Reduce Health Care Spending Research Articles

Marketwide Price Transparency Suggests Significant Opportunities For Value-Based Purchasing.

The extent of price variation across a local market has important implications for value-based purchasing. Using a new data set containing health care prices for nearly every insurer-provider-service triad across a large local market, we comprehensively examined variation in fee-for-service paid commercial prices in Massachusetts for 291 predominantly outpatient medical services. Prices varied considerably across hospital service areas. Prices for medical services at acute hospitals were, on average, 76percent higher than at all other providers. The service categories with the widest price variation were ambulance/transportation services, physical/occupational therapy, and laboratory/pathology testing. In this market, simulations suggested that steering patients toward lower-price providers or setting price ceilings could generate potential savings of 9.0-12.8percent. Marketwide price information at the insurer-provider-service level could help target policy interventions to reduce health care spending.

Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries.

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

Application of the community health worker model in adult asthma and COPD in the U.S.: a systematic review

BackgroundWith rising medical costs, stakeholders and healthcare professionals are exploring community-based solutions to relieve the burden of chronic diseases and reduce health care spending. The community health worker (CHW) model is one example that has proven effective in improving patient outcomes globally. We sought to systematically describe the effectiveness of community health worker interventions in improving patient reported outcomes and reducing healthcare utilization in the adult asthma and chronic obstructive pulmonary disease (COPD) populations in the U.S.MethodsStudies were included if they were a randomized control trial or involved a pre-post intervention comparison with clearly stated disease specific outcomes, targeted adult patients with asthma or COPD, and were performed in the United States. Risk of bias was assessed using the Cochrane Risk of Bias tool. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria and was registered with PROSPERO.ResultThe search yielded 4013 potential articles, of which 47 were chosen for full-text review and 4 were chosen for inclusion; all focused on asthma and three had a comparison group. CHW interventions demonstrated improvement in asthma-related quality of life, asthma control, home trigger scores, and asthma symptom free days. There were no studies that reported COPD specific outcomes as a result of CHW interventions.ConclusionEmerging evidence suggests CHW interventions may improve some aspects of asthma related disease burden in adults, however additional studies with consistent outcome measures are needed to confirm their effectiveness. Further research is also warranted to evaluate the use of community health workers in the COPD population.

Encouraging Obstetrics and Gynecology Residents to Deliver Cost-Conscious Care: A Randomised Controlled Trial [4I

INTRODUCTION: Residents have a professional obligation to the stewardship of healthcare resources yet there is a paucity of research on how to improve their cost-awareness. Rising health care expenditure has highlighted a critical need to improve education in this competency. This study aims to test if an educational module can teach residents to make cost-conscious management plans and reduce health care spending. METHODS: All Canadian Obstetrics and Gynecology residents in 2017 were eligible for this randomised controlled trial. Institutional ethics board approval was obtained. The study was administered online via REDCap. Interested residents were enrolled, stratified by level of training and block randomised. Residents completed a survey to determine their management of four obstetrical scenarios. The intervention group reviewed an educational module on cost-effective ordering prior to completing the survey; the control group had the option to review it after. The primary outcome was mean total expenditure as calculated from the survey. Student t-test was used to compare the mean total expenditure between the two groups. RESULTS: 85 residents were enrolled, 63 residents completed study requirements (30 intervention and 33 control). Mean total expenditure was $291.03 CAD (95% confidence interval [CI] 259.38-322.68) versus $192.98 CAD (95% CI 170.67-215.29) in the control and intervention groups respectively, corresponding to a 33.69% or $98.05 CAD (P=.0001) reduction in total expenditure. CONCLUSION: This educational module decreased expenditure by Canadian Obstetrics and Gynecology residents in the management of hypothetical obstetrical cases. This introduces a potential curriculum innovation to improve resident education in judicious use of healthcare resources.

Convergence in health care spending across counties in New York from 2007 through 2016.

