Identifying undercompensated groups defined by multiple attributes in risk adjustment.

OBJECTIVE: To identify undercompensated groups in plan payment risk adjustment that are defined by multiple attributes with a systematic new approach, improving on the arbitrary and inconsistent nature of existing evaluations. METHODS: Extending the concept of variable importance for single attributes, we construct a measure of 'group importance' in the random forests algorithm to identify groups with multiple attributes that are undercompensated by current risk adjustment formulas. Using 2016-2018 IBM MarketScan and 2015-2018 Medicare claims and enrolment data, we evaluate two risk adjustment scenarios: the risk adjustment formula used in the individual health insurance Marketplaces and the risk adjustment formula used in Medicare. RESULTS: A number of previously unidentified groups with multiple chronic conditions are undercompensated in the Marketplaces risk adjustment formula, while groups without chronic conditions tend to be overcompensated in the Marketplaces. The magnitude of undercompensation when defining groups with multiple attributes is many times larger than with single attributes. No complex groups were found to be consistently undercompensated or overcompensated in the Medicare risk adjustment formula. CONCLUSIONS: Our method is effective at identifying complex undercompensated groups in health plan payment risk adjustment where undercompensation creates incentives for insurers to discriminate against these groups. This work provides policy-makers with new information on potential targets of discrimination in the healthcare system and a path towards more equitable health coverage.

Correlation Between Patient-Reported Outcome Measures and Health Insurance Provider Types in Patients with Hip Osteoarthritis.

BACKGROUND: Patient-reported outcome measures (PROMs) are frequently utilized to assess patient perceptions of health and function. Numerous factors influence self-reported physical and mental health outcome scores. The purpose of this study was to examine if an association exists between insurance payer type and baseline PROM scores in patients diagnosed with hip osteoarthritis. METHODS: We retrospectively reviewed the baseline PROM scores of 5,974 patients diagnosed with hip osteoarthritis according to the International Classification of Diseases, Tenth Revision (ICD-10) code within our institutional database from 2015 to 2020. We examined Hip disability and Osteoarthritis Outcome Score-Physical Function Short-form (HOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, and PROMIS Global-Physical scores. Descriptive analyses, analysis of variance (ANOVA), analysis of covariance (ANCOVA), and post hoc analyses were utilized to assess variations in PROM scores across insurance type. RESULTS: The mean age (and standard deviation) of the study population was 63.5 ± 12.2 years, and 55.7% of patients were female. The Medicaid cohort had a comparatively higher percentage of Black, Hispanic, and non-English-speaking patients and a lower median household income. The Charlson Comorbidity Index was highest in the Medicare and Medicaid insurance cohorts. Patients utilizing commercial insurance consistently demonstrated the highest baseline PROMs, and patients utilizing Medicaid consistently demonstrated the lowest baseline PROMs. Subsequent analyses found significantly poorer mean scores for the Medicaid cohort for all 4 PROMs when compared with the commercial insurance and Medicare cohorts. These score differences exceeded the minimal clinically important differences (MCIDs). For the PROMIS Global-Mental subscore, a significantly lower mean score was observed for the Workers' Compensation and motor vehicle insurance cohort when compared with the commercial insurance and Medicare cohort. This difference also exceeded the MCID. CONCLUSIONS: PROM scores in patients with hip osteoarthritis varied among those with different insurance types. Variations in certain demographic and health indices are potential drivers of these observed baseline PROM differences. For patients with hip osteoarthritis, the use of PROMs for research, clinical, or quality-linked payment metrics should acknowledge baseline variation between patients with different insurance types. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Contrasting Clinician and Insurer Perspectives to Managing Irritable Bowel Syndrome: Multilevel Modeling Analysis.

