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Health Affairs (Project Hope) Jul 2024The Next Generation Accountable Care Organization (NGACO) model (active during 2016-21) tested the effects of high financial risk, payment mechanisms, and flexible care...
The Next Generation Accountable Care Organization (NGACO) model (active during 2016-21) tested the effects of high financial risk, payment mechanisms, and flexible care delivery on health care spending and value for fee-for-service Medicare beneficiaries. We used quasi-experimental methods to examine the model's effects on Medicare Parts A and B spending. Sixty-two ACOs with more than 4.2 million beneficiaries and more than 91,000 practitioners participated in the model. The model was associated with a $270 per beneficiary per year, or approximately $1.7 billion, decline in Medicare spending. After shared savings payments to ACOs were included, the model increased net Medicare spending by $56 per beneficiary per year, or $96.7 million. Annual declines in spending for the model grew over time, reflecting exit by poorer-performing NGACOs, improvement among the remaining NGACOs, and the COVID-19 pandemic. Larger declines in spending occurred among physician practice ACOs and ACOs that elected population-based payments and risk caps greater than 5 percent.
Topics: Accountable Care Organizations; United States; Humans; Health Expenditures; Medicare; Fee-for-Service Plans; COVID-19; Cost Savings
PubMed: 38950305
DOI: 10.1377/hlthaff.2022.01648 -
Health Affairs (Project Hope) Jul 2024Value-based payment has been promoted for increasing quality, controlling spending, and improving patient and practitioner experience. Meanwhile, needed reforms to...
Value-based payment has been promoted for increasing quality, controlling spending, and improving patient and practitioner experience. Meanwhile, needed reforms to fee-for-service payment (the Medicare Physician Fee Schedule) have been ignored as policy makers seek to move payment toward alternatives, even though the fee schedule is an intrinsic part of Alternative Payment Models. In this article, we show how value-based payment and the fee schedule should be viewed as complementary, rather than as separate silos. We trace the origins of embedded flaws in the fee schedule that must be fixed if value-based payment is to succeed. These include payment distortions that directly compromise value by overpaying for certain procedures and imaging services while underpaying for services that add value for beneficiaries. We also show how the fee schedule can accommodate bundled payments and population-based payments that are central to Alternative Payment Models. We draw two conclusions. First, the Centers for Medicare and Medicaid Services should correct misvalued services and establish a hybrid payment for primary care that blends fee-for-service and population-based payment. Second, Congress should alter the thirty-five-year-old statutory basis for setting Medicare fees to allow CMS to explicitly consider policy priorities such as workforce shortages in refining fee levels.
Topics: United States; Fee Schedules; Medicare; Humans; Fee-for-Service Plans; Physicians; Reimbursement Mechanisms
PubMed: 38950303
DOI: 10.1377/hlthaff.2024.00299 -
Health Affairs (Project Hope) Jul 2024As people lose Medicaid because of the end of the COVID-19 public health emergency, many states will route former Medicaid managed care enrollees into Affordable Care...
As people lose Medicaid because of the end of the COVID-19 public health emergency, many states will route former Medicaid managed care enrollees into Affordable Care Act Marketplace coverage with the same carrier. In 2021, 52.1 percent of Medicaid managed care enrollees were enrolled by a carrier that also had a plan on the Marketplace in the same county.
Topics: Medicaid; United States; Humans; Patient Protection and Affordable Care Act; Health Insurance Exchanges; COVID-19; Managed Care Programs; Insurance Coverage; SARS-CoV-2; Insurance Carriers; Male; Female
PubMed: 38950299
DOI: 10.1377/hlthaff.2023.00840 -
Health Affairs (Project Hope) Jul 2024Managed care plans, which contract with states to cover three-quarters of Medicaid enrollees, play a crucial role in addressing the drug epidemic in the United States....
