Health insurance literacy: disparities by race, ethnicity, and language preference.

OBJECTIVES: To measure Connecticut's Affordable Care Act qualified health plan enrollees' health insurance literacy (HIL) by race, ethnicity, and language preference. STUDY DESIGN: Statewide landline and cell phone telephonic survey. METHODS: Geographically balanced cohort that oversampled black and Hispanic enrollees. Questions tested enrollees' knowledge of basic health insurance terminology and their use. Survey data were supplemented by deidentified administrative data from the state's health insurance exchange. RESULTS: Overall, subjects answered 62% of 13 questions correctly. The percentages of correct answers were 53% for black enrollees, 50% for Hispanic enrollees, 74% for white enrollees, and 45% for Spanish-speaking enrollees. The differences by race, ethnicity, and language preference were statistically significant. Overall, enrollees with a college education scored higher across all demographic groups, but disparities by race and ethnicity persisted. CONCLUSIONS: Health insurance terminology and use rules confuse consumers, especially racial and ethnic minorities. Differences in HIL may be a previously underrecognized source of healthcare disparities because even minor errors can result in delayed care or unanticipated medical bills. Low HIL can diminish the practical value of health insurance and exacerbate perceptions of health insurance as offering insufficient value for premium price. Additional research on ways to improve HIL and investments in insurance navigation support for black and Hispanic enrollees are needed.

Reduced Cost Of Specialty Care Using Electronic Consultations For Medicaid Patients.

Specialty care accounts for a significant and growing portion of year-over-year Medicaid cost increases. Some referrals to specialists may be avoided and managed more efficiently by using electronic consultations (eConsults). In this study a large, multisite safety-net health center linked its primary care providers with specialists in dermatology, endocrinology, gastroenterology, and orthopedics via an eConsult platform. Many consults were managed without need for a face-to-face visit. Patients who had an eConsult had average specialty-related episode-of-care costs of $82 per patient per month less than those sent directly for a face-to-face visit. Expanding the use of eConsults for Medicaid patients and reimbursing the service could result in substantial savings while improving access to and timeliness of specialty care and strengthening primary care.

The health care and productivity costs of back and neck pain in a multi-employer sample of utility industry employees.

OBJECTIVE: To determine the cost of back and/or neck (B/N) pain among predominantly rural employees insured through an employee benefits trust. METHODS: Eligible employees had 1 year or more of medical coverage and completed a survey subsequently linked to their claims data. B/N pain costs consisted of medical and pharmacy claims, over-the-counter expenses, and presenteeism and absenteeism costs valued according to median occupational earnings. RESULTS: Of 1342 eligible employees, 52.7% currently had B/N pain of which 87.9% was chronic. The average annualized cost of B/N pain per employee was $1727; 56.1% was due to lost productivity. Covered medical care was utilized by 35.6% of employees, 55.7% used pharmacy care, and 71.6% purchased uncovered over-the-counter pain medication. CONCLUSIONS: Many covered employees did not use formal care. The effect of care choices on productivity costs requires closer scrutiny.

An obesity/cardiometabolic risk reduction disease management program: a population-based approach.

Obesity is a critical health concern that has captured the attention of public and private healthcare payers who are interested in controlling costs and mitigating the long-term economic consequences of the obesity epidemic. Population-based approaches to obesity management have been proposed that take advantage of a chronic care model (CCM), including patient self-care, the use of community-based resources, and the realization of care continuity through ongoing communications with patients, information technology, and public policy changes. Payer-sponsored disease management programs represent an important conduit to delivering population-based care founded on similar CCM concepts. Disease management is founded on population-based disease identification, evidence-based care protocols, and collaborative practices between clinicians. While substantial clinician training, technology infrastructure commitments, and financial support at the payer level will be needed for the success of disease management programs in obesity and cardiometabolic risk reduction, these barriers can be overcome with the proper commitment. Disease management programs represent an important tool to combat the growing societal risks of overweight and obesity.

Cost-effectiveness of fixed-dose combination of isosorbide dinitrate and hydralazine therapy for blacks with heart failure.