BackgroundOne approach considered for reducing health care spending is to narrow the gap in spending between high- and low-spending areas. The goal would be to reduce spending in the high areas to similar levels achieved in areas that use health care more efficiently. This paper examined the degree to which high-spending areas remain high-spending and which types of service lead to convergence or divergence in spending in New York State.MethodsThis analysis utilized publicly available data on county-level spending trends for the Medicare fee-for-service population from 2007 to 2016. The study applied methods previously used to evaluate changes in the regional variation of health care spending nationally to county-level data within New York.ResultsThe spread of health care spending converged slightly over the ten-year period analyzed. There was also evidence for regression to the mean-effects and changes in the relative rankings of spending across counties during this time. While there was strong evidence for convergence, many high-spending counties in 2007 remained high-spending in 2016. There were also differences in which services drove spending variation at the national level compared to within New York.ConclusionsThese findings point to counties with consistently high spending as a potential focus for health care cost-control efforts. Moreover, efforts to reduce unwarranted variation in spending may need to be tailored to the circumstances of particular regions as there are geographic differences in which services drive spending variation. Regression to the mean effects also have important implications for the specifications of alternative provider payment models, such as accountable care organizations, which promote convergence in spending by utilizing spending targets.

Do Family Caregivers Offset Healthcare Costs for Older Adults? A Mapping Review on the Costs of Care for Older Adults With Versus Without Caregivers.

Older adults face significant long-term care and health care costs. But some of these costs can potentially be offset through family caregivers who may serve as substitutes for formal care or directly improve the care recipient's health and reduce health care utilization and expenditures. This article reviews the current literature to determine whether it is possible through existing work to compare the costs of care for individuals with versus without family caregivers and, if not, where the data, measurement, and other methodological challenges lie. A mapping review of published works containing information on health care utilization and expenditures and caregiving was conducted. A narrative approach was used to review and identify methodological challenges in the literature. Our review identified 47 articles that met our criteria and had information on caregiving and health care costs or utilization. Although findings were mixed, for the most part, having a family caregiver was associated with reduced health care utilization and a decreased risk of institutionalization however, the precise difference in health care expenditures for individuals with caregivers compared to those without was rarely examined, and findings were inconsistent across articles reviewed. The number of family caregivers providing care to loved ones is expected to grow with the aging of the Baby Boomers. Various programs and policies have been proposed to support these caregivers, but they could be costly. These costs can potentially be offset if family caregivers reduce health care spending. More research is needed, however, to quantify the savings stemming from family caregiving.

Longitudinal patterns of employee high-deductible health plan choices

Employers in the United States have increasingly provided high-deductible health plans (HDHPs) to their employees to reduce health care spending. Prior studies on employees’ choice of HDHPs were based on one or two years of data. This limits the ability to study the dynamic change in employees’ HDHP choices. This study used group-based trajectory models to classify employees based on their longitudinal patterns of HDHP choices. We also identified employee characteristics associated with HDHP choice, evaluated risk segmentation between HDHP and preferred provider plan (PPO) enrollees and assessed the impact of plan benefit change on health care utilization. The analyses were based on five years of medical claims, pharmacy claims and eligibility information obtained from a large employer. We identified four groups of employees based on their longitudinal patterns of HDHPs choices: early HDHP adopters, late HDHP adopters, HDHP non-adopters and HDHP abandoners. We found that employees’ job type, family type, and health condition were associated with their longitudinal patterns of HDHP choices. We also found increased risk segmentation between HDHP and PPO enrollees over the five-year period. These findings on how employees respond to health plan changes over time could help employers with health plan benefit design.

Sustainable Adoption of Digital Health Innovations: Perspectives From a Stakeholder Workshop.

