Private Payers Research Articles

Anesthesia Practice Finances, 2030

Article| October 2021 Anesthesia Practice Finances, 2030 Gordon Morewood, MD, MBA, FASE, FASA; Gordon Morewood, MD, MBA, FASE, FASA Search for other works by this author on: This Site PubMed Google Scholar Neal H. Cohen, MD, MPH, MS; Neal H. Cohen, MD, MPH, MS Search for other works by this author on: This Site PubMed Google Scholar Sharon K. Merrick, MS, CCS-P Sharon K. Merrick, MS, CCS-P Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor October 2021, Vol. 85, 24–26. https://doi.org/10.1097/01.ASM.0000795164.24106.b8 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Gordon Morewood, Neal H. Cohen, Sharon K. Merrick; Anesthesia Practice Finances, 2030. ASA Monitor 2021; 85:24–26 doi: https://doi.org/10.1097/01.ASM.0000795164.24106.b8 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu nav search search input Search input auto suggest search filter All ContentAll PublicationsASA Monitor Search Advanced Search Topics: finance, health care systems, medicare The finances of an anesthesia practice are dictated primarily by the payment rates and policies of both government and private payors. In recent years, both government and private insurers have focused on reducing the costs of individual episodes of care as well as the rate of growth in overall health care spending. As a result, the past decade has undoubtedly seemed quite turbulent to many physicians, particularly in comparison to the relative stability of the health care payment system during the two decades prior. Despite a variety of approaches to managing these costs, the containment strategies to date have not been successful. New approaches designed to value health care differently are being implemented. Most of these changes are based primarily on quality and safety rather than cost alone. Many of the alternative payment models require providers and health systems to assume new financial risks. These approaches represent more sophisticated attempts... You do not currently have access to this content.

Risk of Early and Late Onset Alzheimer's Disease and Related Dementia among Adults with Congenital and Acquired Disabilities

<h3>Research Objectives</h3> Adults with congenital (cerebral palsy or spina bifida (CP/SB)) or acquired disabilities (spinal cord injury (SCI) or multiple sclerosis (MS)) have higher incidence of age-related health conditions. There is a gap in the literature about the risk of dementia among adults living with these disabilities. This study aimed to examine time to incidence of Alzheimer's disease and related dementia (ADRD) among these disability cohorts. <h3>Design</h3> Incidence of ADRD was compared at 4-years. Cox Regression was used to estimate adjusted hazard ratios (aHR) for incident early and late onset ADRD. <h3>Setting</h3> Using national private payer claims data from 2007-2017, we identified adults (45+) with diagnosis of CP/SB (n=7,226), SCI (n=6,083), and MS (n=6,025). Adults without disability diagnosis were included as controls. Using age, sex, race/ethnicity, cardiometabolic, psychologic, and musculoskeletal chronic conditions, and socioeconomic variables, we propensity score matched persons with and without disabilities. <h3>Participants</h3> We identified adults (45+) with diagnosis of CP/SB (n=7,226), SCI (n=6,083), and MS (n=6,025). Adults without disability diagnosis were included as controls. <h3>Interventions</h3> The exposure variable was diagnosis with either congenital or acquired disability. <h3>Main Outcome Measures</h3> Main outcome variable was incident Alzheimer's disease and related dementia. <h3>Results</h3> Incidence of early and late onset ADRD were substantially higher among people with disabilities compared to their non-disabled counterparts. Adults with CP, SCI, and MS had higher risk for early [CP/SB: aHR=3.35 (95% CI: 2.18-5.14); SCI: aHR=1.93 (95% CI:1.06-3.51); and MS: aHR=4.49 (95% CI:2.62-7.69)] and late [CP: aHR=1.68 (95% CI:1.38-2.03); SCI: aHR: 1.77 (95% CI:1.55-2.02); and MS: aHR=1.26 (95% CI:1.04, 1.54)] onset ADRD. <h3>Conclusions</h3> Risk of ADRD was higher among adults with CP/SB, SCI, and MS compared to their matched cohort without disability. Investment in early screening and use of therapeutic or rehabilitative services that may help preserving cognitive function among these patient cohorts is warranted. <h3>Author(s) Disclosures</h3> There is no conflict of interest to disclose.