BACKGROUND: Fixed-dose combination of isosorbide dinitrate/hydralazine (ISDN/HYD) improved clinical outcomes in the African-American Heart Failure Trial (A-HeFT). We assessed the resource use, costs of care, and cost-effectiveness of ISDN/HYD therapy in the A-HeFT trial population. METHODS AND RESULTS: We obtained resource use data from A-HeFT, assigning costs through the use of US federal sources. Excluding indirect costs, we summarized the within-trial experience and modeled cost-effectiveness over extended time horizons, including a US societal lifetime reference case. During the mean trial follow-up of 12.8 months, the ISDN/HYD group incurred fewer heart failure-related hospitalizations (0.33 versus 0.47 per subject; P=0.002) and shorter mean hospital stays (6.7 versus 7.9 days; P=0.006). When study drug costs were excluded, both heart failure-related and total healthcare costs were lower in the ISDN/HYD group (mean per-subject heart failure-related costs, 5997 dollars versus 9144 dollars; P=0.04; mean per-subject total healthcare costs, 15,384 dollars versus 19,728 dollars; P=0.03). With an average daily drug cost of 6.38 dollars, ISDN/HYD therapy was dominant (reduced costs and improved outcomes) over the trial duration. Assuming that no additional benefits accrue beyond the trial, we project the cost-effectiveness of ISDN/HYD therapy using heart failure-related costs to be 16,600 dollars/life-year at 2 years after enrollment, 37,100 dollars/life-year at 5 years, and 41,800 dollars/life-year over lifetime (reference case). CONCLUSIONS: ISDN/HYD therapy, previously shown to improve clinical outcomes, also reduced resource use and costs in A-HeFT, primarily because of a large reduction in hospitalizations. Long-term use of ISDN/HYD therapy should be associated with a favorable cost-effectiveness profile in this population.

A cohort study of the impact of a national disease management program on HEDIS diabetes outcomes.

Diabetes disease management programs (DDMP) are proliferating, but their overall impact in improving quality of care using Health Employer Data and Information Set (HEDIS) quality metrics has not been well studied. Furthermore, DDMPs are usually ongoing, but the incremental benefits of continuing the program beyond the initial patient educational intervention have not been rigorously tested. This study evaluates the impact of length of DDMP participation on diabetes-related HEDIS 2002 quality indicators across 20 health plans. Results are stratified by duration of DDMP participation into three levels, "full participants" (6-12 months duration), "partial participants" (<6 months duration) and "non-participants" (0 months duration). The overall national compliance rate across all six combined HEDIS quality measures was 65.6% among full-participants (FP), 58.4% among partial-participants (PP) and 57.0% among non-participants (NP). This study demonstrates that participants in a comprehensive DDMP fair better than non-participants and that those with sustained participation (>6 months) benefit the most.

Return on investment in disease management: a review.

The results of 44 studies investigating financial impact and return on investment (ROI) from disease management (DM) programs for asthma, congestive heart failure (CHF), diabetes, depression, and multiple illnesses were examined. A positive ROI was found for programs directed at CHF and multiple disease conditions. Some evidence suggests that diabetes programs may save more than they cost, but additional studies are needed. Results are mixed for asthma management programs. Depression management programs cost more than they save in medical expenses, but may save money when considering productivity outcomes.

Integrating disease management into the outpatient delivery system during and after managed care.

Managed care introduced disease management as a replacement strategy to utilization management. The focus changed from influencing treatment decisions to supporting self-care and compliance. Disease management rendered operational many elements of the chronic care model, but it did so outside the delivery system, thus escaping the financial limitations, cultural barriers, and inertia inherent in effecting radical change from within. Medical management "after managed care" should include the functional and structural integration of disease management with primary care clinics. Such integration would supply the infrastructure that primary care physicians need to coordinate the care of chronically ill patients more effectively.

Effectiveness of a disease management program for patients with diabetes.

Diabetes disease management programs (DDMPs) are proliferating, but their effectiveness in improving quality and mitigating health care spending has been difficult to measure. Using two quasi-experimental methods, this study analyzed the first-year results of a multistate DDMP for people with diabetes sponsored by a national managed care organization. In both analyses, overall cost of care were significantly lower in DDMP sites, and the payer saved more than it spent. Pharmacy costs showed mixed results. Quality scores in the DDMP sites were significantly better than in sites without the program.

A primer on bariatric surgery: treatment of last resort for morbid obesity.

Morbid obesity represents the highest risk state of a growing national problem that is eminently preventable and therefore highly relevant to the disease management community. The obesity epidemic, the failure of conservative treatments to achieve long-term weight loss and heightened media attention to positive short-term results of bariatric procedures among national celebrities has resulted in a dramatic increase in the number of surgeries performed every year. Familiarity with the clinical issues surrounding morbid obesity and bariatric surgery is therefore essential to the disease management community. This paper reviews the state of bariatric surgery, common surgical approaches, their effectiveness, complications, impact on co-morbidities, cost and evolving insurance coverage policies. I also will propose a proactive approach to arrest disease progression to morbid obesity.