDII) for management of diabetes. This study evaluates patterns of healthcare utilization, costs, and blood glucose control for patients with diabetes who initiate CSII. STUDY DESIGN: Pre-post with propensity-matched comparison design involving commercially insured US adults (aged 18-64 years) with insulin-requiring diabetes who transitioned from MDII to CSII between July 1, 2009, and June 30, 2012 ("CSII initiators"; n = 2539), or who continued using MDI (n = 2539). METHODS: Medical claims and laboratory results files obtained from a large US-wide health payer were used to construct direct medical expenditures, hospital use, healthcare encounters for hypoglycemia, and mean concentration of glycated hemoglobin (A1C). We fit difference-in-differences regression models to compare healthcare expenditures for 3 years following the switch to CSII. Stratified analyses were performed for prespecified patient subgroups. RESULTS: Over 3 years, mean per-person total healthcare expenditures were $1714 (95% confidence interval [CI], $1184-$2244) higher per quarter for CSII initiators compared with matched MDII patients (total mean 3-year difference of $20,565). Compared with matched controls, mean A1C concentrations became lower for CSII initiators by 0.46% in year 2 (P = .0003) and by 0.32% in year 3 (P = .047). CSII initiators also had a higher rate of hypoglycemia encounters in year 1 (P = .002). CONCLUSIONS: For adults with insulin-requiring diabetes, transitioning from MDII to CSII was associated with modest improvements in A1C but more hypoglycemia encounters and increased healthcare expenditures, without significant improvement in other potentially offsetting areas of healthcare consumption.

Making genomic medicine evidence-based and patient-centered: a structured review and landscape analysis of comparative effectiveness research.

Comparative effectiveness research (CER) in genomic medicine (GM) measures the clinical utility of using genomic information to guide clinical care in comparison to appropriate alternatives. We summarized findings of high-quality systematic reviews that compared the analytic and clinical validity and clinical utility of GM tests. We focused on clinical utility findings to summarize CER-derived evidence about GM and identify evidence gaps and future research needs. We abstracted key elements of study design, GM interventions, results, and study quality ratings from 21 systematic reviews published in 2010 through 2015. More than half (N = 13) of the reviews were of cancer-related tests. All reviews identified potentially important clinical applications of the GM interventions, but most had significant methodological weaknesses that largely precluded any conclusions about clinical utility. Twelve reviews discussed the importance of patient-centered outcomes, although few described evidence about the impact of genomic medicine on these outcomes. In summary, we found a very limited body of evidence about the effect of using genomic tests on health outcomes and many evidence gaps for CER to address.Genet Med advance online publication 13 April 2017.

Vital Directions for Health and Health Care: Priorities From a National Academy of Medicine Initiative.

Importance: Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost. Objectives: To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity. Evidence Review: Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings. Findings: The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress. Conclusions and Relevance: The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress.

Measuring Physician Quality and Efficiency in an Era of Practice Transformation: PCMH as a Case Study.

Practicing physicians face myriad challenges as health care undergoes considerable transformation, including advancing efforts to measure and report on physician quality and efficiency, as well as the growth of new care models such as Accountable Care Organizations and patient-centered medical homes (PCMHs). How do these transformational forces relate to one another? How should practicing physicians focus and prioritize their improvement efforts? This Special Report examines how physicians' performance on quality and efficiency measures may interact with delivery reforms, focusing on the PCMH. We note that although the PCMH is a promising model, published evidence is mixed. Using data and experience from a large commercial insurer's performance transparency and PCMH programs, we further report that longitudinal analysis of UnitedHealthcare's PCMH program experience has shown favorable changes; however, cross-sectional analysis indicates that National Committee for Quality Assurance's PCMH designation is positively associated with achieving program Quality benchmarks, but negatively associated with program Efficiency benchmarks. This example illustrates some key issues for physicians in the current environment, and we provide suggestions for physicians and other stakeholders on understanding and acting on information from physician performance measurement programs.

A randomized comparative effectiveness trial of using cable television to deliver diabetes prevention programming.

OBJECTIVE: To evaluate the use and effectiveness of two "in-home" strategies for delivering diabetes prevention programming using cable television. METHODS: An individually randomized, two-arm intervention trial including adults with diabetes risk factors living in two US cities. Interventions involved a 16-session lifestyle intervention delivered via "video-on-demand" cable television, offered alone versus in combination with web-based lifestyle support tools. Repeated measures longitudinal linear regression with imputation of missing observations was used to compare changes in body weight. RESULTS: A total of 306 individuals were randomized and offered the interventions. After 5 months, 265 (87%) participants viewed at least 1, and 110 (36%) viewed ≥9 of the video episodes. A total of 262 (86%) participants completed a 5-month weight measurement. In intention-to-treat analysis with imputation of missing observations, mean weight loss at 5 months for both treatment groups combined was 3.3% (95% CI 0.7-5.0%), regardless of intervention participation (with no differences between randomized groups (P = 0.19)), and was 4.9% (95% CI 2.1-6.5%) for participants who viewed ≥9 episodes. CONCLUSIONS: In-home delivery of evidence-based diabetes prevention programming in a reality television format, offered with or without online behavioral support tools, can achieve modest weight losses consistent with past implementation studies of face-to-face programs using similar content.

Getting value from health spending: going beyond payment reform.

