Cross Blue Shield Of Massachusetts Research Articles

Collaborative Learning Among Health Care Organizations to Improve Quality and Advance Racial Equity.

The study examined stakeholder experiences of a statewide learning collaborative, sponsored and led by Blue Cross Blue Shield of Massachusetts (BCBSMA) and facilitated by the Institute for Healthcare Improvement (IHI) to reduce racial and ethnic disparities in quality of care. Interviews of key stakeholders (n=44) were analyzed to assess experiences of collaborative learning and interventions to reduce racial and ethnic disparities in quality of care. The interviews included BCBSMA, IHI, provider groups, and external experts. Breast cancer screening, colorectal cancer screening, hypertension management, and diabetes management were focal areas for reducing disparities. Collaborative learning methods involved expert coaching, group meetings, and sharing of best practices. Interventions tested included pharmacist-led medication management, strategies to improve the collection of race, ethnicity, and language (REaL) data, transportation access improvement, and community health worker approaches. Stakeholder experiences highlighted three themes: (1) the learning collaborative enabled the testing of interventions by provider groups, (2) infrastructure and pilot funding were foundational investments, but groups needed more resources than they initially anticipated, and (3) expertise in quality improvement and health equity were critical for the testing of interventions and groups anticipated needing this expertise into the future. BCBSMA's learning collaborative and intervention funding supported contracted providers in enhancing REaL data collection, implementing equity-focused interventions on a small scale, and evaluating their feasibility and impact. The collaborative facilitated learning among groups on innovative approaches for reducing racial disparities in quality. Concerns about sustainability underscore the importance of expertise for implementing initiatives to reduce racial and ethnic disparities.

The effectiveness and value of tezepelumab for severe asthma.

DISCLOSURES: Drs Rind, Campbell, Pearson, Ms Herce-Hagiwara, Ms Fluetsch, and Ms Herron-Smith report grants from Arnold Ventures; Kaiser Foundation Health Plan, Inc; The Patrick and Catherine Donaghue Medical Research Foundation; Blue Cross Blue Shield of Massachusetts; and California Healthcare Foundation during the course of this study.

Massachusetts BCBS report highlights BH disparities

Observing Massachusetts as a longtime national leader in health care reform and the push toward universal health insurance coverage, a new report released Feb. 8 from the Blue Cross Blue Shield of Massachusetts (BCBSMA) Foundation found gaps in access to health care persist and disproportionately impact people on race, ethnicity, income and other factors. This situation particularly holds true for mental health and substance use disorders, where the delivery system is fragmented and difficult to navigate, the survey stated.

COPD EXACERBATIONS AND PNEUMONIA HOSPITALIZATIONS IN NEW USERS OF COMBINATION MAINTENANCE INHALERS: A COMPARATIVE EFFECTIVENESS AND SAFETY STUDY

