Trends in low-value cancer care during the COVID-19 pandemic.

OBJECTIVE: To assess the association between the onset of the COVID-19 pandemic and change in low-value cancer services. STUDY DESIGN: In this retrospective cohort study, we used administrative claims from the HealthCore Integrated Research Environment, a repository of medical and pharmacy data from US health plans representing more than 80 million members, between January 1, 2016, and March 31, 2021. METHODS: We used linear probability models to investigate the relation between the onset of the COVID-19 pandemic and 4 guideline-based metrics of low-value cancer care: (1) conventional fractionation radiotherapy instead of hypofractionated radiotherapy for early-stage breast cancer; (2) non-guideline-based antiemetic use for minimal-, low-, or moderate- to high-risk chemotherapies; (3) off-pathway systemic therapy; and (4) aggressive end-of-life care. We identified patients with new diagnoses of breast, colorectal, and/or lung cancer. We excluded members who did not have at least 6 months of continuous insurance coverage and members with prevalent cancers. RESULTS: Among 117,116 members (median [IQR] age, 60 [53-69] years; 72.4% women), 59,729 (51.0%) had breast cancer, 25,751 (22.0%) had colorectal cancer, and 31,862 (27.2%) had lung cancer. The payer mix was 18.7% Medicare Advantage or Medicare supplemental and 81.2% commercial non-Medicare. Rates of low-value cancer services exhibited minimal changes during the pandemic, as adjusted percentage-point differences were 3.93 (95% CI, 1.50-6.36) for conventional radiotherapy, 0.82 (95% CI, -0.62 to 2.25) for off-pathway systemic therapy, -3.62 (95% CI, -4.97 to -2.27) for non-guideline-based antiemetics, and 2.71 (95% CI, -0.59 to 6.02) for aggressive end-of-life care. CONCLUSIONS: Low-value cancer care remained prevalent throughout the pandemic. Policy makers should consider changes to payment and incentive design to turn the tide against low-value cancer care.

Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program: A Qualitative Study.

Importance: The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized. Objective: To understand the priorities, strategies, and challenges of ACO leaders in MSSP. Design, Setting, and Participants: In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program. Main Outcomes and Measures: Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians. Results: Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives. Conclusions and Relevance: In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.

The effect of hurricanes on mental health over the long term.

Existing causal studies examining the impact of hurricanes on health and health-related outcomes typically focus on short-run impacts and specific outcomes associated with physical health. In this paper, I explore the long-term effects of Hurricanes Katrina and Rita on the mental health of adults using two individual-level datasets from the Behavioral Risk Factor Surveillance System and the Panel Survey of Income Dynamics. Difference-in-differences models are used to estimate the long-run causal impact of hurricanes. I compare the mental health of adults living in Katrina and Rita affected counties to those in other counties before and after the hurricanes. My findings suggest that the hurricanes increased the number of poor mental health days by 0.49 days per 30 days (14.5 %) during a seven-year post period (2006-2012) and psychological distress by 0.46 K-6 points (15.2 %) during a six-year post period. I also find that the estimated effects were notably larger among specific sub-groups, such as single mothers and black respondents. These results are robust to different sample and functional form specifications. From a policy perspective, these findings suggest that long-lasting effects need to be included in any analysis of the impact of hurricanes in order to capture their full effect.

Distribution of a Remote Medical Exam Device Associated with an Increase in Telehealth Use.

Background: The COVID-19 pandemic accelerated telehealth adoption, but its effects on care quality and costs remain unclear. This study evaluates a remote patient monitoring device's impact on utilization and spending. Methods: A large insurer launched a pilot program involving 2,880 households, representing 6,731 members in three states. Administrative claims data compared participant households to a matched group lacking necessary contact information for participation. Results: Participants had a 0.19 per member (p = 0.03) increase in telehealth visits and a 0.19 per member (p = 0.08) decrease in outpatient in-person visits relative to nonparticipants during the post 6-month period. No significant differences were observed in total outpatient and emergency department visits or total spending. Subgroup analyses revealed a significant reduction in telehealth visits followed by in-person outpatient visits in households with younger children (-9.1%; p < 0.05). Conclusion: This evaluation suggests that remote devices may boost telehealth utilization without increasing costs.