Large Commercial Health Plan Research Articles

At-home hemoglobin A1c testing during COVID-19 improved glycemic control.

COVID-19 has exacerbated barriers to routine testing for chronic disease management. This study investigates whether a home hemoglobin A1c (HbA1c) test kit intervention increases frequency of HbA1c testing and leads to changes in HbA1c 6 months post testing and whether self-reinforcement education improves maintenance of HbA1c testing. Retrospective analysis of a randomized, controlled quality improvement intervention among members with type 2 diabetes (T2D) in a large commercial health plan. Participants were 41,214 commercial fully insured members with T2D without an HbA1c test in the past 6 months or with only 1 HbA1c test in the last 12 months. Members were randomly assigned to either a control group or an at-home HbA1c testing intervention group consisting of either an opt-in test or a direct-to-member opt-out HbA1c test kit shipment. A third cohort of members was assigned to a self-reinforcement group to encourage continued testing twice per year. Main outcomes were HbA1c testing rates and HbA1c levels (in %). A total of 11.1% (508 of 4590) at-home HbA1c kits were completed. At-home HbA1c test kits increased testing rates by 4.9% compared with controls (P < .001). Members with an HbA1c level of at least 7% who requested and completed at-home HbA1c testing had a 0.38% reduction in HbA1c in the 6 months post intervention when controlling for baseline HbA1c (P < .001). Members who received self-reinforcement messaging had a 0.37% HbA1c reduction post intervention (P = .015). This novel, at-home approach to test HbA1c is an effective intervention to increase testing rates and facilitate HbA1c reduction over time in patients with T2D.

HPR113 Trends in Elective Contraception Procedures in Those of Childbearing Age Enrolled in a Large Commercial Health Plan Surrounding Key Legal and Policy Events from 2008 to 2022

Recent legal and policy decisions shaped access to, and costs of, essential reproductive healthcare in the United States. This study evaluated trends in elective contraception procedures in childbearing age individuals enrolled in a large commercial health plan during periods surrounding key legal and policy events.

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.

Integration of the National Comprehensive Cancer Network (NCCN) Distress Screening Tool as a Guidepost for Telephonic Oncology Case Management

Cigna's oncology case management programs identified the opportunity for case managers to integrate distress screening as recommended by the National Comprehensive Cancer Network (NCCN) in oncology populations. Our purpose in conducting this study was to quantify oncology case management program improvements as a result of using the NCCN Distress Screening Tool to guide telephonic case management. The program improvements we measured comprised more efficient identification of biopsychosocial problems and appropriate resource referrals. Case managers in a large commercial health plan piloted integration of distress screening into telephonic case management among U.S. oncology customers experiencing a new diagnosis or care transition from September 2016 to April 2017. A retrospective, matched case-control study was conducted among Cigna customers eligible for oncology case management. The pilot group of 317 received distress screening early in the oncology case management assessment. Outcomes included distress severity ranging from 0 to 10 (where 0 = no distress, 1-3 = mild, 4-7 = moderate, and 8-10 = severe), identification and number of biopsychosocial health problems, and percentage of direct resource referrals by case managers to supportive services. More than half (54%) of the screened customers reported mild or greater distress, and there was a strong correlation between degree of distress and average numbers of biopsychosocial health problems or direct resource referrals. Screened customers were 16% more likely to be referred to internal and external resources than customers not screened with the tool (66% vs. 50%, χp < .001). This study advances evidence-based oncology case management practice during care transitions by providing quantitative evidence for the utility of integrating the NCCN Distress Screening Tool into telephonic oncology case management. Using the tool (thermometer and problem list) to guide telephonic oncology case management and care coordination facilitated more tailored referrals to individuals with cancer enrolled in a large commercial health plan. On the basis of our findings, we integrated distress screening to address unmet biopsychosocial needs in patients with cancer.

A Survey of Patients' Perceptions of Pill Appearance and Responses to Changes in Appearance for Four Chronic Disease Medications.

