Commercial Payers Research Articles

Delay in Knee MRI Scan Completion Since Implementation of the Affordable Care Act:: A Retrospective Cohort Study.

The most impactful resolutions of the Patient Protection and Affordable Care Act (ACA) took effect on January 1, 2014. The clinical and economic effects are widely experienced by orthopaedic surgeons, but are not well quantified. We proposed to evaluate the effect of the ACA on the timing of MRI for knee pathology before and after implementation of the legislation. We conducted a retrospective analysis of all knee MRIs done at our institution from 2011 to 2016 (3 years before and after ACA implementation). The MRI completion time was calculated by comparing the dates of initial clinical evaluation and MRI completion. The groups were subdivided based on insurance payer status (Medicare, Medicaid, and commercial payers). The cohorts were compared to determine differences in average completion time and completion rates at time intervals from initial clinic visit before and after ACA implementation. MRI scans of 5,543 knees were included, 3,157 (57%) before ACA implementation and 2,386 (43%) after. There was a 5.6% increase in Medicaid cohort representation after ACA implementation. Patients waited 14 days longer for MRIs after ACA implementation (116 versus 102 days). There were increased completion times for patients in the commercial payer (113 versus 100 days) and Medicaid (131 versus 96 days) groups. Fewer patients had received MRI after ACA implementation within 2, 6, and 12 weeks of their initial clinic visits. The time between initial clinical evaluation and MRI scan completion for knee pathology markedly increased after ACA implementation, particularly in the commercial payer and Medicaid cohorts. Additional studies are needed to determine the effect of longer wait times on patient satisfaction, delayed treatment, and increased morbidity. As healthcare policy changes continue, their effects on orthopaedic patients and providers should be closely scrutinized. Level III-Retrospective cohort study.

Incidence of mental health conditions by seizure control among adults with epilepsy in the United States

BackgroundMental health conditions (MHCs) are frequent comorbidities among people with epilepsy; however, the influence of seizure control on the incidence of MHCs is not well reported. This retrospective observational cohort study based on claims data evaluated the effects of indicators of poor seizure control on the incidence of MHCs among MHC-naïve people with epilepsy. We hypothesized that poor seizure control is associated with new-onset MHC diagnoses and/or new prescription drugs for MHCs. MethodsThis study utilized a sample of patients from HealthVerity Marketplace, which includes more than 150 US commercial, Medicare, and Medicaid payers, to identify a cohort of adults (age ≥18 years) with prevalent epilepsy. Follow-up started on day 1 (January 1) after a 1-year eligibility assessment period occurring in calendar year 2017 or 2018. Patients were followed up until the occurrence of an incident MHC event (primary outcome), defined as a mental health diagnosis or psychotropic drug prescription. Time from follow-up to incident MHC diagnosis or to a drug prescription specific to depression or anxiety disorder was analyzed as a secondary outcome. Multivariate Cox proportional hazards regressions were estimated with time-varying covariates, measured in 6-month intervals during follow-up. Time-varying covariates were based on the occurrence of 4 variables used as indicators of poor seizure control in the prior period: epilepsy-related emergent care admissions, epilepsy-related inpatient admissions, epilepsy electroencephalography referrals, and exposure to one or more new antiseizure medications (ASMs). ResultsFrom a random sample of 40,000 people with epilepsy, 2563 (mean age 46.1 years; 50.6% male) were included in the analysis. Incident MHC events were observed in 27.7% (incidence rate 24.4 events per 100 person-years over 2,915.7 total person-years of follow-up). Mean (standard deviation [SD]) time to event was 232.7 (186.3) days. Among the 4 variables, epilepsy-related emergent care admissions were associated with an increased risk of incident MHC events in the following 6-month period (hazard ratio [HR] = 1.676, 95% confidence interval [CI]: 1.386, 2.026, p < 0.001) as were prescriptions for new ASMs in the previous period (HR = 1.702, 95% CI: 1.359, 2.132, p < 0.001). Previous epilepsy-related emergent care admissions (HR = 1.650, 95% CI: 1.347, 2.021, p < 0.001) and new ASMs (HR = 1.632, 95% CI: 1.280, 2.081, p < 0.001) also predicted an increased risk of incident depression or anxiety in the following 6-month period. ConclusionsPrevious indicators of poor seizure control, including epilepsy-related emergent care admissions and new ASMs, predicted increased risk of new MHC events, including depression and anxiety, during the following 6-month interval in MHC-naïve patients with prevalent epilepsy. These data suggest that poor seizure control can increase the subsequent risk of new mental health diagnoses and treatment among people with epilepsy.

