Payer Type Research Articles

The Price-Quality Mismatch: Are Negotiated Prices for Total Joint Arthroplasty Associated With Hospital Quality in a Large California Health System?

Price variations in healthcare can be caused by quality or factors other than quality such as market share, negotiating power with insurers, or hospital ownership model. Efforts to improve care value (defined as the ratio between health outcomes and price) by making healthcare prices readily accessible to patients are driven by the assumption this can help patients more easily identify high-quality, low-price clinicians and health systems, thus reducing price variations. However, if price variations are driven by factors other than quality, then strategies that involve payments for higher-quality care are unlikely to reduce price variation and improve value. It is unknown whether prices for total joint arthroplasty (TJA) are correlated with the quality of care or whether factors other than quality are responsible for price variation. (1) How do prices insurers negotiate for TJA paid to a single, large health system vary across payer types? (2) Are the mean prices insurers negotiate for TJA associated with hospital quality? We analyzed publicly available data from 22 hospitals in a single, large regional health system, four of which were excluded owing to incomplete quality information. We chose to use data from this single health system to minimize the confounding effects of between-hospital reputation or branding and geographic differences in the cost of providing care. This health system consists of large and small hospitals serving urban and rural populations, providing care for more than 3 million individuals. For each hospital, negotiated prices for TJA were classified into five payer types: commercial in-network, commercial out-of-network, Medicare Advantage (plans to which private insurers contract to provide Medicare benefits), Medicaid, and discounted cash pay. Traditional Medicare plans were not included because the prices are set statutorily, not negotiated. We obtained hospital quality measures from the Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services quality measures included TJA-specific complication and readmission rates in addition to hospital-wide patient survey star rating (measure of patient care experience) and total performance scores (aggregate measure of clinical outcomes, safety, patient experience, process of care, and efficiency). We evaluated the association between the mean negotiated hospital prices and Centers for Medicare and Medicaid Services quality measures using Pearson correlation coefficients and Spearman rho across all payer types. Statistical significance was defined as p < 0.0025. The mean ± SD overall negotiated price for TJA was USD 54,500 ± 23,200. In the descriptive analysis, the lowest negotiated prices were associated with Medicare Advantage (USD 20,400 ± 1800) and Medicaid (USD 20,300 ± 8600) insurance plans, and the highest prices were associated with out-of-network care covered by commercial insurance plans (USD 78,800 ± 9200). There was no correlation between the mean negotiated price and TJA complication rate (discounted cash price: r = 0.27, p = 0.29; commercial out-of-network: r = 0.28, p = 0.26; commercial in-network: r = -0.07, p = 0.79; Medicare Advantage: r = 0.11, p = 0.65; Medicaid: r = 0.03, p = 0.92), readmission rate (discounted cash price: r = 0.19, p = 0.46; commercial out-of-network: r = 0.24, p = 0.33; commercial in-network: r = -0.13, p = 0.61; Medicare Advantage: r = -0.06, p = 0.81; Medicaid: r = 0.09, p = 0.74), patient survey star rating (discounted cash price: r = -0.55, p = 0.02; commercial out-of-network: r = -0.53, p = 0.02; commercial in-network: r = -0.37, p = 0.13; Medicare Advantage: r = -0.08, p = 0.75; Medicaid: r = -0.02, p = 0.95), or total hospital performance score (discounted cash price: r = -0.35, p = 0.15; commercial out-of-network: r = -0.55, p = 0.02; commercial in-network: r = -0.53, p = 0.02; Medicare Advantage: r = -0.28, p = 0.25; Medicaid: r = 0.11, p = 0.69) for any of the payer types evaluated. There is substantial price variation for TJA that is not accounted for by the quality of care, suggesting that a mismatch between price and quality exists. Efforts to improve care value in TJA are needed to directly link prices with the quality of care delivered, such as through matched quality and price reporting mechanisms. Future studies might investigate whether making price and quality data accessible to patients, such as through value dashboards that report easy-to-interpret quality data alongside price information, moves patients toward higher-value care decisions. Efforts to better match the quality of care with negotiated prices such as matched quality and price reporting mechanisms, which have been shown to increase the likelihood of choosing higher-value care in TJA, could improve the value of care.

Opening of legal proceedings in civil proceedings on Ukrainian lands as part of Poland and Lithuania (middle of the 14th – middle of the 17th centuries)