Examining the Risk of Potentially Preventable Hospitalization in Adults with Congenital and Acquired Disabilities

<h3>Research Objectives</h3> Adults with congenital (cerebral palsy/spina bifida (CP/SB)) or acquired disabilities (spinal cord injury (SCI) or multiple sclerosis (MS)) are more likely than those without disability to develop medical complications. Little is known about potentially preventable hospitalizations (PPH) among adults with disabilities. PPHs are preventable if a patient had timely access to care. Our objective was to estimate PPH risk for each of the aforementioned disabilities. <h3>Design</h3> Logistic regression models with repeated measures were subsequently applied, adjusting for age, sex, race/ethnicity, health indicators, U.S. census divisions, and socioeconomic variables. Odd ratios (OR) were compared over 4-years of follow up. <h3>Setting</h3> We used private payer claims data from 2007-2017 to identify adults (18+) with diagnoses of CP/SB (n=10,617), SCI (n=5,173), and MS (n=6,198). Adults without these disabilities were included as controls.We propensity score matched individuals for age and sex. Logistic regression models with repeated measures were subsequently applied, adjusting for age, sex, race/ethnicity, health indicators, U.S. census divisions, and socioeconomic variables. <h3>Participants</h3> Adults (18+) with diagnoses of CP/SB (n=10,617), SCI (n=5,173), and MS (n=6,198). <h3>Interventions</h3> Use of preventative services and their interactions with our exposure variable (specific disability type). <h3>Main Outcome Measures</h3> Risk and cost of potentially preventable hospitalization. <h3>Results</h3> Adults with CP/SB, SCI, and MS had higher odds of any PPH compared with adults without disability [CP/SB: (OR=4.10; 95% CI: 2.31-7.31); SCI: (OR=1.67; 95% CI: 1.21-2.32); and MS: (OR=1.48; 95% CI: 1.00-2.25)]. Use of preventative services reduced the PPH risk. For example, wellness visit reduced the odds of PPH by almost half [CP/SB: (OR=0.52; 95% CI: 0.41-0.67); SCI: (OR=0.57; 95% CI: 0.45-0.71); and MS: (OR=0.53; 95% CI: 0.40-0.66)]. <h3>Conclusions</h3> Adults with disabilities are at greater odds of PPH compared to adults without disabilities. Clinical guidelines for use of preventative care for adults living with disabilities need to be accordingly updated. <h3>Author(s) Disclosures</h3> There is no conflict of interest to disclose.

Mathematical Foundations for Balancing the Payment System in the Trade Credit Market

The increasingly complex economic and financial environment in which we live makes the management of liquidity in payment systems and the economy in general a persistent challenge. New technologies make it possible to address this challenge through alternative solutions that complement and strengthen existing payment systems. For example, interbank balancing and clearing methods (such as real-time gross settlement) can also be applied to private payments, complementary currencies, and trade credit clearing to provide better liquidity and risk management. The paper defines the concept of a balanced payment system mathematically and demonstrates the effects of balancing on a few small examples. It then derives the construction of a balanced payment subsystem that can be settled in full and therefore that can be removed in toto to achieve debt reduction and payment gridlock resolution. Using well-known results from graph theory, the main output of the paper is the proof—for the general formulation of a payment system with an arbitrary number of liquidity sources—that the amount of liquidity saved is maximum, along with a detailed discussion of the practical steps that a lending institution can take to provide different levels of service subject to the constraints of available liquidity and its own cap on total overdraft exposure. From an applied mathematics point of view, the original contribution of the paper is two-fold: (1) the introduction of a liquidity node with a store of value function in obligation-clearing; and (2) the demonstration that the case with one or more liquidity sources can be solved with the same mathematical machinery that is used for obligation-clearing without liquidity. The clearing and balancing methods presented are based on the experience of a specific application (Tetris Core Technologies), whose wider adoption in the trade credit market could contribute to the financial stability of the whole economy and a better management of liquidity and risk overall.