Sociodemographic and clinical factors associated with receipt of biomarker testing in patients with metastatic colorectal cancer.

Standard clinical practice and national guidelines dictate somatic testing of metastatic colorectal cancer (mCRC) tumors to guide appropriate therapy; however, previous studies suggest that not all patients are tested. The objective of this study was to investigate potential differences in testing for mCRC by demographic and clinical factors. We performed a retrospective review of de-identified patient data derived from electronic health records (EHRs) of 25,469 patients diagnosed with mCRC between the years 2013 and 2020. Our outcome was a receipt of the following tests: (a) biomarker testing (BRAF, KRAS, NRAS, MMR/MSI) and (b) next-generation sequencing (NGS). We interrogated our data using the machine-learning algorithm Classification and Regression Tree (CART), a unique approach to identifying combinations of, rather than individual demographic and clinical characteristics associated with receipt of testing. A total of 25,469 patients were identified with mCRC. Of these, 21,133 (83%) received either biomarker testing only (n= 12,485) or any testing (biomarker + NGS) (n= 8648). The proportion of patients who received any testing increased over calendar time for all age, race, and sex categories. Receipt of any testing was highest (90%) among younger and patients with better performance status, and there was no difference in receipt of any testing by race. The highest percentage of NGS testing was among those with better performance status, <70 years old, commercial or other governmental program payers, and low comorbidity burden; however, those who were Black or Hispanic had a lower prevalence of NGS testing than those who were White. Considerable variations exist in somatic biomarker testing across subgroups of the population. Identification of genomic alterations can aid in determining targeted treatment and improving clinical outcomes; therefore, equitable use of these testing strategies, particularly NGS, is necessary.

The Challenge of Payment Advocacy – Maintaining Focus and Unity

Leadership Perspectives| July 2022 The Challenge of Payment Advocacy – Maintaining Focus and Unity Jeffrey T. Mueller, MD, FASA Jeffrey T. Mueller, MD, FASA Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor July 2022, Vol. 86, 9. https://doi.org/10.1097/01.ASM.0000842020.64753.c9 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Jeffrey T. Mueller; The Challenge of Payment Advocacy – Maintaining Focus and Unity. ASA Monitor 2022; 86:9 doi: https://doi.org/10.1097/01.ASM.0000842020.64753.c9 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: advocacy This is my fourth and final opportunity to contribute to this series of articles as your Vice President for Professional Affairs. During that time, ASA has navigated the COVID-19 pandemic while continuing to simultaneously advocate for anesthesiologists and our patients. In the July 2019 Monitor, I described the Division of Professional Affairs' approach to payment advocacy. Most of that article remains contemporary, and the challenging environment we faced then remains today – with the unfortunate caveat that the overall level of pressure on payments has continued to increase (ASA Monitor 2019;83:6-7). Medicare now prices the anesthesia conversion factor at an inflation-adjusted rate that is less than 60% of the 1992 value, and there's a long line of sequestration, PAYGO, and other mandated Medicare payment cuts yet to be activated. At the same time, many commercial payers are attempting to destroy market-based rates through contract cancellations, vanishingly narrow... You do not currently have access to this content.

HPR75 Representation and Equity in Utility Assessments Used for Cost-Effectiveness Analyses

Cost-effectiveness analysis (CEA) is sometimes considered by U.S. commercial payers when making coverage and reimbursement decisions, reflecting the important role that CEA plays in informing judgments about health value. However, the extent to which utilities – which are key inputs in CEA studies – equitably account for population gender, race, and ethnicity is unknown.

