Health Care Spending Research Articles

Prophylactic use of incisional negative pressure wound therapy for the prevention of surgical site occurrences in general surgery: Consensus document.

Surgical site occurrences pose a threat to patient health, potentially resulting in significant increases in health care spending caused by using additional resources. The objective of this study was to reach a consensus among a group of experts in incisional negative pressure wound therapy to determine the indications for using this type of treatment prophylactically and to analyze the associated risk factors of surgical site occurrences in abdominal surgery. A group of experts in incisional negative pressure wound therapy from Spain and Portugal was formed among general surgery specialists who frequently perform colorectal, esophagogastric, or abdominal wall surgery. The Coordinating Committee performed a bibliographic search to identify the most relevant publications and to create a summary table to serve as a decision-making protocol regarding the use of prophylactic incisional negative pressure wound therapy based on factors related to the patient and type of procedure. The patient risk factors associated with surgical site occurrence development such as age, immunosuppression, anticoagulation, hypoalbuminemia, smoking, American Society of Anesthesiologists classification, diabetes, obesity, and malnutrition were analyzed. For surgical procedure factors, surgical time, repeated surgeries, organ transplantation, need for blood transfusion, complex abdominal wall reconstruction, surgery at a contaminated site, open abdomen closure, emergency surgery, and hyperthermic intraperitoneal chemotherapy were analyzed. In our experience, this consensus has been achieved on a tailored set of recommendations on patient and surgical aspects that should be considered to reduce the risk of surgical site occurrences with the use of prophylactic incisional negative pressure wound therapy, particularly in areas where the evidence base is controversial or lacking.

MP39-14 THE RISK OF CATASTROPHIC HEALTHCARE EXPENDITURES AMONG PROSTATE AND BLADDER CANCER SURVIVORS IN THE UNITED STATES

You have accessJournal of UrologyCME1 Apr 2023MP39-14 THE RISK OF CATASTROPHIC HEALTHCARE EXPENDITURES AMONG PROSTATE AND BLADDER CANCER SURVIVORS IN THE UNITED STATES Benjamin V. Stone, Muhieddine Labban, Dejan K. Filipas, Edoardo Beatrici, Nicola Frego, Zhiyu (Jason) Qian, Sandeep S. Voleti, Stuart R. Lipsitz, Alexander P. Cole, and Quoc-Dien Trinh Benjamin V. StoneBenjamin V. Stone More articles by this author , Muhieddine LabbanMuhieddine Labban More articles by this author , Dejan K. FilipasDejan K. Filipas More articles by this author , Edoardo BeatriciEdoardo Beatrici More articles by this author , Nicola FregoNicola Frego More articles by this author , Zhiyu (Jason) QianZhiyu (Jason) Qian More articles by this author , Sandeep S. VoletiSandeep S. Voleti More articles by this author , Stuart R. LipsitzStuart R. Lipsitz More articles by this author , Alexander P. ColeAlexander P. Cole More articles by this author , and Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Little is known about the rates of catastrophic healthcare expenditures among survivors of prostate and bladder cancer or the factors that place patients at highest risk for undue cost. METHODS: The Medical Expenditure Panel Survey was utilized to identify prostate and bladder cancer survivors from 2011-2019. Rates of catastrophic healthcare expenditures (out-of-pocket healthcare spending >10% household income) were compared between survivors of all urologic cancer, prostate cancer, and bladder cancer versus adults without cancer. Significant differences were further explored with multivariable logistic regression to identify risk factors for catastrophic expenditures, including models with interaction terms for race, income, and insurance status. RESULTS: Among 2,620 urologic cancer survivors, corresponding to a weighted national estimate of 3,251,500 patients after application of survey weights, there were no significant differences in catastrophic expenditures among patients with prostate cancer compared to adults without cancer. Patients with bladder cancer had significantly greater rates of catastrophic expenditures (12.75% versus 8.33% with and without cancer, respectively, p=0.0273). Significant predictors of catastrophic expenditures in bladder cancer survivors included older age, comorbid illnesses, lower income, retirement, poor health status, and private insurance (Table 1). Among white patients, a bladder cancer diagnosis was not associated with increased odds of catastrophic expenditures (9.18% vs. 8.65%, OR 1.08, 95% CI 0.742 - 1.578), while in Black patients bladder cancer was associated with significantly increased odds of catastrophic expenditures (19.49% vs. 5.14%, OR 6.41, 95% CI 1.28 – 32.01, Figure 1). CONCLUSIONS: Bladder cancer survivorship is associated with a significant ongoing risk of catastrophic healthcare expenditures, particularly among Black patients. Interventions to mitigate disparities in the burden of cost should account for these differences in risk. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e540 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benjamin V. Stone More articles by this author Muhieddine Labban More articles by this author Dejan K. Filipas More articles by this author Edoardo Beatrici More articles by this author Nicola Frego More articles by this author Zhiyu (Jason) Qian More articles by this author Sandeep S. Voleti More articles by this author Stuart R. Lipsitz More articles by this author Alexander P. Cole More articles by this author Quoc-Dien Trinh More articles by this author Expand All Advertisement PDF downloadLoading ...