BackgroundThere are various complex reasons that influence sustainable adoption of innovations in health care systems. Low adoption can be caused by a lack of support from one or more stakeholders because their needs and expectations are not always considered or aligned.ObjectiveThis study aimed to identify stakeholders’ perceptions of barriers and facilitators toward the sustainable adoption of digital health innovations.MethodsA stakeholder workshop was attended by 12 participants with a range of backgrounds on August 25, 2017, including people representing the views from patients, carers, local hospitals, pharmacy retailers, health insurers, health services researchers, engineers, and technology and pharmaceutical companies in Switzerland. On the basis of adoption of innovation frameworks, we asked participants to interview each other about 3 factors influencing the adoption of digitally delivered health interventions: (1) Facilitators and barriers in the external system, (2) Needs and expectations of stakeholders, and (3) Safety, quality, and usability of innovations. The worksheets and videos generated from the workshop were qualitatively analyzed and summarized.ResultsFacilitators for adoption mentioned were high levels of income and education, and digital health is a high priority to stakeholders. Main common interests of different stakeholders were patient satisfaction and job protection. Health care spending was a misaligned interest: although some stakeholders were keen on spending more to obtain or provide the highest quality of care, others were focused on reducing health care spending to provide cost-effective services. Switzerland’s diversity and complexity, in terms of its organization with 26 cantons (administrative divisions), were barriers as these made it harder to ensure interoperability of interventions. A culture of innovation was considered a push factor, but adoption was inhibited by persistent paper-based systems, a fear of change, and unwillingness to share data. The sustainability of interventions can be promoted by making them patient-centered, meaning that patients should be involved throughout their development.ConclusionsPromoting sustainable adoption of digital health remains challenging despite various push factors being in place. Barriers related to fragmentation, patient-centeredness, data security, privacy, trust, and job security need to be addressed. A strength is that people from a wide range of backgrounds attended the workshop. A limitation is that the findings are focused on the macro level. In-depth case studies of specific issues need to be conducted in different settings.

Quality & safety in the literature: May 2019

The term ‘value-based purchasing’ describes programmes implemented by healthcare payers that require a modification of payment for medical care services based on the quality and safety of the care delivered....

Quality & safety in the literature: March 2019

The term ‘value-based purchasing’ describes programmes implemented by healthcare payers that require a modification of payment for medical care services based on the quality and safety of the care delivered....

Hospital Prices Grew Substantially Faster Than Physician Prices For Hospital-Based Care In 2007-14.

Evidence suggests that growth in providers' prices drives growth in health care spending on the privately insured. However, existing work has not systematically differentiated between the growth rate of hospital prices and that of physician prices. We analyzed growth in both types of prices for inpatient and hospital-based outpatient services using actual negotiated prices paid by insurers. We found that in the period 2007-14 hospital prices grew substantially faster than physician prices. For inpatient care, hospital prices grew 42percent, while physician prices grew 18percent. Similarly, for hospital-based outpatient care, hospital prices grew 25percent, while physician prices grew 6percent. A majority of the growth in payments for inpatient and hospital-based outpatient care was driven by growth in hospital prices, not physician prices. Our work suggests that efforts to reduce health care spending should be primarily focused on addressing growth in hospital rather than physician prices. Policy makers should consider a range of options to address hospital price growth, including antitrust enforcement, administered pricing, the use of reference pricing, and incentivizing referring physicians to make more cost-efficient referrals.

Price Transparency in Health Care: Impact, Impending Transformation, Competition Strategy, and Policy Implications

We are at the edge of an imminent massive transformation in an industry sector that accounts for about 20\% of spending today, namely health care. This transformation will occur on account of emerging technologies for price transparency which will give decision-making stakeholders (e.g., patients and their advising physicians) timely access to accurate and personalized information about costs of care. Price transparency technologies are (and will be) as revolutionary in health care as Google and Amazon have been to shopping in general. While these technologies are motivated by the pressing need to reduce health care spending through price competition and reduction in market prices, these effects are by no means guaranteed. Achieving them will require careful design and implementation, but also prudent management and regulation that reflects an understanding of how market forces will interact with price transparency technologies to cause transformation in the nature of insurance plans, quality and variety of products and services, and business models and competition within price transparency technologies.