EE274 Estimated Costs of Adverse Event Management in NSCLC Patients with Epidermal Growth Factor Receptor Exon 20 Insertion Mutations Treated with Amivantamab or Mobocertinib after Progression on Platinum-Based Chemotherapy

To estimate the costs of grade 3/4 adverse events (AEs) related to amivantamab or mobocertinib among patients with non-small cell lung cancer (NSCLC) harboring epidermal growth factor receptor exon 20 insertion mutation with disease progression despite prior platinum-based chemotherapy, from a Commercial or Medicare payer perspective.

HPR15 Cause and Cure: Weighing the Prospective Impact of Cures 2.0 ACT Breakthrough Device Coverage on a Linked US Regulatory and Payer Framework

To evaluate the impact on US commercial payer health plan access decision-making of proposed guaranteed temporary coverage and reimbursement of all Breakthrough Device Designation (BDD)-assigned products for Medicare beneficiaries for up to 4 years following FDA approval, as part of Title IV of the Cures 2.0 Act legislation.

EE238 Healthcare Costs of COVID-19 Versus Flu and Pneumonia - a Payer Perspective

EE238 Healthcare Costs of COVID-19 Versus Flu and Pneumonia - a Payer Perspective

EE143 Cost-Effectiveness of Belantamab Mafodotin (BELAMAF) VS. Melphalan Flufenamide in Combination with Dexamethasone (MEL+DEX) in Heavily PRE-Treated Relapsed/Refractory Multiple Myeloma Patients: A U.S. Payer Perspective

Belantamab mafodotin (belamaf) and melphalan flufenamide in combination with dexamethasone (MEL+DEX) have been approved for heavily pretreated relapsed/refractory multiple myeloma (RRMM) patients. Hefty price tags of each highlight the need to evaluate the relationship between the costs and outcomes achieved by these therapies. The objective of the research is to evaluate the cost-effectiveness of belamaf compared with MEL+DEX in RRMM patients who have received at least four prior lines of therapy from a U.S. commercial payer perspective.

PCR31 Commercial Payer and Rare Disease Patient Stakeholder Perspectives on Incorporation of Direct Patient Input on Value of Medicines in Payer Formulary Decision-Making Process in the U.S.

Assess payer and rare disease (RD) patient perception towards payer reputation, patient-centricity, orphan drug (OD) value, and incorporation of patient perspectives on value of ODs in drug formulary decision-making process in the U.S.

Abstract 5248: CDK4/6 inhibition (CDK4/6i) is effective in the real-world setting for hormone receptor-positive metastatic breast cancer (HR+ MBC) with ESR1 mutations and fusions