Managed care plans, which contract with states to cover three-quarters of Medicaid enrollees, play a crucial role in addressing the drug epidemic in the United States. However, substance use disorder benefits vary across Medicaid managed care plans, and it is unclear what role states play in regulating their activities. To address this question, we surveyed thirty-three states and Washington, D.C., regarding their substance use disorder treatment coverage and utilization management requirements for Medicaid managed care plans in 2021. Most states mandated coverage of common forms of substance use disorder treatment and prohibited annual maximums and enrollee cost sharing in managed care. Fewer than one-third of states forbade managed care plans from imposing prior authorization for each treatment service. For most treatment medications, fewer than two-thirds of states prohibited prior authorization, drug testing, "fail first," or psychosocial therapy requirements in managed care. Our findings suggest that many states give managed care plans broad discretion to impose requirements on covered substance use disorder treatments, which may affect access to lifesaving care.
Topics: United States; Managed Care Programs; Medicaid; Substance-Related Disorders; Humans; Insurance Coverage; Cost Sharing; Prior Authorization
PubMed: 38950296
DOI: 10.1377/hlthaff.2023.01023 -
Circulation Jul 2024
Topics: Humans; Medicaid; United States; Health Services Accessibility; Patient Protection and Affordable Care Act
PubMed: 38950112
DOI: 10.1161/CIRCULATIONAHA.124.070084 -
Journal of Family Medicine and Primary... May 2024In the United States, access to evidence-based behavioral health treatment remains limited, contributing to inadequate treatment for individuals with depression and...
CONTEXT AND AIMS
In the United States, access to evidence-based behavioral health treatment remains limited, contributing to inadequate treatment for individuals with depression and anxiety disorders. The Collaborative care model (CoCM), the integration of behavioral healthcare into primary care, has been shown to be effective in addressing this issue, particularly when delivered virtually through telehealth platforms. While collaborative care has been shown to be effective, little has been studied to understand the impact of patient treatment factors on patient improvement. This study aims to analyze factors associated with patient improvement, measured by PHQ-9 and GAD-7 score changes, in patients with depression and anxiety disorders from Concert Health, a national behavioral medical group offering collaborative care across 18 states.
METHODS AND MATERIAL
Stepwise logistic regression models were utilized to identify factors influencing patient improvement in standardized symptom screener scores (PHQ-9 and GAD-7). Relevant patient-level data, including demographics, clinical engagement, insurance type, clinical touchpoints, and other variables, were analyzed. Results are presented as odds ratios (ORs).
RESULTS AND CONCLUSIONS
We find that increased clinical touchpoints were associated with improved outcomes in both depression (PHQ-9) and anxiety (GAD-7) populations. Commercial insurance was linked to a greater likelihood of improvement relative to Medicaid, and the use of C-SSRS suicide screeners had varied effects on patient outcomes depending on the diagnosis. The duration of time spent in appointments showed a nuanced impact, suggesting an optimal length for touchpoints. Psychiatric consults also impact patient outcomes in both populations. This study sheds light on factors influencing patient outcomes in virtual collaborative care for depression and anxiety disorders, which may be used to inform and motivate further research and allow providers to better optimize and understand the impacts of treatment choices in collaborative care settings.
PubMed: 38948587
DOI: 10.4103/jfmpc.jfmpc_1493_23 -
Drug and Alcohol Dependence Reports Jun 2024As the US opioid-involved morbidity and mortality increase, uptake and implementation of evidence-based interventions remain key policy responses. Respond to Prevent was...
Policies, adaptations, and ongoing challenges to naloxone, buprenorphine and nonprescription syringe access across four-states: Findings from an environmental scan and key informant interviews.
BACKGROUND
As the US opioid-involved morbidity and mortality increase, uptake and implementation of evidence-based interventions remain key policy responses. Respond to Prevent was a multi-component, randomized trial implemented in four states and two large pharmacy chains with the aim of improving the pharmacy's capacity to provide naloxone, dispense buprenorphine, and sell nonprescription syringes (NPS). We sought to provide context and assess how policies and organizational practices affect communities and pharmacies across the study states.