The article examines the peculiarities of opening proceedings in a lawsuit based on the analysis of medieval Polish-Lithuanian legislation, which maintained its influence in Ukraine for almost half a millennium. The author conducts an analysis of the system of courts that operated at that time, as their status had a significant impact on the particularity of the exercise of the right to sue. It is noted that the feudal legislation was very careful to ensure that the claim was not filed in the wrong court contrary to the established rules of judicial jurisdiction. To a certain extent, this was connected with the presence in some states of the privilege to try in a court where representatives of their state tried (state courts).&#x0D; Attention is drawn to preserving the heredity of opening proceedings in the case from the «princely era» at the initial stages of the occupation of the territory of Ukraine by Poland and Lithuania. But in the future, such a procedure for opening proceedings on the basis of a claim is formed, which in some ways resembles a modern civil process.&#x0D; The author examines the written form of the claim and analyzes its details, indicating their significance. A comparison of Polish and Lithuanian legislation on this issue is carried out. In particular, the Complete Code of Laws of Casimir the Great of 1347 and the Formula processus of 1523 and the three Statutes of the Grand Duchy of Lithuania of 1529, 1566 and 1588 are compared on the other, respectively. It is noted that at the first stages, the Lithuanian legislation more succinctly defined the details of the claim, but later they were almost the same, which is explained by the rapprochement of Poland and Lithuania and the formation of the single state of the Polish-Lithuanian Commonwealth in 1569. However, both states did not compactly contain thesedetails of the claim in one article , and were scattered not only on different articles, but sometimes also on different chapters of feudal codes.&#x0D; The existence of strict rules for preserving the authenticity of the text of the lawsuit is noted, which should guarantee not only the interests of the parties to fair justice, but also the authority of the judiciary, since the lawsuit was issued on behalf of the sovereign, that is, it was a judicial procedural document. It indicates various types of payments and property penalties that could take place at the initial stage of proceedings in a civil case. First of all, they were directed to official earning of money by court employees and prevention of abuse of procedural rights by the parties.&#x0D; Compared to the previous period, the role of the state in opening legal proceedings is growing significantly. She, with the help of various officials, helps the plaintiff bring his dispute to an official hearing before the court, so that he can claim what is rightfully his. The stage of opening proceedings in a civil case ends with the registration of a lawsuit in government books (for example, Zemstvo books).

The Differential Impact of the COVID-19 Pandemic on Prenatal Care Utilization Among US Women by Medicaid Expansion and Race and Ethnicity.

The 2014 Medicaid expansion improved racial and ethnic equity in insurance coverage and access to maternal care among women of reproductive age. This study examines differential effects of the COVID-19 pandemic on prenatal care utilization by Medicaid expansion and by race and ethnicity. Using the pooled 2019-2020 National Natality file (N = 7 361 190), logistic regression was used to estimate the effect of COVID-19 on prenatal care utilization among US women aged 10 to 54 years after controlling for maternal age, race, ethnicity, marital status, parity, nativity/immigrant status, education, payment type, and smoking during pregnancy. Outcome measures were having no care and delayed prenatal care (third trimester or no care). Stratified models by race/ethnicity and Medicaid expansion status yielded the differential effects of COVID-19 on prenatal care utilization. During the COVID-19 pandemic, the adjusted odds of having no prenatal care decreased by 4% (adjusted odds ratio [AOR] = 0.96; 95% confidence interval [CI], 0.94-0.97) in expansion states but increased by 13% (AOR = 1.13; 95% CI, 1.11-1.15) in nonexpansion states. While most racial and ethnic groups in expansion states experienced a decrease in having no prenatal care, the adjusted odds of having no prenatal care increased by 15% for non-Hispanic Whites, 9% for non-Hispanic Blacks, 33% for American Indians/Alaska Natives, 25% for Asian/Pacific Islanders, and 13% for Hispanics in nonexpansion states. Women in expansion states experienced no change in delayed prenatal care during the pandemic, but women in nonexpansion states experienced an increase in delayed care. Prenatal care utilization decreased during the pandemic among women in nonexpansion states, particularly for American Indians/Alaska Natives and Asian/Pacific Islanders, compared with expansion states.

Costs of biomarker testing among patients with metastatic lung or thyroid cancer in the USA: a real-world commercial claims database study

ObjectiveThis real-world retrospective database study quantified the costs of biomarker testing in a US population of patients with lung or thyroid cancers.Materials and methodsThe commercial claims IBM Marketscan database, a de-identified real-world dataset, was used to identify patients diagnosed with lung or thyroid cancer between 1/2015 and 12/2019. Eligible patients were 18 years or older with two or more lung or thyroid diagnosis codes. Patients were excluded who had evidence of prior cancer diagnoses. Subgroup analyses evaluated eligible patients with metastatic disease. Descriptive statistics were used to evaluate commercial insurance plan payer and patient out-of-pocket costs for diagnostic testing overall as well as by test procedure code and payer type. Costs were adjusted to 2020 US dollars.ResultsA total of 23,633 patients with lung cancer were eligible, 13,320 of whom had metastatic disease. There were 36,867 patients with thyroid cancer, 2,241 of whom had metastatic disease. Biomarker codes were observed among 68.4/75.8% (lung/metastatic lung) and 18.2/42.3% (thyroid/metastatic thyroid). Few patients had codes for comprehensive biomarker tests (5.2/6.7% lung/metastatic lung, 0.3/2.2% thyroid/metastatic thyroid) Among those with biomarker tests, the median per-patient total payer lifetime costs of all biomarker testing were $394/$462 (lung/metastatic lung) and $148/$232 (thyroid/metastatic thyroid). Total lifetime biomarker costs for payers ranged from a median of $128 (consumer-driven health plans) to $477 (preferred provider organizations). Median lifetime patient out-of-pocket costs were $0.00 for both tumor types and all payer types except for consumer-driven health plans ($12 for thyroid and $10 for metastatic lung).ConclusionsWhile comprehensive testing adds to the cost of biomarker testing, these data suggest the relatively low lifetime cost of biomarker testing for both payers and patients. Costs for biomarker testing should not be a limitation to access among these populations with commercial insurance plans in the US.

