A primer on brand-name prescription drug contracting.

Prescription drug contracting in the United States has evolved over decades from discounts provided to members of early health maintenance organization plans to rebate contracts to more complex value-based purchasing arrangements. This primer describes the history of contracting between pharmaceutical manufacturers and managed care pharmacy organizations and details the various contracting methods used today.

Concordance of Disclosed Hospital Prices With Total Reimbursements for Hospital-Based Care Among Commercially Insured Patients in the US.

Importance: To improve health care price transparency and promote cost-conscious selection of health care organizations and practitioners, the Centers for Medicare & Medicaid Services (CMS) required that hospitals share payer-specific negotiated prices for selected shoppable health services by January 2021. While this regulation improves price transparency, it is unclear whether disclosed prices reflect total costs of care, since many hospital-based services are delivered and billed separately by independent practitioners or other health care entities. Objective: To assess the extent to which prices disclosed under the new hospital price transparency regulation are correlated with total costs of care among commercially insured individuals. Design, Setting, and Participants: This cross-sectional study used a large database of commercial claims from 2018 to analyze encounters at US hospitals for shoppable health care services for which price disclosure is required by CMS. Data were analyzed from November 2020 to February 2021. Exposures: Whether the service was billed by the hospital or another entity. Main Outcomes and Measures: Outcomes of interest were the percentage of encounters with at least 1 service billed by an entity other than the hospital providing care, number of billing entities, amounts billed by nonhospital entities, and the correlation between hospital and nonhospital reimbursements. Results: The study analyzed 4 545 809 encounters for shoppable care. Independent health care entities were involved in 7.6% (95% CI, 6.7% to 8.4%) to 42.4% (95% CI, 39.1% to 45.6%) of evaluation and management encounters, 15.9% (95% CI, 15.8% to 16%) to 22.2% (95% CI, 22% to 22.4%) of laboratory and pathology services, 64.9% (95% CI, 64.2% to 65.7%) to 87.2% (95% CI, 87.1% to 87.3%) of radiology services, and more than 80% of most medicine and surgery services. The median (IQR) reimbursement of independent practitioners ranged from $61 ($52-$102) to $412 ($331-$466) for evaluation and management, $5 ($4-$6) to $7 ($4-$12) for laboratory and pathology, $26 ($20-$32) to $210 ($170-$268) for radiology, and $47 ($21-$103) to $9545 ($7750-$18 277) for medicine and surgery. The reimbursement for services billed by the hospital was not strongly correlated with the reimbursement of independent clinicians, ranging from r = -0.11 (95% CI, -0.69 to 0.56) to r = 0.53 (95% CI, 0.13 to 0.78). Conclusions and Relevance: This cross-sectional study found that independent practitioners were frequently involved in the delivery of shoppable hospital-based care, and their reimbursement may have represented a substantial portion of total costs of care. These findings suggest that disclosed hospital reimbursement was usually not correlated with total cost of care, limiting the potential benefits of the hospital price transparency rule for improving consumer decision-making.

Private payers' varicose vein policies are inaccurate, disparate, and not evidence based, which mandates a proposal for a reasonable and responsible policy for the treatment of venous disease.

Varicose veins afflict more than one in five Americans, and although varicose veins may be an asymptomatic cosmetic concern in some, many others experience symptoms of pain, aching, heaviness, itching, and swelling. More advanced venous disease can result from untreated venous insufficiency. The complications of chronic venous disease, including bleeding, thrombosis, and ulceration, are seen in up to 2 million Americans annually. Numerous reports have documented venous disease adversely affects quality of life and that treatment of venous disease can improve quality of life. It has previously been documented that private insurers, and Centers for Medicare & Medicaid Services subcontractors for that matter, have disparate policies that in many instances are self-serving, contain mistakes, use outdated evidence, and disregard evidence-based guidelines. The two leading venous medical societies, the American Venous Forum and the American Venous and Lymphatic Society, have come together to review the varicose vein coverage policies of seven major U.S. private medical insurance carriers whose policies cover more than 150 million Americans. The authors reviewed the policies for venous disease and, if significant gaps or inconsistencies are found, we hope to point them out, and, finally, to propose a thoughtful and reasonable policy based on the best available evidence.