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: Current guidelines recommend inhalers containing long-acting muscarinic antagonists (LAMA) and long-acting beta agonists (LABA) over inhalers containing inhaled corticosteroids (ICS) and LABAs as first-line dual therapy for chronic obstructive pulmonary disease (COPD). However, recent data from randomized controlled trials examining the efficacy and safety of LAMA-LABA versus ICS-LABA inhalers have been conflicting and raised concerns of generalizability. The purpose of this study was to determine whether LAMA-LABA therapy is associated with reduced COPD exacerbations and pneumonia hospitalizations compared to ICS-LABA therapy in real-world clinical practice. METHODS: A 1:1 propensity-score matched observational cohort study was conducted using a large US commercial insurance database. The study included patients with COPD who filled a new prescription for a combination LAMA-LABA or ICS-LABA inhaler between January 1, 2014 to December 31, 2019. Patients with a prior diagnosis of asthma were excluded. The primary effectiveness outcome was first moderate or severe COPD exacerbation, and the primary safety outcome was first pneumonia hospitalization. RESULTS: Among 138,395 patients (107,518 new ICS-LABA users and 30,877 new LAMA-LABA users), 30,772 matched pairs were identified for the primary analysis. The propensity-score matched cohort had a mean age of 70 years and 47% were women. Compared to ICS-LABA use, LAMA-LABA use was associated with a 10% reduction in the rate of first moderate or severe COPD exacerbation (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.87, 0.94) and a 24% reduction in the rate of first pneumonia hospitalization (HR 0.76, 95% CI 0.70, 0.84). These findings were robust across a range of prespecified sensitivity and subgroup analyses. CONCLUSIONS: LAMA-LABA therapy was associated with improved clinical outcomes compared to ICS-LABA therapy in a cohort of patients treated in routine clinical practice. CLINICAL IMPLICATIONS: In keeping with current guidelines, LAMA-LABA therapy should be preferred to ICS-LABA therapy for most patients with COPD. DISCLOSURES: No relevant relationships by Jerry Avorn, source=Web Response Consultant relationship with Alosa Health Please note: 2019-present Added 04/14/2021 by William Feldman, source=Web Response, value=Consulting fee Consultant relationship with Aetion Please note: 2019-2020 Added 04/14/2021 by William Feldman, source=Web Response, value=Consulting fee Consultant relationship with Blue Cross Blue Shield of Massachusetts Please note: 2019-2020 Added 04/14/2021 by William Feldman, source=Web Response, value=Honoraria no disclosure on file for Joshua Gagne; No relevant relationships by Aaron Kesselheim, source=Web Response

Some Insurers Working to Encourage Psychiatrists to Join Their Networks

Some Insurers Working to Encourage Psychiatrists to Join Their Networks

The Effectiveness and Value of Rivaroxaban and Icosapent Ethyl as Additive Therapies for Cardiovascular Disease.

Funding for this summary was contributed by Arnold Ventures, Commonwealth Fund, California Health Care Foundation, National Institute for Health Care Management (NIHCM), New England States Consortium Systems Organization, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, Kaiser Foundation Health Plan, and Partners HealthCare to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, America's Health Insurance Plans, Anthem, Allergan, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Cambia Health Services, CVS, Editas, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, Health Partners, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, and United Healthcare. Pearson is employed by ICER; Synnott was employed by ICER at the time of this report. Ollendorf, Campbell, and McQueen received grants from ICER for work on this review. Ollendorf also reports advisory board, consulting, and other fees from Sarepta Therapeutics, DBV Technologies, EMD Serono, Gerson Lehman Group, The CEA Registry Sponsors, Autolus, Analysis Group, Amgen, AbbVie, Cytokinetics, Aspen Institute/University of Southern California, and University of Colorado, unrelated to this review.

The Effectiveness and Value of Oral Immunotherapy and Viaskin Peanut for Peanut Allergy.

Funding for this summary was contributed by Arnold Ventures, Commonwealth Fund, California Health Care Foundation, National Institute for Health Care Management (NIHCM), New England States Consortium Systems Organization, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, Kaiser Foundation Health Plan, and Partners HealthCare to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, America's Health Insurance Plans, Anthem, Allergan, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Cambia Health Services, CVS, Editas, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, Health Partners, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, and United Healthcare. Herron-Smith and Pearson are employed by ICER, which has a contract with the University of California, San Francisco, to perform work for these analyses. Segal was employed by ICER at the time of this review. Tice and Walsh are employed by the University of California, San Francisco. Gazauskas and Hansen have nothing to disclose.

The Effectiveness and Value of Siponimod for Secondary Progressive Multiple Sclerosis.

Funding for this summary was contributed by Arnold Ventures, Commonwealth Fund, California Health Care Foundation, National Institute for Health Care Management (NIHCM), New England States Consortium Systems Organization, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, Kaiser Foundation Health Plan, and Partners HealthCare to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, America's Health Insurance Plans, Anthem, Allergan, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Cambia Health Services, CVS, Editas, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, Health Partners, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, and United Healthcare. Synnott and Pearson are employed by ICER. Bloudek and Carlson report a research agreement between the University of Washington and ICER; Bloudek reports consulting fees from Allergan, Seattle Genetics, Dermira, Sunovion, TerSera Therapeutics, Cook Regentech, and Mallinckrodt Pharmaceuticals; and Carlson reports personal fees from Bayer, unrelated to this report. Sharaf reports consulting fees from ICER.