The NP's role in increasing RVU values.

The NP's role in increasing RVU values.

Age-related disparities and trends in national healthcare spending formanagement of appendicitis in the United States: A retrospective cost-analysis.

Changes in clinical care for appendicitis have impacted healthcare use associated with treatment. We evaluated national trends and assessed factors associated with healthcare costs for appendicitis in the United States. The Disease Expenditure Project, the Global Burden of Disease study, and the National Inpatient Sample were used to estimate total national expenditures, per-capita costs for incident cases, and factors associated with inpatient costs for appendicitis management, respectively. The national estimates of appendicitis costs were obtained from 1996 to 2016. Appendicitis incidence was estimated to calculate per-capita costs. After application of survey weights for the stratified sample design, 191,180 weighted discharges for appendicitis from the 2016 National Inpatient Sample study were evaluated. The Disease Expenditure Project and the Global Burden of Disease study were used to estimate total and per-capita spending. Temporal trends were evaluated using joinpoint regression, expressed as annual percent change. Multivariable linear regression was used to evaluate patient factors associated with total hospital charges. In 2016, total spending on appendicitis was $9.3 billion (95% confidence interval: $8.0-$10.8], a 2-fold increase from $4.7 billion ($4.0-$5.3) in 1996. Per-capita spending decreased significantly after 2011 (annual percent change -3.7% [-4.4% to -2.9%]). Patients ≥65 years accounted for 64.1% (61.1%-67.3%) of total spending for appendicitis. The hospital charges for older patients were significantly higher among those undergoing appendectomy. Overall healthcare spending for appendicitis has doubled from 1996 to 2016, but per capita spending has decreased since 2011, driven by improved efficiency of inpatient care. Nearly two-thirds of spending is on patients ≥65 years, with significantly higher costs associated with surgical management in this population.

Comparison of antibody responses before and after booster doses with the Pfizer-BioNTech or Oxford-AstraZeneca vaccines in healthcare workers in Thailand.

The severe acute respiratory syndrome 2 (SARS-CoV-2) has spread rapidly worldwide, not only causing significant morbidity and mortality but also dramatically increasing health care spending. To manage this in Thailand, healthcare workers first received two doses of the CoronaVac vaccine followed by a booster vaccine with either BNT162b2 vaccine (Pfizer-BioNTech; PZ) or ChAdOx1 nCoV-19 vaccine (Oxford-AstraZeneca; AZ). Given that the difference in anti-SARS-CoV-2 levels following vaccination may vary depending on the vaccine and on demographic characteristics, we measured the antibody response after the second CoronaVac dose and after the booster with either the PZ or AZ vaccine. Our results in 473 healthcare workers show that the variation in antibody response to the full CoronaVac dose depends on demographic characteristics such as age, gender, body mass index, and underlying disease. After receiving a booster dose, anti-SARS-CoV-2 levels were significantly higher in participants who received the PZ vaccine than in people who received the AZ vaccine. Overall, however, receiving a booster dose of either the PZ or AZ vaccine promoted strong antibody responses, even in the old and those with obesity or diabetes mellitus. In conclusion, our results support the use of a booster vaccination program after full vaccination with the CoronaVac vaccine. This approach effectively enhances immunity against SARS-CoV-2, especially in clinically vulnerable groups and healthcare workers.