Generic versions of a drug can vary in appearance, which can impact adherence. To assess the preferences, perceptions, and responses of patients who experienced a change in the appearance of a generic medication. Cross-sectional survey of patients from a large commercial health plan. Adults receiving generic versions of lisinopril, fluoxetine, lamotrigine, or simvastatin who experienced a change in the color or shape of their pills between March 2014 and November 2015. Likert-scale responses to questions concerning perceptions of generic drug safety and effectiveness, reliance on and preferences for pill appearance, and responses to pill appearance changes. Multivariable logistic regression-modeled predictors of seeking advice and adjusting use following a pill appearance change. Of 814 respondents (response rate = 41%), 72% relied on pill appearance to ensure they took the correct medication. A similar percentage wanted their pills to remain the same color (72%), shape (71%), and size (75%) upon refill, but 58% would not have paid a $1 premium on a $5 co-pay to ensure such consistency. Most respondents (86%) wanted their pharmacists to notify them about pill appearance changes, but only 37% recalled such notification; 21% thought they received the wrong medication, and 8% adjusted medication use. Younger respondents (18-33 vs. 50-57years) were more likely to seek advice (odds ratio [OR] = 1.91; 95% confidence interval [CI],1.02-3.59), and respondents with lower household income (< $30,000 vs. > $100,000) were more likely to adjust medication use (OR = 3.40; 95% CI,1.09-10.67). Requiring uniform pill appearance may help increase adherence but presents challenges. Standardized pharmacy notification and education policies may be a more feasible short-term solution.

Opioid Use is Associated with Higher Severity-Adjusted Episode Costs in Patients with Conservatively Managed Degenerative Joint Disease of the Back and Neck.

Opioid use and misuse are urgent health issues. Previous studies suggest that opioid use increases healthcare resource use but severity adjustment is lacking. The objective of this study wasto evaluate the severity-adjusted cost difference between opioid users and non-users among patients with conservatively managed degenerative joint disease of the spine within a large commercial health plan population in the United States. A retrospective observational study was performed using a national commercial database covering 531,819 patients aged 18-64years with non-surgically managed cervical or lumbar degenerative spine disease during 2015-6. Patients were grouped based on whether there was evidence for an opioid prescription. Costs for the opioids themselves were excluded. Severity adjustment, on an ascending integer scale from 1 to 4, was performed based on member demographics, clinical comorbidities, disease progression indicators, and complications. Median episode costs for patients given opioids were approximately twice that for patients not given opioids after severity adjustment. For patients with episodes in both years and stable severity, patients with new prescriptions for opioids in 2016 doubled their median 2015 costs, and patients who had opioids discontinued in 2016 had a 60% cost reduction. Episode costs showed a nearly linear increase based on the length of time taking opioids, as well as with a higher average daily dose. Cost increases with opioids were broad across service categories even when comparing within the same severity-adjusted episodes of care. The data suggest a clinically and statistically significant increase in episode costs associated with opioid use for degenerative joint disease of the spine, both within and between patients, and higher costs with a longer duration of opioid use as well as with higher daily dosages. Given the health consequences surrounding the overuse of opioids, concerted efforts to move towards a non-opioid pain control strategy are needed.

PDB94 - INITIAL ANTIDIABETIC PHARMACOTHERAPY PRESCRIBED TO PATIENTS WITH NEWLY DIAGNOSED TYPE-2 DIABETES IN A COMMERCIAL HEALTH PLAN IN THE UNITED STATED

In 2010, the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) updated their guidelines for treatment of type-2 diabetic patients. This study assessed the selection of initial antidiabetic pharmacotherapy among newly diagnosed with type-2 diabetes patients from 2010- 2016 in a commercial health plan in the United States. A retrospective cohort study was conducted using a large commercial health plan claims database. Patients with a first diagnosis of diabetes from 2010 to 2016 were identified by the International Classification of Disease, ninth & tenth revisions, Clinical Modification diagnostic codes. We included patients aged ≥18 years, with normal renal and liver function, HbA1C >6.4%, and with at least 1 year of continuous enrollment in the health plan before the first antidiabetic prescription. We excluded pregnant woman. Data were classified based on HbA1C level, pharmacological class, active ingredient, and strength. Differences in utilization of initial antidiabetic pharmacotherapy according to the HbA1C levels were evaluated using Chi-squared test. From 2010 to 2016, 71,739 newly diagnostic type-2 diabetic patients were prescribed antidiabetic pharmacotherapy. A total of 70,228 (97.9%) patients started pharmacotherapy with oral antidiabetic drugs, and 1,697 (2.4%) patients started pharmacotherapy with insulin. Most patients were treated with biguanides class (metformin) (93.1%) and sulfonylurea class (5.5%). The strength of metformin, the use a drug combination and the use of insulin were positively associated with the HbA1C level (p <0.001). Most newly diagnosed type-2 diabetic patients were prescribed metformin which is the preferred agent for initial treatment recommended by the ADA/AACE guidelines. The HbA1C levels influenced the choice of initial antidiabetic pharmacotherapy and strength, and the use of a drug combination.

Pharmacogenetic testing among patients with mood and anxiety disorders is associated with decreased utilization and cost: A propensity-score matched study.

