Multi-Payer Advanced Primary Care Practice Demonstration on quality of care.

OBJECTIVES: We evaluated whether primary care practices in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration improved the quality of care and patient outcomes for beneficiaries. STUDY DESIGN: For our quantitative analyses, we employed a pre-post study design with a comparison group using enrollment data, Medicare fee-for-service claims data, and Medicaid managed care and fee-for-service claims data, covering the period 2 to 4 years before Medicare joined the state patient-centered medical home initiatives through December 2014. We used difference-in-differences (DID) regression analysis to compare quality and outcomes in the period before and after the demonstration began. METHODS: We examined the extent to which MAPCP and comparison group beneficiaries received up to 11 process and preventive care measures, as well as 4 measures of potentially avoidable hospitalizations to assess patient outcomes. RESULTS: Analyses of Medicare and Medicaid data did not consistently reflect the positive impacts intended by the demonstration. Our descriptive and DID analysis found an inconsistent pattern among the process-of-care results, and there were some significant unfavorable associations between participation in MAPCP and avoidable hospitalizations. CONCLUSIONS: Our analyses showed few statistically significant, favorable impacts on quality metrics among Medicare or Medicaid beneficiaries receiving care from MAPCP practices.

Adapting Healthcare Quality Measures to Transgender Individuals.

The healthcare system's rapid shift toward value-based payment poses unique quality measurement challenges and new foci for researchers and policy makers. Quality measures that use sex-specific criteria may inappropriately include or exclude transgender individuals. More large-scale studies must be conducted to incorporate transgender individuals into measures that use sex-specific criteria, and "measure stewards" should consider the existing clinical guidelines and recommendations regarding transgender individuals when developing measures. Systems designed only for cisgender individuals will exacerbate existing transgender healthcare disparities unless they are revamped and flexible to transgender individuals' needs.

Financial and quality impacts of the Medicare physician group practice demonstration.

OBJECTIVE: To examine the impact of the Medicare Physician Group Practice (PGP) demonstration on expenditure, utilization, and quality outcomes. DATA SOURCE: Secondary data analysis of 2001-2010 Medicare claims for 1,776,387 person years assigned to the ten participating provider organizations and 1,579,080 person years in the corresponding local comparison groups. STUDY DESIGN: We used a pre-post comparison group observational design consisting of four pre-demonstration years (1/01-12/04) and five demonstration years (4/05-3/10). We employed a propensity-weighted difference-in-differences regression model to estimate demonstration effects, adjusting for demographics, health status, geographic area, and secular trends. PRINCIPAL FINDINGS: The ten demonstration sites combined saved $171 (2.0%) per assigned beneficiary person year (p<0.001) during the five-year demonstration period. Medicare paid performance bonuses to the participating PGPs that averaged $102 per person year. The net savings to the Medicare program were $69 (0.8%) per person year. Demonstration savings were achieved primarily from the inpatient setting. The demonstration improved quality of care as measured by six of seven claims-based process quality indicators. CONCLUSIONS: The PGP demonstration, which used a payment model similar to the Medicare Accountable Care Organization (ACO) program, resulted in small reductions in Medicare expenditures and inpatient utilization, and improvements in process quality indicators. Judging from this demonstration experience, it is unlikely that Medicare ACOs will initially achieve large savings. Nevertheless, ACOs paid through shared savings may be an important first step toward greater efficiency and quality in the Medicare fee-for-service program.

Pharmaceutical technology assessment: perspectives from payers.

BACKGROUND: Advancements in biologics and personalized medicine and the implementation of national prescription drug policies have likely prompted payers to implement additional health technology assessment and cost-containment strategies. A payer's decision to provide coverage for a drug and its associated benefit design draws on information from many sources. However, there is an incomplete understanding of the process employed and the criteria applied in formulary assessments of pharmaceuticals by public and private health plans. OBJECTIVES: To explore the pharmaceutical technology assessment (PTA) process to determine (a) who is involved in the decision making, (b) the timing and process of assessment and decision making, (c) the information and data that are considered, and (d) the outcomes of the assessment. METHODS: Using a convenience sample drawn for exploratory purposes, we targeted health plans, pharmacy benefit management (PBM) companies, stand-alone Medicare Part D prescription drug plans, Medicaid agencies, and drug compendia. We used multiple approaches to identify and recruit medical and pharmacy directors responsible for prescription drug benefit design and formulary management. We conducted 1-hour semistructured telephone interviews with pharmacy benefit decision makers between November 2009 and April 2010 to address the PTA process, and they rated the importance of different sources and types of evidence. Qualitative analysis and descriptive statistics were used to explore coverage, preferred choice, and utilization management. RESULTS: Thirty-two respondents representing 26 organizations participated in the interview. On a scale from 1 to 5 (not important to very important), interview respondents most valued published peer-reviewed studies, technology assessments, and internal data on drug utilization as sources of information (means = 4.68, 4.22, and 4.14, respectively). Randomized controlled trials (RCTs) and systematic reviews/meta-analyses were the most valued types of evidence (means = 4.40 and 3.66, respectively); economic and observational data studies received low ratings (means = 3.19 and 3.03, respectively). There was substantial variation in the process of evidence review, who and how individuals participated in the process, and outcomes related to formulary tier placement and utilization management. CONCLUSIONS: U.S. health plan payers have established processes for PTA and prefer certain sources and types of evidence. Formulary decision makers value a broad range of information, and the specific factors influencing coverage and utilization management decisions vary across organizations and therapeutic areas.

Evaluation of the Massachusetts Behavioral Health Program: Year 8.

The eight-year provider evaluation of the Massachusetts Behavioral Health Program showed positive assessments of care provision, continuing problems in integration of care, high assessments of the clinical review process, high evaluations for administration, and positive ratings compared with other managed care organizations. Changes in provider organizations continue. Substance abuse and mental health providers gave similar ratings, while inpatient providers were more critical than outpatient providers. Ratings in Year 8 were higher generally than in Year 7. The program continues to be a success; however, improvement in several areas continues to be difficult.