The Longitudinal Impact Of A Multistate Commercial Accountable Care Program On Cost, Use, And Quality.

The prevalence of accountable care organizations (ACOs) has grown significantly across Medicare and commercial payers in the past decade, but there are limited insights regarding the effect of ACOs on costs in the commercial population. We used longitudinal administrative claims data over the course of nineteen calendar quarters from 2016 to 2021 to assess the ongoing incremental impact of Elevance Health's commercial ACO program on cost and use across fifteen US states. We also analyzed the program's impact on spending subcategories (inpatient, outpatient, professional, and pharmacy) and measured differences in quality performance. The program was associated with incremental savings during this period. Incremental savings were greater in the fully insured population relative to the administrative services only population and were due to outpatient and pharmacy savings. ACO providers had superior quality performance measures relative to contracted providers not participating in ACOs. Payers should be aware of the potential for diminishing marginal returns of ACO contracting on containing health care costs.

Incremental burden of mental health conditions in adult patients with focal seizures.

INTRODUCTION: Clinical research has consistently established mental health conditions (MHCs) as frequent comorbidities of epilepsy. However, the extent of economic burden of comorbid MHC in patients with focal seizures has not been systematically investigated. This retrospective cohort analysis of health plan claims compared healthcare use and costs among adult patients with focal seizures with and without comorbid MHC. METHODS: We utilized the Inovalon Medical Outcomes Research for Effectiveness and Economics (MORE2) Registry, longitudinal data from over 150 commercial, Medicare Advantage, and managed Medicaid health plans for the analysis, and identified a cohort of patients with focal (partial-onset) seizure with relevant ICD9/10 diagnosis codes with and without MHC. Mental health conditions were defined as diagnoses for anxiety, bipolar condition/mania, attention-deficit conduct condition, major depression, schizophrenia, and other psychotic conditions, and patients without MHC were propensity score-matched to patients with preexisting MHC on baseline patient characteristics. The assessment examined a series of outcomes, including 1) direct healthcare resource utilization and 2) total provider reimbursement. RESULTS: Patients with preexisting MHC were more likely to receive adjunctive epilepsy therapy as well as broad-spectrum antiepileptic drugs/antiseizure medications (ASMs). Additionally, patients with focal seizures and MHC were significantly more likely to utilize high-cost healthcare services. The presence of MHC was associated with approximately 50% greater utilization of emergency department (ED), physician, and inpatient services. Consequently, healthcare expenditures were significantly higher among patients with MHC ($17,596 vs. $10,857; 62% higher, p < 0.001), with the trend consistent across all care settings. CONCLUSIONS: This analysis illustrates the health service utilization and cost implications of MHC among patients with focal seizures. The data suggest that patients with MHC have a greater overall clinical burden, which may be associated with higher healthcare resource use and expenditures. Because of the potential burden and costs associated with MHC, neurologists should consider screening patients with focal seizures for mental health disorders to identify and initiate treatment for comorbid mental health disorders.

Economic evaluation of a supported employment program for veterans with spinal cord injury.

Objective: To estimate the net monetary benefit of an individual placement and support-based supported employment program for Veterans with spinal cord injuries.Design: Economic evaluation comparing a supported employment program to treatment as usual, using cost and quality-of-life data from a longitudinal study of Veterans with spinal cord injuries.Setting: Spinal cord injury centers in the Veterans Health Administration.Participants: Subjects (N = 213) who participated in a 24-month supported employment program at seven spinal cord injury centers. Supported employment participants were compared with a group of spinal cord injury Veterans who received treatment as usual in a prior study.Main outcome measures: Costs and quality-adjusted life years using the Veterans Rand-6 Dimension, estimated from the Veterans Rand 36-Item Health Survey.Results: The supported employment program was more effective at both 1- and 2-year periods compared with treatment as usual. Outpatient costs were significantly higher for supported employment, but inpatient costs were not significantly different from treatment as usual. When cost and effectiveness were compared jointly using net monetary benefit, a supported employment program following the core principles of Individual Placement and Supported employment was more effective but not cost-effective at standard willingness to pay thresholds. When we considered a sub-group of the supported employment participants who more closely resemble the treatment as usual group from a randomized trial, there was no significant difference in the cost-effectiveness of supported employment when compared to treatment as usual.Conclusions: With higher effectiveness and similar costs, supported employment for spinal cord injury Veterans has the potential to be cost-effective. Future studies need to randomize participants or carefully match participants based on observable patient characteristics to improve cost-effectiveness evaluations of this population.Implications for RehabilitationSupported employment as part of ongoing rehabilitation care helps individuals with spinal cord injury return to work and improve their quality of life.Many studies show that supported employment programs are cost effective for persons with mental disabilities, but there is only limited economic evaluation data on use of supported employment with persons with spinal cord injury.This study shows that supported employment integrated with ongoing rehabilitation care is more effective in restoring employment and health-related quality of life.