MP69-09 A SEER-MEDICARE BASED QUALITY SCORE FOR PATIENTS WITH METASTATIC UPPER TRACT UROTHELIAL CARCINOMA AND ITS ASSOCIATION WITH COST AND SURVIVAL

You have accessJournal of UrologyCME1 Apr 2023MP69-09 A SEER-MEDICARE BASED QUALITY SCORE FOR PATIENTS WITH METASTATIC UPPER TRACT UROTHELIAL CARCINOMA AND ITS ASSOCIATION WITH COST AND SURVIVAL Daniel D. Joyce, Yong Shan, Courtney A. Stewart, Karim Chamie, Stephen A. Boorjian, Stephen B. Williams, and Vidit Sharma Daniel D. JoyceDaniel D. Joyce More articles by this author , Yong ShanYong Shan More articles by this author , Courtney A. StewartCourtney A. Stewart More articles by this author , Karim ChamieKarim Chamie More articles by this author , Stephen A. BoorjianStephen A. Boorjian More articles by this author , Stephen B. WilliamsStephen B. Williams More articles by this author , and Vidit SharmaVidit Sharma More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003332.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Population-based studies evaluating outcomes exclusively for metastatic upper tract urothelial carcinoma (mUTUC) are sparse and often only capture patients with de novo (synchronous) metastases as opposed to those who progress to metastatic disease (metachronous). We sought to evaluate the outcomes and costs associated with mUTUC and employ a novel methodology to identify both synchronous and metachronous mUTUC patients using claims data. Additionally, we created a guideline-based quality score to improve quality of care in this space. METHODS: Using the SEER-Medicare database we identified all patients aged 66 years and older diagnosed with mUTUC between 2004 and 2012. Achievement of the following quality criteria was assessed: 1) cancer-specific survival greater than 12 months; 2) receipt of systemic therapy; 3) receipt of hospice/palliative care. Kaplan-Meier survival curves and Cox proportional hazard models were used to compare overall survival between quality scores (0 vs. ≥1) and synchronous vs. metachronous mUTUC. Total healthcare and Medicare Part D out-of-pocket costs within two years of diagnosis were evaluated. Regression analyses were performed to assess characteristics associated with quality criteria and total healthcare costs. RESULTS: Of the 1,223 patients identified, 381 (31.2%) and 842 (68.8%) had synchronous and metachronous mUTUC, respectively. At least one quality criterion was met in 40.2% of patients. Notably, only 54 patients (4.4%) received palliative care services. On multivariable analysis, patients with synchronous mUTUC (Odds Ratio [OR] 0.55, 95% CI 0.41–0.72), and at least 3 comorbidities (OR 0.68, 95% CI 0.47–0.98), were less likely to achieve at least one quality criterion. Patients who achieved at least one quality score criterion had longer survival compared with patients who did not meet criteria (HR 0.52, 95% CI 0.46–0.59). Meeting at least one quality criterion was independently associated with increased costs ($94,677, 95% CI 87702–101652 vs. $63575, 95% CI 59598–67552) on multivariable regression analysis. CONCLUSIONS: Less than half of mUTUC patients met at least one quality criterion, and in particular palliative care services were significantly underutilized. Quality score achievement was associated with longer overall survival at a modest increase in total healthcare spending. These findings not only provide guidance for future study of rare diseases using secondary data, but also highlight inadequacies in the current management of mUTUC. Source of Funding: DoD PRCRP. UroGen Pharma © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e967 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel D. Joyce More articles by this author Yong Shan More articles by this author Courtney A. Stewart More articles by this author Karim Chamie More articles by this author Stephen A. Boorjian More articles by this author Stephen B. Williams More articles by this author Vidit Sharma More articles by this author Expand All Advertisement PDF downloadLoading ...