Meeting the affordability challenges posed by orphan drugs: a survey of payers, providers, and employers.

BACKGROUND: As an increasing number of orphan drugs are FDA approved, health care payers, employers, and providers are attempting to strike a balance between patient access to innovative treatments and overall affordability. Payers and employers are evaluating how traditional specialty pharmacy management strategies and innovative models can support continued coverage of orphan drugs. OBJECTIVE: To understand how health care stakeholders are meeting the financial challenges posed by the increasing number and cost of orphan drugs and how these strategies are affecting orphan drug acquisition for providers. METHODS: A survey was conducted with payer, provider, and employer decision makers recruited from both AMCP and a proprietary database of market-access decision makers in July and August 2020. Respondents were asked about their experiences and activities in the orphan disease space, including tactics to manage affordability of drugs to treat orphan diseases. RESULTS: Reinsurance was the most commonly utilized strategy to maintain affordability of the benefit for both payers (42%) and employers (55%). Although 31% of payers have adopted gene therapy carve-outs, no employers had done so. Approximately three quarters (76%) of payers believe that limited distribution networks impede their abilities to manage orphan drugs, compared with 4% who believe limited networks improve orphan drug management. For most payers (78%), the decision to cover orphan drugs on either the medical or pharmacy benefit depends on the specific drug. Medical benefit coverage was driven primarily by site-of-care policies (55%) and the lower drug cost of average sales price pricing (50%). Pharmacy benefit coverage was driven primarily by a greater ability to manage the orphan drug (71%) and by rebates (62%). One in 3 (33%) of providers with experience treating orphan diseases acquire orphan drugs exclusively through buy and bill, whereas 10% acquire them exclusively through a specialty pharmacy provider. Buy-and-bill acquisition by providers was driven primarily by improved patient affordability (47%) and 340b pricing (47%). Specialty pharmacy provider acquisition was driven primarily by payer requirements (64%) and reduced administrative burden (64%). CONCLUSIONS: Payers and employers are adopting innovative benefit designs and strategies to cover orphan drugs while maintaining plan affordability. Cost considerations are prominent factors in determining whether orphan drugs will be covered under the pharmacy or medical benefit and how providers will acquire orphan drugs. DISCLOSURES: This research was sponsored by AMCP and PRECISIONvalue. Lopata, Terrone, and Gopalan are employees of PRECISIONvalue. Ladikos and Richardson are employees of AMPC. The authors have nothing further to disclose. This research was presented during the AMCP Partnership Forum "Preparing for and Managing Rare Diseases" held virtually September 8-10, 2020.

AMCP Partnership Forum: Preparing for and managing rare diseases.

Despite the opportunity for large health gains, there are many challenges associated with rare disease therapies. Among these are striking the appropriate balance between the urgency to respond to patient needs with the uncertainty that is often inherent in rare disease therapy datasets leading to concerns with developing and interpreting clinical data; uncertainty around financial impact, value determination, and affordability; and variation in approach to coverage and potential effects on access. To discuss these challenges and opportunities to address them, AMCP held a virtual multidisciplinary stakeholder forum on September 8-10, 2020. Forum participants represented diverse sectors of the health care industry, including integrated delivery systems, health plans, pharmacy benefit managers, employer groups, biopharmaceutical companies, patient advocacy organizations, health policy researchers, and consulting firms; they evaluated strategies to plan for and manage rare disease therapies and recommended best practices and next steps. DISCLOSURES: This forum was sponsored by the following: AstraZeneca, Dicerna, Genentech, National Pharmaceutical Council, Novo Nordisk, Pfizer, Precision Value, Sanofi, Sarepta Therapeutics, Seattle Genetics, Spark Therapeutics, and Takeda. These proceedings were prepared as a summary of the forum to represent common themes; they are not necessarily endorsed by all attendees nor should they be construed as reflecting group consensus.

Patient experience after modifying visit delivery during the COVID-19 pandemic.