Factors Associated With COVID‐19 Disease Severity in US Children and Adolescents

Little is known about the clinical factors associated with COVID-19 disease severity in children and adolescents. We conducted a retrospective cohort study across 45 US children's hospitals between April 2020 to September 2020 of pediatric patients discharged with a primary diagnosis of COVID-19. We assessed factors associated with hospitalization and factors associated with clinical severity (eg, admission to inpatient floor, admission to intensive care unit [ICU], admission to ICU with mechanical ventilation, shock, death) among those hospitalized. Among 19,976 COVID-19 encounters, 15,913 (79.7%) patients were discharged from the emergency department (ED) and 4063 (20.3%) were hospitalized. The clinical severity distribution among those hospitalized was moderate (3222, 79.3%), severe (431, 11.3%), and very severe (380, 9.4%). Factors associated with hospitalization vs discharge from the ED included private payor insurance (adjusted odds ratio [aOR],1.16; 95% CI, 1.1-1.3), obesity/type 2 diabetes mellitus (type 2 DM) (aOR, 10.4; 95% CI, 8.9-13.3), asthma (aOR, 1.4; 95% CI, 1.3-1.6), cardiovascular disease, (aOR, 5.0; 95% CI, 4.3- 5.8), immunocompromised condition (aOR, 5.9; 95% CI, 5.0-6.7), pulmonary disease (aOR, 5.3; 95% CI, 3.4-8.2), and neurologic disease (aOR, 3.2; 95% CI, 2.7-5.8). Among children and adolescents hospitalized with COVID-19, greater disease severity was associated with Black or other non-White race; age greater than 4 years; and obesity/type 2 DM, cardiovascular, neuromuscular, and pulmonary conditions. Among children and adolescents presenting to US children's hospital EDs with COVID-19, 20% were hospitalized; of these, 21% received care in the ICU. Older children and adolescents had a lower risk for hospitalization but more severe illness when hospitalized. There were differences in disease severity by race and ethnicity and the presence of selected comorbidities. These factors should be taken into consideration when prioritizing mitigation and vaccination strategies.

Population Health Innovations and Payment to Address SocialNeeds Among Patients and Communities With Diabetes.

Increasingly, health care organizations are implementing interventions to improve outcomes for patients with complex health and social needs, including diabetes, through cross-sector partnerships with nonmedical organizations. However, fee-for-service and many value-based payment systems constrain options to implement models of care that address social and medical needs in an integrated fashion. We present experiences of eight grantee organizations from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative to improve diabetes outcomes by transforming primary care and addressing social needs within evolving payment models. Analysis of eight grantees through site visits, technical assistance calls, grant applications, and publicly available data from US census data (2017) and from Health Resources and Services Administration Uniform Data System Resources data (2018). Organizations represent a range of payment models, health care settings, market factors, geographies, populations, and community resources. Grantees are implementing strategies to address medical and social needs through augmented staffing models to support high-risk patients with diabetes (e.g., community health workers, behavioral health specialists), information technology innovations (e.g., software for social needs referrals), and system-wide protocols to identify high-risk populations with gaps in care. Sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Sites encounter challenges accessing flexible up-front funding to support infrastructure for interventions. Value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs interventions. Federal, state, and private payers should support critical infrastructure to address social needs and incentivize care that addresses social needs and outcomes sensitive to social risk. Population health strategies that address medical and social needs for populations living with diabetes will need to be tailored to a range of health care organizations, geographies, populations, community partners, and market factors. Payment models should support and incentivize these strategies for sustainability.