Association Between Community-Level Social Risk and Spending Among Medicare Beneficiaries

Payers are increasingly using approaches to risk adjustment that incorporate community-level measures of social risk with the goal of better aligning value-based payment models with improvements in health equity. To examine the association between community-level social risk and health care spending and explore how incorporating community-level social risk influences risk adjustment for Medicare beneficiaries. Using data from a Medicare Advantage plan linked with survey data on self-reported social needs, this cross-sectional study estimated health care spending health care spending was estimated as a function of demographics and clinical characteristics, with and without the inclusion of Area Deprivation Index (ADI), a measure of community-level social risk. The study period was January to December 2019. All analyses were conducted from December 2021 to August 2022. Census block group-level ADI. Regression models estimated total health care spending in 2019 and approximated different approaches to social risk adjustment. Model performance was assessed with overall model calibration (adjusted R2) and predictive accuracy (ratio of predicted to actual spending) for subgroups of potentially vulnerable beneficiaries. Among a final study population of 61 469 beneficiaries (mean [SD] age, 70.7 [8.9] years; 35 801 [58.2%] female; 48 514 [78.9%] White; 6680 [10.9%] with Medicare-Medicaid dual eligibility; median [IQR] ADI, 61 [42-79]), ADI was weakly correlated with self-reported social needs (r = 0.16) and explained only 0.02% of the observed variation in spending. Conditional on demographic and clinical characteristics, every percentile increase in the ADI (ie, more disadvantage) was associated with a $11.08 decrease in annual spending. Directly incorporating ADI into a risk-adjustment model that used demographics and clinical characteristics did not meaningfully improve model calibration (adjusted R2 = 7.90% vs 7.93%) and did not significantly reduce payment inequities for rural beneficiaries and those with a high burden of self-reported social needs. A postestimation adjustment of predicted spending for dual-eligible beneficiaries residing in high ADI areas also did not significantly reduce payment inequities for rural beneficiaries or beneficiaries with self-reported social needs. In this cross-sectional study of Medicare beneficiaries, the ADI explained little variation in health care spending, was negatively correlated with spending conditional on demographic and clinical characteristics, and was poorly correlated with self-reported social risk factors. This prompts caution and nuance when using community-level measures of social risk such as the ADI for social risk adjustment within Medicare value-based payment programs.

Parental Obesity: The Pandemic of Intergenerational Physical and Mental Health Carnage

A review of the maternal and paternal impact of obesity at conception on the subsequent health of the offspring paints a nightmarish future in terms of suffering and out-of-control healthcare spending. Consequences of parental obesity on the offspring include obesity, type 2 diabetes, cardiovascular disease, chronic kidney disease, stroke, and premature death. Children of obese women tend to have high blood pressure, left ventricular thickening, increased abdominal fat mass, hyperlipidemia with reduced high-density lipoprotein levels, increased aortic root diameter, insulin resistance, and elevated inflammatory markers, which culminate in a threefold greater risk of cardiometabolic complications than in children of normal-weight mothers. Babies are at greater risk of developing asthma, autism spectrum disorder, attention deficit hyperactivity disorder, cognitive delays, inflammation, cerebral palsy, epilepsy, and the chronic diseases of obesity (such as insulin resistance, high blood pressure, atherosclerosis, cardiovascular disease, stroke, some cancers, including breast, endometrial, and colon cancer, gall bladder disease, polycystic ovarian syndrome, musculoskeletal problems such as osteoarthritis and back pain, gout, cataracts, stress incontinence, and sleep apnea), as well as psychiatric disorders including substance abuse. All parents desire healthy babies, as does society, to avoid the health costs and consequences of our obesity pandemic, but significant personal, societal, public policy, economic, and marketplace interventions will be necessary to avert further devastating impacts. We need to publicize the intergenerational harm caused by obesity, offer support to individuals to help change eating habits and produce a healthier food chain for the nation. Interventions fashioned after the twelve-step program of Alcoholics Anonymous and the adoption of a low carbohydrate abstinence model have proven effective. The time has come to spread the research findings concerning obesity and intergenerational obesity. that are long-accepted by the scientific community but still not recognized by the public at large so that another generation is not impacted by lifestyles that have continuously worsened since the 1970s.

