Reduce Health Care Spending Research Articles

Role of fluid biomarkers in the early diagnosis of Alzheimer’s disease

Alzheimer’s disease (AD) is the most common form of dementia in the elderly, which is clinically characterized by the progressive deterioration of memory and other cognitive functions that results in the loss of autonomy and ultimately leading to death. Increasing life expectancy has resulted in AD becomes a global public health concern, especially in developing countries as Vietnam. While there is currently no effective treatment for the disease, early detection of AD is critical to slow disease progression, prevent long-term morbidity and mortality, as well as reducing healthcare spending. The diagnosis of AD currently relies on clinical criteria, including mental status assessment, neurological examination, and brain imaging tests. However, these imaging methods are conclusive only in the advanced stages of disease, whereas AD physiopathology begins several decades before onset of the first symptoms. It is therefore particularly important to identify potential biomarkers that can be used in the early detection of AD aim to evaluate the efficiency of therapeutic agents under testing and to thus accelerate the therapeutic discovery process. The aim of the review was to highlight the current knowledge as well as future perspectives on the role of biomarkers in screening, diagnosis, treatment and follow-up of Alzheimer’s disease.

Direct Medical Costs Associated With Treatment Nonpersistence in Patients With Higher-Risk Myelodysplastic Syndromes Receiving Hypomethylating Agents: A Large Retrospective Cohort Analysis

BackgroundSuboptimal use of hypomethylating agents (HMAs) among higher-risk myelodysplastic syndrome (HR-MDS) patients can translate into worse health outcomes and economic burden. We estimated the direct medical costs associated with HMA treatment nonpersistence among HR-MDS patients. Patients and MethodsUsing the Surveillance, Epidemiology, and End Results–Medicare linked database, a retrospective cohort of patients diagnosed with refractory anemia with excess blasts (RAEB), a diagnosis that substantially overlaps with HR-MDS, between January 2011 and December 2015 was analyzed. Patients who had ≥ 1 year of continuous Medicare enrollment before diagnosis and who did not receive stem cell transplant or lenalidomide in the follow-up period were included. Patients receiving HMAs were stratified into HMA persistent (≥4 HMA cycles) and HMA nonpersistent (<4 cycles or a gap of ≥ 90 days between cycles) groups. Healthcare resource use and costs during the follow-up period were reported descriptively as total and per patient per month (PPPM). Weighted generalized linear models (GLM) were used to compare estimated healthcare resource use and costs between HMA groups. ResultsAmong the 664 patients with RAEB, 295 (44.4%) were HMA nonpersistent and 369 (55.6%) HMA persistent. On the basis of weighted GLM analysis, the HMA nonpersistent group incurred significantly (P < .05) higher total PPPM costs compared to the HMA persistent group ($18,039 vs. $13,893), particularly for hospitalization ($3,375 vs. $2,131), and emergency room ($5,517 vs. $2,867) costs. ConclusionThere is a substantial economic burden associated with early discontinuation of guideline-recommended HMA therapy in RAEB patients. The study findings necessitate closer care management in this population in order to improve outcomes and reduce healthcare spending.

Costs Associated with Recurrent Epistaxis in a Patient with a Ventricular Assist Device

Mucosal bleeding is a well-known complication of having a ventricular assist device and commonly presents with epistaxis. Although the frequency of epistaxis as a complication in patients with a ventricular assist device has been documented in the literature, to our knowledge the cost of this complication has not been reported. This case report examines the financial burden of ventricular assist device-associated epistaxis in a single patient from September 2018 to December 2019 using ICD 10 diagnostic codes. The patient was found to have accumulated $138,020 in costs over 38 encounters. This case report not only highlights the recurrent nature and potential high cost of epistaxis in this patient population, but also identifies a target to reduce healthcare spending. Further research is needed to assess whether cheap and simple preventative measures such as nasal hygiene regimen can decrease the frequency and/or severity of epistaxis in the patients with a ventricular assist device.