Abstract Background For HR+ MBC, ESR1 point mutations (ESR1-MUT) are a common mechanism of acquired resistance to aromatase inhibition (AI); ESR1 fusions (ESR1-FUS) are rare and promote intrinsic resistance to ER-targeting drugs. Retrospective analyses of CDK4/6i trials suggest ESR1-MUT does not cause CDK4/6i resistance, but whether CDK4/6i is effective for ESR1-MUT, or for ESR1-FUS, in the real-world setting is unknown. Methods Real-world evidence was sourced from the GuardantInform database of commercial payer claims and ctDNA tests from 170,000+ individuals. Patients with MBC who started CDK4/6i within 30 days of ctDNA testing were categorized as ESR1-MUT vs. ESR1-WT and analyzed for time-to-next-treatment (TTNT). Separately, cases with ESR1-FUS detected by tissue RNA-Seq were extracted from a clinicopathologic database at an academic cancer center. Results There was no significant difference in TTNT on CDK4/6i for ESR1-MUT vs. ESR1-WT. As expected, ESR1-MUT had shorter overall survival (OS), even after adjustment for age, CDK4/6i drug, and prior treatment (HR 0.58 (0.42-0.82), p=0.002, multivariable Cox). Endocrine partner analysis was limited by lack of clinical annotation to 27% of cases: AI was given to 55% of ESR1-WT and 25% of ESR1-MUT; fulvestrant was given to 39% of ESR1-WT and 68% of ESR1-MUT. Additional stratified analyses will be presented. In the clinicopathologic database, we identified 4 ESR1-FUS cases, and all received CDK4/6i. Progression-free survival durations on CDK4/6i were 4, 10, 11, and 33+ months. Conclusions Using real-world evidence, we demonstrate that CDK4/6i is effective in both ESR1-MUT and ESR1-WT HR+ MBC, supporting the use of CDK4/6i in this setting. CDK4/6i may be additionally beneficial for patients with ESR1-FUS. Future directions include expanding the ESR1-FUS cohort and deciphering the heterogeneity of CDK4/6i responses in this patient population. ESR1-WT ESR1-MUT p-value n=612 n=145 TTNT, median days (95% CI) 99 (85-121) 102 (85-152) 0.84 (log-rank) OS, median years (95% CI) 5.1 (4.5-NA) 2.2 (2.0-NA) &amp;lt;0.0001 (log-rank) CDK4/6i drug palbociclib: 71.1% ribociclib: 9.8% abemaciclib: 19.1% palbociclib: 60% ribociclib: 5.5% abemaciclib: 34.5% 0.038 (chi-square) Prior lines of treatment 0: 21.2% 1: 26.1% 2: 18.6% 3+: 34.0% median: 2 0: 15.9% 1: 22.8% 2: 17.2% 3+: 44.1% median: 2 0.013 (Mann-Whitney U) Citation Format: Jamie O. Brett, Caroline M. Weipert, Lauren L. Ritterhouse, Nicole Zhang, Junhua Yu, Lianne Y. Ryan, Laura M. Spring, Miguel N. Rivera, Jochen K. Lennerz, Dora Dias-Santagata, Leif W. Ellisen, Aditya Bardia, Seth A. Wander. CDK4/6 inhibition (CDK4/6i) is effective in the real-world setting for hormone receptor-positive metastatic breast cancer (HR+ MBC) with ESR1 mutations and fusions [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5248.

896-P: Dapagliflozin Cost Offsets in Chronic Kidney Disease for Commercial U.S. Payers

One in 7 adults have chronic kidney disease (CKD) , which is associated with high mortality and costly healthcare resource utilization (HCRU) . Data from a US employer-sponsored health insurance plan show rising per-member-per-year costs for treatment of cardiac and renal complications associated with CKD. A cost-offset model (COM) was deployed to quantify the predicted clinical and economic benefits of treatment with dapagliflozin. The COM used real-world cost and member count data from a US employer-sponsored commercial payer and the phase 3 DAPA-CKD (NCT03036150) clinical trial event rates for outcomes, including ≥ 50% decline in estimated glomerular filtration rate (eGFR) , end-stage kidney disease (ESKD) , and hospitalization for heart failure (HHF) . HCRU cost-offsets were calculated over a 3-year time horizon in a population of 130 members with CKD stages 2-4 who were modeled for treatment with either dapagliflozin plus standard of care (SOC) or SOC alone. Over a 3-year period, 9 instances of ≥ 50% decline in eGFR were estimated for treatment with dapagliflozin versus (vs.) 15 with SOC (6 fewer events; number needed to treat [NNT]: 20) , amounting to estimated cumulative cost-offsets of $0.57 million (M) . Similarly, 6 ESKD events were avoided with dapagliflozin vs. SOC (8 vs. 14; NNT: 24) , resulting in $1.92 M in cumulative cost-offsets. Dapagliflozin use also avoided 20 HHF events compared with SOC (13 vs. 33; NNT: 7) , totaling $0.79 M in cumulative cost-offsets. Overall, better clinical outcomes translated into total cumulative HCRU cost-offsets of $3.89 M (36.6% reduction in favor of dapagliflozin + SOC vs. treatment with SOC alone) . Results of our COM estimate that dapagliflozin greatly decreases HCRU costs in plan members with CKD by reducing cardiac and renal clinical events over a 3-year period. Modeling these outcomes for members with CKD with and without type 2 diabetes demonstrates that dapagliflozin can be a cost-effective way to reduce HCRU costs associated with CKD for commercial payers. Disclosure R.Chang: Employee; AstraZeneca, UnitedHealth Group. J.Huang: Employee; AstraZeneca. D.Reck: None. J.Hurst: Employee; AstraZeneca. K.Wolf khachatourian: Consultant; Bayer AG, Xcenda. M.H.Shannon: Consultant; Bayer AG, Speaker's Bureau; Bayer AG, Novo Nordisk A/S. Funding AstraZeneca