OECD AND UKRAINE: TRENDS IN HEALTH CARE FINANCING

The article examines current trends in healthcare financing in OECD countries and Ukraine. The focus is on assessing the dynamics of total healthcare spending and it is found that in 2020, the COVID-19 pandemic caused a significant increase in funding in all countries. In particular, only in 2019-2020, the share of healthcare costs in the GDP of OECD countries increased by 1% on average. Thus, advanced countries, realizing the impact of the healthcare industry on the economy and well-being of the country as a whole, tried to maximally strengthen its financial stability in general and to epidemic challenges in particular. The priority sources of health care financing were analyzed and it was found that the governments of the OECD countries diversify the sources of financing in the sector to protect their citizens from excessive financial burden and to ensure affordable and high-quality medical care. It was found that the direct costs of patients from OECR countries account for an average of 20% of all health care costs, while in Ukraine the population finances more than 46% of medical costs. It was noted that this indicator is threatening for the country, since the poor do not have access to medical care due to lack of funds and, as a result, the number of diseases, the level of disability, and mortality of citizens is increasing. It was established that the priority sources of financing for one group of OECD countries (Denmark, Sweden, Norway, Great Britain, Canada, etc.) are budget funds, and for another (Germany, Japan, France, etc.) - funds from the mandatory health insurance system. In recent years, there has been a tendency to increase the share of mandatory health insurance in the structure of financing sources of OECD countries, which increased by 2% on average and amounted to 39%. It was concluded that the Ukrainian health care system, in which the reform began in 2015, annually increases the amount of funding and has positive feedback from WHO and World Bank experts about the results of the reform. However, due to political changes in 2014 and economic constraints due to the COVID-19 pandemic, total health spending in dollar terms in 2020 did not reach the 2013 funding level. In addition, the war made adjustments to the activity of the industry, introducing a regime of maximum preservation of infrastructure, simplification of financing, and ensuring the availability of medical services. Despite this, the government developed a post-war healthcare recovery plan to revive destroyed facilities and radically transform the industry in peacetime.

Impact of Telehealth and Process Virtualization on Healthcare Utilization

Telehealth has emerged as a tool to improve patient access by virtualizing healthcare services, particularly during the COVID-19 pandemic. However, concerns have been raised that telehealth may actually increase healthcare spending by leading to new types of utilization. Our research provides empirical evidence that this concern is unfounded based on a state-wide study of patient visit-level data of telehealth use in 58 hospitals in Maryland from 2012 to 2021. On average, telehealth use can reduce future outpatient visits by 13.6% within 30 days after a telehealth visit, leading to a cost reduction of $239. The benefits of telehealth are most apparent for diseases with high potential for process virtualization, such as mental health, skin disorders, metabolic, and musculoskeletal diseases. Although telehealth has a substitution effect on future healthcare utilization, this effect is not observed among rural patients who use telehealth as a gateway to utilize more primary care and specialist services. Our findings suggest that policymakers should promote the use of telehealth in a value-based healthcare environment by providing monetary incentives to expand telehealth use among patients and providers, and expand the scope of telehealth services to include consultation with specialists especially among rural patients.

Falling ill raises the health insurer's administration bill

In many countries, governments use payment systems to compensate health insurers more for enrollees with higher expected costs. However, little empirical research has examined whether these payment systems should also include health insurers' administrative costs. We provide two sources of evidence that health insurers with a more morbid population have higher administrative costs. First, we show at the customer level a causal relationship between individual morbidity and individual administrative contacts with the insurer, using the weekly evolution of the number of individual customer contacts (calls, emails, in-person visits etc.) of a large Swiss health insurer. Using a difference-in-differences design, we find that the onset of a chronic illness causes on average a persistent increase of about 40% in individuals’ contacts with the health insurer. Second, we provide evidence that this relationship also holds for total administrative costs at the insurer level. We study twenty years of Swiss health insurance market data and find a positive elasticity of around 1, indicating that, all else equal, an insurer with a more morbid population, equal to 1% more health care spending, faces about 1% higher administrative costs.

