Blue Cross Research Articles

1039-P: Examining Physician Case Studies on Success of Treatment Initiation in Patients with Type 2 Diabetes

Introduction: The Michigan Collaborative for Type 2 Diabetes (MCT2D) is a state-wide quality initiative supported by Blue Cross Blue Shield of Michigan that aims to improve the treatment of diabetes through three initiatives-encouraging increased prescribing of continuous glucose monitoring (CGM), SGLT2i/GLP-1RA medications, and low carbohydrate diet (LCD), defined as 80-130 total grams of carbohydrates per day, with patients on an SGLT2i instructed to stay >100g among 264 primary care practices. The aim of this study was to evaluate physician experience prescribing LCD through case studies. Methods: Each physician participating in MCT2D submitted a case study evaluating their experience implementing MCT2D initiatives. Close-ended questions were assessed using a 4-point scale (Yes, Somewhat, Too Early to Tell, No). Open-ended responses on intervention success were analyzed using a multi-step process of data immersion, generating initial codes, and reorganization. Results: Physicians prescribed a LCD either alone or in combination with CGM and/or SGLT2i/GLP-1RA in 375 of 970 case studies. More than half (51.5%) reported that the intervention(s) achieved the target outcome. Case studies incorporating all three interventions were associated with greater physician satisfaction with results, as compared to diet alone (p<0.01). Five major themes regarding intervention effectiveness were: glycemic control, weight loss, patient motivation, simplification of medications, and combined benefit of multiple interventions. Improvement of blood glucose was reported in 45.9% of LCD alone cases and in 69.1% of cases that involved all three interventions. An increase in patient motivation to achieve improvement in health was most frequently discussed in cases where diet and CGM were combined (67.3%). Conclusion: LCD may have a synergistic effect with the use of CGM and newer medications. These exploratory findings require confirmation through future investigations. Disclosure K.L.Khosrovaneh: None. H.L.Diez: None. C.R.Richardson: Other Relationship; Annals of Family Medicine, JMIR Diabetes, Research Support; Dexcom, Inc., Blue Cross Blue Shield of Michigan, Neilson Foundation. L.Oshman: Stock/Shareholder; Abbott, AbbVie Inc., Merck & Co., Inc., Procter & Gamble, Johnson & Johnson, Eli Lilly and Company. N.Kim: None. J.Rau: None. J.Reiss: None. R.Hisamatsu: None. D.H.Griauzde: None. L.A.Young: None. J.Weisensel: None. J.E.Aikens: None.

1015-P: Impact of Social Vulnerability on Resources for CGM Initiation across Michigan Primary Care Practices

