Research Roundup - August 2017


The Doctor Will Analyze You Now: How a Health Center Successfully Integrated Care for Alaska Natives, a Potential Model for Other Systems

By Joanne Silberner | Politico | Aug. 9, 2017

The Southcentral Foundation’s NUKA Model of Care has significantly improved patient satisfaction and decreased the use of avoidable medical services by embedding treatment for mental and emotional illness into its primary care practices, reports Politico. In 2011, the Foundation was awarded the Malcolm Baldrige National Quality Award for delivering top-quality care at a lower cost than most U.S. providers. Integrative care models like the NUKA Model are increasing in popularity in response to mounting pressure to bend the healthcare cost curve, but reimbursement challenges threaten the model’s success.


CA’s Hospital Quality Institute Receives AHA’s 2017 Quality Milestone Award

By Advisory Board | Aug. 11, 2017

California’s Hospital Quality Institute was named one of the American Hospital Association’s 2017 “Stars of the Field,” according to the Advisory Board. The Hospital Quality Institute was formed by the California Hospital Association, the Hospital Council of Northern and Central California, the Hospital Association of Southern California, and the Hospital Association of San Diego and Imperial Counties. Results included a 47 percent decrease in early elective deliveries, a 34 percent decrease in obstetric trauma, and a 30 percent decrease in sepsis mortality over a five-year period.

California Demand for Primary Care Providers to Exceed Supply by 2030

Joanne Spetz, Janet Coffman and Igor Geyn | Healthforce Center at UCSF | Aug. 15, 2017

California is expected to face a statewide shortfall of primary care providers in the next 15 years, with acute shortages in the Central Valley, Central Coast and Southern Border areas, due to the uneven distribution of care across the state, according to a report by the Healthforce Center at UCSF. The study predicts mid-range shortfalls of about 4,700 primary care clinicians in 2025, and the need for about 4,100 additional providers in 2030 to meet the expected population demand. Close monitoring of the clinician supply, along with targeted efforts to recruit and retain new primary care physicians is recommended.


Rauner Names Winners in Illinois Medicaid Overhaul 

By Kristen Schorsch | Modern Healthcare | Aug. 14, 2017

The Rauner administration has awarded bids to six insurers in a quest to overhaul a major Medicaid cost-saving initiative in Illinois which will cut the number of participating carriers in half, according to a report by Modern Healthcare. In Illinois, 12 insurers currently manage the benefits for about 63 percent of Medicaid recipients, though only 9 carriers bid for contracts. Under Rauner's overhaul, 80 percent of Medicaid enrollees must choose or be assigned to a managed care plan. The new contracts are expected to save between $200 million and $300 million a year through due to cost-cutting incentives for insurers.


CMS Approves Maryland Waiver to Encourage Care Coordination

By Virgil Dickinson | Modern Healthcare | July 27, 2017

Under a new CMS waiver, Maryland hospitals and doctors can enter care-coordination partnerships and share savings stemming from more efficient treatment, according to Modern Healthcare. Sixteen hospitals will participate in the Care Redesign Program, and more will be able to join next year. In addition to allowing hospitals and doctors to share in savings, the effort will make it easier for multiple providers to access patient’s data, ensuring that all providers responsible for that person's care are aware of all treatments being received.

Maryland Seeks to Expand Hospital Cost-Control Program to Include Doctors, Other Providers

By Sarah Gantz | Baltimore Sun | Aug. 24, 2017

Maryland is seeking federal approval to expand a hospital cost-savings program to include doctors, rehabilitation facilities, skilled-nursing centers and others who treat patients insured by Medicare. According to the Baltimore Sun, the 10-year program, which would take effect in January 2019, aims to provide an incentive for health care providers to work more closely with hospitals to improve quality and reduce Medicare costs. The plan calls for Maryland to save $300 million in annual Medicare costs by the end of 2023.


MassHealth Partners with 17 Health Care Organizations to Improve Healthcare Outcomes for Members

By Massachusetts Department of Health and Human Services | Aug. 17, 2017

Seventeen healthcare organizations in Massachusetts have agreed to participate in a major restructuring of the MassHealth program, according to a press release from the state’s Department of Health and Human Services. Effective March 1, 2018, participants—including Accountable Care Organizations (ACOs), physician networks, hospitals and other community based healthcare providers—will be financially accountable for cost, quality, and patient experience of more than 850,000 MassHealth members. “Historically, MassHealth has operated under a fee-for-service model that leads to gaps in care and inefficiencies,” said the state’s Assistant Secretary and Director of the MassHealth program. “Under this new model, MassHealth will be partnering with provider organizations directly to deliver coordinated, quality care to members.”