The Effectiveness and Value of Esketamine for the Management of Treatment-Resistant Depression.

Funding for this summary was contributed by the Laura and John Arnold Foundation, National Institute for Health Care Management, California Health Care Foundation, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Healthcare, and Kaiser Foundation Health Plan to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, America's Health Insurance Plans, Anthem, AstraZeneca, Allergan, Alnylam, Biogen, Blue Shield of California, Cambia Health Services, CVS Caremark, Editas, Express Scripts, Genentech, GlaxoSmithKline, Harvard Pilgrim Health Care, Health Care Service Corporation, HealthPartners, HealthFirst, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinkrodt Pharmaceuticals, Merck, Novartis, National Pharmaceutical Council, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, and United Healthcare. Agboola, Fazioli, and Pearson are employed by ICER. Touchette reports grants from ICER during the course of this work and personal fees from Monument Analytics, unrelated to this work. Atlas has nothing to disclose.

The Effectiveness and Value of Treatments for Spinal Muscular Atrophy.

Funding for this summary was contributed by the Laura and John Arnold Foundation and California Health Care Foundation to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, AHIP, Anthem, Blue Shield of California, CVS Caremark, Express Scripts, Harvard Pilgrim Health Care, Cambia Health Solutions and MedSavvy, United Healthcare, Kaiser Permanente, Premera Blue Cross, AstraZeneca, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, National Pharmaceutical Council, Sanofi, Alnylam, Novartis, HealthPartners, Blue Cross Blue Shield of Massachusetts, Health Care Services Corporation, Mallinkrodt Pharmaceuticals, Prime Therapeutics, Regeneron, National Institute for Health Care Management, Commonwealth Fund, Partners Healthcare, New England States Consortium Systems, Allergan, Biogen, Editas, LEO Pharma, and HealthFirst. ICER has also received grants from Kaiser Foundation Health Plan, California Health Care Foundation, and the Laura and John Arnold Foundation. Pearson and Rind are employees of ICER. Thokala and Stevenson have no potential conflicts of interest to disclose.

Massachusetts report a ‘call to action’ for transformation of BH system

Despite ongoing success at maintaining near‐universal health care coverage since the passage of Massachusetts' health care reform law in 2006, adults and their families, especially vulnerable populations, are having difficulty accessing behavioral health services, a new report by the Blue Cross Blue Shield of Massachusetts (BCBS) Foundation finds. Cited as a call to action for policymakers and stakeholders, the report calls for reforming the state's fragmented, difficult‐to‐navigate behavioral health care system.

Effects of Global Payment and Accountable Care on Medication Treatment for Alcohol and Opioid Use Disorders.

The Alternative Quality Contract (AQC) implemented in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA) is intended to improve quality and control costs by putting providers at risk for total medical spending and tying payment to performance on specified quality measures. We examined the AQC's early effects on use of and spending on medication treatment (MT) for addiction among individuals with alcohol use disorders (AUDs) and opioid use disorders (OUDs), conditions not subject to any performance measurement in the AQC. Using data from 2006 to 2011, we use difference-in-difference estimation of the effect of the AQC on MT using a comparison group of enrollees in BCBSMA whose providers did not participate in the AQC. We compared AQC and non-AQC enrollees with AUDs (n = 37,113 person-years) and/or OUDs (n = 12,727 person-years) on any use of MT, number of prescriptions filled, and MT spending adjusting for demographic and health status characteristics. There was no difference in MT use among AQC enrollees with OUD (38.7%) relative to the comparison group (39.1%) (adjusted difference = -0.4%, 95% confidence interval -3.8% to 3.0%, P = 0.82). Likewise, there was no difference in MT use for AUD between the AQC (6.3%) and comparison group (6.5%) (P = 0.64). Similarly, we detected no differences in number of prescriptions or spending. Despite incentives for improved integration and quality of care under a global payment contract, the initial 3 years of the AQC showed no impact on MT use for AUD or OUD among privately insured enrollees with behavioral health benefits.