Objective: The Michigan Collaborative for Type 2 Diabetes (MCT2D) is a state-wide quality initiative supported by Blue Cross Blue Shield of Michigan. MCT2D aims to improve type 2 diabetes care by encouraging prescribing of continuous glucose monitoring (CGM), SGLT2i/GLP-1RA medications, and low carbohydrate diets. The study’s purpose was to describe clinic-level resources and barriers to CGM initiation in counties with high and low social vulnerabilities. Methods: We surveyed primary care practice providers about practice-level CGM patient education and barriers, and providers’ understanding of insurance coverage. 169 of 264 practices (64%) completed the survey. We classified practices as high vulnerability (HV; quartile 4), or low vulnerability (LV; quartiles 1-3) using the county-level CDC Social Vulnerability Index. Results: Among HV practices, the main CGM education was prescriber instruction (61.5%), while for LV it was printed material (69.8%). For both HV and LV practices the second most common educational resource was web links (53.9% and 51.6%, respectively). For both practice types, the most common barrier to CGM was patients’ lack of smartphone (60.5%, 62.4%, respectively), followed by patients’ lack of internet (55.3%) for HV practices and patients’ ability to use CGM (38.5%) for LV practices. Provider understanding of Michigan Medicaid CGM coverage policy was similar across practices with most reporting incorrectly that it was akin to Medicare (≥3 injections daily) (35.3% (HV) and 44.0% (LV)) or reporting lack of awareness of coverage (32.4% (HV) and 24.1% (LV)). Conclusions: There is a mismatch between practices’ educational approaches and patients’ access to technology. Improved transparency of CGM coverage criteria would enhance provider understanding and promote equitable access for patients. Limitations include that the data is county-level and further analysis evaluating other practice level social determinants of health is needed. Disclosure K.L.Khosrovaneh: None. R.Busui: Board Member; American Diabetes Association, Consultant; Averitas Pharma, Inc., Lexicon Pharmaceuticals, Inc., Nevro Corp., Novo Nordisk, Roche Diagnostics, Procter & Gamble, Research Support; Novo Nordisk, Medtronic, National Institutes of Health. C.D.Jamison: None. C.R.Richardson: Other Relationship; Annals of Family Medicine, JMIR Diabetes, Research Support; Dexcom, Inc., Blue Cross Blue Shield of Michigan, Neilson Foundation. H.L.Diez: None. J.E.Aikens: None. L.Oshman: Stock/Shareholder; Abbott, AbbVie Inc., Merck & Co., Inc., Procter & Gamble, Johnson & Johnson, Eli Lilly and Company. J.Rau: None. J.Reiss: None. L.A.Young: None. J.Weisensel: None. P.Okeke: None. K.R.Mizokami-stout: None.

Availability of Outpatient Child Psychiatric Care During COVID-19: A Simulated-Patient Study in Three U.S. Cities.

In this study, the authors sought to ascertain the availability of outpatient child psychiatric appointments in three U.S. cities. Using a simulated-patient methodology, investigators called 322 psychiatrists who were listed in a major insurer's database for three U.S. cities, and they attempted to make appointments for a child with three payment types: Blue Cross-Blue Shield, Medicaid, and self-pay. Initial appointments were available 11% of the time, and it was most difficult to obtain an appointment under Medicaid coverage. Nineteen percent of phone numbers were wrong, and 25% of psychiatrists were not accepting new patients. These results are concerning given the current mental health crisis among youths and suggest the need for more psychiatrists, higher reimbursement rates for psychiatric services, and continued efforts to increase access to care. This study also highlights the need for insurance companies to maintain accurate information in their databases.

MSR79 Predicting Medication Adherence Using Blue Cross and Blue Shield of Louisiana's Historical Medical Claims

Medication non-adherence contributes to significant health care costs and detriments overall quality of life. Non-adherence may cause underlying conditions to spiral out of control until a disease is no longer manageable. Historically, only around 60% of prescribed medications are taken properly. Blue Cross and Blue Shield of Louisiana introduces the risk of medication non-adherence (RoMNA) models which leverage machine learning to predict whether someone is at risk of not taking their medication as prescribed. The models predict three classes of drugs: diabetes medications (non-insulin), anti-hypertensives and statins.

PCR197 Right Member, Right Time, Right Care: Evaluating Blue Cross and Blue Shield of Louisiana’s Impactability Score

Targeting only high-risk members can lead to missed opportunities. That prompted Blue Cross and Blue Shield of Louisiana in 2019 to develop an impactability score that measures a member’s likelihood of being affected by intervention. Blue Cross further developed the score in 2021 by adding new and more granular score drivers (such as newly identified diabetes and out-of-control diabetes) and expanding the score to different intervention approaches. Blue Cross began applying these outreach efforts in January 2022 by prioritizing members with a higher score. This research evaluates the effectiveness of the modified outreach prioritization effort.

OP4 Prioritization of ADT Notifications Improves Efficiency of New Blue Cross and Blue Shield of Louisiana Care Management Referral Process

Blue Cross and Blue Shield of Louisiana in 2018 began receiving daily admission-discharge-transfer (ADT) notifications to develop a clinical intervention program. To improve management of resources and increase the efficacy of outreach efforts, Blue Cross developed a daily selection algorithm to prioritize members with the highest risk, highest cost, or frequent use of emergency departments, and who are most likely to respond positively to clinical intervention. Prioritized outreach began December 2021 and is ongoing.