Predictive characteristics of limb salvage versus amputation in lower extremity trauma: A review of the National Trauma Data Bank

The decision between limb salvage or amputation in patients with severely injured lower extremities has major consequence to patients. There is a paucity of data on socioeconomic and institutional factors that affect this decision. We aim to evaluate the association of institutional and payment factors on management of Gustilo III lower extremity trauma. Patients with Gustilo III lower extremity injuries were identified from the National Trauma Data Bank (NTDB) from 2016 through 2017. Amputation and limb salvage outcomes were analyzed in relation to patient demographics, comorbidities, payment type, and hospital characteristics. Independent T-tests, Chi squared tests, and multivariate logistic regression was performed with statistical significance set at p < 0.05. A total of 587 patients were identified, of which 81.4% were men and 18.6% were women. Sex, race, BMI, and injury severity score were not statistically different. Compared with amputation, limb salvage patients were younger (39.2 years versus 44.9 years, p = 0.001), had government-assisted health insurance (34.0% versus 14.5%, p = <0.001), and were evaluated at an academic medical center (68.7% versus 53.8%, p = 0.003) or level I trauma center (73.3% vs. 64.3%, p = 0.049 ) . Limb salvage was 1.73 times more likely at teaching hospitals versus nonteaching hospitals and 4.47 times more likely with public government-assisted insurance versus private insurance. This study presents data on lower extremity care following Gustilo III injuries from the NTDB. Patients are more likely to undergo limb salvage if they are evaluated at an academic center or have government-assisted health insurance. • Patients who underwent limb salvage were younger and hospitalized eight days longer. • Limb salvage was 1.73 times more likely at an academic hospital compared to a community or nonteaching hospital. • Patients with government-assisted health insurance were 4.47 times more likely to undergo limb salvage compared to patients with private or commercial insurance.

Features of Self-Taxation as a Form of Local Budget Revenues

Abstract The aim of the article is to reveal the features of self-taxation as an independent form of local budget revenues. There is no consensus among domestic and foreign scholars on understanding the nature, place, and role of self-taxation in the system of income sources of territorial communities. Another problem is the fact that today in Ukraine there is virtually no legislative regulation of this financial and legal institution. The research methodology is based on formal-dogmatic, comparative-legal, systemic-structural and other scientific methods. It is substantiated that self-taxation is an independent type of mandatory payment, which is non-tax in nature and is used to address issues of local importance, the population at a general meeting or local referendum independently determines its size, procedure for introduction, and use.

A Study on the Role of Demographic Variables on Online Payment in Delhi NCR

The first part discusses the introduction of the topic, followed by the different types of online payments. The research discusses the present condition of e- commerce, and the online payment mechanisms used in Delhi NCR. The study segment employs a questionnaire survey to investigate several types of client attitudes concerning online payments. The questionnaire was filled out by 50 respondents from Delhi NCR. The statistical test used was ANOVA. The main objectives of the study were to understand whether there is a difference between respondents’ gender & the frequency of online payments, the pros & cons of online payments & challenges of online payments. Also, the researcher tries to understand whether there is difference between respondents’ age & the fre- quency of online payments, the pros & cons of online payments & challenges of online payments. The findings concluded that there is no significant asso- ciation between the gender of the respondent & other parameters, whereas, in the case of the age of the respondent, a significant association has been seen.

The current state and priority trends in the development of legislation in the field of providing social benefits and other payments to prosecutors and their family members

The article examines general and special issues of providing social benefits and other social payments to prosecutors and their family members. The work of scientists regarding the coverage of the concept and signs of social assistance has been disclosed and analyzed, and its essential legal features have been clarified. On the basis of this, the author's definition of the category "social assistance to prosecutors and members of their families" was formed and its essential features were identified, to which the author attributed the following: 1) guarantee; 2) social benefits are material in nature; 3) addressability; 4) in order to ensure effective targeting, it is more important to provide social benefits in the established case of their actual occurrence; 5) alimony and gratuity.In the future, the existing trends in the reform of the social security legislation as a whole are determined, which directly determine the specifics of the legal regulation of the provision of social benefits and other payments to prosecutors and their family members. It was noted that the key idea of the specified changes in the system of social assistance to prosecutors is to strengthen the unity of social security, to provide its various types on uniform grounds and rules, and to abolish excessive differentiation in the law of social security. A comparative legal analysis of the previously effective and current legislation, which regulated the investigated issue, was carried out. The specifics of providing social benefits and other payments to prosecutors and their family members have been determined. It is noted that the above payments can be divided into universal and special. It is emphasized that social benefits and other additional types of social payments to prosecutors and their family members are a means of social protection, which is designed to prevent the impoverishment of the specified category of persons, adequately and effectively respond to additional (those not provided for by the system of mandatory state social insurance) social risks, including, first of all, caused by the specifics of professional activity, performance of official duties. The priority trends of the further development of social security legislation in this area are outlined.