Characteristics And Spending Patterns Of Persistently High-Cost Medicare Patients.

One strategy for reducing health care spending is to target the Medicare beneficiaries who remain persistently high cost over time. Using a 20percent sample of Medicare fee-for-service beneficiaries in the period 2012-14, we sought to identify the proportion of patients who remained persistently high cost (that is, in the top 10percent of spending each year) and determine the characteristics and spending patterns that differentiated them from other patients. We found that 28.1percent of patients who were high cost in 2012 remained persistently high cost over the subsequent two years. On average, persistently high-cost patients were younger, more likely to be members of racial/ethnic minority groups, eligible for Medicare based on having end-stage renal disease, and dually eligible for Medicaid, compared to transiently and never high-cost patients. Persistently high-cost patients had greater relative spending on outpatient care and medications, while very little of their spending was related to preventable hospitalizations. Health care systems and policy makers can use this information to better target spending reductions and care improvements over time.

Going Beyond Clinical Care to Reduce Health Care Spending: Findings From the J-CHiP Community-based Population Health Management Program Evaluation: Erratum.

Going Beyond Clinical Care to Reduce Health Care Spending: Findings From the J-CHiP Community-based Population Health Management Program Evaluation: Erratum.

Who benefits most in disease management programs: Improving target efficiency.

Disease management programs aim to reduce cost by improving the quality of care for chronic diseases. Evidence of their effectiveness is mixed. Reducing health care spending sufficiently to cover program costs has proved particularly challenging. This study uses a difference in differences design to examine the impact of a diabetes disease management program for high risk patients on preventive tests, health outcomes, and cost of care. Heterogeneity is examined along the dimensions of severity (measured using the proxy of poor glycemic control) and preventive testing received in the baseline year. Although disease management programs tend to focus on the sickest, the impact of this program concentrates in the group of people who had not received recommended tests in the preintervention period. If confirmed, such findings are practically important to improve cost-effectiveness in disease management programs by targeting relevant subgroups defined both based on severity and on (missing) test information.

Impact of Medicare Advantage Enrollment on Utilization of Intensity-Modulated Radiation Therapy and Cost of Care for Cancer Treatment

Intensity-modulated radiation therapy (IMRT) is an important driver of rising costs in oncology care, but the level of evidence supporting its routine use varies across disease sites, including breast, lung, and prostate. While Medicare Advantage (MA) plans have incentives to reduce health care spending, the effect of MA enrollment on utilization of high-cost medical services and quality of care is unclear, especially for cancer patients. We examined differences in IMRT utilization and health care spending between MA and traditional fee-for-service (FFS) Medicare for patients receiving radiation therapy (RT) across these disease sites. We performed a retrospective cohort study using 2009-2012 health insurance claims data from the Health Care Cost Institute (HCCI) and the Centers for Medicare and Medicaid Services (CMS). We identified 2,571 MA and 6,062 FFS Medicare beneficiaries from the HCCI and CMS databases, respectively, who were newly diagnosed with non-metastatic breast, lung, or prostate cancer in 2011 and were treated with external beam RT within 12 months of diagnosis. We measured utilization rate of IMRT, unit price of RT delivery, and RT-specific spending among patients within each cancer-type cohort. Outcomes were adjusted for differences in patient characteristics (age, sex, and Charlson co-morbidity index) and geography between MA and FFS beneficiaries. Statistical significance of the differences between groups was assessed using two-sample t tests. In both MA and FFS Medicare, the adjusted rate of IMRT utilization was highest among prostate patients and lowest among breast patients. Across all three disease sites, IMRT utilization was lower in MA than FFS Medicare, but the difference was statistically significant only for the prostate cohort (18.0 vs. 20.2%, p=0.149 for breast; 32.8 vs. 36.0%, p=0.385 for lung; 94.0 vs. 98.5%, p<0.001 for prostate). Average unit price of IMRT delivery was not significantly different in MA versus FFS Medicare. However, per patient RT-related costs were lower among MA patients in the breast and prostate cancer cohorts ($12,630 vs. $13,214 and $25,990 vs. $27,685, respectively; p=0.005 and p<0.001), but not significantly different among lung cancer patients ($15,653 vs. $15,024; p=0.301). IMRT utilization rates in both MA and FFS Medicare were consistent with the relative level of evidence supporting its use in each disease site. MA enrollment was associated with modestly lower IMRT utilization for all patients, with no evidence of a differential impact based on cancer type. The unit price of IMRT delivery was similar in MA versus FFS Medicare. We found no evidence that MA plans adopted utilization management tools that more effectively targeted high-cost therapies based on clinical evidence than in traditional Medicare.