METHODS
Using a multi-method approach we: 1) conducted an environmental scan of published literature and online materials spanning January 2015 to June 2021, 2) created timelines of key events pertaining to those policies and practices and 3) conducted semi-structured interviews with stakeholders (key informants) at the state and local levels (N=36) to provide further context for the policies and practices we discovered.
RESULTS
Key informants discussed state policies, pharmacy policies and local practices that facilitated access to naloxone, buprenorphine and NPSs. Interviewees from all states spoke about the impact of naloxone standing orders, active partnerships with community-based harm reduction organizations, and some federal and state policies like Medicaid coverage for naloxone and buprenorphine, and buprenorphine telehealth permissions as key facilitators. They also discussed patient stigma, access in rural settings, and high cost of medications as barriers.
CONCLUSION
Findings underscore the important role harm reduction-related policies play in boosting and institutionalizing interventions in communities and pharmacies while also identifying structural barriers where more focused state and local attention is needed.
PubMed: 38948428
DOI: 10.1016/j.dadr.2024.100243 -
Screening for Unhealthy Alcohol Use Among Patients With Multiple Chronic Conditions in Primary Care.AJPM Focus Aug 2024Unhealthy alcohol use increases the risk for and exacerbation of chronic health conditions. As such, screening, prevention, and management of unhealthy alcohol use is...
INTRODUCTION
Unhealthy alcohol use increases the risk for and exacerbation of chronic health conditions. As such, screening, prevention, and management of unhealthy alcohol use is especially critical to improving health outcomes for patients with multiple chronic health conditions. It is unclear to what extent multiple chronic condition status is a barrier to screening for unhealthy alcohol use in the primary care setting. The authors hypothesized that patients with multiple chronic conditions would be at lower odds of being screened for unhealthy alcohol use than patients without multiple chronic conditions.
METHODS
The authors performed a secondary analysis of electronic health record data for patients from 67 primary care practices in Virginia (2020-2023). Using the Center for Medicare and Medicaid Services' chronic disease framework, they classified patients by multiple chronic condition status: no multiple chronic conditions, physical multiple chronic conditions, mental health multiple chronic conditions, and physical and mental health multiple chronic conditions. They used multiple logistic regressions with an added practice-level random effect to analyze the relationship between multiple chronic condition status and the odds of receiving an alcohol-related assessment, of being screened for unhealthy alcohol use with a U.S. Preventive Services Task Force-recommended instrument, and of screening positive for unhealthy alcohol use within the past 2 years.
RESULTS
Within a final cohort of =11,789, a total of 6,796 patients (58%) had multiple chronic conditions (29% physical multiple chronic conditions, 4% mental health multiple chronic conditions, and 25% physical and mental health multiple chronic conditions). In all, 69% of patients were screened for unhealthy alcohol use, whereas 16% were screened with a U.S. Preventive Services Task Force-recommended instrument, and 7% screened positive for unhealthy alcohol use. Patients with physical and mental health multiple chronic conditions had 0.9 times lower odds of receiving any screening for unhealthy alcohol use than those with no multiple chronic conditions (95% CI=0.8, 1.0; =0.0240), whereas patients with only physical multiple chronic conditions or only mental health multiple chronic conditions had similar odds. There was no difference in the odds of being screened with a U.S. Preventive Services Task Force-recommended instrument on the basis of multiple chronic condition status. Patients with mental health multiple chronic conditions and physical and mental health multiple chronic conditions had 1.8 and 1.5 times greater odds of screening positive for unhealthy alcohol use, respectively (95% CI=1.3, 2.7; =0.0014 and 95% CI=1.2, 1.8; =0.0003).
CONCLUSIONS
Although patients with chronic mental health conditions were more likely to screen positive for unhealthy alcohol use than patients without multiple chronic conditions, Virginia primary care patients with physical and mental health multiple chronic conditions were less likely to receive an alcohol-related assessment during the past 2 years. Given the overall modest rate of screening with a U.S. Preventive Services Task Force-recommended instrument, further efforts are needed to create the conditions for high-quality alcohol-related preventive service delivery in primary care, particularly for patients with high complexity and/or mental health conditions.