Consumer perception of product-service systems: Depicting sector-specific barriers in the mobility, clothing and tooling sectors

The viability of PSS models has been shown to be frequently jeopardized by low levels of consumer appeal and retention. Using Social Practice Theory (SPT) and the habitual practice approach, this paper posits that barriers to consumer adoption and retention of PSS offers are twofold: 1) generic to the PSS offers—that is, common to all sectors but playing differently from one sector to another and 2) sector-specific. The purpose of the paper is to study how routinization of habitual practices differently affects consumers’ propensity to change their consumption practices and to move towards PSS offers across sectors. To gain in-depth understanding of generic and sector-specific barriers and to distinguish between them, three sectors of PSS are analysed and compared: mobility, clothing and tooling. A quantitative and qualitative mixed methodology was used with consumers in the Brussels Region (Belgium). Two results emerge from the study. First, we confirm the existence of generic barriers to the adoption of PSS offers (e.g., not feeling like a target customer, flawed price representation, fear of unavailability of the product, not wanting to share the use of the product, dislike for subscription, or preference for ownership). Second, just as the relative weight of the barriers differs according to the sectors and there are specific obstacles to certain sectors (e.g., morphology in the clothing industry), we demonstrate that determinants of pleasure and determinants of consumption type (purchase or PSS) differ across cases. In addition, we discuss the fact that the type of payment (pay-per-use or subscription) and the related consumer engagement (requiring a change in established practice or not) have an impact on the perception and adoption of PSS offers by consumers.

Peripherally Inserted Central Line Catheters following Hand and Wrist Infections.

The PearlDiver Patients Records Database was queried to identify patients who underwent treatment for infection of the hand, wrist, and forearm between 2010 and 2018. Logistic regression analysis was utilized to evaluate the association of patient-related risk factors with PICC utilization, complications, readmissions, and length of stay (LOS). A total of 24,665 patients with an upper extremity infection were included in the study. Ultimately, 416 patients required a PICC placement (1.69%). Patients with older age, male gender, certain medical comorbidities, and infection involving deeper structures were more likely to require a PICC. Ninety-day all-cause medical complication rates were significantly higher for the PICC group (19.7% versus 6.7%) compared to those without. Any hospital readmission rates were significantly higher for PICC group at 90 days (28.4% versus 6.3%) and 1 year (35.8% versus 10.9%). Readmission rates remained slightly higher at 1 year for both groups. The PICC group demonstrated significantly longer LOS by 2 days (7.72 days versus 5.14 days). While not required for the majority of hand, wrist, and forearm infections, PICC placement is associated with increased medical complications, more frequent hospital readmissions, and longer LOS.

P065Long acting reversible contraceptive (larc) insertions in 2019 in the states with most restrictive and trigger abortion policies

<h3>Objectives</h3> As of May 2022, 26 states have been identified as certain or almost certain to ban abortion should the 1973 Roe decision recognizing women's constitutional right to choose to terminate be overturned. The purpose of this analysis was to describe the rate of insertions of long-acting reversible contraceptives (LARCs), the most effective forms of contraception, in those 26 states. <h3>Methods</h3> Data was from a HealthVerity Marketplace claims data source representing 130 million patients, representing 58% of the US census population. Women aged 15–44 were included in the analysis. For each healthcare encounter, the following data were gathered: three-digit zip code, age, implant insertion (y/n), intrauterine device (IUD) insertion (y/n), provider specialty, and payer type (Medicaid or commercial). LARC insertion rates by three-digit zip code geographic areas in the 26 states with pending abortion bans were described. <h3>Results</h3> In four states with pending abortion bans, LARC insertion rates were consistently low: <2.6% in either all or nearly all three-digit zip code areas. Four states had consistently top quartile LARC insertion rates (>4.1%). The remaining states had wide variation in LARC insertion rates; some three-digit zip code areas fell in the lowest quartile of insertions (<2.6%) and other areas showing highest percentiles of LARC insertions (>4.1%) <h3>Conclusions</h3> Use of LARCs vary among the geographic areas within the states with certain or near-certain abortion trigger bans. These variations in LARC insertion rates may indicate significant additional reproductive health burdens for women who may already be facing significant restrictions on their reproductive health choices.

Evaluation of Industry Payments to US Advanced Practice Clinicians in 2021

Advanced practice clinicians (APCs) are a growing part of the US health care system, and their financial relationships with pharmaceutical and medical device companies have not been well studied. To examine the value, frequency, and types of payments made to APCs and the association of state scope-of-practice laws with these payments. This cross-sectional study used 2021 Open Payments Program data to analyze payments from pharmaceutical or medical device companies to physicians or APCs between January 1 and December 31, 2021. Doctors of medicine and osteopathy were categorized as physicians, and nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, and anesthesiologist assistants as APCs. The total value and total number of payments were calculated in aggregate and per clinician for each type of APC, all APCs, and physicians. These calculations were repeated by submitting manufacturer, form of payment, nature of payment, and state scope-of-practice law for nurse practitioners, physician assistants, and physicians. A total of 412 000 physicians and 232 000 APCs collectively received $1.99 billion in payments from industry in 2021, of which APCs received $121 million (6.1%). The median total value of payments per clinician for physicians was $167 (IQR, $45-$712) and for APCs was $117 (IQR, $33-$357). The median total number of payments per clinician was equal for physicians and APCs (n = 4). The most common payments to APCs included food and beverage ($69 million [57.6%]), compensation for services other than consulting ($32 million [26.4%]), and consulting fees ($8 million [6.6%]). Advanced practice clinicians in states with the most restrictive scope-of-practice laws received 15.9% lower total value of payments than those in the least restrictive states (P = .002). Physician assistants received 7.6% (P = .005) higher value and 18.1% (P < .001) greater number of payments than nurse practitioners. In this cross-sectional study, 232 000 APCs collectively received $121 million in industry payments in 2021. The frequency of industry interactions with APCs was similar to that for physicians, but the average value was lower. The greater value of payments to APCs who practice in states with the least restrictive scope-of-practice laws suggests that industry payments may be related to clinician autonomy.