Associations of Intensive Lifestyle Intervention in Type 2 Diabetes With Health Care Use, Spending, and Disability

Intensive lifestyle interventions focused on diet and exercise can reduce weight and improve diabetes management. However, the long-term effects on health care use and spending are unclear, especially for public payers. To estimate the association of effective intensive lifestyle intervention for weight loss with long-term health care use and Medicare spending. This ancillary study used data from the Look AHEAD randomized clinical trial, which randomized participants with type 2 diabetes to an intensive lifestyle intervention or control group (ie, diabetes support and education), provided ongoing intervention from 2001 to 2012, and demonstrated improved diabetes management and reduced health care costs during the intervention. This study compared Medicare data between study arms from 2012 to 2015 to determine whether the intervention was associated with persistent reductions in health care spending. Starting in 2001, Look AHEAD's intervention group participated in sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists with the goal of reducing weight 7% in the first year. Sessions occurred weekly in the first 6 months of the intervention and decreased over the intervention period. The controls participated in periodic group education sessions that occurred 3 times per year in the first year and decreased to 1 time per year later in the trial. Outcomes included total Medicare spending, Part D prescription drug costs, Part A and Part B Medicare spending, hospital admissions, emergency department visits, and disability-related Medicare eligibility. This study matched Medicare administrative records for 2796 Look AHEAD study participants (54% of 5145 participants initially randomized and 86% of 3246 participants consenting to linkages). Linked intervention and control participants were of a similar age (mean [SD] age, 59.6 [5.4] years vs 59.6 [5.5] years at randomization) and sex (818 [58.1%] women vs 822 [59.3%] women). There was no statistically significant difference in total Medicare spending between groups (difference, -$133 [95% CI, -$1946 to $1681]; P = .89). In the intervention group, compared with the control group, there was statistically significantly higher Part B spending (difference, $513 [95% CI, $70 to $955]; P = .02) but lower prescription drug costs (difference, -$803 [95% CI, -$1522 to -$83]; P = .03). This ancillary study of a randomized clinical trial found that reductions in health care use and spending associated with an intensive lifestyle intervention for type 2 diabetes diminished as participants aged. Intensive lifestyle interventions may need to be sustained to reduce long-term health care spending. ClinicalTrials.gov Identifier: NCT03952728.

Implications of Early Health Care Spending Reductions for Expected Spending as the COVID-19 Pandemic Evolves

This cohort study examines how early spending changes vary by incidence of coronavirus disease 2019 and how implementation of policies to limit transmission affect health care spending as the pandemic evolves.

Reduction in US Health Care Spending Required to Meet the Institute of Medicine's 2030 Target.

Objectives. To quantify changes in US health care spending required to reach parity with high-resource nations by 2030 or 2040 and identify historical precedents for these changes.Methods. We analyzed multiple sources of historical and projected spending from 1970 through 2040. Parity was defined as the Organisation for Economic Co-operation and Development (OECD) median or 90th percentile for per capita health care spending.Results. Sustained annual declines of 7.0% and 3.3% would be required to reach the median of other high-resource nations by 2030 and 2040, respectively (3.2% and 1.3% to reach the 90th percentile). Such declines do not have historical precedent among US states or OECD nations.Conclusions. Traditional approaches to reducing health care spending will not enable the United States to achieve parity with high-resource nations; strategies to eliminate waste and reduce the demand for health care are essential.Public Health Implications. Excess spending reduces the ability of the United States to meet critical public health needs and affects the country's economic competitiveness. Rising health care spending has been identified as a threat to the nation's health. Public health can add voices, leadership, and expertise for reversing this course.

Health burden and economic costs of smoking in Chile: The potential impact of increasing cigarettes prices.