Depression, Cognition, and Pain: Exploring Individual, Cultural and Country-Level Effects Across Europe

The aim of this paper was to investigate the role of economic (eg, GDP per capita), political (eg, healthcare spending), cultural (country-level aggregates norms) and individual correlates (eg, depression) of pain in a secondary analysis of a sample of 76,000 adults in 19 countries across Europe. The sample was aggregated from 2 waves of the Study of Health, Ageing and Retirement in Europe cohort, using multilevel models with cross-level interactions between individual and country-level effects. While there has been extensive focus on individual risk factors (eg, depression, cognition, BMI), the role of social, political and cultural contextual factors has been relatively underexplored. In addition to replicating well-established individual risk factors (eg, increased depression), we demonstrate that higher levels of depression, chronic pain diagnosis, and collectivism, aggregated at the country-level, are also associated with increased pain severity. There was evidence that these country-level effects moderate the effect of individual correlates of pain. These results contribute to the literature by identifying the importance of broader cultural factors alongside individual psychological indices of pain reporting. PerspectiveIn this study we model how individual, political and cultural factors influence pain in a large cross-national sample. In addition to replicating established individual effects, it shows how cultural (ie, collectivism) and political (eg, GDP, healthcare spending) factors affect individual expressions of pain, and how the cultural and individual factors interact with each other.

Lifetime healthcare expenses across demographic and cardiovascular risk groups: The application of a novel modeling strategy in a large multiethnic cohort study

ObjectiveTo understand the burden of healthcare expenses over the lifetime of individuals and evaluate differences among those with cardiovascular risk factors and among disadvantaged groups based on race/ethnicity and sex. MethodsWe linked data from the longitudinal multiethnic Dallas Heart Study, which recruited participants between 2000 and 2002, with inpatient and outpatient claims from all hospitals in the Dallas-Fort Worth metroplex through December 2018, capturing encounter expenses. Race/ethnicity and sex, as well as five risk factors, hypertension, diabetes, hyperlipidemia, smoking, and overweight/obesity, were defined at cohort enrollment. For each individual, expenses were indexed to age and cumulated between 40 and 80 years of age. Lifetime expenses across exposures were evaluated as interactions in generalized additive models. ResultsA total of 2184 individuals (mean age, 45±10 years; 61% women, 53% Black) were followed between 2000 and 2018. The mean modeled lifetime cumulative healthcare expenses were $442,629 (IQR, $423,850 to $461,408). In models that included 5 risk factors, Black individuals had $21,306 higher lifetime healthcare spending compared with non-Black individuals (P < .001), and men had modestly higher expenses than women ($5987, P < .001). Across demographic groups, the presence of risk factors was associated with progressively higher lifetime expenses, with significant independent association of diabetes ($28,075, P < .001), overweight/obesity ($8816, P < .001), smoking ($3980, P = .009), and hypertension ($528, P = .02) with excess spending. ConclusionOur study suggests Black individuals have higher lifetime healthcare expenses, exaggerated by the substantially higher prevalence of risk factors, with differences emerging in older age.

Factors Associated with End-Of-Life Health Care Use and Spending in Korea in Comparison with the General Population

ABSTRACT This study investigated the factors associated with end-of-life health care use and spending in Korea. Chronically ill decedents, who were hospitalized for one of nine chronic conditions during the year before death, were identified from the National Health Insurance Database in 2017. For comparison, the end-of-life care spending for all decedents and the annual health care spending for the general population were analyzed. The inpatient and outpatient end-of-life care spending for the chronically ill decedents were sixteen and seven times the annual inpatient and outpatient spending for the general population respectively. The regional income level was positively associated with both inpatient and outpatient spending among the decedents with a stronger association in the chronically ill decedents, while a negative association was found in the general population. No significant association was found between the inpatient spending and the number of hospital beds for the chronically ill decedents, whereas the number of beds in small to medium-sized hospitals was positively associated with inpatient spending for the total decedents and the general population. The findings suggest that hospitalization for end-of-life care depends more on the income of the patients, while the inpatient spending for total decedents and the general population are more likely to be affected by the supply of beds.