Budget Impact Analysis of Veterans Affairs Medical Foster Homes versus Community Living Centers.

The objectives were to determine whether and by what amounts the US Department of Veterans Affairs (VA) use of Medical Foster Homes (MFH) rather than Community Living Centers (CLC) reduced budget impacts to the VA. This was a retrospective, matched, case-control study of veterans residing in MFH or CLC in the VA health care system from 2008 to 2012. Administrative data sets, nearest neighbor matching, generalized linear models, and a secondary analysis were used to capture and analyze budget impacts by veterans who used MFH or CLC exclusively in 2008-2012. Controls of 1483 veterans in CLC were matched to 203 cases of veterans in MFH. Use of MFH instead of CLC reduced budget impacts to the VA by at least $2645 per veteran per month. A secondary analysis of the data using different matching criteria and statistical methods produced similar results, demonstrating the robustness of the estimates of budget impact. When the average out-of-pocket payments made by MFH residents, not made by CLC residents, were included in the analysis, the net reduction of budget impact ranged from $145 to $2814 per veteran per month or a savings of $1740 to $33,768 per veteran per year. Even though outpatient costs of MFH are higher, much of the reduced budget impact of MFH use arises from lower inpatient or hospital costs. Reduced budget impacts on the VA system indicate that expansion of the MFH program may be cost-effective. Implications for further research are suggested.

EFFECTS OF THE GENIUM KNEE SYSTEM ON FUNCTIONAL LEVEL, STAIR AMBULATION, PERCEPTIVE AND ECONOMIC OUTCOMES IN TRANSFEMORAL AMPUTEES.

Compared to non-microprocessor knees, the C-Leg microprocessor knee (MPK) is bioenergentically and economically more efficient and safer for transfemoral amputation (TFA) patients. The Genium MPK has demonstrated improvements in perceived function, knee kinematics, and physical functional performance compared to C-Leg. Clinical and health economic analyses have not been conducted with the Genium knee system. The purpose of this study was to determine if laboratory determined benefits of Genium are detectable using common clinical assessments and if there are economic benefits associated with its use. This study utilized a randomized AB crossover study with 60 d follow-up including cost-effectiveness analysis. Twenty TFA patients tested with both knees in mobility and preference measures. Incremental cost-effectiveness ratios (ICER) were calculated based on performance measures. Stair Assessment Index scores improved with Genium. Mean stair completion times and descent stepping rate were not different between knees. Stair ascent stepping rate for C-Leg was greater compared with Genium (p = 0.04). Genium use decreased Four square step test completion time and increased functional level and step activity (p ≤ 0.05). Further, Genium use improved (p ≤ 0.05) function and safety in three out of five Activities of Daily Living (ADL) survey domains. Finally, more subjects preferred Genium following testing. Functional measures were used to calculate ICERs. ICER values for Genium fall within established likely-to-accept value ranges. Compared with C-Leg, Genium use improved stair walking performance, multi-directional stepping, functional level, and perceived function. In this group of community ambulators with TFA, Genium was preferred, and, while more costly, it may be worth funding due to significant improvements in functional performance with ADLs.

ECONOMIC EVALUATIONS OF INTERVENTIONS FOR TRANSTIBIAL AMPUTEES: A SCOPING REVIEW OF COMPARATIVE STUDIES.

Transtibial amputation (TTA) is life-altering emotionally, functionally, and economically. The economic impact to all stakeholders is largely unknown, as is the cost-effectiveness of prosthetic intervention. This scoping report's purpose was to determine if there is sufficient evidence to conduct a formal systematic review or meta-analysis in any particular prosthetic intervention area and to determine if any evidence statements could be synthesized relative to economic evaluation of interventions provided to patients with TTA. The scoping review revealed six articles representing three topical areas of transtibial care: Care Models, Prosthetic Treatment, and Prosthetic Sockets. All six articles were cost-identification or cost-consequence design and included a total of 704 subjects. Presently, it can be concluded with moderate confidence that specific weight-bearing and total-contact sockets for transtibial amputees are functionally and economically equivalent in the short term when costs, delivery time, and all stakeholder perspectives are considered. Long-term socket outcomes are relatively unexplored. Further primary research is needed beyond this to determine cost-effectiveness for other areas of transtibial prosthetic care although clinical outcomes are somewhat established through systematic review and meta-analysis in other areas of care. Conversely, evaluation of narrative economic reports relative to transtibial care may be sufficient to warrant further analysis. Guidance from the profession may also be useful in devising a strategy for how to assure economic analyses are a routine element of future prosthetic science.

The impact of social support at home on health-related quality of life among veterans with spinal cord injury participating in a supported employment program.