HSD68 Improving Care Via Timely Health Information Exchange: A Blue Cross and Blue Shield of Louisiana ADT System Referral Program Evaluation

The admission-discharge-transfer (ADT) system is a key source for member referrals to the Population Health intervention program at Blue Cross and Blue Shield of Louisiana (BCBSLA). It is triggered by an episodic event such as an emergency department visit or hospitalization. The system notifies BCBSLA’s Care Management team in near real time so they may act promptly. Their actions (such as health coaching, personalized disease self-management skills for members to adhere to recommended treatment plans) aim to improve quality of care and reduce health care costs. The purpose of this study is to evaluate the effect of timely referrals for Care Management interventions.

PCR159 The Clinical and Financial Impact of Blue Cross and Blue Shield of Louisiana Waiving Cost Share for the First Mental Health and Substance Use Disorder Follow-up Visit

Waiving cost share for the first Mental Health and Substance Use Disorder (MHSU) follow-up visit after MHSU hospitalization is a Blue Cross and Blue Shield of Louisiana health care quality improvement program designed to remove potential financial barriers that the follow-up visit must take place within seven days of discharge from an inpatient stay. A mental health provider must perform the follow-up visit. The purpose of this effort is to encourage patient compliance of completing follow-up visits within seven days of a MHSU inpatient discharge. Follow-up within seven days helps close the gap for the Follow-Up After Hospitalization for Mental Illness (FUH) HEDIS measure. This study evaluates the clinical and financial effect of this waived cost share.

RWD77 $0 Drug Copay Program Increases Generic Drug Use Among Members with Diabetes in Louisiana: Six-Month Outcomes Analysis

Blue Cross and Blue Shield of Louisiana (BCBSLA) designed the $0 Drug Copay (ZDC) program to reduce financial barriers by offering $0 copays for certain drugs, mostly generics, used to treat certain chronic conditions for eligible members with copay pharmacy benefits. The ZDC program has improved medication adherence and clinical outcomes, and reduced health care costs—as published in ISPOR’s Value in Health and the American Journal of Managed Care. This study’s purpose was to examine medication use patterns in members with diabetes.

OP2 Race and Social Determinants of Health Data Inform Blue Cross and Blue Shield of Louisiana’s Understanding of Its Medicare Advantage Members

Blue Cross and Blue Shield of Louisiana (BCBSLA) is using race and Social Determinants of Health (SDOH) data for the first time to help understand its members and potential inequities. For BCBSLA Medicare Advantage (MA) members, 98% of the population has self-identified with one or more race categories, as the U.S. Centers for Medicare & Medicaid Services (CMS) sets. This information will help BCBSLA enhance intervention programs and address potential health disparities to improve members’ health and wellness.

Risk Factors and outcomes associated with inappropriate empiric broad-spectrum antibiotic use in hospitalized patients with community-acquired pneumonia