Routine Pathology Examination of Breast Tissue in Adolescent Reduction Mammaplasty: Not Cost Effective in a 7-Year Review.

Routine pathology examination of breast tissue in reduction mammaplasty (RM) is performed with aims of detecting incidental malignancy or risk-increasing lesions. In adolescent patients, the reported incidence ranges between 0% to 0.01%, and costs of pathology claims range between $23 and $614 per analysis. We aim to investigate the rate of incidental findings and the cost-effectiveness of routine pathology examination in adolescent RM. A single-center retrospective review of the pathology results for 132 breast specimens from 66 consecutive RM patients was performed. Data collected for analysis included breast cancer risk factors, demographic information, and operative variables. Zero cases of incidental malignant or risk-increasing lesions were found among the 132 breast specimens from 66 patients aged between 10 and 24 years. Of the 132 specimens, 34 (26%) contained benign fibrocystic disease, which was significantly associated a body mass index greater than 30 kg/m 2 and tissue resection weight greater than 1000 g per breast ( P = 0.003, P = 0.007) respectively. Based on the available data, the use of routine specimen analysis costs more than US $150 million for one breast cancer diagnosis during RM in this age group. In our study, zero atypical, precancerous, or cancerous lesions were detected in a 7-year analysis. The results of this study support the current literature, which reports no occurrence of incidental findings in young women and may promote a greater understanding of evidence-based healthcare spending while concomitantly decreasing the strain placed on histopathology services.

The Influence of a Wearable-Based Reward Program on Health Care Costs: Retrospective, Propensity Score–Matched Cohort Study

Mobile health (mHealth) technology holds great promise as an easily accessible and effective solution to improve population health at scale. Despite the abundance of mHealth offerings, only a minority are grounded in evidence-based practice, whereas even fewer have line of sight into population-level health care spending, limiting the clinical utility of such tools. This study aimed to explore the influence of a health plan-sponsored, wearable-based, and reward-driven digital health intervention (DHI) on health care spending over 1 year. The DHI was delivered through a smartphone-based mHealth app available only to members of a large commercial health plan and leveraged a combination of behavioral economics, user-generated sensor data from the connected wearable device, and claims history to create personalized, evidence-based recommendations for each user. This study deployed a propensity score-matched, 2-group, and pre-post observational design. Adults (≥18 years of age) enrolled in a large, national commercial health plan and self-enlisted in the DHI for ≥7 months were allocated to the intervention group (n=56,816). Members who were eligible for the DHI but did not enlist were propensity score-matched to the comparison group (n=56,816). Average (and relative change from baseline) medical and pharmacy spending per user per month was computed for each member of the intervention and comparison groups during the pre- (ie, 12 months) and postenlistment (ie, 7-12 months) periods using claims data. Baseline characteristics and medical spending were similar between groups (P=.89). On average, the total included sample population (N=113,632) consisted of young to middle-age (mean age 38.81 years), mostly White (n=55,562, 48.90%), male (n=46,731, 41.12%) and female (n=66,482, 58.51%) participants. Compared to a propensity score-matched cohort, DHI users demonstrated approximately US $10 per user per month lower average medical spending (P=.02) with a concomitant increase in preventive care activities and decrease in nonemergent emergency department admissions. These savings translated to approximately US $6.8 million in avoidable health care costs over the course of 1 year. This employer-sponsored, digital health engagement program has a high likelihood for return on investment within 1 year owing to clinically meaningful changes in health-seeking behaviors and downstream medical cost savings. Future research should aim to elucidate health behavior-related mechanisms in support of these findings and continue to explore novel strategies to ensure equitable access of DHIs to underserved populations that stand to benefit the most.