In Ohio, Tension Brews over Who’s Funding the Opposition to a Drug Price-Control Ballot Measure

By Rebecca Robbins | Stat News | Aug. 14, 2017

A battle over high drug prices has become a battle over transparency—specifically, which drug makers are funding an effort to block a measure on the Ohio ballot this November that seeks to rein in the state’s drug prices. According to Stat News, the proposal in Ohio is similar to the one that California voters shot down last November following a huge oppositional push from drug companies; it’s even backed by the same group, the AIDS Healthcare Foundation, which runs a nonprofit network of clinics.

Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination

By Martha Hostetter, Sarah Klein, Douglas McCarthy | The Commonwealth Fund | Aug. 17, 2017

The northeast region of Ohio, centered around the city of Akron, has improved on more performance measures (19 of 33) than any other region, according to the Commonwealth Fund’sScorecard on Local Health System Performance, 2016 Edition. The region has made notable progress expanding access to care. Health systems also have strengthened primary care and improved care transitions, which may explain reductions in potentially avoidable hospitalizations and unplanned readmissions. Collaboration across health and social service sectors is a hallmark of the region, exemplified by use of a shared set of measures assessing residents’ quality of life.

Recent Reports

Americans Support Price Shopping for Healthcare, But Few Actually Seek Out Price Information

By Ateev Mehrotra, et al. | Health Affairs | August 2017

A survey of nonelderly adults who had received medical care in the previous year found that only 13 percent of respondents who had some out-of-pocket spending in their last healthcare encounter had sought out cost information, and just 3 percent had compared costs across providers before receiving care. Yet, the majority of respondents reported believing that price shopping for care is important and did not believe that higher-cost providers were of higher quality, according to the Heath Affairs study. Common barriers to shopping included difficulty obtaining price information and a desire not to disrupt existing provider relationships.

Offering a Price Transparency Tool Didn’t Reduce Spending Among CA Public Employees and Retirees

By Sunita Desai, et al. | Health Affairs | August 2017

A large insured population that was offered a price transparency tool did not spend less on shoppable services, according to this Health Affairs article. Only 12 percent of employees who were offered the tool used it in the first 15 months after it was introduced, and use of the tool was not associated with lower prices for lab tests or office visits. Though the average price paid for imaging services preceded by a price search was 14 percent lower than that paid for imaging services not preceded by a price search, only 1 percent of those who received advanced imaging actually conducted a price search. The authors conclude that simply offering a price transparency tool is not sufficient to meaningfully decrease health care prices or spending.

The Price May Not Be Right: The Value of Comparison Shopping for Prescription Drugs

By Sanjay Arora, et al. | Journal of Managed Care | July 28, 2017

Price shopping for medications within a small geographic area can yield considerable cost savings for uninsured and insured consumers in high-deductible health plans, according to this American Journal of Managed Care study. A lack of price transparency and difficulty in assessing a particular medical service’s quality are the likely reasons why the price of medical care varies so widely. This paper examines the potential benefit of comparison shopping for prescription drug prices and pharmacy characteristics that patients should consider when shopping for medications.

Association of Reference Pricing with Drug Selection and Spending

By James Robinson, Christopher M. Whaley and Timothy T. Brown | New England Journal of Medicine | August 2017

Implementation of reference pricing was associated with significant changes in drug selection and spending for a population of patients covered by employment-based insurance in the United States, according to this NEJM study. The researchers analyzed changes in prescriptions and pricing for 1302 drugs in 78 therapeutic classes in the U.S., before and after implementation of reference pricing by an alliance of private employers. During the first 18 months after implementation, spending for employers was $1.34 million lower but total copayments for employees was $0.12 million higher than in a comparison group that did not receive reference pricing.