INTRODUCTION: Insurance coverage is an important determinant of treatment choice in irritable bowel syndrome (IBS), often taking precedence over desired mechanisms of action or patient goals/values. We aimed to determine whether routine and algorithmic coverage restrictions are cost-effective from a commercial insurer perspective. METHODS: A multilevel microsimulation tracking costs and outcomes among 10 million hypothetical moderate-to-severe patients with IBS was developed to model all possible algorithms including common global IBS treatments (neuromodulators; low fermentable oligo-, di-, and mono-saccharides, and polyols; and cognitive behavioral therapy) and prescription drugs treating diarrhea-predominant IBS (IBS-D) or constipation-predominant IBS (IBS-C) over 1 year. RESULTS: Routinely using global IBS treatments (central neuromodulator; low fermentable oligo-, di-, and mono-saccharides, and polyols; and cognitive behavioral therapy) before US Food and Drug Administration-approved drug therapies resulted in per-patient cost savings of $9,034.59 for IBS-D and $2,972.83 for IBS-C over 1 year to insurers, compared with patients starting with on-label drug therapy. Health outcomes were similar, regardless of treatment sequence. Costs varied less than $200 per year, regardless of the global IBS treatment order. The most cost-saving and cost-effective IBS-D algorithm was rifaximin, then eluxadoline, followed by alosetron. The most cost-saving and cost-effective IBS-C algorithm was linaclotide, followed by either plecanatide or lubiprostone. In no scenario were prescription drugs routinely more cost-effective than global IBS treatments, despite a stronger level of evidence with prescription drugs. These findings were driven by higher prescription drug prices as compared to lower costs with global IBS treatments. DISCUSSION: From an insurer perspective, routine and algorithmic prescription drug coverage restrictions requiring failure of low-cost behavioral, dietary, and off-label treatments appear cost-effective. Efforts to address insurance coverage and drug pricing are needed so that healthcare providers can optimally care for patients with this common, heterogenous disorder.

Pricing in commercial dental insurance and provider markets.

OBJECTIVE: To examine the impact of commercial dental insurer and provider concentration on dentist reimbursement. DATA SOURCES: We utilized provider data from the American Dental Association, reimbursement data from IBM Watson MarketScan® Commercial Research Databases, submitted billed charges from FAIR Health® , dental insurance market concentration data from FAIR Health® , and county-level demographic and economic data from the Area Health Resources File and the Council for Community and Economic Research. STUDY DESIGN: We used the Herfindahl-Hirschman Index to separately measure commercial dental insurance concentration and dentist concentration. We studied the effect of provider and insurance concentration on dentist reimbursement. Using two-stage least squares, we accounted for potential endogeneity in dental insurer and provider concentration. PRINCIPAL FINDINGS: Across the dental procedures we examined, a 10 percent increase in dental insurance concentration is associated with a 1.95 percent (P-value = .033) reduction in gross payments to dentists. Conversely, a 10 percent increase in dentist concentration is associated with a more modest 0.71 percent (P-value = .024) increase in gross payments. A 10 percent increase in dental insurance concentration is associated with a 1.16 percentage point (P-value = .016) decline in the allowed-to-list price ratio, while a 10 percent increase in dentist concentration is associated with a 0.56 percentage point (P-value = .001) increase in the allowed-to-list price ratio. Similar patterns were found across dental procedure subcategories. CONCLUSIONS: Dental provider markets are substantially less concentrated than insurance markets, which may limit the ability of dentists to garner higher reimbursement.

Japanese insurers' attitudes toward adverse selection and genetic discrimination: a questionnaire survey and interviews with employees about using genetic test results.

Since the 1990s, insurance has been the primary field focused on the social disadvantages of using genetic test results because of the concerns related to adverse selection. Although life insurance is popular in Japan, Japan does not currently have any regulations on the use of genetic information and insurers have largely kept silent for decades. To reveal insurers' attitudes on the topic, we conducted an anonymous questionnaire survey with 100 insurance company employees and recruited nine interviewees from the survey respondents. We found that genetic discrimination is not generally considered as a topic of human rights. We also found that insurers have uncertain fears and concerns about adverse selection in terms of actuarial fairness but not regarding profits. When it comes to preparing guidelines on the use of genetic information by Japanese insurers, we believe that public dialog and consultation are necessary to gain understanding of the people.

Changes in Drug List Prices and Amounts Paid by Patients and Insurers.

Importance: High out-of-pocket drug costs can cause patients to skip treatment and worsen outcomes, and high insurer drug payments could increase premiums. Drug wholesale list prices have doubled in recent years. However, because of manufacturer discounts and rebates, the extent to which increases in wholesale list prices are associated with amounts paid by patients and insurers is poorly characterized. Objective: To determine whether increases in wholesale list prices are associated with increases in amounts paid by patients and insurers for branded medications. Design, Setting, and Participants: Cross-sectional retrospective study analyzing pharmacy claims for patients younger than 65 years in the IBM MarketScan Commercial Database and pricing data from SSR Health, LLC, between January 1, 2010, and December 31, 2016. Pharmacy claims analyzed represent claims of employees and dependents participating in employer health benefit programs belonging to large employers. Rebate data were estimated from sales data from publicly traded companies. Analysis focused on the top 5 patent-protected specialty and 9 traditional brand-name medications with the highest total drug expenditures by commercial insurers nationwide in 2014. Data were analyzed from July 2017 to July 2020. Exposures: Calendar year. Main Outcomes and Measures: Changes in inflation-adjusted amounts paid by patients and insurers for branded medications. Results: In this analysis of 14.4 million pharmacy claims made by 1.8 million patients from 2010-2016, median drug wholesale list price increased by 129% (interquartile range [IQR], 78%-133%), while median insurance payments increased by 64% (IQR, 28%-120%) and out-of-pocket costs increased by 53% (IQR, 42%-82%). The mean percentage of wholesale list price accounted for by discounts increased from 17% in 2010 to 21% in 2016, and the mean percentage of wholesale list price accounted for by rebates increased from 22% in 2010 to 24% in 2016. For specialty medications, median patient out-of-pocket costs increased by 85% (IQR, 73%-88%) from 2010 to 2016 after adjustment for inflation and 42% (IQR, 25%-53%) for nonspecialty medications. During that same period, insurer payments increased by 116% for specialty medications (IQR, 100%-127%) and 28% for nonspecialty medications (IQR, 5%-34%). Conclusions and Relevance: This study's findings suggest that drug list prices more than doubled over a 7-year study period. Despite rising manufacturer discounts and rebates, these price increases were associated with large increases in patient out-of-pocket costs and insurer payments.