PURPOSE: To investigate the impact of social support at home on health-related quality of life (HRQOL) as measured by the VR-6D utility index for spinal cord injury (SCI) veterans participating in a program of supported employment (SE). METHODS: We calculated a preference-based utility index called the VR-6D from the responses from a 36-item instrument called the VR-36. We estimated a growth curve model to examine the change in the VR-6D utility index over time adjusting for social support status, demographics, and chronic comorbidities. RESULTS: Study participants experienced an increase in HRQOL over time. The initial level and the rate of increase in HRQOL varied by groups based on their support status. The rate of increase in HRQOL diminished over time. Participants reporting no support at home experienced lower initial HRQOL but reached the same level of those who reported having support at home by the ninth month of follow-up. Quality-adjusted life-years, as measured by the area under the curves, were approximately the same for both groups after 2 years. CONCLUSIONS: Differences in the rate of change in HRQOL by support status have important implications for evaluations of SE programs. Participants in this program of SE experienced improvement in HRQOL beyond 12 months and extending to 2 years. Follow-up times for evaluations should extend beyond 12 months to assess complete improvements in HRQOL. Future comparison groups in comparative effectiveness evaluations of SE need to be balanced carefully on support status in addition to other factors.

Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial.

BACKGROUND & AIMS: Although surgery is the standard technique for drainage of pancreatic pseudocysts, use of endoscopic methods is increasing. We performed a single-center, open-label, randomized trial to compare endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage. METHODS: Patients with pancreatic pseudocysts underwent endoscopic (n = 20) or surgical cystogastrostomy (n = 20). The primary end point was pseudocyst recurrence after a 24-month follow-up period. Secondary end points were treatment success or failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and total costs. RESULTS: At the end of the follow-up period, none of the patients who received endoscopic therapy had a pseudocyst recurrence, compared with 1 patient treated surgically. There were no differences in treatment successes, complications, or re-interventions between the groups. However, the length of hospital stay was shorter for patients who underwent endoscopic cystogastrostomy (median, 2 days, vs 6 days in the surgery group; P < .001). Although there were no differences in physical component scores and mental health component scores (MCS) between groups at baseline on the Medical Outcomes Study 36-Item Short-Form General Survey questionnaire, longitudinal analysis showed significantly better physical component scores (P = .019) and mental health component scores (P = .025) for the endoscopy treatment group. The total mean cost was lower for patients managed by endoscopy than surgery ($7011 vs $15,052; P = .003). CONCLUSIONS: In a randomized trial comparing endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage, none of the patients in the endoscopy group had pseudocyst recurrence during the follow-up period, therefore there is no evidence that surgical cystogastrostomy is superior. However, endoscopic treatment was associated with shorter hospital stays, better physical and mental health of patients, and lower cost. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00826501.

Safety, energy efficiency, and cost efficacy of the C-Leg for transfemoral amputees: A review of the literature.

The purpose of this paper was to review the literature through a structured literature review and provide a grade of recommendation for patient safety, gait energy efficiency, and cost effectiveness of the C-Leg microprocessor-controlled prosthetic knee for transfemoral amputees. Medline (Ovid) and CINAHL (EBSCO) data bases were searched to identify potentially pertinent studies within the 1995-2009 time range. Studies were screened and sorted. Pertinent studies were rated for methodologic quality and for risk of bias. Following assessment of methodologic quality and bias risk, the level of evidence and a grade of recommendation was determined for each of three categories: Safety, energy efficiency, and cost effectiveness. A total of 18 articles were determined to be pertinent: seven for safety, eight for energy efficiency, and three for cost effectiveness. Methodologic quality was low with a moderate risk of bias in the safety and energy effectiveness categories. Studies in cost effectiveness received high scores for methodologic quality. Though methodologic quality varied across the selected topics, there was sufficient evidence to suggest increased efficacy of the C-Leg in the areas of safety, energy efficiency and cost when compared with other prosthetic knees for transfemoral amputees.

The impact of cost on the availability of fruits and vegetables in the homes of schoolchildren in Birmingham, Alabama.

OBJECTIVES: Fruit and vegetable cost is a presumed barrier to intake. We sought to determine whether fruit and vegetable cost and consumers' race and income would predict availability of fruits and vegetables in homes of schoolchildren in the Birmingham, Ala, area. METHODS: Data on availability of 27 fruit and vegetable items were obtained from homes of 1355 children (32% African American) in the Birmingham area. Fruit and vegetable costs were obtained from the US Department of Agriculture. We used discrete choice analysis with the dependent variable represented as presence or absence of the fruit or vegetable item. Explanatory variables included fruit and vegetable price per serving; child's gender, race, and age; and parent's body mass index and income. RESULTS: Higher cost was inversely related to fruit and vegetable availability. Higher income, African American race, and female gender were positively related to availability. Cost per serving was stratified into 3 categories-low, medium, and high. Relative to low-cost items, only high-cost items decreased the odds of availability significantly. CONCLUSIONS: Fruit and vegetable cost does impact availability and has the greatest impact for high-cost items. Although cost was inversely related to availability, African Americans reported higher fruit and vegetable availability than Whites. Additional studies are needed to determine whether food items of lower nutritive value and comparable cost impact availability.