OBJECTIVES: To describe real-time changes in medical visits (MVs), visit mode, and patient-reported visit experience associated with rapidly deployed care reorganization during the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Cross-sectional time series from September 29, 2019, through June 20, 2020. METHODS: Responding to official public health and clinical guidance, team-based systematic structural changes were implemented in a large, integrated health system to reorganize and transition delivery of care from office-based to virtual care platforms. Overall and discipline-specific weekly MVs, visit mode (office-based, telephone, or video), and associated aggregate measures of patient-reported visit experience were reported. A 38-week time-series analysis with March 8, 2020, and May 3, 2020, as the interruption dates was performed. RESULTS: After the first interruption, there was a decreased weekly visit trend for all visits (ß3 = -388.94; P < .05), an immediate decrease in office-based visits (ß2 = -25,175.16; P < .01), increase in telephone-based visits (ß2 = 17,179.60; P < .01), and increased video-based visit trend (ß3 = 282.02; P < .01). After the second interruption, there was an increased visit trend for all visits (ß5 = 565.76; P < .01), immediate increase in video-based visits (ß4 = 3523.79; P < .05), increased office-based visit trend (ß5 = 998.13; P < .01), and decreased trend in video-based visits (ß5 = -360.22; P < .01). After the second interruption, there were increased weekly long-term visit trends for the proportion of patients reporting "excellent" as to how well their visit needs were met for all visits (ß5 = 0.17; P < .01), telephone-based visits (ß5 = 0.34; P < .01), and video-based visits (ß5 = 0.32; P < .01). Video-based visits had the highest proportion of respondents rating "excellent" as to how well their scheduling and visit needs were met. CONCLUSIONS: COVID-19 required prompt organizational transformation to optimize the patient experience.

State strategies to address medicaid prescription spending: negotiated pricing vs price transparency.

This research longitudinally examines the association between levels of state Medicaid prescription spending and the state strategies intended to constrain cost increases: the negotiated pricing strategy, as indicated by state rebate programs, and the price transparency strategy, as indicated by state operation of All-Payer Claims Databases. The findings demonstrate evidence that state Medicaid prescription spending is influenced by the negotiated pricing strategy, especially Managed Care Organization (MCO) rebates under the Patient Protection and Affordable Care Act, but not influenced by the price transparency strategy. State decisions for MCO rebates, such as carving prescription benefits into managed care benefits, were effective in containing levels of Medicaid prescription spending over time, while other single- and multi-state rebate programs were not. Based on these findings, state policymakers may consider utilizing the MCO rebate program to address increases in Medicaid prescription spending.

Cost Minimization Analysis of a Teledermatology Triage System in a Managed Care Setting.

Importance: Teledermatology (TD) enables remote triage and management of dermatology patients. Previous analyses of TD systems have demonstrated improved access to care but an inconsistent fiscal impact. Objective: To compare the organizationwide cost of managing newly referred dermatology patients within a TD triage system vs a conventional dermatology care model at the Zuckerberg San Francisco General Hospital and Trauma Center (hereafter referred to as the ZSFG) in California. Design, Setting, and Participants: A retrospective cost minimization analysis was conducted of 2098 patients referred to the dermatology department at the ZSFG between June 1 and December 31, 2017. Intervention: Implementation of the TD triage system in January 2015. Main Outcomes and Measures: The main outcome was mean cost to the health care organization to manage newly referred dermatology patients with or without TD triage. To estimate costs, decision-tree models were constructed to characterize possible care paths with TD triage and within a conventional dermatology care model. Costs associated with primary care visits, dermatology visits, and TD visits were then applied to the decision-tree models to estimate the mean cost of managing patients following each care path for 6 months. The mean cost for each visit type incorporated personnel costs, with the mean cost per TD consultation also incorporating software implementation and maintenance costs. Finally, ZSFG patient data were applied within the models to evaluate branch probabilities, enabling calculation of mean cost per patient within each model. Results: The analysis captured 2098 patients (1154 men [55.0%]; mean [SD] age, 53.4 [16.8] years), with 1099 (52.4%) having Medi-Cal insurance and 879 (41.9%) identifying as non-White. In the decision-tree model with TD triage, the mean (SD) cost per patient to the health care organization was $559.84 ($319.29). In the decision-tree model for conventional dermatology care, the mean (SD) cost per patient was $699.96 ($390.24). Therefore, the TD model demonstrated a statistically significant mean (SE) cost savings of $140.12 ($11.01) per patient. Given an annual dermatology referral volume of 3150 patients, the analysis estimates an annual savings of $441 378. Conclusions and Relevance: Implementation of a TD triage system within the dermatology department at the ZSFG was associated with cost savings, suggesting that managed health care settings may experience significant cost savings from using TD to triage and manage patients.