Globally, tobacco consumption continues to cause a huge burden of preventable diseases. Chile has been leading the tobacco burden ranking in the Latin American region for the last ten years; it has currently a 33. 3% prevalence of current smokers. A microsimulation economic model was developed within the framework of a multi-country project in order to estimate the burden attributable to smoking in terms of morbidity, mortality, disability-adjusted life-years (DALYs), and direct costs of care. We also modelled the impact of increasing cigarettes' taxes on this burden. In Chile, 16,472 deaths were attributable to smoking in 2017, which represent around 16% of all deaths. This burden corresponds to 416,445 DALYs per year. The country's health system spends 1.15 trillion pesos annually (in Dec 2017 CLP, approx. U$D 1.8 billion) in health care treatment of illnesses caused by smoking. If the price of tobacco cigarettes was to be raised by 50%, around 13,665 deaths and 360,476 DALYs from smoking-attributable diseases would be averted in 10 years, with subsequent savings on health care costs, and increased tax revenue collection. In Chile, the tobacco tax collection does not fully cover the direct healthcare costs attributed to smoking. Despite a reduction observed on smoking prevalence between 2010 (40.6%) and 2017 (33.3%), this study shows that the burden of disease, and the economic toll due to smoking, remain high. As we demonstrate, a rise in the price of cigarettes could lead to a significant reduction of this burden, averting deaths and disability, and reducing healthcare spending.

Cost-Effective Approach to the Laparoscopic Appendectomy : Balancing Disposable Instrument Cost With Operative Time.

Surgeons can help reduce health care spending by selecting affordable and efficient instruments. The laparoscopic appendectomy (LA) is commonly performed and can serve as a model for improving health care cost. We retrospectively reviewed all adult patients who underwent LA for non-perforated appendicitis from March 2015 to November 2017. Our objective was to determine which combination of disposable instruments afforded the lowest total operative cost without compromising postoperative outcomes. In total, 1857 consecutive patients were reviewed from 2 hospitals. After determining the 8 most commonly utilized combinations of disposable instruments, 846 patients were ultimately analyzed. The combination of a LigaSure, Endoloop, and an EndoBag (LEB) had the shortest median operative time (25 minutes, P < .001) and lowest median total operative cost ($1893, P < .001). The LEB instrument combination rendered the shortest operative time, lowest total operative cost, and can be used to maximize surgical value during LA.

Patient Medication Adherence Among Pharmacies Participating in a North Carolina Enhanced Services Network.

Improving medication adherence can reduce health care spending, and studies have demonstrated community pharmacists can positively affect adherence through the provision of enhanced services. The North Carolina (NC) Community Pharmacy Enhanced Services Network (CPESN) was formed in early 2014 with the goal of enhancing the care provided through its network pharmacies. To evaluate differences in medication adherence performance scores between pharmacies that participated in the NC-CPESN and control pharmacies in NC that did not. Medication adherence performance data for statins, renin-angiotensin system antagonists, oral diabetes medications, and a custom multiple chronic medication measure were gathered from quarterly reports between December 2014 and September 2016. Data for these quarterly reports were derived from NC Medicaid claims. These data were combined with pharmacy demographics and service offerings data from the National Council on Prescription Drug Plans dataQ database. Descriptive statistics were used to evaluate differences in demographics and service offerings between study cohorts. Generalized estimating equations were used to evaluate the relationship between medication adherence and pharmacy cohorts, demographics, and service offerings. There were 267 enhanced services pharmacies and 1,872 control pharmacies included in this analysis. Enhanced services pharmacies were much more likely to be independent pharmacies, located in rural counties, offer multidose compliance packaging, and offer delivery services, but were less likely to offer 24-hour emergency services. Persistently higher adherences scores were observed for enhanced services pharmacies, with differences across measures ranging from 3.0% to 7.2% (P < 0.001). In multivariable models, the difference between enhanced services and control pharmacies was explained by differences in offerings of multidose compliance packaging and delivery services, which were associated with 3.4%-8.2% and 3.3%-4.0% improvements in adherence, respectively (P < 0.001). This study found that enhanced services pharmacies had greater adherence performance scores for the NC Medicaid population. These differences appear to be due to CPESN enhanced services pharmacies' offering of multidose compliance packaging and delivery. Future work is needed to expand this analysis to other populations, as well as to explore the relationship between delivery and adherence. The project described was supported by Funding Opportunity Number 1C12013003897 from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. Ulrick reports consulting fees from Pharmacy Quality Solutions, unrelated to this work. Bhosle is an employee of Community Care of North Carolina, the not-for-profit company that sponsored the North Carolina enhanced services pharmacy network, and CPESN USA, a for-profit company that developed out of the original grant-funded project. Farley has nothing to disclose.