Factors associated with U.S. hospital payer-specific negotiated mammography charges.

e13633 Background: The Hospital Price Transparency Rule, effective 1/1/2021, requires hospitals to publish payer-specific negotiated charges and cash prices. Given differences in insurance coverage for screening versus diagnostic mammography, we evaluate factors associated with these payer-negotiated charges. Methods: We conducted a cross-sectional study of U.S. acute care and critical access hospitals in CMS’ Care Compare linked to Turquoise Health (payer-negotiated charges), Healthcare Cost Report Information System (hospital characteristics) and Social Vulnerability Indices by county. Negotiated charges for mammography (CPT: screening 77067; diagnostic unilateral 77065, bilateral 77066) were estimated by payer type (self-pay, managed Medicare/Medicaid, or commercial). Adjusted models estimated commercial charges accounting for hospital factors. Results: Most hospitals (N=4212) were non-profits (61%) and acute care hospitals (69%). Median operating margin was .03 (IQR:-.03, .09), asset-to-liability ratio was 1.79 (1.06, 2.96), and social vulnerability index was .53 (.29, .74). 48-50% reported mammography charges. Charges were greater for commercial insurance compared to Medicare/Medicaid (+$55-$82 screening, +$122-$132 bilateral diagnostic; P&lt;.001, all tests). Charges for commercial insurance were similar to self-pay for bilateral screening (p=.41) and diagnostic (p=.08) mammography. See Table for adjusted analysis of commercial charges. Conclusions: Our analysis showed U.S. negotiated mammography charges are similar for self-pay and commercial payers. Commercial charges are higher at private hospitals and those with higher operating margins for diagnostic exams, and lower in socially vulnerable areas. Price transparency may promote competition to lower healthcare prices and highlight any financial toxicity associated with self-pay charges. [Table: see text]

Value-based care will "continue to evolve" even if OCM expires.

Four experts from The US Oncology Network partnered with The American Journal of Managed Care® to present a webinar, “Beyond the OCM: How Are Commercial Payers & Employers Delivering Value-Based Cancer Care?”

Racial and socioeconomic disparities in telemedicine use among US patients initiating cancer treatment during the COVID-19 pandemic.