Review of Health Insurance Policy Inclusivity of Gender Nonconforming and Nonbinary Individuals Seeking Gender-Affirming Health Care.

An increasing number of individuals who present to health care professionals identify as transgender, gender nonconforming (GNC), and gender nonbinary (NB). GNC/NB individuals experience higher rates of discrimination in health care settings compared with their binary (e.g., trans male and trans female) counterparts. Outdated language excludes the nuances of gender identity. The goal of this study was to evaluate whether current terminology found in health insurance policies may be a barrier to gender-affirming health care for GNC/NB individuals. Health insurance policies for a diverse subset of government (n=4) and private (n=6) payers were obtained in May 2020. Policies were reviewed independently by two members of the research team to determine whether each was supportive or unsupportive to GNC/NB individuals. An arbitrary scoring system was designed that allowed the reviewers to assign a specific number of points to each policy based on the aggregation of mention, coverage, and inclusivity. Most policies performed poorly as indicated by a support score less than zero. It was also noted that most policies used binary, gendered language, and terminology that excludes the unique gender identities of many GNC/NB individuals. Most policies currently failed to provide clear, inclusive coverage to GNC/NB individuals for relevant and important aspects of their care. In their current state, these policies are a source of confusion, uncertainty, and discouragement for these individuals, which can present as a barrier to accessing quality, inclusive, gender-affirming health care.

How to fix the Merit-based Incentive Payment System (MIPS) in emergency medicine.

How to fix the Merit-based Incentive Payment System (MIPS) in emergency medicine.

Patient and Clinician Characteristics Associated With Secure Message Content: Retrospective Cohort Study.

BackgroundGood communication has been shown to affect patient outcomes; however, the effect varies according to patient and clinician characteristics. To date, no research has explored the differences in the content of secure messages based on these characteristics.ObjectiveThis study aims to explore characteristics of patients and clinic staff associated with the content exchanged in secure messages.MethodsWe coded 18,309 messages that were part of threads initiated by 1031 patients with hypertension, diabetes, or both conditions, in communication with 711 staff members. We conducted four sets of analyses to identify associations between patient characteristics and the types of messages they sent, staff characteristics and the types of messages they sent, staff characteristics and the types of messages patients sent to them, and patient characteristics and the types of messages they received from staff. Logistic regression was used to estimate the strength of the associations.ResultsWe found that younger patients had reduced odds of sharing clinical updates (odds ratio [OR] 0.77, 95% CI 0.65-0.91) and requesting prescription refills (OR 0.77, 95% CI 0.65-0.90). Women had reduced odds of self-reporting biometrics (OR 0.78, 95% CI 0.62-0.98) but greater odds of responding to a clinician (OR 1.20, 95% CI 1.02-1.42) and seeking medical guidance (OR 1.19, 95% CI 1.01-1.40). Compared with White patients, Black patients had greater odds of requesting preventive care (OR 2.68, 95% CI 1.30-5.51) but reduced odds of requesting a new or changed prescription (OR 0.72, 95% CI 0.53-0.98) or laboratory or other diagnostic procedures (OR 0.66, 95% CI 0.46-0.95). Staff had lower odds of sharing medical guidance with younger patients (OR 0.83, 95% CI 0.69-1.00) and uninsured patients (OR 0.21, 95% CI 0.06-0.73) but had greater odds of sharing medical guidance with patients with public payers (OR 2.03, 95% CI 1.26-3.25) compared with patients with private payers. Staff had reduced odds of confirming to women that their requests were fulfilled (OR 0.82, 95% CI 0.69-0.98). Compared with physicians, nurse practitioners had greater odds of sharing medical guidance with patients (OR 2.74, 95% CI 1.12-6.68) and receiving prescription refill requests (OR 3.39, 95% CI 1.49-7.71). Registered nurses had greater odds of deferred information sharing (OR 1.61, 95% CI 1.04-2.49) and receiving responses to messages (OR 3.93, 95% CI 2.18-7.11) than physicians.ConclusionsThe differences we found in content use based on patient characteristics could lead to the exacerbation of health disparities when content is associated with health outcomes. Disparities in the content of secure messages could exacerbate disparities in patient outcomes, such as satisfaction, trust in the system, self-care, and health outcomes. Staff and administrators should evaluate how secure messaging is used to ensure that disparities in care are not perpetuated via this communication modality.