Risk Adjustments Based on Socioeconomic Status in Pediatrics: Adjusting Our Expectations.

* Abbreviations: ABSM — : area-based socioeconomic measure BCBSMA — : Blue Cross Blue Shield of Massachusetts In their article in this issue of Pediatrics , Chien et al1 appear to raise an interesting policy dilemma. By using data from Blue Cross Blue Shield of Massachusetts (BCBSMA) during the period from 2008 to 2012, the authors linked annual plan payment claims to geocoded socioeconomic background information on the plan’s pediatric participants aged 0 to 20 years. They found that children living in census tracks with higher socioeconomic characteristics used more services at higher unit prices than children living in census tracts with lower socioeconomic characteristics. If payments to plans are risk-adjusted on the basis of the socioeconomic status of enrollees, then these findings suggest that resources will be directed to plans that enroll children from better-off families relative to plans that enroll poorer children, which is an impact at odds with the expectations of those who advocate for adding socioeconomic status to risk stratification algorithms. The study’s principal finding should not be all that surprising. Health care services are “normal” goods, meaning that as income rises, … Address correspondence to Andrew D. Racine, MD, PhD, Executive Offices, Montefiore Health System, 111 East 210th St, Bronx, NY 10467. E-mail: aracine{at}montefiore.org

Socioeconomic Background and Commercial Health Plan Spending.

Risk-adjustment algorithms typically incorporate demographic and clinical variables to equalize compensation to insurers for enrollees who vary in expected cost, but including information about enrollees' socioeconomic background is controversial. We studied 1 182 847 continuously insured 0 to 19-year-olds using 2008-2012 Blue Cross Blue Shield of Massachusetts and American Community Survey data. We characterized enrollees' socioeconomic background using the validated area-based socioeconomic measure and calculated annual plan payments using paid claims. We evaluated the relationship between annual plan payments and geocoded socioeconomic background using generalized estimating equations (γ distribution and log link). We expressed outcomes as the percentage difference in spending and utilization between enrollees with high and low socioeconomic backgrounds. Geocoded socioeconomic background had a significant, positive association with annual plan payments after applying standard adjusters. Every 1 SD increase in socioeconomic background was associated with a 7.8% (95% confidence interval, 7.2% to 8.3%; P < .001) increase in spending. High socioeconomic background enrollees used higher-priced outpatient and pharmacy services more frequently than their counterparts from low socioeconomic backgrounds (eg, 25% more outpatient encounters annually; 8% higher price per encounter; P < .001), which outweighed greater emergency department spending among low socioeconomic background enrollees. Higher socioeconomic background is associated with greater levels of pediatric health care spending in commercially insured children. Including socioeconomic information in risk-adjustment algorithms may address concerns about adverse selection from an economic perspective, but it would direct funds away from those caring for children and adolescents from lower socioeconomic backgrounds who are at greater risk of poor health.

Declines in Opioid Prescribing After a Private Insurer Policy Change - Massachusetts, 2011-2015.

Overdose deaths involving opioid pain medications are epidemic in the United States, in part because of high opioid prescribing rates and associated abuse of these drugs (1). In 2014, nearly 2 million U.S. residents either abused or were dependent on prescription opioids (2). In Massachusetts, unintentional opioid-related overdose deaths, including deaths involving heroin, increased 45% from 2012 to 2013.* In 2014, the rate of these deaths reached 20.0 per 100,000, nearly 2.5 times higher than the U.S. rate overall (3,4). On July 1, 2012, Blue Cross Blue Shield of Massachusetts (BCBSMA), the largest insurer in the state with approximately 2.8 million members,† implemented a comprehensive opioid utilization program after learning that many of its members were receiving new prescriptions with a >30-day supply of opioids. The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain recommends avoiding opioids as a first-line therapy for chronic pain and limiting quantities when initiating opioids for acute pain (5). CDC analyzed BCBSMA prescription claims data for the period 2011-2015 to assess the effect of the new utilization program on opioid prescribing rates. During the first 3 years after policy implementation, the average monthly prescribing rate for opioids decreased almost 15%, from 34 per 1,000 members to 29. The percentage of BCBSMA members per month with current opioid prescriptions also declined. The temporal association between implementation of the program and statistically significant declines in both prescribing rates and proportion of members using opioids suggests that the BCBSMA initiative played a role in reducing the use of prescription opioids among its members. Public and private insurers in the United States could benefit from developing their own best practices for prescription opioid utilization that ensure accessible pain care, while reducing the risk for dependence and abuse associated with these drugs.