A US National View of Prevalent and Newly Diagnosed Multiple Myeloma in 2021: A Retrospective Analysis of National All-Payer Claims Database

Introduction: Multiple myeloma (MM) is a rare and heterogeneous cancer with steadily improving patient survival in recent years due to advancement in therapies. Updates to the prevalence and incidence of MM using the latest nationally representative data are needed to support population health management, resource planning, and health economic assessments. Furthermore, disparities in disease burden, access to care, treatment patterns, and outcomes could exist across patient subpopulations with MM, prompting a need for comprehensive data to understand the population. Currently, there is a gap in such data due to the highly fragmented health care system in the US in which real-world evidence is often siloed and represents only a portion of the population. This study aims to provide a national view of MM by estimating the prevalence and incidence in US adults overall and by state/territory, payer type, race, and ethnicity in 2021. Methods: This is a retrospective study using the All-Payer Real-World Multiple Myeloma Research-Ready Data built using the US national all-payer claims database (APCD), which covers ~87% of the nationally insured population from 1/1/2014 to 1/31/2022. Data included adults with ≥2 claims with MM diagnosis (ICD-9-CM: 203.0x and ICD-10-CM: C90.0x) who had continuous capture with medical and pharmacy benefits for ≥12 months prior to and 30 days after the first MM diagnosis date. To be included in this study, patients also had to have ≥1 claim in 2021. The latest claim date in 2021 was defined as the index date. A subcohort of patients with newly diagnosed MM (NDMM; incident MM cases) were additionally required to have their first MM diagnosis date (the index date for the NDMM cohort) in 2021. Prevalence and incidence of MM were estimated using the number of patients in MM and NDMM cohorts, divided by the total APCD adult population with similar continuous capture eligibility. Prevalence and incidence were calculated for the overall population and stratified by state/territory, payer type, race, and ethnicity. Patient characteristics were captured at the index date and during the baseline period. The proportion of patients with NDMM who initiated their first treatment in 2021 and the time from diagnosis to their first treatment were captured. Results: A total of 63,281 MM and 9,674 NDMM patients met the study criteria. Mean age was 71.1 and 70.0 years, 51.4% and 52.9% were male, and 68.7% and 72.0% were covered by Medicare, respectively. Overall, about two-thirds of the patients had available race (74%), ethnicity (69%), and income data (76%), while 46% had education status. Among those with data, 15.6% of MM and 14.7% of NDMM cohorts were Black, 12.2% and 11.9% were Hispanic, 65.1% and 64.5% had an annual income ≤$50,000, and 67.5% and 67.2% had high school as their highest level of education. The overall prevalence of MM was 73.8 per 100,000 adults in 2021, with the prevalence being the highest among those who were Black (124.8), non-Hispanic (101.3), covered by Medicare (245.2), and residing in the US Virgin Islands (243.6) and Arkansas (126.5). The overall incidence of NDMM was 11.3 per 100,000 adults in 2021, and the incidence was highest among those who were Black (17.8), non-Hispanic (15.3), covered by Medicare (39.3), and those residing in Puerto Rico (24.5), the US Virgin Islands (22.8), and Washington (20.7; Tables 1 and 2). The mean Quan-Charlson comorbidity index (excluding MM diagnosis) was 2.8 for the MM cohort and 2.4 for the NDMM cohort. Commonly observed comorbidities for both cohorts included anemia (44.8% and 47.4%), diabetes with chronic complications (23.9% and 22.4%), peripheral neuropathy (24.8% and 15.2%), renal impairment (22.7% and 20.1%), and infections (21.9% and 14.4%). There were 3,377 (35%) patients with NDMM who initiated their first treatment in 2021, with a mean and median time to treatment of 50.8 (standard deviation = 67.5) and 27 days. Conclusions: While the prevalence and incidence of MM in 2021 estimated in this study were consistent with projected estimates from the literature, variations in rates of MM were observed across race, ethnicity, payer type, and state/territory, indicating potential disparities in the burden of MM. Such a comprehensive view of rates of MM could serve as a foundation for future health policy decisions, quality improvement, resource deployment, and initiatives to address health disparities across subpopulations. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Total Cost of Care in Relapsed/Refractory (R/R) Diffuse Large B-Cell Lymphoma (DLBCL)