Profiting from Most-Favored Customer Procurement Rules: Evidence from Medicaid

We exploit a 2010 reform to Medicaid drug reimbursement to provide empirical evidence that “most-favored customer” clauses (MFCC) in procurement rules can increase private-market prices and profits, even when suppliers have significant market power. Under a bargaining model, Medicaid's MFCC creates a credible threat point that drug manufacturers exploit to negotiate smaller discounts with private payers. Using novel data on estimated discounts and a difference-in-difference framework, we show that the reform, which reduced the scope of the MFCC constraint, led to higher discounts and lower profits in non-Medicaid segments for drugs with high exposure to Medicaid.

The use of visceral techniques in Australian osteopathic practice: A descriptive cross-sectional study

Background Visceral techniques have taken their place in the established osteopathic treatment approaches, however, very little research exists on their use in clinical settings in Australia. This study reports on the prevalence, enablers of and barriers to visceral technique use by registered osteopaths currently practising in Australia utilising a nationally representative database from the Osteopathy Research and Innovation Network (ORION). Methods The recruitment invitation pack for this study was distributed via email to the ORION database during July 2019. The study utilised a 27-item survey with both Likert scale and free text responses. All data were imported into the statistical software package SPSSTM 25 for descriptive statistical analysis. Results A total of 143 Australian osteopaths participated in the study representing a response rate of 14.4%. The participants reported a mean number of 16.1 years in practice, with 55.3% identifying as female and approximately 70% reporting as working from a metropolitan location. The majority of respondents (71.5%) reported using visceral techniques within the preceding 6 months, with 12.8% indicating that they had previously used visceral techniques in practice but had subsequently elected to stop using them. Key barriers identified by the study in relation to visceral technique usage related to practitioner knowledge, confidence and a perceived lack of support, while enablers were linked to perceived benefit in patient management and private payment. Conclusion This study provides an important step forward in our understanding of the current use of visceral techniques by the Australian osteopathic workforce. Further research is required to better understand practitioners’ rationale for including visceral techniques in practice, patient outcomes where visceral techniques are used, and the cost-effectiveness of their inclusion in patient care.

Mental health disorders in newly diagnosed non-functional pitutary adenoma under initial observation: an observational cohort study using the nationwide MarketScan database.

Nonfunctioning pituitary adenomas account for 15-30% of pituitary tumors. Studies exploring the role of an intracranial tumor diagnosis, specifically nonfunctioning pituitary adenomas, on mental health disorders (MHDs) in patients have been limited. We characterize the incidence and factors affecting the development of MHDs in untreated pituitary adenomas. Utilizing a large-scale private payor database, MarketScan, we performed a retrospective study of patients with an untreated pituitary adenomas and corresponding MHD. We found that in patients diagnosed with an untreated pituitary adenomas, approximately 15% were newly diagnosed with a MHD within 1 year of the pituitary adenoma diagnosis. Independent risk factors included female gender and substance abuse. Headaches, visual symptoms, and higher Charlson Co-morbidity indexes were also independently associated with a subsequent diagnosis of MHD. On multivariable analysis, patients in the pituitary tumor cohort were more likely to be diagnosed with a MHD than those in the matched cohort (aOR: 1.31, CI: 1.19-1.44). By identifying risk factors, advanced screening can focus on non-operative pituitary adenoma patients at high-risk for the development of MHD.