Effects of accountable care and payment reform on substance use disorder treatment: evidence from the initial 3 years of the alternative quality contract.

Global payment and accountable care reform efforts in the United States may connect more individuals with substance use disorders (SUD) to treatment. We tested whether such changes instituted under an Alternative Quality Contract (AQC) model within the Blue Cross Blue Shield of Massachusetts' (BCBSMA) insurer increased care for individuals with SUD. Difference-in-differences design comparing enrollees in AQC organizations with a comparison group of enrollees in organizations not participating in the AQC. Massachusetts, USA. BCBSMA enrollees aged 13-64years from 2006 to 2011 (3 years prior to and after implementation) representing 1333 534 enrollees and 42 801 SUD service users. Outcomes were SUD service use and spending and SUD performance metrics. Primary exposures were enrollment into an AQC provider organization and whether the AQC organization did or did not face risk for behavioral health costs. Enrollees in AQC organizations facing behavioral health risk experienced no change in the probability of using SUD services (1.64 versus 1.66%; P=0.63), SUD spending ($2807 versus $2700; P=0.34) or total spending ($12 631 versus $12 849; P=0.53), or SUD performance metrics (identification: 1.73 versus 1.76%, P=0.57; initiation: 27.86 versus 27.02%, P=0.50; engagement: 11.19 versus 10.97%, P=0.79). Enrollees in AQC organizations not at risk for behavioral health spending experienced a small increase in the probability of using SUD services (1.83 versus 1.66%; P=0.003) and the identification performance metric (1.92 versus 1.76%; P=0.007) and a reduction in SUD medication use (11.84 versus 14.03%; P=0.03) and the initiation performance metric (23.76 versus 27.02%; P=0.005). A global payment and accountable care model introduced in Massachusetts, USA (in which a health insurer provided care providers with fixed prepayments to cover most or all of their patients' care during a specified time-period, incentivizing providers to keep their patients healthy and reduce costs) did not lead to sizable changes in substance use disorder service use during the first 3 years following its implementation.

Effects of Global Payment and Accountable Care on Tobacco Cessation Service Use: An Observational Study

Tobacco use is the leading cause of preventable death and disability. New payment and delivery system models including global payment and accountable care have the potential to increase use of cost-effective tobacco cessation services. To examine how the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA) has affected tobacco cessation service use. We used 2006-2011 BCBSMA claims and enrollment data to compare adults 18-64 years in AQC provider organizations to adults in non-AQC provider organizations. We examined the AQC's effects on all enrollees; a subset at high risk of tobacco-related complications due to certain medical conditions; and behavioral health service users. We examined use of: (1) any cessation treatment (pharmacotherapy or counseling); (2) varenicline or bupropion; (3) nicotine replacement therapies (NRTs); (4) cessation counseling; and (4) combination therapy (pharmacotherapy plus counseling). We also examined duration of pharmacotherapy use and number of counseling visits among users. Rates of tobacco cessation treatment use were higher following implementation of the AQC relative to the comparison group overall (2.02 vs. 1.87%, p < 0.0001), among enrollees at risk for tobacco-related complications (4.97 vs. 4.66%, p < 0.0001), and among behavioral health service users (3.67 vs. 3.25%, p < 0.0001). Statistically significant increases were found for use of varenicline or bupropion alone, counseling alone, and combination therapy, but not for NRT use, pharmacotherapy duration, or number of counseling visits among users. In its initial three years, the AQC was associated with increases in use of tobacco cessation services.