Reference Pricing: Patient Use of Cost and Quality Data When Choosing a Joint Replacement Provider

By Ryan Kandrack, et al. | RAND Corporation | June 12, 2017

Despite growing availability of information on cost and quality, patients almost never use such information to make a decision regarding hip or knee replacement surgery, according to a report by RAND Corporation. Rather, patients focused on the choice of a surgeon as opposed to a hospital, and the surgeon choice was primarily made based on reputation. Most patients had long-standing relationships with an orthopedic surgeon and tended to stay with that surgeon for their replacement.

Characteristics of Preapproval and Postapproval Studies for Drugs Granted Accelerated Approval by the FDA

By Huseyin Naci, et al. | Journal of the American Medical Association | August 2017

When the Food and Drug Administration (FDA) uses an accelerated path to drug approvals, follow-up trials are slow and lack rigor, according to this JAMA article. Drugs treating serious or life-threatening conditions can receive FDA accelerated approval based on showing an effect in surrogate measures that are only reasonably likely to predict clinical benefit. Confirmatory trials are then required to determine whether these effects translate to clinical improvements.

Industry Payments to Physicians for Opioid Products, 2013–2015

By Scott E Hadland, Maxwell S. Krieger and Brandon D. L. Marshall | American Journal of Public Health | August 2017

One in 12 physicians received payments from opioid manufacturers during a 29-month period from 2013 to 2015, according to a study published in the American Journal of Public Health. Eighty-two percent of the payments, which totaled $46 million, were received by the top 1 percent of doctors who received payments. The study found that anesthesiologists were the primary beneficiaries of payments from opioid manufacturers.

Improving Population Health Management Strategies: Identifying Patients Who Are More Likely To Be Users of Avoidable Costly Care

By Judith H. Hibbard, et al. | Health Services Research | August 2017

Assessing patient activation may help identify patients who may become higher users of ambulatory care services and who may be more likely to have a new chronic disease diagnosis according to a study in Health Services Research. The study examined adult patients from primary care clinics who had a Patient Activation Measure in 2011 and at least one clinic visit in each of the subsequent three years. Researchers found that less activated patients had significantly higher odds of ambulatory care use compared to those with high activation scores. Accountable care organizations may be able to use these findings to identify patients that may need more support earlier, which may help these organizations reach population health  goals.

Access to SNAP Reduces Risk of Nursing Home and Hospital Admission and Cuts Costs for Seniors

By Ginger Zielinskie, et al. | Benefits Data Trust | August 2017

Providing low-income seniors access to quality food can save money by reducing the number and duration of hospital visits and nursing home admissions. A study of elderly Maryland residents found that participation in the Supplemental Nutrition Assistance Program (SNAP) reduced the odds of hospital admissions by 14 percent, the need for emergency department visits by 10 percent, and the likelihood of requiring nursing home care by nearly one quarter. Policymakers can use these findings as motivation to decrease barriers to SNAP benefits participation so that all eligible older adults can age in their community while reducing healthcare costs.

Curbing Unfair Drug Prices: A Primer for States

By Aaron Berman, et al. | Yale School of Public Health, National Physicians Alliance and Universal Health Care Foundation of Connecticut | August 2017

The Yale Global Health Justice Partnership, National Physicians Alliance and Universal Health Care Foundation of Connecticut released a report intended to promote state efforts to reduce drug prices. The report aims to identify key steps that states can and should take to reduce drug prices. The report helps inform legislators, government officials, advocates, and constituents concerned about high drug prices on two promising categories of legislative efforts: unfair pricing bills, which are intended to directly regulate drug prices or drug price increases, and transparency and reporting bills, which seek to clarify the rationale for high drug prices by requiring manufacturers to disclose information relevant to pricing decisions.  The paper makes a legal argument that states could write price gouging legislation that addresses brand name drugs, not just generics.

Telehealth Private Payer Laws: Impact and Issues

By Milbank Memorial Fund | Aug. 23, 2017

Since 2010, the number of states that have enacted legislation related to telehealth care has nearly tripled. But there has not been a comprehensive analysis of these laws or the impact they may have on expanding the use and payment for telehealth services. To further understand and assess the impact of these laws on telehealth utilization, the Milbank Memorial Fund conducted a study that assessed and described the impact of telehealth private payer laws on commercial payers and provided suggestions to improve private payer laws and their impact.