2021 E/M Code Changes: Forecasted Impacts to Gastroenterology Practices

Evaluation and management (E/M) coding was established by Congress in the early 1990s, with major updates in 1995 and 1997 that shifted the focus from qualitative to quantitative variables. These E/M codes are based on the Current Procedural Terminology (CPT) codes created and edited by the American Medical Association (AMA). In turn, this coding system has been adopted by government and private payers alike as the method for billing for patient visits.

Mobilizing the U.S. Military's TRICARE Program for Value-Based Care: A Report From the Defense Health Board.

The U.S. Military Health System spends about $50 billion annually to provide care to 9.6 million active duty service members, retirees, and their families through its TRICARE health plans. TRICARE follows the predominant payment model in the USA-fee-for-service-although the Department of Defense (DoD) and Congress encourage and mandate a move toward alternative payment models-mainly, fee-for-value. For the next TRICARE contracts which will begin in 2023, the DoD asked its health-focused federal advisory committee, the Defense Health Board (DHB), to recommend how best to assess and prioritize leading value-based healthcare initiatives identified from private, public, and employer-based health plans. The November 2020 report, 'Modernization of the TRICARE Benefit', specifies a rubric to evaluate these value-based care initiatives not only in traditional measures of effectiveness but also in terms of the Defense Health Agency's Quadruple Aim with its focus on readiness. The goal of TRICARE's move toward value-based care is to leverage its size and focus on prevention of disease and injury to maintain the readiness of the U.S. Armed Forces in addition to delivering great outcomes and value to the DoD's nearly 10 million beneficiaries. The DHB emphasizes that TRICARE's size and focus on providing quality care at lower cost will incentivize providers to participate in the shift toward value-based care despite the potential challenges in transitioning to this system. This shift also aims to motivate other large government and private payors to accelerate the adoption of value-based care through TRICARE's example.

Disparities in Potentially Preventable Emergency Department Visits for Children with Asthma among Asian Americans, Pacific Islanders, and Whites in Hawai‘i

The cost burdens of potentially preventable emergency department visits for pediatric asthma were estimated for Asian Americans, Pacific Islanders, and Whites using Hawai‘i statewide 2015–2016 data. The cost burden of the 3234 preventable emergency department visits over the study period was over $1.9 million. Native Hawaiians had the largest proportion (36.5%) of all preventable emergency department visits and accounted for the highest costs for the two years at $709,698. After adjusting for other factors, costs for preventable pediatric-asthma-related emergency department visits differed significantly by age, insurance provider, and island of residency. Reducing potentially preventable emergency department visits would not only improve health disparities among Native Hawaiians compared to other racial or ethnic populations in Hawai‘i, but could also generate cost savings for public and private insurance payers.

Propensity Score Matching Analysis of the Effect of Payer Status on the Survival of Colon Cancer Patients.