Naturalistic and small randomized trials have suggested that pharmacogenetic testing may improve treatment outcomes in depression, but its cost-effectiveness is not known. There is growing enthusiasm for personalized medicine, relying on genetic variation as a contributor to heterogeneity of treatment effects. We sought to examine the relationship between a commercial pharmacogenetic test for psychotropic medications and 6-month cost of care and utilization in a large commercial health plan. We performed a propensity-score matched case-control analysis of longitudinal health claims data from a large US insurer. Individuals with a mood or anxiety disorder diagnosis (N=817) who received genetic testing for pharmacokinetic and pharmacodynamic variation were matched to 2,745 individuals who did not receive such testing. Outcomes included number of outpatient visits, inpatient hospitalizations, emergency room visits, and prescriptions, as well as associated costs over 6 months. On average, individuals who underwent testing experienced 40% fewer all-cause emergency room visits (mean difference 0.13 visits; P<0.0001) and 58% fewer inpatient all-cause hospitalizations (mean difference 0.10 visits; P<0.0001) than individuals in the control group. The two groups did not differ significantly in number of psychotropic medications prescribed or mood-disorder related hospitalizations. Overall 6-month costs were estimated to be $1,948 (SE 611) lower in the tested group. Pharmacogenetic testing represents a promising strategy to reduce costs and utilization among patients with mood and anxiety disorders.

Differences in rates of switchbacks after switching from branded to authorized generic and branded to generic drug products: cohort study

ObjectivesTo compare rates of switchbacks to branded drug products for patients switched from branded to authorized generic drug products, which have the same active ingredients, appearance, and excipients as the...

Primary care physician perspectives on basal insulin initiation and maintenance in patients with type 2 diabetes mellitus

AimsTo describe primary care physicians’ (PCPs) perceptions of patient reactions and concerns about insulin initiation and identify opportunities for increased support. MethodsCross-sectional, online survey of PCPs prescribing basal insulin to adults with type 2 diabetes mellitus (T2DM). PCPs were identified from administrative claims of a large commercial health plan and descriptive results of PCP responses were reported. ResultsPCPs (N=100) treated an average of 17 patients receiving insulin during a typical week. More than 85% of insulin initiation recommendations originated with PCPs. Most offered glucose monitoring instructions (96%) and advice on diet, exercise, and diabetes management (96%); 35% provided insulin titration algorithms; 93% reported that patients often or always took their insulin daily within 3 months of initiation; 31% of PCPs reported monthly office contacts with patients for the first 3 months; 16% reported no outreach efforts; fewer than 20% connected patients with support groups. When starting basal insulin, PCPs reported patients feeling personal failure regarding their diabetes treatment (33% often/always) and lacking confidence in their ability to manage insulin therapy (38% often/always). ConclusionsStudy results identify additional opportunities for assisting patients in making the transition to insulin, including more frequent direct outreach to monitor insulin usage.

A commercial transplant network's perspective of value in solid organ transplantation: Strategizing for value in transplant care.

Solid organ transplantation has been an area of great interest to commercial payers ever since it moved into mainstream medical care beginning in the 1980s. Over the years a system of evaluating transplant program performance based on volume and one year graft and patient survival has developed. While this system has served its purpose, there is an increasing realization from payers that a need exists for a more sophisticated way to evaluate quality and cost-effectiveness of these complex procedures. We report on the perspective of a large transplant network and its efforts to better understand the drivers of value over the entire continuum of care from referral through one year post-transplant. We evaluated members of a large commercial health plan who were referred for solid organ transplantation between January 1, 2010 and April 30, 2014. A total of 18,453 cases were evaluated for both clinical and economic outcomes. We report on two areas that can impact value over the entire continuum of care. Large variation in clinical practice and cost was noted. The observed variation was independent of inclusion in the transplant network's preferred network. The average pre-transplant and post-transplant costs for kidney, liver and heart transplantation cases at center level showed a variation of between 18 and 250% of the network's average. Clinical outcomes of median days on the waitlist, waitlist mortality and readmission within thirty days after transplant also showed wide variation. There was similar wide variation in cardiac evaluation of transplant candidates despite the existence of published recommendations. We demonstrated that pre-emptive renal transplantation is a high value strategy for this membership independent of donor source. In the studied population the data show wide variation in both clinical and economic parameters related to the transplant process in programs with statistically similar one year patient and graft survival. These results require further examination. In this era of increased concern about delivering value in medical care we may need to reassess how we evaluate organ transplantation programs.

Health-related quality of life and treatment satisfaction in patients with gout: results from a cross-sectional study in a managed care setting.