Financial Implications of Avapritinib for Treatment of Unresectable Gastrointestinal Stromal Tumors in Patients With a PDGFRA Exon 18 Variant or After 3 Previous Therapies in a Hypothetical US Health Plan.

Importance: With the approval of avapritinib for adults with unresectable or metastatic gastrointestinal stromal tumors (GISTs) harboring a platelet-derived growth factor receptor alpha (PDGFRA) exon 18 variant, including PDGFRA D842V variants, and National Comprehensive Cancer Network guideline recommendations as an option for patients with GIST after third-line treatment, it is important to estimate the potential financial implications of avapritinib on a payer's budget. Objective: To estimate the budget impact associated with the introduction of avapritinib to a formulary for metastatic or unresectable GISTs in patients with a PDGFRA exon 18 variant or after 3 or more previous treatments from the perspective of a US health plan. Design, Setting, and Participants: For this economic evaluation, a 3-year budget impact model was developed in March 2020, incorporating costs for drug acquisition, testing, monitoring, adverse events, and postprogression treatment. The model assumed that avapritinib introduction would be associated with increased PDGFRA testing rates from the current 49% to 69%. The health plan population was assumed to be mixed 69% commercial, 22% Medicare, and 9% Medicaid. Base case assumptions included a GIST incidence rate of 9.6 diagnoses per million people, a metastatic PDGFRA exon 18 mutation rate of 1.9%, and progression rate from first-line to fourth-line treatment of 17%. Exposures: The model compared scenarios with and without avapritinib in a formulary. Main Outcomes and Measures: Annual, total, and per member per month (PMPM) budget impact. Results: In a hypothetical 1-million member plan, fewer than 0.1 new patients with a PDGFRA exon 18 variant per year and 1.2 patients receiving fourth-line therapy per year were eligible for treatment. With avapritinib available, the total increase in costs in year 3 for all eligible adult patients with a PDGFRA exon 18 variant was $46 875, or $0.004 PMPM. For patients undergoing fourth-line treatment, the total increase in costs in year 3 was $69 182, or $0.006 PMPM. The combined total budget impact in year 3 was $115 604, or $0.010 PMPM, including an offset of $3607 in postprogression costs avoided or delayed. The higher rates of molecular testing resulted in a minimal incremental testing cost of $453 in year 3. Conclusions and Relevance: These results suggest that adoption of avapritinib as a treatment option would have a minimal budget impact to a hypothetical US health plan. This would be primarily attributable to the small eligible patient population and cost offsets from reduced or delayed postprogression costs.

Racial disparities in medication use: imperatives for managed care pharmacy.

The COVID-19 pandemic and the social unrest pervading U.S. cities in response to the killings of George Floyd and other Black citizens at the hands of police are historically significant. These events exemplify dismaying truths about race and equality in the United States. Racial health disparities are an inexcusable lesion on the U.S. health care system. Many health disparities involve medications, including antidepressants, anticoagulants, diabetes medications, drugs for dementia, and statins, to name a few. Managed care pharmacy has a role in perpetuating racial disparities in medication use. For example, pharmacy benefit designs are increasingly shifting costs of expensive medications to patients, creating affordability crises for lower income workers, who are disproportionally persons of color. In addition, the quest to maximize rebates serves to inflate list prices paid by the uninsured, among which Black and Hispanic people are overrepresented. While medication cost is a foremost barrier for many patients, other factors also propagate racial disparities in medication use. Even when cost sharing is minimal or zero, medication adherence rates have been documented to be lower among Blacks as compared with Whites. Deeper understandings are needed about how racial disparities in medication use are influenced by factors such as culture, provider bias, and patient trust in medical advice. Managed care pharmacy can address racial disparities in medication use in several ways. First, it should be acknowledged that racial disparities in medication use are pervasive and must be resolved urgently. We must not believe that entrenched health system, societal, and political structures are impermeable to change. Second, the voices of community members and their advocates must be amplified. Coverage policies, program designs, and quality initiatives should be developed in consultation with those directly affected by racial disparities. Third, the industry should commit to dramatically reducing patient cost sharing for essential medication therapies. Federal and state efforts to limit annual out-of-pocket pharmacy spending should be supported, even though increased premiums may be an undesirable (yet more equitable) consequence. Finally, information about race should be incorporated into all internal and external reporting and quality improvement activities. DISCLOSURES: No funding was received for the development of this manuscript. Kogut is partially supported by Institutional Development Award Numbers U54GM115677 and P20GM125507 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR), and the RI Lifespan Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose, respectively. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.