The Impact of COVID-19 on the Insurance Industry.

This study investigated the impact of COVID-19 on the insurance industry by studying the case of Ghana from March to June 2020. With a parallel comparison to previous pandemics such as SARS-CoV, H1N1 and MERS, we developed outlines for simulating the impact of the pandemic on the insurance industry. The study used qualitative and quantitative interviews to estimate the impact of the pandemic. Presently, the trend is an economic recession with decreasing profits but increasing claims. Due to the cancellation of travels, events and other economic losses, the Ghanaian insurance industry witnessed a loss currently estimated at GH Ȼ112 million. Our comparison and forecast predicts a normalization of economic indicators from January 2021. In the meantime, while the pandemic persists, insurers should adapt to working from remote locations, train and equip staff to work under social distancing regulations, enhance cybersecurity protocols and simplify claims/premium processing using e-payment channels. It will require the collaboration of the Ghana Ministry of Health, Banking Sector, Police Department, Customs Excise and Preventive Service, other relevant Ministries and the international community to bring the pandemic to a stop.

Fraudster's and victims' profiles and loss predictors' hierarchy in the mental healthcare industry in the US.

BACKGROUND: Fraud- or theft-related crimes account for the highest number of crimes in the mental health industry in the US. AIM: This exploratory study aims to demonstrate a fraudster's and respective victims' profiles as well as to identify the loss predictors' hierarchy in the mental health industry in the US. MATERIALS AND METHODS: The Psychiatric Crime database and mixed-effects models are utilized for this purpose. RESULTS: A typical fraudster's profile is defined as a 53-year old male psychiatrist who victimizes one or two of the largest federal insurance programs in states with high property crime ratios. The results revealed the year and state where the fraud is prosecuted explain the largest portion of the variance in loss size. Predictably, case-specific factors also have a significant impact on the loss. Specifically, Medicaid, the existence of collusion, and fraudster's age are associated with the fraud loss. CONCLUSIONS: This study empirically justifies considering loss, due to healthcare fraud, from a multi-level perspective. Identified typical fraudster's and respective victim's profiles helped to elaborate on specific practical recommendations aimed at fraud prevention in the mental healthcare system in the US.

Economic impact of cardiac implantable electronic device infections: cost analysis at one year in a large U.S. health insurer.

Aims: Cardiac device infections (CDIs) are serious adverse events associated with morbidity and mortality, significant costs and increased healthcare utilization. The objective of the current study was to characterize the CDI rate by device type, risk factors for infection and healthcare costs from a large U.S. health insurer perspective.Materials and Methods: A retrospective analysis of a large U.S. health insurer database identified commercial and Medicare Advantage with Part D (MAPD) members ≥18 years with ≥1 claim for a cardiac implantable electronic device (CIED) procedure between 01 October 2011 and 31 October 2015. CIEDs included pacemakers (IPG), implantable cardioverter defibrillators (ICDs), and cardiac resynchronization therapy - pacemakers without (CRT-P) and with defibrillation (CRT-D). Probabilities of CDI through one-year post implant were estimated using the Kaplan-Meier method. A regression model with stepwise variable selection was used to select risk factors associated with CDIs.Results: A total of 63,406 patients were included with an overall CDI rate of 1.28% (1.0% de novo and 1.74% replacement devices), varying by device type: IPG = 0.91%; ICD = 1.63%; CRT-p = 1.50%; CRT-D = 2.22%. The average adjusted annual medical costs were 2.4 times greater [95% confidence interval (CI) = 2.1-2.7] for those with an infection compared to those without, and the incremental cost difference was estimated to be $57,322 [95% CI $46,572-$70,484]. Observed risk factors of CDIs included prior device infection [Odds ratio (OR) = 11.356; 95% CI = 7.923-16.276], undergoing a CIED replacement procedure (OR = 1.644; 95% CI = 1.361-1.987), implantation of a high-power device (OR = 1.354; 95% CI = 1.115-1.643), and younger age (age < 65) (OR = 1.607; 95% CI = 1.307-1.976).Conclusions: The CDI rate at one year ranged from 0.91%-2.22% depending on device type. Management of CDIs among commercial and MAPD members is associated with high healthcare expenditures.