6511 Background: The COVID-19 pandemic was associated with declines in in-person clinical visits. While telemedicine visits have increased, uptake has varied. Here we assess demographic and socioeconomic factors associated with telemedicine use among patients initiating treatment for 21 common cancers at community oncology clinics. Methods: This retrospective study uses the nationwide Flatiron Health electronic health record-derived de-identified database of patients with cancer. Patient characteristics were determined using structured and unstructured data curated via technology-enabled abstraction. We included patients (≥ 18 years) who initiated first-line cancer treatment between March 2020 and September 2021 (follow-up through December 2021). We focused on differences in telemedicine use (≥ 1 telemedicine visit within 90 days after treatment initiation) across race/ethnicity, insurance coverage, rurality (per Rural-Urban Commuting Areas), and socioeconomic status (SES). SES was defined using census block group data from the American Community Survey (2015-2019) (quintiles representing least to most affluent areas) based on patient addresses and measured using the Yost Index (incorporating income, home values, rental costs, poverty, blue-collar employment, unemployment, and education information). We used logistic regression models adjusted for clinical characteristics ( i.e., age, sex, performance status, and stage) to examine differences in telemedicine use. Results: This study included 24,164 patients (48.1% women, median age: 69 [interquartile range: 61-77] years), of whom 15.9% used telemedicine services. Black patients were less likely to use telemedicine services than White patients (11.4% vs. 15.6%, odds ratio [OR] 0.69 [95% confidence interval [CI]: 0.59-0.79], p&lt;0.01). Telemedicine use was also lower among patients without documented insurance than well-insured (commercial and Medicare payers) patients (10.7% vs. 15.9%, OR 0.62 [95% CI: 0.54-0.72], p&lt;0.01). Those in rural (9.8%, OR 0.51 [95% CI: 0.45-0.58], p&lt;0.01) and suburban areas (13.1%, OR 0.71 [95%: 0.64-0.79], p&lt;0.01) were less likely to use telemedicine services than patients in urban areas (17.6%). Finally, patients in the least affluent areas had lower telemedicine use than those in the most affluent areas (10.2% vs. 24.3%, OR 0.35 [95% CI: 0.31-0.40], p&lt;0.01). Conclusions: During the COVID-19 pandemic, nearly one-fifth of patients initiating cancer treatment used telemedicine services. However, there were substantial disparities: Black, uninsured, non-urban, and less affluent patients are less likely to use telemedicine services. While telemedicine may expand access to specialty care, the proliferation of these services may widen cancer care disparities if vulnerable populations do not have equitable access.

Addressing Challenges to Alternative Payment Models for New Alzheimer's Disease Therapies for US Commercial Payers.

Commercial payers that ultimately decide to cover aducanumab or other Alzheimer's disease therapies may require innovative payment tools to minimize their financial risk given the uncertain benefits and high cost of such treatments. Drawing on the published evidence, we propose two different types of payment models applicable to disease-modifying therapies in Alzheimer's disease, and suggest four strategies to overcome challenges in their implementation. Such strategies range from developing best practices for outcome measurement in Alzheimer's disease, investing in infrastructure to collect real-world data, increasing representativeness of registry data in Alzheimer's disease, and integrating the diagnostic, treatment, and payment landscape. These important steps could make access to emerging therapies in Alzheimer's disease more sustainable in the long term, and could serve as a blueprint for better access to novel therapies in other indications in the future.

MP26-15 RURAL HOSPITAL LOCATION IS ASSOCIATED WITH HIGHER REPORTED PRICES FOR URETEROSCOPY WITH LASER LITHOTRIPSY AMONG COMMERCIALLY INSURED PATIENTS