Milestones in managed care pharmacy.

Managed care pharmacy has a relatively short history, but one that is defined by significant achievements. Since the late 1960s, managed care pharmacists have applied their unique skills to formulary management, clinical programs, benefit design, and contract negotiations to support patient access to life-saving therapies, while also ensuring cost-effective use of limited health care resources. Key milestones include establishing the pharmacy benefit as an essential component of the U.S. health care system, launching the Medicare Part D program, and expanding medication therapy management services. The year 2020 brings another milestone-the 25th anniversary of AMCP's flagship publication, the Journal of Managed Care + Specialty Pharmacy. This year also serves as an inflection point. As managed care pharmacy professionals prepare for change and the challenges ahead-including the imperative to address the rising costs of health care and health disparities-the use of evidence, utilization management strategies, and innovation will support our continued success. DISCLOSURES: No funding supported the writing of this commentary. The authors have nothing to disclose.

Medicaid managed care and preventable emergency department visits in the United States.

OBJECTIVES: In the United States the percentage of Medicaid enrollees in some form of Medicaid managed care has increased more than seven-fold since 1990, e.g., up from 11% in 1991 to 82% in 2017. Yet little is known about whether and how this major change in Medicaid insurance affects how recipients use hospital emergency rooms. This study compares the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the occurrence of potentially preventable emergency department (ED) use. METHODS: Using data from the 2003-2015 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the non-institutionalized US population, we estimated multivariable logistic regression models to examine the relationship between Medicaid HMO status and potentially preventable ED use. To accommodate the composition of the Medicaid population, we conducted separate repeated cross-sectional analyses for recipients insured through both Medicaid and Medicare (dual eligibles) and for those insured through Medicaid only (non-duals). We explicitly addressed the possibility of selection bias into HMOs in our models using propensity score weighting. RESULTS: We found that the type of Medicaid held by a recipient, i.e., whether an HMO or FFS coverage, was unrelated to the probability that an ED visit was potentially preventable. This finding emerged both among dual eligibles and among non-duals, and it occurred irrespective of the adopted analytical strategy. CONCLUSIONS: Within the U.S. Medicaid program, Medicaid HMO and FFS enrollees are indistinguishable in terms of the occurrence of potentially preventable ED use. Policymakers should consider this finding when evaluating the pros and cons of adopting Medicaid managed care.

AMCP Partnership Forum: What's Next for Specialty Medication Benefit Design and Reimbursement.

Rising specialty drug costs present a challenge for patients and payers. High-cost products, such as gene therapies or immunotherapies, can significantly affect the budget of a payer that does not have the ability to spread risk across a large population. Stakeholders are considering new reimbursement and benefit designs for specialty medications to improve efficiencies and better manage costs. The potential effect of changes to specialty medication benefit designs and reimbursement systems on patient care, access to medications, and the overall health care system are important considerations when assessing the benefits and challenges associated with reform proposals. Options to better manage the affordability of specialty medications are needed to ensure that patients can continue to access medications, while allowing payers to remain good stewards of health care dollars and supporting marketplace competition and incentives to stimulate innovation. New benefit designs that address these needs, while also supporting marketplace competition and providing incentives that stimulate innovation, have been considered. To explore options, AMCP convened a multidisciplinary stakeholder forum on December 10-11, 2019, in Alexandria, VA. Health care leaders representing academia, health plans, integrated delivery systems, industry leaders, pharmaceutical manufacturers, pharmacy benefit managers, employers, federal government agencies, national health care provider organizations, and patient advocacy organizations participated in the forum. The forum was designed for stakeholders to discuss strategies for the following: (a) reduce costs for beneficiaries while maintaining or improving access to prescription drugs; (b) support marketplace competition and incentives for biopharmaceutical innovation; (c) minimize physicians' financial risk associated with managing drug inventories; (d) remove adverse reimbursement incentives for prescribing higher priced drugs; (e) consider the cost-effectiveness of treatments and services across the health care continuum; and (f) support quality measurement and program evaluation metrics. Recommendations emerging from the forum included creation of novel payment models for the most expensive therapies that allow for larger risk pools, while maintaining the sustainability of the reinsurance market remains. Simplification and standardization were cited as goals for system reform and technological innovations that allow health care providers to view cost-effectiveness information at the point of prescribing, combined with value-based contracting were also recommended. Finally, ensuring that plans remain patient-centric and are designed to address patient needs holistically was stressed as an important goal. DISCLOSURES: This partnership forum was sponsored by Amgen, AstraZeneca, Bayer, GSK, Merck, Pfizer, PhRMA, Takeda, and Xcenda. These proceedings were prepared as a summary of the forum to represent common themes; they are not necessarily endorsed by all attendees nor should they be construed as reflecting group consensus.