The economic burden of systemic lupus erythematosus in commercially- and medicaid-insured populations in the United States

ObjectiveTo estimate the economic burden of systematic lupus erythematous (SLE), stratified by disease severity, in commercially- and Medicaid-insured US populations. MethodsAdults (≥18 years) with SLE treated with antimalarials, selected biologics, immunosuppressants, and systemic glucocorticoids (2010–2014) were identified within the commercial and Medicaid insurance IBM MarketScan® databases (index date = first SLE medication claim). Both cohorts were stratified into mild (receiving antimalarial or glucocorticoid monotherapy ≤5 mg/day) versus moderate/severe SLE (receiving glucocorticoids >5 mg/day, biologic, immunosuppressant, or combination therapy) during a 6-month exposure period. All-cause healthcare utilization and costs were evaluated during the 12 months following the exposure period. ResultsAmong 8231 commercially-insured patients, 32.6% had mild and 67.4% had moderate/severe SLE by our definition. Among 802 Medicaid-insured patients, 25.2% had mild and 74.8% had moderate/severe SLE. Adjusted mean total healthcare costs, excluding pharmacy, for moderate/severe SLE patients were higher than for mild SLE patients in the commercially-insured ($39,021 versus $23,519; p < 0.0001) and Medicaid-insured populations ($56,050 versus $44,932; p = 0.06). In both SLE severity populations total unadjusted costs were significantly higher among Medicaid-insured than commercially-insured patients. ConclusionCommercially-insured patients with treatment suggesting moderate/severe SLE incurred significantly higher adjusted mean healthcare costs, excluding pharmacy, compared with mild SLE patients. While not reaching statistical significance, moderate/severe Medicaid-insured patients had higher costs then mild SLE patients. Total unadjusted healthcare costs were significantly higher among Medicaid-insured than commercially-insured patients. These differential costs are important to consider and monitor when implementing interventions to improve health and reduce healthcare spending for SLE.

Taking the Leap Toward Cost-Conscious Education in Obstetrics and Gynaecology: A Preliminary Randomized Controlled Trial.

Residents have a professional obligation with respect to the stewardship of health care resources, yet there is a paucity of research on how to improve residents' cost-awareness. Rising health care expenditures highlight a critical need to improve education related to this competency. This study aimed to test if an educational module can teach residents to make cost-conscious decisions and reduce health care spending. All Canadian obstetrics and gynaecology residents in 2017 were eligible to participate in this randomized controlled trial. The study was administered online via REDCap. Interested residents were enrolled, stratified by level of training, and block randomized. Residents completed a survey to determine their management of 4 obstetrical scenarios. The intervention group reviewed an educational module on cost-effective ordering prior to completing the survey; the control group was given the option to review the module afterward. The primary outcome was mean total expenditures, compared between the 2 groups using the t test. Eighty-five residents were enrolled between August and November 2017, and 63 residents from 13 Canadian residency programs completed the study requirements (33 control and 30 intervention). Mean total expenditure was CAD$291.03 (95% CI 259.38-322.68) versus CAD$192.98 (95% CI 170.67-215.29) for the control and intervention groups, respectively. These figures corresponded to a 33.69% or CAD$98.05 reduction in total expenditures (P=0.0001). This educational module decreased expenditures by Canadian obstetrics and gynaecology residents managing hypothetical obstetrical cases. This introduces a potential curriculum innovation to improve resident education in judicious use of health care resources.