You have accessJournal of UrologyCME1 May 2022MP26-15 RURAL HOSPITAL LOCATION IS ASSOCIATED WITH HIGHER REPORTED PRICES FOR URETEROSCOPY WITH LASER LITHOTRIPSY AMONG COMMERCIALLY INSURED PATIENTS Ian Berger, Vishnukamal Golla, Marcelo Cerullo, Yuqi Zhang, Michael E. Lipkin, Gary J. Faerber, Deborah R. Kaye, and Charles D. Scales Ian BergerIan Berger More articles by this author , Vishnukamal GollaVishnukamal Golla More articles by this author , Marcelo CerulloMarcelo Cerullo More articles by this author , Yuqi ZhangYuqi Zhang More articles by this author , Michael E. LipkinMichael E. Lipkin More articles by this author , Gary J. FaerberGary J. Faerber More articles by this author , Deborah R. KayeDeborah R. Kaye More articles by this author , and Charles D. ScalesCharles D. Scales More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002569.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Price negotiation between hospitals and insurers is influenced by market competition factors. For rural hospitals, decreased inter-hospital competition may favor hospital negotiating power. However, price differences between rural and metropolitan hospitals for urologic surgeries have not been studied. Our objective was to evaluate prices for ureteroscopy with laser lithotripsy (URS) between rural and metropolitan hospitals in the context of urologist density. METHODS: The Turquoise Health Price Transparency dataset contains publicly available prices from reporting hospitals. We abstracted prices for commercial payers for URS (CPT 52356). We averaged prices across payers by hospital. County level urologist and population density were obtained from the 2019 Area Health Resource File and aggregated into Health Service Areas (HSA) defined by the National Center of Health Statistics. Rural-Urban Commuting Area (RUCA) codes were used to classify each hospital as rural versus metropolitan. Facility features were obtained from the 2019 Centers for Medicare and Medicaid Services Healthcare Cost Reporting Information System and Wage Index. A generalized linear model with gamma distribution and log link evaluated the association of mean price of URS with RUCA classification, controlling for urologist density and facility features. RESULTS: A total of 659 hospitals reported prices for URS with a median rate of $6,161 (interquartile range $3,836 – $10,338). Rural hospitals comprised 24% (158/659) of facilities. Among HSA with a hospital reporting a URS price, 25th percentile of urologist density was 1.6 per 100,000 persons, 50th was 2.5, and 75th was 3.6. Controlling for hospital factors and urologist density, the price for URS was 26% higher (p=0.004) at rural versus metropolitan hospitals and for profit hospital price was 34% higher versus non-profit (p<0.001) [Table 1]. Price was 32% lower in the Northeast compared to West region (p<0.001). CONCLUSIONS: URS prices are higher at rural hospitals. Rural hospitals may face decreased competition for negotiating prices with insurance companies. Higher prices in these areas may exacerbate disparities for rural patients who may struggle to afford health care. Source of Funding: Duke University Bass Connections © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e445 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ian Berger More articles by this author Vishnukamal Golla More articles by this author Marcelo Cerullo More articles by this author Yuqi Zhang More articles by this author Michael E. Lipkin More articles by this author Gary J. Faerber More articles by this author Deborah R. Kaye More articles by this author Charles D. Scales More articles by this author Expand All Advertisement PDF DownloadLoading ...

Current Controversies in Radiology on Cost, Reimbursement, and Price Transparency: AJR Expert Panel Narrative Review.

Many believe that fundamental reform of the U.S. health care system is overdue and necessary given rising national health care expenditures, poor performance on key population health metrics, meaningful health disparities, concerns about potential financial toxicity of care, inadequate price transparency, pending insolvency of Medicare Part A, increasing commercial insurance premiums, and large uninsured and underinsured populations. The Medicare Payment Advisory Commission, an independent congressional agency, believes that part of this reform includes redistribution of reimbursements away from specialties such as radiology. Thus, despite an increase in the Medicare population and spending, Medicare payments for medical imaging have been decreasing for years. Further, the No Surprises Act, a federal law intended to curb the problem of surprise medical billing, was repurposed in federal rulemaking to reduce reimbursement from commercial payers to certain specialties, including radiology. In this article, we examine challenges facing the U.S. health care system, focusing on cost, reimbursement, and price transparency and the role of radiology in addressing such challenges. Medical imaging is a minor contributor to national health care expenditures but has an outsized impact on patient care. The radiology community should work together to reinforce the value of medical imaging and reduce inappropriate utilization of low-value care.

Downstream Mammary and Extramammary Cascade Services and Spending Following Screening Breast Magnetic Resonance Imaging vs Mammography Among Commercially Insured Women