Association of Participation in a Value-Based Insurance Design Program With Health Care Spending and Utilization

Value-based insurance design (VBID) has mostly been used in improving medication use and adherence for certain conditions or patients, but its outcomes remain uncertain when applied to other services and to all health plan enrollees. To determine the association of participation in a California Public Employees' Retirement System (CalPERS) VBID program with its enrollees' health care spending and utilization. A retrospective cohort study with difference-in-differences propensity-weighted 2-part regression models was performed in 2021 to 2022. A VBID cohort was compared with a non-VBID cohort both before and after VBID implementation in California in 2019 with 2 years' follow-up. The study sample included CalPERS preferred provider organization continuous enrollees from 2017 through 2020. Data were analyzed from September 2021 to August 2022. The key VBID interventions include (1) if selecting and using a primary care physician (PCP) for routine care, PCP office visit copayment is $10 (otherwise, PCP office visit copayment is $35 as for specialist visit); and (2) annual deductibles reduced by a half through completion of the following 5 activities: annual biometric screening, influenza vaccine, nonsmoking certification, second opinion for elective surgical procedures, and disease management participation. The primary outcome measures included annual per member total approved payments for multiple inpatient and outpatient services. The 2 compared cohorts of 94 127 participants (48 770 were female [52%]; 47 390 were younger than 45 years old [50%]) had insignificant baseline differences after propensity-weighting adjustment. The VBID cohort had significantly lower probabilities of inpatient admissions (adjusted relative odds ratio [OR], 0.82; 95% CI, 0.71-0.95), and higher probabilities of receiving immunizations (adjusted relative OR, 1.07; 95% CI, 1.01-1.21) in 2019. Among those with positive payments, VBID was associated with higher mean total allowed amounts for PCP visits in 2019 and 2020 (adjusted relative payments ratio, 1.05; 95% CI, 1.02-1.08). There were no significant differences for inpatient and outpatient combined totals in 2019 and 2020. The CalPERS VBID program achieved desired goals for some interventions with no added total costs in its first 2 years of operation. VBID may be used to promote valued services while containing costs for all enrollees.

Why Are Some Value-Based Programs Successful?

Original Investigation Participation in a Value-Based Insurance Design Program and Health Care Spending and Utilization Hui Zhang, PhD; David W. Cowling, PhD

Delivery system emergency department capacity and its effect on nonsystem service utilization.

Emergency department (ED) use is often seen as a source of excess health care spending, prompting managers to limit ED capacity in their health systems. However, if limited ED capacity in a delivery system leads patients to seek emergency care elsewhere, then health care quality and efficient management may be compromised within the system. The objective of this study was to explore the effect of the Veterans Health Administration (VHA) in-house ED clinician capacity on VHA community care (CC) ED claims. We used administrative data from the VHA to identify CC ED claims and Department of Veterans Affairs emergency physician (EP) capacity for 2014-2019. We used quasi-experimental instrumental variables approach with two different instruments: percent weekday federal holidays and VHA EP full-time equivalents (FTEs). We controlled for VHA ED variables such as ED wait times (door to triage, door to doctor, and door to admission) and demand variables such as alternative insurance coverage, driving time to VHA care, and demographic variables (employment, age, household income, race, gender, and VHA priority status). After instrumenting for capacity with percent weekday federal holidays, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 61 CC ED claims per 10,000 enrollees. After instrumenting for capacity with EP FTE, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 48 CC ED claims per 10,000 enrollees. Both of these results are statistically significant at p< 0.001. Our findings imply that offering more in-house ED care, in the form of clinician capacity, can substantially reduce out-of-system ED use. The results may be of interest to integrated health care system managers who prefer their patients to stay within network.

Does environment quality affect the health care spending? Nexus among CO2 emissions, non-renewable energy production, financial development, and health care spending.

This study investigates the dynamic associations among carbon dioxide (CO2) emissions, non-renewable energy production from petroleum derivatives, financial development, and healthcare expenditures to improve environmental quality. This research has employed the balanced annual panel of thirty (30) Organizations for Economic Co-operation and Development (OECD) countries' data set and applied panel vector autoregression (VAR) method depending on the generalized method of moments (GMM). Furthermore, the empirical findings reveal that health spending and CO2 emissions have a favorable bidirectional link, but there is no indication that health spending promotes power generation. The results demonstrate that increased energy consumption and productions affect pollution, and higher CO2 emissions increase healthcare costs. Whereas, energy consumption, financial development, and healthcare expenditures have a positive toward environmental quality.