PND117 IDENTIFYING PREDICTORS OF HIGH-COST MULTIPLE SCLEROSIS PATIENTS: A MACHINE LEARNING APPROACH

Multiple sclerosis (MS) is the leading cause of non-traumatic neurological disability in young adults. High healthcare resource utilization in MS patients is linked to relapses and disease progression. The goal of this study is to identify predictors of future high-cost MS patients through machine learning (ML) methods. Newly diagnosed MS patients were identified using ICD-9/10 codes in Medicare Part A/B claims (5% sample) between 2011Q1-2015Q1. The total Medicare expenditures during 12 months after the index diagnosis were summed, with the highest decile of average monthly spending defined as “high cost”. Data were partitioned using a 60%/25%/15% split to train, validate and test performance on unseen data. A traditional logistic regression model was estimated as a reference model. Random forest (RF), XGBoost and support vector machine (SVM) models were developed and the best model was selected through assessment of the area under the ROC curve (AUC). Accuracy, recall, precision and F1 scores were also reported. Features that were consistently important for prediction based on model specific importance metrics across all models were noted. The study population included 5,863 MS patients (mean age=63.1 years; females=67%). All ML methods (AUC RF: 78.1%, SVM: 77.4%, XGBoost: 74.6%) outperformed the logistic regression model (AUC: 64.4%). The best performing ML model was RF, which had accuracy: 70.4%; recall: 72.7%; precision: 21.3% and F1: 0.33. The top 15 features identified as positively associated with high-cost patients across all ML methods were being male, selected medication use (epoetin alfa, heparins, insulin), limitations of mobility, musculoskeletal deformities, indicators of past inpatient service utilization, stroke, and comorbidities including chronic kidney disease, hypertension, and pulmonary diseases. In predicting high-cost patients, ML methods provided a significant improvement over the logistic regression model. Our findings can be used to guide further research to proactively manage care and reduce healthcare spending.

Awareness of Surgical Cost in Gynecology [09B

INTRODUCTION: With the rising cost of healthcare in the United States, recent efforts have focused on reducing healthcare spending without compromising quality and outcomes. Studies have suggested that most surgeons are unaware of the costs related to surgery. The purpose of our study was to assess provider knowledge of the cost of surgical instruments and adjuncts used during gynecologic laparoscopy. METHODS: After IRB approval was obtained, an anonymous survey of practicing gynecologists, OR technologists, and OR nurses at Stony Brook University Hospital was conducted. We inquired about duration of training, formal education regarding cost, self-awareness of cost, and cost estimates for 37 commonly used disposable surgical instruments and items. Similarly to previously published studies assessing cost in other surgical specialties, we defined cost estimate accuracy as within 20% of the hospital cost. RESULTS: A total of 104 surveys were distributed, and 29 complete responses (28%) were received. Of the participants, 17 were attendings, 3 were fellows, 6 were residents, and 3 were OR techs and nurses. On average, participant estimates were within the defined accuracy range for only 13.5% items. There were no differences in accuracy when comparing educational level, years in practice, self-perceived awareness, history of formal cost education, or whether individuals factor in cost. CONCLUSION: Gynecologic surgeons and trainees have poor awareness regarding the cost of the items used during laparoscopic surgery. Providing further education regarding the cost of these items may aid surgeons in making more informed choices and help reduce healthcare costs.

What Does a Provider Network Do? Evidence from Random Assignment in Medicaid Managed Care

A distinguishing feature of health insurance plans in the United States is the breadth of their provider networks. To study how provider networks impact consumers, I leverage a natural experiment in New York where 50,000 Medicaid recipients were randomly assigned to plans with different provider networks. Assignment to a narrower network reduced healthcare spending and consumer satisfaction, but not quality. I then examine the mechanisms by which narrower networks affect consumers and propose an alternative assignment policy that reduces spending without harming satisfaction. This is achieved by matching recipients with narrower networks that nevertheless include their usual source of care.

Design Considerations for Hydrogel Wound Dressings: Strategic and Molecular Advances.