Background: Inappropriate broad-spectrum antibiotic use targeting methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa can result in increased adverse events, antibiotic resistance, and Clostridioides difficile infection. In 2019, revised ATS/IDSA community-acquired pneumonia (CAP) guidelines removed healthcare-associated pneumonia (HCAP) as a clinical entity and modified patient factors warranting empiric broad-spectrum antibiotic (BSA) use. As a result, most patients hospitalized with CAP should receive empiric antibiotics targeting standard CAP pathogens. Based on revised guidelines, we evaluated predictors and outcomes associated with inappropriate BSA use among hospitalized patients with CAP. Methods: Between November 2019 and July 2022, trained abstractors collected data on non-ICU adult medical patients admitted with CAP at 67 Michigan hospitals who received either an inappropriate empiric BSA on hospital day 1 or 2 or a standard CAP regimen. Inappropriate empiric BSA use was defined as use of an anti-MRSA or anti-pseudomonal antibiotic in a patient eligible for standard CAP coverage per IDSA guidelines. Patients with immune compromise, moderate or severe chronic obstructive pulmonary disease (COPD), pulmonary complication, or guideline-concordant treatment with BSA were excluded. Data collected included comorbidities, antibiotic use and hospitalizations in the preceding 90 days, cultures in the preceding year, signs or symptoms of pneumonia, hospital characteristics, and 30-day postdischarge patient outcomes. Data were collected through chart review and patient phone calls. Predictors of inappropriate empiric BSA were evaluated using logistic general estimating equation (GEE) models, accounting for hospital-level clustering. We assessed the effect of inappropriate empiric BSA (vs standard CAP therapy) on 30-day patient outcomes using logistic GEE models controlling for predictors associated with the outcome and probability of treatment. Results: Of 8,286 included patients with CAP, 2,215 (26.7%) were empirically treated with inappropriate BSA. The median BSA treatment was 3 days (IQR, 2.5). After adjustments, factors associated with inappropriate empiric BSA treatment included hospitalization or treatment with high-risk antibiotics in preceding 90 days, transfer from a postacute care facility, hemodialysis, support with ≥3 L supplemental oxygen, severe sepsis, leukocytosis, and higher pneumonia severity index (Fig. 1). After adjustments, patients with inappropriate empiric BSA treatment had higher readmissions 30 days after discharge, more transfers to the intensive care unit, more antibiotic-associated adverse events, and longer hospitalizations (Fig. 2). Conclusions: Patients hospitalized with CAP often received inappropriate BSA as empiric coverage, and this inappropriate antibiotic selection was associated with worse patient outcomes. To improve patient outcomes, stewardship efforts should focus on reducing inappropriate BSA use in patients hospitalized for CAP with historic HCAP risk factors or severe CAP without other guideline-directed indications for BSA.Financial support. H.M.S. initiative is underwritten by Blue Cross and Blue Shield of Michigan.Disclosures: None

EE462 The Financial Impact of Closing the Diabetes Hemoglobin HBA1C Care Gap at Blue Cross and Blue Shield of Louisiana

HbA1c is the average blood glucose levels for the previous two to three months. It’s the main test to help health care teams manage patients’ diabetes. Closing the HbA1c gap in diabetes care is essential. But few studies explore the relationship between healthcare cost and HbA1c care gap closure. This study seeks to quantify the financial impact of diabetic HbA1c care gap closure on healthcare cost.

MSR46 ADTs Drive Real-Time Readmission Prediction for Blue Cross and Blue Shield of Louisiana Members: A Model Evaluation

The emergency department (ED) plays an important role in treating millions of patients each year. Some patients live with acute and chronic illness or experience accidents or injuries that require immediate care. However, the ED is expensive and inefficient for those visits where it is avoidable. Predictive modeling can improve the efficiency of ED use by identifying patients at high risk of visiting. This study evaluates a Blue Cross and Blue Shield of Louisiana predictive model that identifies members at high risk of readmitting to the emergency department.

OP19 Early Detection of High-Risk Pregnancy for Blue and Cross Blue Shield of Louisiana Members

Blue Cross and Blue Shield of Louisiana examines risk factors prior to the first indication of eligible member’s pregnancy. In combination with early detection of pregnancy, the risk factors are used for enhanced and prolonged intervention during the pregnancy with the intention of preventing adverse maternal outcomes. This study evaluates the timeliness of pregnancy identification and evaluates the relationship between risk factors known before pregnancy and maternal outcomes.

Access to Total Knee Arthroplasty for Military Insured Patients.