Background and objectiveColon cancer is one of the most common types of cancer globally. The factors that could affect colon cancer survival include age, stage, treatment, and other socioeconomic aspects. Payer status has been shown to be a significant predictor of cancer patient survival in retrospective studies. However, due to the limitations of retrospective studies, patient baseline characteristics between payer statuses are not comparable. Few studies have addressed the effect of payer status on the overall survival (OS) of patients using propensity score matching (PSM). In light of this, we conducted a study to examine the effect of payer status on the survival of colon cancer patients based on PSM.Materials and methods About 66,493 stage II/III colon cancer patients aged 40-90 years and diagnosed between 2004 and 2015 were analyzed from a de-identified National Cancer Database (NCDB) file. All patients had undergone surgery, and patients who had received radiation therapy, hormone therapy, immunotherapy, palliative care, or therapies other than chemotherapy were excluded. Only private or Medicaid payer status was included. The propensity score was calculated by computing the probability of patients being in the Medicaid group using logistic regression. The PSMATCH procedure in the SAS software (SAS Inc., Gary, NC) was used to perform PSM on patients with Medicaid and private insurance. The greedy nearest neighbor matching method was used to match one Medicaid to one privately insured patient with a caliper of 0.2. At the same time, an exact match was done for gender, age group, race, and stage at diagnosis. Multivariate Cox regression was then used to estimate the effect of payer status on survival before and after PSM.ResultsAmong the 66,493 patients, 90.3% were privately insured and 9.7% had Medicaid. In univariate analysis, payer status was found to be a significant predictor of OS. Prior to PSM, the median overall survival (MOS) for patients with private insurance was 12.75 years, while those with Medicaid had a MOS of 9.02 years. After PSM, 6,167 paired patients were matched, and patients with private insurance had a MOS of >12.82 years and Medicaid patients had a MOS of 8.88 years. After PSM, patients with Medicaid had a 50% increased risk of death, and payer status proved to be a statistically significant predictor of OS of colon cancer.ConclusionBased on our findings, as per the PSM method, payer status can be a significant predictor of survival among colon cancer patients. Also, chemotherapy, race, age, and other socioeconomic factors were also found to be significant predictors of OS. Further research should be conducted to investigate other covariates not studied here and the mediation effect of payer on the survival of cancer patients.

An Environmental Scan of Virtual "Walk-In" Clinics in Canada: Comparative Study.

BackgroundCanada has been slow to implement virtual care relative to other countries. However, in recent years, the availability of on-demand, “walk-in” virtual clinics has increased, with the COVID-19 pandemic contributing to the increased demand and provision of virtual care nationwide. Although virtual care facilitates access to physicians while maintaining physical distancing, there are concerns regarding the continuity and quality of care as well as equitable access. There is a paucity of research documenting the availability of virtual care in Canada, thus hampering the efforts to evaluate the impacts of its relatively rapid emergence on the broader health care system and on individual health.ObjectiveWe conducted a national environmental scan to determine the availability and scope of virtual walk-in clinics, cataloging the services they offer and whether they are operating through public or private payment.MethodsWe developed a power term and implemented a structured Google search to identify relevant clinics. From each clinic meeting our inclusion criteria, we abstracted data on the payment model, region of operation, services offered, and continuity of care. We compared clinics operating under different payment models using Fisher exact tests.ResultsWe identified 18 virtual walk-in clinics. Of the 18 clinics, 10 (56%) provided some services under provincial public insurance, although 44% (8/18) operated on a fully private payment model while an additional 39% (7/18) charged patients out of pocket for some services. The most common supplemental services offered included dermatology (15/18, 83%), mental health services (14/18, 78%), and sexual health (11/18, 61%). Continuity, information sharing, or communication with the consumers’ existing primary care providers were mentioned by 22% (4/18) of the clinics.ConclusionsVirtual walk-in clinics have proliferated; however, concerns about equitable access, continuity of care, and diversion of physician workforce within these models highlight the importance of supporting virtual care options within the context of longitudinal primary care. More research is needed to support quality virtual care and understand its effects on patient and provider experiences and the overall health system utilization and costs.

Use of a Commercially Available Clinical Decision Support Tool to Expedite Prior Authorization in Partnership With a Private Payer.

The aim of this study was to determine if a clinical decision support (CDS) tool could be used in partnership with a private payer to successfully expedite the prior authorization process for advanced (ie, MRI, CT, PET, nuclear medicine) imaging requests. A single academic institution integrated a commercially available CDS tool utilizing the ACR Appropriateness Criteria into the ordering process for outpatient advanced imaging tests within the electronic health record. Ordering providers could elect to use the CDS tool or ignore the available technology. In partnership with a health care insurance company and a contracted radiology benefits management company, orders deemed as "usually indicated" by the CDS tool underwent expedited prior authorization in a pilot program from June 2018 to October2019. Providers used the CDS tool for 15% (1,453 of 9,640) of outpatient advanced imaging orders. Of these orders with elective CDS scores, 69% (n= 997) qualified for an expedited prior authorization process. Under specific circumstances, a commercially available CDS tool was used in partnership with a private payer and a radiology benefits management company to expedite prior authorization of outpatient advanced imaging examination orders deemed likely to be appropriate by multispecialty professional guidelines.