Wound dressings are traditionally used to protect a wound and to facilitate healing. Currently, their function is expanding. There is an urgent need for new smart products that not only act as a protective barrier but also actively support the wound healing process. Hydrogel dressings are an example of such innovative products and typically facilitate wound healing by providing a hospitable and moist environment in which cells can thrive, while the wound can still breathe and exudate can be drained. These dressings also tend to be less painful or have a soothing effect and allow for additional drug delivery. In this review, various strategic and molecular design considerations are discussed that are relevant for developing a hydrogel into a wound dressing product. These considerations vary from material choice to ease of use and determine the dressing's final properties, application potential, and benefits for the patient. The focus of this review lies on identifying and explaining key aspects of hydrogel wound dressings and their relevance in the different phases of wound repair. Molecular targets of wound healing are discussed that are relevant when tailoring hydrogels toward specific wound healing scenarios. In addition, the potential of hydrogels is reviewed as medicine advances from a repair-based wound healing approach toward a regenerative-based one. Hydrogels can play a key role in the transition toward personal wound care and facilitating regenerative medicine strategies by acting as a scaffold for (stem) cells and carrier/source of bioactive molecules and/or drugs. Impact statement Improved wound healing will lead to a better quality of life around the globe. It can be expected that this coincides with a reduction in health care spending, as the duration of treatment decreases. To achieve this, new and modern wound care products are desired that both facilitate healing and improve comfort and outcome for the patient. It is proposed that hydrogel wound dressings can play a pivotal role in improving wound care, and to that end, this review aims to summarize the various design considerations that can be made to optimize hydrogels for the purpose of a wound dressing.

Economic Burden Associated With Extended-Release vs Immediate-Release Drug Formulations Among Medicare Part D and Medicaid Beneficiaries

The United States spends more money on medications than any other country. Most extended-release drugs have not consistently shown therapeutic or adherence superiority, and switching these medications to less expensive, generic, immediate-release formulations may offer an opportunity to reduce health care spending. To evaluate Medicare Part D and Medicaid spending on extended-release drug formulations and the potential savings associated with switching to generic immediate-release formulations. This cross-sectional study used the 2012 to 2017 Medicare Part D Drug Event and Medicaid Spending and Utilization data sets to analyze 20 extended-release drugs with 37 Medicare formulations and 36 Medicaid formulations. Only cardiovascular, diabetes, neurologic, and psychiatric extended-release drugs saving at most 1 additional daily dose compared with their immediate-release counterparts were included. Extended-release drugs with therapeutic superiority were excluded. Analyses were conducted from January to December 2019. Estimated Medicare Part D and Medicaid savings from switching extended-release to immediate-release drug formulations between 2012 and 2017. Of the 6252 drugs screened for eligibility from the 2017 Medicaid Drug Utilization database and the 2017 Medicare Part D database, 67 drugs with extended-release formulations that were identified in the Medicare data set (20 distinct drugs with 37 formulations [19 brand, 18 generic]) were included in the analysis. In 2017, Medicare Part D spent $2.2 billion and Medicaid spent $952 million (a combined $3.1 billion) on 20 extended-release drugs. Between 2012 and 2017, Medicare Part D and Medicaid spent $12 billion and $5.9 billion, respectively, on extended-release formulations. Switching from brand-name to generic extended-release formulations was estimated to be associated with a $247 million reduction in Medicare spending and $299 million reduction in Medicaid spending in 2017, whereas switching all brand-name and generic extended-release formulations to immediate-release formulations in both Medicare and Medicaid was estimated to reduce spending by $2.6 billion ($1.8 billion for Medicare and $836 million for Medicaid) in 2017. During the study period, the estimated spending reduction associated with switching all patients receiving extended-release formulations (brand name extended-release and generic extended-release) to generic immediate-release formulations was $13.7 billion ($8.5 billion from Medicare and $5.2 billion from Medicaid). The findings suggest that switching from extended-release drug formulations to therapeutically equivalent immediate-release formulations when available represents a potential option to reduce Medicare and Medicaid spending.