It is widely held that fee-for-service (FFS) payment systems reward volume and intensity of services, contributing to overall cost inflation, while doing little to reward quality, efficiency, or care coordination. Recently, The National Commission on Physician Payment Reform (sponsored by SGIM) has recommended that payers "should largely eliminate stand-alone fee-for-service payment to medical practices because of its inherent inefficiencies and problematic financial incentives." As the current and former Chief Medical Officers of a large national insurer, we agree that payment reform is a critical component of health care modernization. But calls to transform payment simultaneously go too far, and don't go far enough. Based on our experience, we believe there are several critical ingredients that are either missing or under-emphasized in most payment reform proposals, including: health care is local so no one size fits all; upgrading performance measures; monitoring/overcoming unintended consequences; using a full toolbox to achieve transformation; and ensuring that the necessary components for successful delivery reform are in place. Thinking holistically and remembering that healthcare is a complex adaptive system are crucial to achieving better results for patients and the health system.

UnitedHealthcare experience illustrates how payers can enable patient engagement.

Patient engagement is crucial to better outcomes and a high-performing health system, but efforts to support it often focus narrowly on the role of physicians and other care providers. Such efforts miss payers' unique capabilities to help patients achieve better health. Using the experience of UnitedHealthcare, a large national payer, this article demonstrates how health plans can analyze and present information to both patients and providers to help close gaps in care; share detailed quality and cost information to inform patients' choice of providers; and offer treatment decision support and value-based benefit designs to help guide choices of diagnostic tests and therapies. As an employer, UnitedHealth Group has used these strategies along with an "earn-back" program that provides positive financial incentives through reduced premiums to employees who adopt healthful habits. UnitedHealth's experience provides lessons for other payers and for Medicare and Medicaid, which have had minimal involvement with demand-side strategies and could benefit from efforts to promote activated beneficiaries.

Growth of molecular diagnostics and genetic testing in the USA, 2008-2011: analysis and implications.

AIMS: Advances in genomics and molecular diagnostic testing are expanding, but national data on which to base clinical, regulatory and reimbursement policies in the USA are lacking. The study objective is to provide current estimates of utilization/spending trends for private and public payers. PATIENTS & METHODS: Healthcare utilization/expenditure claims data for 32 million individuals across the USA in 2008-2011 were analyzed. Genetic testing and molecular diagnostic usage was categorized by major testing groups: infectious disease, cancer and inherited/other acquired conditions. RESULTS: Per-person testing cost grew by 14% per year between 2008 and 2011, primarily resulting from increased utilization. Spending per person for Medicare and Medicaid was higher than for commercially insured patients. Expenditure across the USA was estimated at US$5.5 billion in 2011, up 13% from 2010. DISCUSSION: Greater understanding of usage and technology diffusion requires increased data transparency and granularity. Conclusion & future perspective: The use of genetic testing and molecular diagnostics will grow over the next 5 years, with uncertainty about the precise diffusion trajectory. By strengthening the capacity to capture and analyze trends in this changing area of medicine, we increase our chances of promoting positive change to the benefit of patients.

Wide variation in episode costs within a commercially insured population highlights potential to improve the efficiency of care.

Reforming payment methods to move away from fee-for-service reimbursement is widely seen as a crucial step toward controlling health care costs. Although there is a good deal of evidence about variability in costs under Medicare, little has been published about the variability of costs for care that is financed by private insurance. We examined both quality and actual medical costs for episodes of care provided by nearly 250,000 US physicians serving commercially insured patients nationwide. Overall, episode costs for a set of major medical procedures varied about 2.5-fold, and for a selected set of common chronic conditions, episode costs varied about 15-fold. Among doctors meeting quality and efficiency benchmarks, however, costs for episodes of care were on average 14 percent lower than among other doctors. Some markets exhibited much higher variation in episode costs, but there was essentially no correlation between average episode costs and measured quality across markets. The overall analysis suggests that changing incentives through payment reforms could help to improve performance, but providers are at different stages of readiness for such reforms and thus will often need support in order to succeed.

The political economy of U.S. primary care.

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort--a new Charter for Primary Care--is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations.

Episode-based physician profiling: a guide to the perplexing.

Most current strategies to improve quality and efficiency in health-care delivery focus on measuring and improving physician practice. A new "second generation" of physician profiling--episode-based profiling--is moving beyond legacy "first-generation" physician profiles based on population health and preventive services measures. Episode-based profiling measures physician practice at the "episode of care" level with sophisticated analytic methods and tools using data from claim and other administrative data sets, and it has an underlying "theory of change" consistent with the evolution of the US health-care marketplace. While offering potential advantages in informing consumer choice and enabling practice improvement, episode-based profiling also has limitations and challenges, both analytically and in the process of physician engagement and improvement. Nonetheless, episode-based profiling is likely to continue to spread and have growing influence, and it has significant implications for research, policy, and clinical stakeholders.

Electronic health records in four community physician practices: impact on quality and cost of care.

OBJECTIVE: To assess the impact of the electronic health record (EHR) on cost (i.e., payments to providers) and process measures of quality of care. STUDY DESIGN: Retrospective before-after-study-control. From the database of a large managed care organization (MCO), we obtained the claims of patients from four community physician practices that implemented the EHR and from about 50 comparison practices without the EHR in the same counties. The diverse patient and practice populations were chosen to be a sample more representative of typical private practices than has previously been studied. MEASUREMENTS: For four chronic conditions, we used commercially-available software to analyze cost per episode over a year and the rate of adherence to clinical guidelines as a measure of quality. RESULTS: The implementation of the EHR had a modest positive impact on the quality measure of guideline adherence for hypertension and hyperlipidemia, but no significant impact for diabetes and coronary artery disease. No measurable impact on the short-term cost per episode was found. Discussions with the study practices revealed that the timing and comprehensiveness of EHR implementation varied across practices, creating an intervention variable that was heterogeneous. CONCLUSIONS: Guideline adherence increased across practices without EHRs and slightly faster in practices with EHRs. Measuring the impact of EHRs on cost per episode was challenging, because of the difficulty of completely capturing the long-term episodic costs of a chronic condition. Few practices associated with the study MCO had implemented EHRs in any form, much less utilizing standardized protocols.