Opportunities and Challenges for Payment Reform: Observations from Massachusetts.

Policy makers and private health plans are expanding their efforts to implement new payment models that will encourage providers to improve quality and deliver health care more efficiently. Over the past five years, payment reforms have progressed faster in Massachusetts than in any other state. The reasons include a major effort by Blue Cross Blue Shield of Massachusetts to implement global payment, the presence of large integrated systems willing to take on financial risk, and a supportive state policy environment. By 2014, thirty-seven percent of Massachusetts's residents enrolled in health plans were covered under risk-based payment models tied to global budgets. But the expansion of payment reform in Massachusetts slowed between 2012 and 2015 because some commercial enrollment shifted from risk-based health maintenance organization products to fee-for-service preferred provider organization (PPO) plans, and the state Medicaid program fell short of its payment reform goals. Provider groups will not fully commit to population-based clinical models if they believe it will result in large reductions in fee-for-service revenue. The use of alternative payment models will accelerate in 2016 when Blue Cross begins implementing PPO payment reforms, but it is unknown how quickly other payers will follow. Massachusetts's experience illustrates the complexity of payment reform in pluralistic health care markets and the need for complementary efforts by public and private stakeholders.

Novel Data Sharing Between a Comprehensive Cancer Center and a Private Payer to Better Understand Care at the End of Life

ContextUnderstanding end-of-life (EOL) care patterns is a prerequisite to improving the experience for cancer patients. EOL measures endorsed by the National Quality Forum (NQF) have been examined in older patients using Medicare claims. ObjectivesTo evaluate EOL care for patients treated at a comprehensive cancer center, using private payer claims data. MethodsA retrospective cohort study was conducted of Dana-Farber Cancer Institute (DFCI) patients who died between July 2010 and December 2012, and were insured by Blue Cross Blue Shield of Massachusetts. Primary data sources included Blue Cross Blue Shield of Massachusetts claims information and DFCI administrative data. We assessed NQF-endorsed measures of EOL care related to emergency department visits, hospitalizations, and intensive care unit admissions in the last 30 days, chemotherapy in the last 14 days, hospice stay, and death in an acute care setting. Patterns of care by cancer type and service location were determined. ResultsAmong 674 patients (mean age 58 years), event rates for NQF-endorsed EOL measures were similar to those reported using Medicare claims. Decedents with hematologic malignancies received significantly more intensive care and were less likely to have enrolled in hospice, compared to decedents with solid tumors. Thirty to 45% of EOL events occurred outside of DFCI and its affiliated hospitals. ConclusionData sharing between a private payer and a large cancer center proved feasible and informative. High rates of hospital service use outside of our sites of care were unexpected. The findings suggest opportunities to better manage care at the end of life.

The Impact of a Tiered Network on Hospital Choice.

To evaluate the effect of a tiered network on hospital choice for scheduled admissions. The 2009-2012 patient-level claims data from Blue Cross Blue Shield of Massachusetts (BCBSMA). BCBSMA's three-tiered hospital network employs large differential cost sharing to encourage patients to seek care at hospitals on the preferred tier. During the study period, 44 percent of hospitals were moved to a different tier based on changes in cost or quality performance. We relied on this longitudinal variation for identification and specified conditional logit models to estimate the effect of the tiered network (TN) on patients' hospital choices relative to a non-TN comparison group. The TN was associated with increased use of hospitals on the preferred and middle tiers relative to the nonpreferred tier for planned admissions. The results suggest that if all members were in a TN plan, relative to all members being in a non-TN plan, scheduled admissions to hospitals on the nonpreferred tier would drop by 7.6 percentage points, while those to middle and preferred tier hospitals would rise by 0.9 and 6.6 percentage points, respectively. Differential cost sharing can steer patients toward preferred hospitals for planned admissions.