Background: DLBCL is the most common type of non-Hodgkin lymphoma, and 30-40% of patients develop R/R DLBCL (Sehn LH and Salles G. N Engl J Med 2021), which is associated with substantial treatment cost. Previous studies evaluated the total healthcare costs by line of therapy (LoT) (Danese MD, et al. Leuk Lymphoma 2017; Tkacz J, et al. Leuk Lymphoma 2020; Yang X, et al. Oncologist 2021; Mutebi A, et al. ISPOR 2022); however, these studies have not been updated with more recent real-world data. This analysis evaluated the total cost of care and health resource utilization associated with R/R DLBCL therapies by LoT, including those recently approved, to understand the impact of novel therapies such as chimeric antigen receptor T-cell (CAR-T) therapy on total cost of care and resource use in the R/R DLBCL setting. Methods: We evaluated healthcare costs and resources for each regimen in the second-line (2L) setting and beyond in patients who received rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) or R-CHOP-like therapy (at least rituximab, cyclophosphamide, and one corticosteroid) as first-line (1L) treatment for DLBCL between January 1, 2015 and June 30, 2021 using the IQVIA PharMetrics® Plus Database (Figure A). Costs were assessed for each LoT from the first administration date until the beginning of a new regimen (defined by receipt of a new regimen given after a treatment gap of 60 days, or the addition/substitution of new agents ≥30 days after starting initial therapy [adapted from Yang X, et al. Oncologist 2021]), a treatment gap of 180 days, or end of follow-up. Systemic therapies initiated <30 days before the start of CAR-T therapy or stem cell transplant (SCT) were considered pre-treatment and were included in the costs for only that LoT, to be inclusive of conditioning and bridging treatments. Total cost of care (TCC) was defined as all-cause healthcare costs. Healthcare resource utilization (HCRU) costs and events were defined using inpatient, outpatient, pharmacy, and emergency room (ER) categories. Baseline characteristics, including age and payer type at index, sex, and US region were assessed in the 12 months pre-index. TCC was reported as per patient per month (PPPM) and per patient per LoT. Data were descriptively assessed. Results: The final analysis cohort included 236 patients with a median age at first ≥2L treatment of 60 years (interquartile range [IQR] 54-64), 37% of patients were female, and median follow-up from 1L initiation was 21 months [IQR 13-35]. Of the patients who received 2L treatment, 44.5% (105/236) received third-line (3L) treatment and 16.9% (40/236) received fourth-line (4L) treatment. CAR-T therapy use increased in later LoTs (5.9% in 2L, 5.7% in 3L, and 17.5% in 4L). SCT was frequently used across all LoTs (25.8% in 2L, 50.5% in 3L, and 32.5% in 4L). The mean TCC PPPM by LoT was $41,700 (standard deviation [SD] $39,767) for 2L, $58,906 (SD $70,966) for 3L, and $81,927 (SD $79,152) for 4L. Mean PPPM HCRU costs generally increased by LoT for inpatient and pharmacy claims, and costs were highest in 4L for all HCRU categories (Figure B). PPPM HCRU events were highest in the 4L setting for outpatient visits only (Figure B). Conclusion: This economic analysis demonstrated that total healthcare costs in R/R DLBCL increase with each additional LoT. Cost estimates by LoT appeared higher than previously reported (Tkacz J, et al. Leuk Lymphoma 2020; Mutebi A, et al. ISPOR 2022), and may be a result of the increase in SCT and CAR-T therapy use. Inpatient costs represented the highest percentage of total costs, followed by outpatient costs. New 1L treatments that are both efficacious and cost-effective in DLBCL are needed to reduce the economic burden to the healthcare system in the R/R DLBCL setting. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of Initiating Oral Anticancer Agent Therapy for Chronic Lymphocytic Leukemia Among Adults with Multiple Chronic Conditions

Background: Increased use of oral anticancer agents (OAA) has empowered adults with chronic lymphocytic leukemia (CLL) to manage their therapy independently. However, comorbid chronic disease is common among patients with CLL, and initiating OAA therapy increases the treatment burden on adults with both cancer and multiple chronic conditions (MCC). The objective of this research was to examine adherence to OAAs in adult patients with CLL newly initiating OAA treatment and assess the extent to which such initiation impacted adherence to medications for existing comorbid chronic conditions. Methods: This retrospective cohort study used commercial (MarketScan) and Medicare (20% sample) claims data for 2013-2018 to assess medication use in adults with CLL. To be included, patients must have been: 1) at least 18 years old; 2) diagnosed with and had 2+ claims for an OAA indicated for either CLL; 3) continuously enrolled 12 months before and after OAA initiation; and 4) treated for (2+ fills before and after OAA initiation) at least 2 select chronic conditions (diabetes, hypertension, or hyperlipidemia plus at least 1 other chronic condition). Proportion of days covered (PDC) determined medication adherence for all included medication classes and was compared for the 12 months before and after OAA initiation by Wilcoxon signed-rank tests and McNemar's tests. Multivariable logistic regression identified predictors of OAA adherence in the first year of therapy while controlling for available demographic and clinical characteristics. Difference-in-differences models assessed the change in adherence to select comorbid chronic disease medications before and after OAA initiation. Results: The final analysis included 246 (commercial) and 805 (Medicare) adults with CLL and MCC. Mean OAA adherence in the first year of therapy was 79.8% (SD: 21.1) and 74.7% (SD: 24.9) for commercial and Medicare patients, respectively, translating to 68.3% (commercial) and 59.1% (Medicare) being adherent (PDC>80%). An increase in comorbidity burden was associated with a lower odds of OAA adherence and was the sole significant predictor in the Medicare models: OR=0.87 (95% CI: 0.82-0.92) for Medicare members and OR=0.83 (95% CI: 0.73-0.95) with commercial coverage. Among adults with commercial coverage, the odds of OAA adherence were lower for residents of the South (OR=0.39; 95% CI: 0.16-0.94; compared to the Northeast), but higher among those using a greater number of medications overall (OR=1.08; 95% CI: 1.01-1.16). No significant changes in mean adherence to MCC medications were observed, irrespective of payer, when comparing values before and after OAA initiation (Figure Panel A), including when accounting for OAA adherence in the first year of therapy. However, compared to the first 6 months post-OAA initiation, mean PDCs in the second half of the year noticeably declined, irrespective of comorbidity or payer cohort, with PDC declines ranging from 3.0 (antihypertensives, Medicare) to 11.1 (antihypertensives, Medicare) percentage points (Figure Panel B). Conclusion: Using nationally representative claims data, this study found that initial OAA adherence was generally good among adults with CLL, with a majority of patients reaching accepted thresholds of adequate anticancer medication use. Additionally, few differences in adherence were observed in multivariable analyses using a range of patients’ characteristics, irrespective of payer or cancer type. Importantly, limited evidence of changes in adherence to oral antidiabetic, antihypertensive, or lipid-lowering agents were found in the first year following OAA initiation. However, these findings do not negate the need for careful monitoring of medication use in these populations over the course of time as some eventual declines in comorbid chronic disease medication adherence were observed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Mental Health Outcomes for Youths With Public Versus Private Health Insurance Attending a Telehealth Intensive Outpatient Program: Quality Improvement Analysis.