Increasing use of screening breast magnetic resonance imaging (MRI), including among women at low or average risk of breast cancer, raises concerns about resulting mammary and extramammary cascades (downstream services and new diagnoses) of uncertain value. To estimate rates of cascade events (ie, laboratory tests, imaging tests, procedures, visits, hospitalizations, and new diagnoses) and associated spending following screening breast MRI vs mammography among commercially insured US women. This cohort study used 2016 to 2018 data from the MarketScan research database (IBM Corporation), which includes claims and administrative data from large US employers and commercial payers. Participants included commercially insured women aged 40 to 64 years without prior breast cancer who received an index bilateral screening breast MRI or mammogram between January 1, 2017, and June 30, 2018. We used propensity scores based on sociodemographic, clinical, and utilization variables to match MRI recipients to mammogram recipients in each month of index service use. Data were analyzed from October 8, 2020, to October 28, 2021. Breast MRI vs mammography. Mammary and extramammary cascade event rates and associated total and patient out-of-pocket spending in the 6 months following the index test. In this study, 9208 women receiving breast MRI were matched with 9208 women receiving mammography (mean [SD] age, 51.4 [6.7] years). Compared with mammogram recipients, breast MRI recipients had 39.0 additional mammary cascade events per 100 women (95% CI, 33.7-44.2), including 5.0 additional imaging tests (95% CI, 3.8-6.2), 17.3 additional procedures (95% CI, 15.5-19.0), 13.0 additional visits (95% CI, 9.4-17.2), 0.34 additional hospitalizations (95% CI, 0.18-0.50), and 3.0 additional new diagnoses (95% CI, 2.5-3.6). For extramammary cascades, breast MRI recipients had 19.6 additional events per 100 women (95% CI, 8.6-30.7) including 15.8 additional visits (95% CI, 10.2-21.4) and no statistically significant differences in other events. Breast MRI recipients had higher total spending for mammary events ($564 more per woman; 95% CI, $532-$596), extramammary events ($42 more per woman; 95% CI, $16-$69), and overall ($1404 more per woman; 95% CI, $1172-$1636). They also had higher overall out-of-pocket spending ($31 more per woman; 95% CI, $6-$55). In this cohort study of commercially insured women, breast MRI was associated with more mammary and extramammary cascade events and spending relative to mammography. These findings can inform cost-benefit assessments and coverage policies to ensure breast MRI is reserved for patients for whom benefits outweigh harms.

Healthcare resource utilization and costs before and after long-acting injectable antipsychotic initiation in commercially insured young adults with schizophrenia

BackgroundLong-acting injectable (LAI) antipsychotics use is associated with improved adherence which can reduce the rate of relapse, hospitalization, and associated costs in patients with schizophrenia. Young adults could be at higher risk of poor adherence, hence use of LAI in this population may offer a benefit but the evidence is limited. This study aimed to compare clinical and economic outcomes before and after the initiation of LAI antipsychotics in commercially insured young adults (18-35 years of age) with schizophrenia.MethodsA retrospective claims data study was conducted using the data from the IBM MarketScan® Commercial Claims and Encounters (CCAE) Database. Patients with a continuous enrollment of at least 1-year before and 1-year after the first observed schizophrenia diagnosis (index date) and with the use of ≥1 typical or atypical LAI antipsychotic during the post-index follow-up period were included. A pre-post analysis was conducted to compare relapse rates, healthcare resource utilization, and costs before (from index date to LAI initiation) and after LAI initiation (to end of follow up).ResultsA total of 2222 patients who initiated LAIs after an index schizophrenia diagnosis were identified. The per patient per month (PPPM) composite relapse event rate (0.109 pre-LAI to 0.073 post-LAI) and hospitalization rate (0.091 to 0.058), all-cause inpatient visits (0.231 to 0.119), and length of stay (2.694 to 1.092 days) significantly decreased from before LAI initiation to after LAI initiation with similar trends seen for mental health and schizophrenia-related measures (all significant; P < 0.0001). All-cause total costs ($4898 to $3078 PPPM) were also decreased after LAI initiation, with similar trends seen for mental health and schizophrenia-related costs (all significant; P < 0.0001). Although medication costs were higher post-LAI period ($311 to $542 PPPM), the cost increase was substantially offset by the decreased costs associated with total healthcare costs.ConclusionsTreatment with LAI antipsychotics was associated with a decrease in relapse event rate, healthcare resource utilization, and costs after LAI initiation compared to before LAI initiation in commercially insured young adults with schizophrenia. Treatment with LAIs in young adults with schizophrenia is potentially associated with significant cost savings to commercial payers.