Economic outcomes of insurer-led care management for high-cost Medicaid patients.

OBJECTIVES: To evaluate the impact of the Community-Based Care Management (CBCM) program on total costs of care and utilization among adult high-need, high-cost patients enrolled in a Medicaid managed care organization (MCO). CBCM was a Medicaid insurer-led care coordination and disease management program staffed by nurse care managers paired with community health workers. STUDY DESIGN: Retrospective cohort analysis. METHODS: We obtained deidentified health plan claims data, enrollment information, and the MCO's monthly registry of the top 10% of costliest patients. The analysis included 896 patients enrolled in CBCM over the course of 2 years (January 2016 to December 2017) and a propensity score-matched cohort of high-cost patients (n = 2152) who received primary care at sites that did not participate in CBCM during the same time period. The primary outcomes were total costs of care and utilization in the 12-month period after enrollment. Secondary outcomes included utilization by care setting: outpatient, inpatient, emergency department, pharmacy, postacute care, and all other remaining sites. We used zero-inflated gamma and Poisson regression models to estimate average differences in postperiod costs and utilization between CBCM enrollees versus non-CBCM enrollees. RESULTS: We did not observe meaningful differences in total costs or visit frequency among CBCM enrollees relative to non-CBCM enrollees. CONCLUSIONS: Although our study found no association between the CBCM program and subsequent cost or utilization outcomes, understanding why these outcomes were not achieved will inform how future Medicaid programs are designed to achieve better patient outcomes and lower costs.

Tests, surgical masks, hospital beds, and ventilators: add big data to the list of tools to fight the coronavirus that are in short supply.

Big data could help identify potential clues about the immediate (and future) impact of coronavirus disease 2019, but it is in short supply.

Strategies for implementing best practices in independent physician associations.

OBJECTIVES: Scholars have highlighted the importance of preventing hospital admissions and readmissions for individuals with costly chronic conditions. Providing effective care management strategies can help reduce inpatient admissions, thereby reducing rising health care costs. However, implementing effective care management strategies may be more difficult for independent physician associations (IPAs) that contract with multiple organizations that have competing interests and agendas. This study aims to identify and investigate strategies that facilitate the implementation of evidence-based best practices among IPAs. STUDY DESIGN: The research synthesized peer-reviewed literature to identify best practices in chronic disease management for Medicare beneficiaries. Subsequently, 20 key informant interviews were conducted to explore barriers and facilitators in adapting these best practices in IPA settings. Informant interviews were conducted with 3 key groups: executives, medical directors, and care managers. METHODS: Key informant interviews were conducted to explore barriers and facilitators in implementing best care management practices. RESULTS: Key informants provided unique insights regarding the challenges of implementing best care management practices among IPAs. These challenges included implementing and sustaining the operations of evidence-based care management programs while maintaining contractual obligations to health plans, engaging physicians in large and diverse networks, and building high-touch programs in large geographic areas using risk-stratifying algorithms. CONCLUSIONS: IPA managed care organizations require unique considerations in regard to selected strategies used to manage chronic disease in Medicare populations. These considerations are critical for optimal management of the population, particularly in a risk-based or pay-for-performance environment.