COVID-19 exacerbated a growing mental health crisis among youths and young adults, worsened by a lack of existing in-person options for high-acuity care. The emergence and growth of remote intensive outpatient programs (IOPs) is a solution to overcome geographic limitations to care. However, it remains unclear whether remote IOPs engender equivalent clinical outcomes among youths with public insurance (eg, Medicaid) versus private insurance (eg, commercial) given the disparities found in previous research on place-based treatment in both clinical and engagement outcomes. This analysis sought to establish, as part of ongoing quality improvement efforts, whether engagement and clinical outcomes among adolescents and young adults attending remote IOP treatment differed between youths with public and those with private insurance. The identification of disparities by payer type was used to inform programmatic decisions within the remote IOP system for which this quality improvement analysis was conducted. Pearson chi-square analyses and independent 2-tailed t tests were used to establish that the 2 groups defined by insurance type were equivalent on clinical outcomes (depression, suicidal ideation, and nonsuicidal self-injury [NSSI]) at intake and compare changes in clinical outcomes. McNemar chi-square analyses and repeated-measure 2-tailed t tests were used to assess changes in clinical outcomes between intake and discharge in the sample overall. In total, 495 clients who attended the remote IOP for youths and young adults in 14 states participated in ≥7 treatment sessions, and completed intake and discharge surveys between July 2021 and April 2022 were included in the analysis. Overall, the youths and young adults in the remote IOP attended a median of 91% of their scheduled group sessions (mean 85.9%, SD 16.48%) and reported significantly fewer depressive symptoms at discharge (t447=12.51; P<.001). McNemar chi-square tests of change indicated significant reductions from intake to discharge in suicidal ideation (N=470, χ21=104.4; P<.001), with nearly three-quarters of youths who reported active suicidal ideation at intake (200/468, 42.7%) no longer reporting it at discharge (142/200, 71%), and in NSSI (N=430, χ21=40.7; P<.001), with more than half of youths who reported NSSI at intake (205/428, 47.9%) reporting lower self-harm at discharge (119/205, 58%). No significant differences emerged by insurance type in attendance (median public 89%, median private 92%; P=.10), length of stay (t416=-0.35; P=.73), or reductions in clinical outcomes (depressive symptom severity: t444=-0.87 and P=.38; active suicidal ideation: N=200, χ21=0.6 and P=.49; NSSI frequency: t426=-0.98 and P=.33). Our findings suggest that youths and young adults who participated in remote IOP had significant reductions in depression, suicidal ideation, and NSSI. Given access to the same remote high-acuity care, youths and young adults on both public and private insurance engaged in programming at comparable rates and achieved similar improvements in clinical outcomes.

Financial outcomes of high-flow nasal cannula use for bronchiolitis on the general pediatric floor.

High-flow nasal cannula (HFNC) is an increasingly common treatment utilized for bronchiolitis on general pediatric hospital floors. This could present a financial burden for hospitals if reimbursement has not accounted for the increased costs associated with increased HFNC use. Pediatric Health Information System and Revenue Management Program data set discharges from 2018 to 2019 were utilized to calculate the ratio of reimbursements to costs as a cost coverage ratio (CCR). The CCR was compared by HFNC use, the severity of illness, and payor type. The CCR was highest at 1.68 for children with high severity and HFNC use but varied greatly by payor. The lowest CCR at 0.77 was seen for children with low severity and public insurance and indicated potential financial losses for these patients. This was lower than low-severity patients on HFNC with private payors (1.68) and high-severity patients on HFNC with public payors (1.18).