BackgroundPatient satisfaction with treatment directly impacts adherence to medication.ObjectiveThe objective was to assess and compare treatment satisfaction with the Treatment Satisfaction Questionnaire for Medication (TSQM), gout-specific health-related quality of life (HRQoL) with the Gout Impact Scale (GIS), and generic HRQoL with the SF-12v2® Health Survey (SF-12) in patients with gout in a real-world practice setting.MethodsThis cross-sectional mail survey included gout patients enrolled in a large commercial health plan in the US. Patients were ≥18 years with self-reported gout diagnosis, who filled ≥1 prescription for febuxostat during April 26, 2012 to July 26, 2012 and were not taking any other urate-lowering therapies. The survey included the TSQM version II (TSQM vII, score 0–100, higher scores indicate better satisfaction), GIS (score 0–100, higher scores indicate worse condition), and SF-12 (physical component summary and mental component summary). Patients were stratified by self-report of currently experiencing a gout attack or not to assess the discriminant ability of the questionnaires.ResultsA total of 257 patients were included in the analysis (mean age, 54.9 years; 87% male). Patients with current gout attack (n=29, 11%) had worse scores than those without gout attack on most instrument scales. Mean differences between current attack and no current attack for the TSQM domains were: −20.6, effectiveness; −10.6, side effects; −12.1, global satisfaction (all P<0.05); and −6.1, convenience (NS). For the GIS, mean differences were: 30.5, gout overall concern; 14.6, gout medication side effects; 22.7, unmet gout treatment needs; 11.5, gout concern during attack (all P<0.05); and 7.9, well-being during attack (NS). Mean difference in SF-12 was −6.6 for physical component summary (P<0.05) and −2.9 for mental component summary (NS). Correlations between several TSQM and GIS scales were moderate.ConclusionThe TSQM and GIS were complementary in evaluating the impact of gout flare on treatment satisfaction and HRQoL. Correlations between the two instruments supported the relationship between treatment satisfaction and HRQoL.

Autism occurrence by MMR vaccine status among US children with older siblings with and without autism.

Despite research showing no link between the measles-mumps-rubella (MMR) vaccine and autism spectrum disorders (ASD), beliefs that the vaccine causes autism persist, leading to lower vaccination levels. Parents who already have a child with ASD may be especially wary of vaccinations. To report ASD occurrence by MMR vaccine status in a large sample of US children who have older siblings with and without ASD. A retrospective cohort study using an administrative claims database associated with a large commercial health plan. Participants included children continuously enrolled in the health plan from birth to at least 5 years of age during 2001-2012 who also had an older sibling continuously enrolled for at least 6 months between 1997 and 2012. MMR vaccine receipt (0, 1, 2 doses) between birth and 5 years of age. ASD status defined as 2 claims with a diagnosis code in any position for autistic disorder or other specified pervasive developmental disorder (PDD) including Asperger syndrome, or unspecified PDD (International Classification of Diseases, Ninth Revision, Clinical Modification 299.0x, 299.8x, 299.9x). Of 95,727 children with older siblings, 994 (1.04%) were diagnosed with ASD and 1929 (2.01%) had an older sibling with ASD. Of those with older siblings with ASD, 134 (6.9%) had ASD, vs 860 (0.9%) children with unaffected siblings (P < .001). MMR vaccination rates (≥1 dose) were 84% (n = 78,564) at age 2 years and 92% (n = 86,063) at age 5 years for children with unaffected older siblings, vs 73% (n = 1409) at age 2 years and 86% (n = 1660) at age 5 years for children with affected siblings. MMR vaccine receipt was not associated with an increased risk of ASD at any age. For children with older siblings with ASD, at age 2, the adjusted relative risk (RR) of ASD for 1 dose of MMR vaccine vs no vaccine was 0.76 (95% CI, 0.49-1.18; P = .22), and at age 5, the RR of ASD for 2 doses compared with no vaccine was 0.56 (95% CI, 0.31-1.01; P = .052). For children whose older siblings did not have ASD, at age 2, the adjusted RR of ASD for 1 dose was 0.91 (95% CI, 0.67-1.20; P = .50) and at age 5, the RR of ASD for 2 doses was 1.12 (95% CI, 0.78-1.59; P = .55). In this large sample of privately insured children with older siblings, receipt of the MMR vaccine was not associated with increased risk of ASD, regardless of whether older siblings had ASD. These findings indicate no harmful association between MMR vaccine receipt and ASD even among children already at higher risk for ASD.

Perspectives on complementary data sources in diabetes health technology assessment: an enrolling practice-based research network and a large commercial health plan

Perspectives on complementary data sources in diabetes health technology assessment: an enrolling practice-based research network and a large commercial health plan

PDB99 - Perspectives on complementary data sources in diabetes health technology assessment: An enrolling practice-based research network and a large commercial health plan

PDB99 - Perspectives on complementary data sources in diabetes health technology assessment: An enrolling practice-based research network and a large commercial health plan