The Burden of Cost in Inflammatory Bowel Disease: A Medical Economic Perspective and the Future of Value-Based Care.

To examine the quantifiable economic impact of inflammatory bowel disease (IBD), key cost drivers and determinants, and the impact of value-based care in IBD. Finally, we prognosticate on future directions and opportunities on healthcare economics in IBD. New value-based initiatives, technologically driven interventions, and quality improvement programs have demonstrated reductions in healthcare utilization and enhanced patient outcomes, and several have realized cost of care reductions. IBD is a costly, chronic illness with unbalanced spending by a small proportion of individuals. Pharmaceutical costs are overtaking inpatient expenses as the primary cost driver. Value-based care initiatives including the IBD medical home, remote monitoring platforms such as myIBDcoach and Project Sonar, and learning healthcare networks exemplified by ImproveCareNow have all demonstrated successes in improving care quality, patient outcomes, and reduced healthcare spending in some populations. The future of value-based care in IBD is bright, with ample opportunities for model refinement, collaboration, and growth.

The Response to Dynamic Incentives in Insurance Contracts with a Deductible: Evidence from a Differences-in-Regression-Discontinuities Design

We develop a new approach to quantify how patients respond to dynamic incentives in health insurance contracts with a deductible. Our approach exploits two sources of variation in a differences-in-regression-discontinuities design: deductible contracts reset at the beginning of the year, and cost-sharing limits change over the years. Using rich claims-level data from a large Dutch health insurer we find that individuals are forward-looking. Changing dynamic incentives by increasing the deductible by 100 Euros leads to a reduction in healthcare spending of around 3% on the first days of the year and 6% at the annual level. The response to dynamic incentives is an important part of the overall effect of cost-sharing schemes on healthcare expenditures - much more so than what the previous literature has suggested.

Recruitment, partnerships shape Montana integrated care work

Noticing a lack of providers and community partners and the need for integrated service access for individuals with behavioral health needs, Montana health care leaders embarked on an initiative with the goal to improve chronic conditions and reduce health care spending.

Cardiologist Participation in Accountable Care Organizations and Changes in Spending and Quality for Medicare Patients With Cardiovascular Disease.

Despite widespread adoption of Medicare accountable care organizations (ACOs), healthcare spending reductions have been modest. This may relate to variable participation in ACOs by specialist physicians, who disproportionately drive spending. To examine whether specialist participation in Medicare ACOs was associated with changes in healthcare spending and clinical quality, we analyzed national Medicare data. Working with a 20% random sample of Medicare beneficiaries (2008 to 2015), we identified those with cardiovascular disease. We estimated linear regression models at the beneficiary-quarter level to evaluate changes in healthcare spending and clinical quality after the start of the Shared Savings Program in 2012. We then examined whether changes in spending and quality across ACOs were conditional on cardiologist participation. Our study included ≈1.6 million beneficiaries per year. Although the number of ACOs increased over the study period (from 114 in 2012 to 392 in 2015), the proportion with any cardiologist participation remained stable (from 80% in 2012 to 83% in 2015). Compared with unaligned beneficiaries, those cared for by ACOs without cardiologist participation were associated with a spending reduction (per quarter) of -$75 (95% CI, -$105 to -$46; P<0.001). Care receipt in an ACO with cardiologist participation was associated with an additional difference in spending of -$56 (95% CI, -$87 to -$25; P<0.001), driven by lower spending for skilled nursing facilities, evaluation and management services, procedural care, and testing. While heart failure admission rates were similar among aligned and unaligned beneficiaries, ACO care was associated with fewer all-cause readmissions (P<0.001) and emergency department visits (P<0.001). Rates of these outcomes did not vary by cardiologist participation. Annual spending for beneficiaries with cardiovascular disease was ≈$200 lower when cared for by ACOs with cardiologist participation (compared with those without). These spending reductions did not come at the expense of clinical quality.