PubMed: 38947491
DOI: 10.1016/j.focus.2024.100233 -
Annals of Surgery Jul 2024To assess the association between the Global Budget Revenue (GBR) payment model and shifts to the outpatient setting for surgical procedures among Medicare...
OBJECTIVE
To assess the association between the Global Budget Revenue (GBR) payment model and shifts to the outpatient setting for surgical procedures among Medicare fee-for-service beneficiaries in Maryland versus control states.
SUMMARY BACKGROUND DATA
The GBR model provides fixed global payments to hospitals to reduce spending growth and incentivize hospitals to reduce the costs of care while improving care quality. Since surgical care is a major contributor to hospital spending, the GBR model might accelerate the ongoing shift from the inpatient to the outpatient setting to generate additional savings.
METHODS
A difference-in-differences (DiD) design was used to compare changes in surgical care settings over time from pre-GBR (2011-2013) to post-GBR (2014-2018) for Maryland versus control states for common surgeries that could be performed in the outpatient setting. A cross-sectional approach was used to compare the difference in care settings in 2018 for total knee arthroplasty which was on Medicare's Inpatient-Only List before then.
RESULTS
We studied 47,542 surgical procedures from 44,410 beneficiaries in Maryland and control states. GBR's 2014 implementation was associated with an acceleration in the shift from inpatient to outpatient settings for surgical procedures in Maryland (DiD: 3.9 percentage points, 95% CI: 2.3, 5.4). Among patients undergoing total knee arthroplasty in 2018, the proportion of outpatient surgeries in Maryland was substantially higher than that in control states (difference: 27.6 percentage points, 95% CI: 25.6, 29.6).
CONCLUSIONS
Implementing Maryland's GBR payment model was associated with an acceleration in the shift from inpatient to outpatient hospital settings for surgical procedures.
PubMed: 38946545
DOI: 10.1097/SLA.0000000000006427 -
Journal of Addictive Diseases Jun 2024The increasing rate of Hepatitis C virus (HCV) infection has been attributed to the substance use epidemic. There is limited data on the current rates of the paralleling...
BACKGROUND
The increasing rate of Hepatitis C virus (HCV) infection has been attributed to the substance use epidemic. There is limited data on the current rates of the paralleling HCV epidemic.
OBJECTIVES
To estimate the prevalence of maternal HCV infection in West Virginia (WV) and identify contributing factors.
METHODS
Population-based retrospective cohort study of all pregnant individual(s) who gave birth in WV between 01/01/2020 to 01/30/2024 ( = 69,925). Multiple log-binomial regression models were used to estimate the adjusted risk ratio (ARR) and the 95% confidence intervals (CI).
RESULTS
The rate of maternal HCV infection was 38 per 1,000 deliveries. The mean age of pregnant individual(s) with HCV was 29.99 (SD 4.95). The risk of HCV was significantly higher in White vs. minority racial groups [ARR 1.93 (1.50, 2.49)], those with less than [ARR 1.57 (1.37, 1.79)] or at least high school [ARR 1.31 (1.17, 1.47)] vs. more than high school education, those on Medicaid [ARR 2.32 (1.99, 2.71)] vs. private health insurance, those residing in small-metro [ARR 1.32 (1.17, 1.48)] and medium-metro [ARR 1.41 (1.24, 1.61)], vs. rural areas, and those who smoked [ARR 3.51 (3.10, 3.97)]. HCV risk was highest for those using opioids [ARR 4.43 (3.95, 4.96)]; followed by stimulant use [ARR = 1.79 (1.57, 2.04)].
CONCLUSIONS
Our findings highlight that maternal age, race, education, and type of health insurance are associated with maternal HCV infection. The magnitude of association was highest for pregnant individual(s) who smoked and used opioids and stimulants during pregnancy in WV.
PubMed: 38946107
DOI: 10.1080/10550887.2024.2372484