PHP44 - EXPLORING THE KNOWLEDGE AND PERCEPTION OF GENERIC MEDICINE USE AMONG COMMUNITY PHARMACISTS IN SAUDI ARABIA

Generic medicines are one of the main avenues for reducing health care spending by all payers. There are no clear guidelines for generic and brand substitution in Saudi Arabia’s community pharmacies. We assessed knowledge, attitude, perception, factors and current practices among community pharmacists towards generic medicines substitution in Saudi Arabia. A cross-sectional study was conducted between November 2017 to January 2018 including licensed community pharmacists from different regions in Saudi Arabia. A 38-item validated self-completed questionnaire, the data were analyzed using SPSS, and descriptive statistics were applied. Out of 1928 responses, 75.8% believed that pharmacists are allowed to change between generic and brand medications without consulting physicians. Almost 30 % believed that generics are less effective than brands. Almost 55.8% of participants support generic substitution where generic is available. However, 67% thinks that promotional activities by pharmaceutical companies plays important role in choosing the dispensed generic product. Generally, 35 % of pharmacists believe they would dispense generic products for their clients. However, 29% believed they would not. The main reasons pharmacists cited for not consulting the physician before substitution was the over the counter drugs (78%), and unavailability of physicians' contact numbers (54%). The two most common reasons for recommending generics were patient demand and cost (79%, 78% respectively). The community pharmacists knowledge and perception about generic medicines were somehow limited and needs improvement. Patients demand and marketing activities influences the substitution decision. There is a need to implement polices to improve proper use and awareness generic medicines in Saudi Arabia.

Association of the Overall Well-being of a Population With Health Care Spending for People 65 Years of Age or Older

New US health care payment models have increasingly incentivized health care systems to promote health and reduce health care spending at the population level, with Medicare beneficiaries representing one of the largest populations affected by new payment models. Identifying novel strategies to promote health and reduce health care spending is necessary. To assess whether the overall well-being of a population is associated with health care spending for people 65 years of age or older. This US national, population-based cross-sectional study examined the association between county well-being and Medicare fee-for-service (FFS) spending. Population well-being, a holistic assessment of the overall health of the population comprising interrelated domains, including physical, mental, and social health, as measured by the Gallup-Sharecare Well-Being Index (2010), was linked to the mean spending per Medicare FFS beneficiary (2010) and county characteristics data for all US counties assessed. The data were adjusted for prevalence of 4 low-variation conditions (hip fracture, stroke, colorectal cancer, and acute myocardial infarction) and regional penetration of Medicare Advantage. Data analyses were conducted October 13, 2016, to October 31, 2017. Mean spending per Medicare FFS beneficiary per county. In total, 2998 counties were assessed using county-level mean values, with 4 to 7317 participants (mean [SD] number of participants, 755 [1220]) per county. The mean (SD) values of the demographic characteristics of the participants were 50.8% (1.3%) female, 74.9% (16.5%) white, 12.1% (13.0%) black, 4.0% (5.3%) Asian, and 13.7% (14.8%) Hispanic with a mean (SD) of the median county age of 38.2 (4.4) years. Medicare spent a mean (SE) of $992 ($110) less per Medicare FFS beneficiary in counties in the highest quintile of well-being compared with counties in the lowest well-being quintile. This inverse association persisted after accounting for key population characteristics such as median household income and contextual factors such as urbanicity and health care system capacity. Medicare spent a mean (SE) of $1233 ($104) less per Medicare FFS beneficiary in counties with the greatest access to basic needs than in those with the lowest access. In this US national study, the overall well-being of a geographically defined population was inversely associated with its health care spending for people 65 years and older. Identifying this association between well-being and health care spending at the population level may help to lay the foundation for further study to first illuminate the mechanisms underlying the association and to second study interventions aimed at creating greater well-being and lower health care spending at the population level.