Effective Care for High-Need Patients

By Peter Long, et al. | National Academy of Medicine | July 2017

This report details the characteristics of high-need patients, the challenges they face and the features of successful care models for this population. The authors conclude that health systems should work with payers, providers and other health systems to better identify and target high-need patients, test new practices and tools and develop interactive electronic health records that can include functional and behavioral status and social needs. Further, they should use established metrics and quality improvement approaches to continuously assess and improve care models. They also should partner with community organizations, patients, caregivers and social and behavioral health service providers outside the healthcare system to create patient-centered care plans. Finally, health systems should assess their current culture and promote changes needed to build new and successful care models, blending medical, social and behavioral approaches.

The Company Behind Many Surprise Emergency Room Bills

By Julie Creswell, Reed Abelson and Margot Sanger-Katz | New York Times | July 24, 2017

A recent study by Yale researchers found that the rate of out-of-network doctor’s bills for customers of one large insurer jumped when EmCare, one of the nation’s largest physician-staffing companies for emergency departments, entered a hospital. According to this New York Times article, EmCare did not sign contracts with the insurance company and was able to charge higher prices. When emergency department doctors work for a company that has not under contract with an insurer, they are free to charge whatever they want and patients can be left with inflated bills.

Visit these pages for more information on price shopping, meeting the needs of complex patients, drug pricing, reference pricing and more


Take the Generic, Patients are Told. Until They Are Not 

By Charles Ornstein and Katie Thomas | New York Times | Aug. 6, 2017

Consumers have grown accustomed to being told by insurers, and middlemen known as pharmacy benefit managers, that they must give up their brand-name drugs in favor of cheaper generics. Now some are finding the opposite is true, as pharmaceutical companies squeeze the last profits from products that are facing cheaper generic competition, according to an article by The New York Times. Out of public view, corporations are cutting deals that give consumers little choice but to buy brand-name drugs, and sometimes pay more at the pharmacy counter than they would for generics.

Climbing Cost of Decades-Old Drugs Threatens to Break Medicaid Ban

By Sydney Lupkin | Kaiser Health News | Aug. 14, 2017

Hundreds of old, commonly used drugs cost the Medicaid program billions of extra dollars due to price increases in 2016, Kaiser Health News data analysis shows. Eighty of the drugs—some generic and some still carrying brand names—were more than two decades old. In 2016, rising costs for 313 brand-name drugs lifted Medicaid’s spending by as much as $3.2 billion over the prior year, and Medicaid spending for 67 generics and other non-branded drugs cost taxpayers an extra $258 million.

What Should We Conclude from ‘Mixed’ Results in Payment Reform Evaluations

By Len Nichols, et al. | Health Affairs Blog | Aug. 14, 2017

A review of payment reform evaluations indicates that improvement in care and cost performance takes time and that targeting key patients may be more important than building capacity to provide patient-centered care to all—as some do not need it now but will be glad the capacity exists some day. The review also found that savings may result in unexpected places (e.g., post-acute), and that care transformation while bending the cost curve is hard work and requires an up-front resource investment and a shared commitment to data sharing and incentive realignment to really take hold. The savings from these efforts, when present, are still small enough that more robust cost reduction strategies may be necessary for policy makers to achieve the goals of freezing or even reducing the share of gross domestic product devoted to healthcare in the U.S.

CMS Cancels Two Mandatory Pay Models and Scales Back a Third

By Virgil Dickson | Modern Healthcare | Aug. 15, 2017

CMS will cancel two bundled-payment models and cut down the number of providers required to participate in a third, citing providers' requests to have more input in the models' designs. According to Modern Healthcare, the number of mandatory geographic areas participating in the Comprehensive Care for Joint Replacement model will be reduced from 67 to 34. CMS also plans to cancel the Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model, which will give CMS greater flexibility to design and test innovations that will improve quality and care coordination across the inpatient and post-acute-care spectrum.

Medicare Unveils ‘Skeletal’ Site for Hospice Comparison Shopping

By Melissa Bailey | Kaiser Health News | Aug. 18, 2017

CMS recently released Hospice Compare, a consumer-focused website that lets families compare up to three hospice agencies at a time, among 3,876 nationwide. According to Kaiser Health News, the site aims to improve transparency and empower families to “take ownership of their health.” However, experts say that the self-reported quality measures that are featured on the website have limited utility.