Machine learning methods to predict 30-day hospital readmission outcome among US adults with pneumonia: analysis of the national readmission database

BackgroundHospital readmissions for pneumonia are a growing concern in the US, with significant consequences for costs and quality of care. This study developed the rule-based model and other machine learning (ML) models to predict 30-day readmission risk in patients with pneumonia and compared model performance.MethodsThis population-based study involved patients aged ≥ 18 years hospitalized with pneumonia from January 1, 2016, through November 30, 2016, using the Healthcare Cost and Utilization Project-National Readmission Database (HCUP-NRD). Rule-based algorithms and other ML algorithms, specifically decision trees, random forest, extreme gradient descent boosting (XGBoost), and Least Absolute Shrinkage and Selection Operator (LASSO), were used to model all-cause readmissions 30 days post-discharge from index pneumonia hospitalization. A total of 61 clinically relevant variables were included for ML model development. Models were trained on randomly partitioned 50% of the data and evaluated using the remaining dataset. Model hyperparameters were tuned using the ten-fold cross-validation on the resampled training dataset. The area under the receiver operating curves (AUROC) and area under precision-recall curves (AUPRC) were calculated for the testing set to evaluate the model performance.ResultsOf the 372,293 patients with an index hospital hospitalization for pneumonia, 48,280 (12.97%) were readmitted within 30 days. Judged by AUROC in the testing data, rule-based model (0.6591) significantly outperformed decision tree (0.5783, p value < 0.001), random forest (0.6509, p value < 0.01) and LASSO (0.6087, p value < 0.001), but was less superior than XGBoost (0.6606, p value = 0.015). The AUPRC of the rule-based model in the testing data (0.2146) was higher than the decision tree (0.1560), random forest (0.2052), and LASSO (0.2042), but was similar to XGBoost (0.2147). The top risk-predictive rules captured by the rule-based algorithm were comorbidities, illness severity, disposition locations, payer type, age, and length of stay. These predictive risk factors were also identified by other ML models with high variable importance.ConclusionThe performance of machine learning models for predicting readmission in pneumonia patients varied. The XGboost was better than the rule-based model based on the AUROC. However, important risk factors for predicting readmission remained consistent across ML models.

The effect of cigarette and e-cigarette taxes on prescriptions for smoking cessation medications.

To test the effect of cigarette and e-cigarette taxes on prescriptions for smoking cessation medications. Symphony Health, IDV all-payer prescription claims data for the United States over the period 2009-2017. Prescription fills for smoking cessation products were provided at the patient's age, patient's sex, brand/generic, payment type, year, and quarter levels. We study the effect of state-level cigarette and e-cigarette tax rates on prescriptions for smoking cessation medications using two-way fixed effect modified difference-in-differences regressions. We also use a multiperiod difference-in-differences estimator robust to bias from dynamic and heterogeneous treatment effects with a staggered policy rollout. We use fills for Chantix, Zyban, and their generics, as well as Food and Drug Administration-approved nicotine replacement therapies that are paid for by insurance. We observe no statistically significant change in prescription fills following an increase in the e-cigarette tax rate, though we are unable to rule out potentially large effects. However, following a $1.00 increase in the cigarette tax rate, we observe a 1052 increase in prescription fills per 100,000 adults (95% CI: 57, 2046; 4.2% increase). The effect of cigarette taxes on prescription fills was particularly large for 18-34 year-olds. Our findings suggest that, during a period when e-cigarettes are widely available, cigarette tax increases remain effective in increasing use of these medications, but e-cigarette taxes do not increase use of these medications.

Inequities in Telehealth Use Associated with Payer Type During the COVID-19 Pandemic.

Introduction: The COVID-19 pandemic has prompted a shift in health care delivery and compelled a heavier reliance on telehealth. The objective of this study was to determine if differences in coverage policies by payer type resulted in differential telehealth use during the first 3 months of the COVID-19 pandemic. In this population-based cohort study of low-income Arkansans, Medicaid beneficiaries enrolled in the traditional Primary Care Case Management (PCCM) program were compared with Medicaid beneficiaries covered through premium assistance in private Qualified Health Plans (QHPs). Methods: A retrospective review was conducted of insurance claims records from June 1, 2019, to June 30, 2020, for synchronous telehealth and mobile health (m-health) visits, as well as other forms of telehealth. To establish the baseline equivalence of enrollees in the two groups, propensity score matching design was used on demographic and geographic characteristics, Charlson Comorbidity Index, broadband availability, and prior service utilization. Results: Compared with enrollees in the PCCM program, Medicaid expansion enrollees in QHPs had higher odds of having had at least one telehealth visit (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.29-1.42) during the early phase of the COVID-19 pandemic. Categorizing utilizations by domain, QHP enrollees were more likely to use synchronous telehealth (aOR = 1.31; 95% CI: 1.25-1.37) and m-health (aOR = 5.91; 95% CI: 4.25-8.21). A higher proportion of QHP enrollees also had at least one mental or behavioral health telehealth session (aOR = 1.13; 95% CI: 1.07-1.19). Conclusions: Our study demonstrated that within low-income populations, payer type was associated with inequitable access to telehealth during the early phase of the COVID-19 pandemic.