Modelling the cost-effectiveness of pay-for-performance in primary care in the UK

BackgroundIntroduced in 2004, the United Kingdom’s (UK) Quality and Outcomes Framework (QOF) is the world’s largest primary-care pay-for-performance programme. Given some evidence of the benefits and the substantial costs associated with the QOF, it remains unclear whether the programme is cost-effective. Therefore, we assessed the cost-effectiveness of continuing versus stopping the QOF.MethodsWe developed a lifetime simulation model to estimate quality-adjusted life years (QALYs) and costs for a UK population cohort aged 40–74 years (n = 27,070,862) exposed to the QOF and for a counterfactual scenario without exposure. Based on a previous retrospective cross-country analysis using data from 1994 to 2010, we assumed the benefits of the QOF to be a change in age-adjusted mortality of −3.68 per 100,000 population (95% confidence interval –8.16 to 0.80). We used cost-effectiveness thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY to determine the optimal strategy in base-case and sensitivity analyses.ResultsIn the base-case analysis, continuing the QOF increased population-level QALYs and health-care costs yielding an incremental cost-effectiveness ratio (ICER) of £49,362/QALY. The ICER remained >£30,000/QALY in scenarios with and without non-fatal outcomes or increased drug costs, and under differing assumptions about the duration of QOF benefit following its hypothetical discontinuation. The ICER for continuing the programme fell below £30,000/QALY when QOF incentive payments were 36% lower (while preserving QOF mortality benefits), and in scenarios where the QOF resulted in substantial reductions in health-care spending or non-fatal cardiovascular disease events. Continuing the QOF was cost-effective in 18%, 3% and 0% of probabilistic sensitivity analysis iterations using thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY, respectively.ConclusionsCompared to stopping the QOF and returning all associated incentive payments to the National Health Service, continuing the QOF is not cost-effective. To improve population health efficiently, the UK should redesign the QOF or pursue alternative interventions.

Clinical and Dermoscopic Features of Lichenoid Keratosis: A Retrospective Case Study.

Lichenoid keratosis is a benign cutaneous lesion exhibiting many clinical faces and different dermoscopic features. This study aims to determine the pattern of different clinical subtypes of lichenoid keratosis and to establish whether there is any correlation between the clinical variants of lichenoid keratosis and their dermoscopic appearance. We retrospectively analyzed the medical records and clinical database of patients who had received a histological diagnosis of lichenoid keratosis. Based on the literature review and the clinical-dermoscopic features of lichenoid keratosis, we divided the lesions into 6 clinical subtypes to evaluate potential correlations between clinical and dermoscopic features in all subtypes. Fifty-one lesions were included in this clinical study. Preoperatively, only 1.9% of cases were clinically diagnosed as lichenoid keratosis, and the most common misdiagnosis was basal cell carcinoma (52.9%). We identified 6 subtypes of lichenoid keratosis and their corresponding dermoscopic features and clues. Since lichenoid keratosis has no pathognomonic dermoscopic clues and it is commonly misdiagnosed as malignant skin neoplasms, such as basal cell carcinoma and melanoma, improving the knowledge of both clinical and dermoscopic variability of lichenoid keratosis may help dermatologists to reduce unnecessary surgery and to reduce health care spending.