A ready-to-use liquid glucagon for treatment of severe hypoglycemia demonstrates reduced healthcare payer costs in a budget impact model.

Research aim: To model the annual value of a novel ready-to-use, room-temperature stable liquid glucagon rescue pen and prefilled syringe (GRP, G-PFS; Xeris Pharmaceuticals, Inc.) for treatment of severe hypoglycemia events (SHE) versus current lyophilized powder glucagon emergency kits (GEK). GRP is a prefilled auto-injector designed to promptly administer concentrated liquid glucagon in a simple two-step process. G-PFS is a stable liquid formulation of glucagon in a prefilled syringe. In simulated emergencies, GRP and G-PFS demonstrated high functional efficacy, where 99% of users successfully administered a full-dose of drug. Studies with currently available injectable GEK suggest very low success rates (6-31%). The high functional efficacy of GRP and G-PFS significantly reduces user errors and may reduce utilization across emergency medical services (EMS), emergency departments (ED), and inpatient and outpatient costs for SHE.Methods: To estimate the economic impact of GRP and G-PFS, we developed a one-year budget impact model from a US commercial health plan perspective. Cost offsets from successful glucagon administration incorporated EMS, ED, inpatient, and outpatient utilization. Diabetes prevalence and event probabilities were estimated from publicly-available sources and clinical expert opinion. Costs (US$) were obtained from the 2018 Medicare Fee Schedules and adjusted to represent commercial payer costs.Results: GRP and G-PFS led to fewer EMS, ED, inpatient, and outpatient costs compared to GEK and no kit, resulting in total per-patient SHE costs of $2,564, $3,606, and $3,849, respectively. Costs for 1 million covered lives were 8.2 million following the introduction of GRP and G-PFS compared to almost 9 million before GRP and G-PFS.Limitations: The model is limited by reliance on assumptions based on expert opinion for key variables, primarily the probability of: (1) ambulance calls, (2) ambulance transport to the ED, and (3) non-ambulance transport to the ED.Conclusions: A budget impact model suggests GRP and G-PFS can lead to significant annual cost savings for US commercial payers.

A budget impact analysis for making treatment decisions based on anti-cyclic citrullinated peptide (anti-CCP) testing in rheumatoid arthritis.

Aim: Given that rheumatoid arthritis (RA) patients with high anti-citrullinated protein antibodies (ACPA) titer values respond well to abatacept, the aim of this study was to estimate the annual budget impact of anti-cyclic citrullinated peptide (anti-CCP) testing and treatment selection based on anti-CCP test results.Materials and methods: Budget impact analysis was conducted for patients with moderate-to-severe RA on biologic or Janus kinase inhibitor (JAKi) treatment from a hypothetical US commercial payer perspective. The following market scenarios were compared: (1) 90% of target patients receive anti-CCP testing and the results of anti-CCP testing do not impact the treatment selection; (2) 100% of target patients receive anti-CCP testing and the results of anti-CCP testing have an impact on treatment selection such that an increased proportion of patients with high titer of ACPA receive abatacept. A hypothetical assumption was made that the use of abatacept would be increased by 2% in Scenario 2 versus 1. Scenario analyses were conducted by varying the target population and rebate rates.Results: In a hypothetical health plan with one million insured adults, 2,181 patients would be on a biologic or JAKi treatment for moderate-to-severe RA. In Scenario 1, the anti-CCP test cost was $186,155 and annual treatment cost was $101,854,295, totaling to $102,040,450. In Scenario 2, the anti-CCP test cost increased by $20,684 and treatment cost increased by $160,467, totaling an overall budget increase of $181,151. This was equivalent to a per member per month (PMPM) increase of $0.015. The budget impact results were consistently negligible across the scenario analyses.Limitations: The analysis only considered testing and medication costs. Some parameters used in the analysis, such as the rebate rates, are not generalizable and health plan-specific.Conclusions: Testing RA patients to learn their ACPA status and increasing use of abatacept among high-titer ACPA patients result in a small increase in the total budget (<2 cents PMPM).