Fixed effects analysis of the incidence of cardiovascular outcomes under managed care following the managed care backlash.

ABSTRACTS: To examine the impact of increased managed care activity on 30-day readmission and mortality for acute myocardial infarctions and congestive heart failure in U.S. hospitals following the managed care backlash against managed care cost containment practices.The Centers for Medicare and Medicaid Services (CMS) Hospital Compare files, CMS Hospital Cost Report, CMS Medicare Advantage Enrollment files, and Health Resources and Services Administration Area Resource File data for the period 2008 to 2011 were used to construct the study sample. Multivariate fixed effects regression with robust standard errors, hospital fixed effects, and year fixed effects were used to estimate the impact of managed care penetration on adverse cardiovascular outcomes. Our primary outcome measures were readmission and mortality for patients discharged with acute myocardial infarction and congestive heart failure for acute, non-federal hospitals with emergency rooms. To examine effects of hospital ownership status, not-for-profit hospitals were compared to proprietary hospitals.The main analysis revealed that an increase in managed care penetration was associated with a decline in both 30-day readmission and mortality for acute myocardial infarction and congestive heart failure. In the hospital ownership analysis, only the acute myocardial infarction results for proprietary hospitals was statistically significant. All hospital types reported similar congestive heart failure trends as the full sample; however, proprietary hospitals reported greater declines in readmission and mortality.Increased managed care activity is associated with reductions in hospital readmission and mortality following the legislative and consumer backlash against managed care, with differential impacts across hospital ownership type. These finding highlights the important role of managed care in creating quality improvements in the delivery of care in the hospital setting.

Pediatric outpatient utilization by differing Medicaid payment models in the United States.

BACKGROUND: In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients' healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children's outpatient utilization. METHODS: This retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1-18 years using Truven's 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively. RESULTS: Of 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15-1.26]; aOR 2.07[95%CI 2.03-2.13]; aOR 1.86 [95%CI 1.82-1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8-0.83]; aOR 0.61 [95%CI 0.59-0.62], respectively), compared to FFS. CONCLUSIONS: The majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.

Economic burden of osteoporotic fractures in US managed care enrollees.

OBJECTIVES: To examine healthcare resource utilization (HRU) and costs in a population of managed care enrollees who experienced an osteoporotic fracture. STUDY DESIGN: Retrospective cohort study using the Optum Research Database (January 2007 to May 2017). METHODS: All-cause and osteoporosis-related HRU and costs were analyzed in patients 50 years and older with a qualifying index fracture and continuous enrollment with medical and pharmacy benefits for 12 months preindex (baseline period). RESULTS: Of 1,841,263 patients with fractures during the identification period, 302,772 met eligibility criteria. Two-thirds (66.6%) were 65 years and older, 71.6% were women, and 41.2% were commercial (not Medicare Advantage) enrollees. The most common fracture sites were spine (21.9%), radius/ulna (19.5%), and hip (13.7%). Mean (SD) total all-cause healthcare cost was $34,855 ($56,094), with most paid by health plans ($31,863 [$55,025]) versus patients ($2992 [$2935]). Most healthcare costs were for medical ($31,766 [$54,943]) versus pharmacy ($3089 [$6799]) services. Approximately 75% of patients received rehabilitation services (mean [SD] cost = $18,025 [$41,318]). Diagnosis of index fracture during an inpatient stay versus an outpatient visit (cost ratio, 2.16; 95% CI, 2.13-2.19) and fractures at multiple sites (cost ratio, 1.23; 95% CI, 1.21-1.26) were the leading predictors of cost. Kaplan-Meier estimated cumulative second-fracture rates were 6.6% at 1 year, 12.3% at 2 years, 16.9% at 3 years, and 20.9% at 4 years after index fracture. CONCLUSIONS: These findings suggest a significant economic burden associated with fractures, including a high total all-cause cost of care. Early identification and treatment of patients at high risk of fractures are of paramount importance to reduce fracture risk and associated healthcare costs.

The Economic Burden of Out-of-Pocket Expenses for Plastic Surgery Procedures.

BACKGROUND: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients. METHODS: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars. RESULTS: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures. CONCLUSIONS: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.