PCV27 Hospital Length of Stay, Total Costs and Comorbidities in Patients with Acute Pericarditis: Analysis of National In-patient Hospital Database

To analyze trends in hospital length of stay, total costs and comorbidities in patients with acute pericarditis. The 2016 National Inpatient Sample (NIS) data set from the Healthcare Cost and Utilization Project was utilized in order to determine the number of hospital admissions for acute pericarditis. Propensity score matched analysis was conducted to compare hospital LOS and costs in patients with low and high LOS. Thirty comorbidities were assessed using Elixhauser scoring. Multivariate logistic regression was conducted to assess predictor variables for LOS and costs. In 2016, there were an estimated 20490 hospitalizations with a diagnosis of PNH. The mean age was 52.85 (SD 19.64) years and 61% of the patients were male. Payer distribution was 35%, 17% and 39% for Medicare, Medicaid and Private, respectively. The majority of the patients were White (66%), followed by Black (18%) and Hispanic (9%). The mean LOS of 5.74 (SD 7.81) days, with longer LOS for patients covered under Private Payer versus Medicare (8.84 [SD 20.81] and 7 [SD 9.6] days). The total mean hospital charges were $91343, with significantly higher charges for Private Payer versus Medicare ($134020 and $91993, respectively). Approximately 2.34% of the patients died in the hospital. Most common comorbidities were Cardiac Arrhythmias (37%), Hypertension (36%), Renal Failure (16%), Chronic Pulmonary Disease (19%) and Obesity (16%). Approximately 71% of hospitalizations were associated with an emergency department visit. Acute pericarditis leads to high resource use and long hospital length of stay. There is a need for better management of patients with acute pericarditis.

Financial Burden of Discarded Weight-based Antineoplastic Drugs to Payers and Patients in the Private Insurance Market.

BackgroundOur study estimated insurance payments and patient out-of-pocket (OOP) expenses associated with discarded weight-based intravenous antineoplastic drugs for privately insured US adult patients with cancer.MethodsWe identified patients who received weight-based antineoplastic drugs from a 2017 MarketScan health risk assessment (IBM Corp, Armonk, NY) linked to claims data. Using weight information in the health risk assessment, we derived the recommended dose and calculated the percentage of drugs discarded. We applied β-regression to determine factors associated with the discarded percentages. To compare patients with and without high-deductible plans, we employed a generalized linear model and a 2-part model to examine insurance payment and OOP expense, respectively. All statistical tests were 2-sided.ResultsOf 27 350 claims for 58 weight-based antineoplastic drugs from 1970 patients, the median discarded percentage was 9.8% (mean [SD] = 12.8% [10.5%]). Aside from drug and tumor type, statistically significantly higher discarded percentages were found for patients in the lowest weight group (5.5% [95% confidence interval = 4.7% to 6.4%]; P < .001; weight <150 lb [68.0 kg] vs ≥200 lb [90.7 kg]). Private payers spent $5090 per patient in 2017 on discarded weight-based antineoplastic drugs, and patients’ mean OOP expense on discarded drugs was $63. In total, 39.7% of patients had high-deductible plans. The adjusted mean OOP expense for discarded drugs was statistically significantly higher for those in high-deductible plans ($95 vs $47; P < .001).ConclusionsPrivate insurers incurred substantial financial burden from discarded weight-based antineoplastic drugs. Although the OOP expenses of discarded drugs were modest for most privately insured patients with cancer, approximately 5% spent more than $400 on the discarded drugs. Policies designed to reduce drug waste from single-dose, weight-based antineoplastic drugs should evaluate their financial consequences for payers and patients.