Rigorous training may lead to increased rates of knee osteoarthritis and arthroplasties in military service members. Given the large numbers of arthritis and the increasing need for total joint replacements, access to appropriate care can be difficult for this population based on insurance restrictions. The aim of this study was to evaluate access to total knee arthroplasty for TRICARE patients in contracted civilian medical facilities. Orthopedic surgeons contracted to perform total knee replacements in the state of Florida were identified via TRICARE's website. Investigators used a secret shopper methodology with a standardized script to request an appointment for their family member for a total knee arthroplasty using either TRICARE Select or BlueCross preferred provider organization. The appointment acceptance rates, wait times, call duration, and accuracy of the physician listing were collected. A total of 228 offices that perform total knee arthroplasties in Florida were successfully contacted. Overall, 43.1% of the clinics had an inaccurate online listing, and 207 (91%) were able to schedule an appointment with TRICARE, compared to 93% for BlueCross Blue Shield (P= .06). The average wait for TRICARE patients was 24 days and 18 days for BlueCross (P < .01). Call times for TRICARE patients averaged 7.2 minutes, compared to 5.2 minutes for BlueCross (P < .01). TRICARE patients encountered longer waiting periods and inaccurate provider listings when accessing orthopedic care. Our results suggest a disparity in healthcare access for patients using TRICARE, which may result in negative health outcomes from receiving delayed care.

PCR203 The Clinical and Financial Impact of GLP-1 Receptor Agonist and SGLT-2 Inhibitor Use in Type 2 Diabetes Management of Blue Cross and Blue Shield of Louisiana Members

This study seeks to evaluate the effectiveness of GLP-1 Receptor Agonists (GLP-1 RA) and SGLT-2 Inhibitors (SGLT-2i) for lowering HbA1c and reducing health care costs and utilization in members with Type 2 Diabetes.

Anticipating the End of Medicaid Continuous Enrollment and the Ramifications for Surgical Care.

*University of Michigan Medical School, Ann Arbor, Michigan †Department of Surgery, Michigan Medicine, Ann Arbor, Michigan ‡Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan Conflicts of Interest and Source of Funding: Luca Borah reported short-term funding from the National Institutes of Health. Victor Agbafe reported consulting payments for his fellowship with Third Culture Capital. Unrelated to the current work, Dr. Scott reported receiving funding from the Agency for Healthcare Research and Quality as principal investigator on grant K08-HS028672 and co-investigator on grant R01-HS027788 and reported receiving salary support from Blue Cross Blue Shield of Michigan through the initiative known as Michigan Social Health Interventions to Eliminate Disparities. No other disclosures were reported. [email protected]

Social determinants of racial health inequities

Social determinants of racial health inequities

Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis

There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization. This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy. We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated. There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001). This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

Rapid screening of sixty potato cultivars for starch profiles to address a consumer glycemic dilemma.

Potatoes are a dietary staple consumed by a significant portion of the world, providing valuable carbohydrates and vitamins. However, most commercially produced potatoes have a high content of highly branched amylopectin starch, which generally results in a high glycemic index (GI). Consumption of foods with high levels of amylopectin elicit a rapid spike in blood glucose levels, which is undesirable for individuals who are pre-diabetic, diabetic, or obese. Some cultivars of potatoes with lower amylopectin levels have previously been identified and are commercially available in niche markets in some countries, but they are relatively unavailable in the United States and Latin America. The high glycemic index of widely available potatoes presents a problematic "consumer's dilemma" for individuals and families that may not be able to afford a better-balanced, more favorable diet. Some native communities in the Andes (Bolivia, Chile, and Peru) reportedly embrace a tradition of providing low glycemic tubers to people with obesity or diabetes to help people mitigate what is now understood as the negative effects of high blood sugar and obesity. These cultivars are not widely available on a global market. This study examines 60 potato cultivars to identify potatoes with low amylopectin. Three independent analyses of potato starch were used: microscopic examination of granule structure, water absorption, and spectrophotometric analysis of iodine complexes to identify potato cultivars with low amylopectin Differences among cultivars tested were detected by all three types of analyses. The most promising cultivars are Huckleberry Gold, Muru, Multa, Green Mountain, and an October Blue x Colorado Rose cross. Further work is necessary to document the ability of these low amylopectin cultivars to reduce blood glucose spike levels in human subjects.