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This Viewpoint discusses the Comprehensive Care for Joint Replacement model created by the Centers for Medicare & Medicaid Services and how it and other payment reforms can help reduce disparities in joint replacements and other high-priority conditions nationally. [ABSTRACT FROM AUTHOR]

Objective To assess whether patient choice of physician or health plan was affected by physician tier-rankings. Data Sources Administrative claims and enrollment data on 171,581 nonelderly beneficiaries enrolled in Massachusetts Group Insurance Commission health plans that include a tiered physician network and who had an office visit with a tiered physician. Study Design We estimate the impact of tier-rankings on physician market share within a plan of new patients and on the percent of a physician's patients who switch to other physicians with fixed effects regression models. The effect of tiering on consumer plan choice is estimated using logistic regression and a pre-post study design. Principal Findings Physicians in the bottom (least-preferred) tier, particularly certain specialist physicians, had lower market share of new patient visits than physicians with higher tier-rankings. Patients whose physician was in the bottom tier were more likely to switch health plans. There was no effect of tier-ranking on patients switching away from physicians whom they have seen previously. Conclusions The effect of tiering appears to be among patients who choose new physicians and at the lower end of the distribution of tiered physicians, rather than moving patients to the 'best' performers. These findings suggest strong loyalty of patients to physicians more likely to be considered their personal doctor. [ABSTRACT FROM AUTHOR]

PURPOSE We undertook a study to evaluate the effects of medical home transformation on job satisfaction in the primary care setting. METHODS We collected primary data from 20 primary care practices participating in medical home pilot projects in Rhode Island and Colorado from 2009 to 2011. We surveyed clinicians and staff about the quality of their practice environments (eg, office chaos, communication, difficulties in providing safe, high-quality care) and job satisfaction at baseline and 30 months, and about stress, burnout, and intention to leave at 30 months. We interviewed practice leaders about the impact of pilot project participation. We assessed longitudinal changes in the practice environment and job satisfaction and, in the final pilot year, examined cross-sectional associations between the practice environment and job satisfaction, stress, burnout, and intention to leave. RESULTS Between baseline and 30 months, job satisfaction improved in Rhode Island (P = .03) but not in Colorado. For both pilot projects, reported difficulties in providing safe, high-quality care decreased (P <.001), but emphasis on quality and the level of office chaos did not change significantly. In cross-sectional analyses, fewer difficulties in providing safe, high-quality care and more open communication were associated with greater job satisfaction. Greater office chaos and an emphasis on electronic information were associated with greater stress and burnout. CONCLUSIONS Medical home transformations that emphasize quality and open communication while minimizing office chaos may offer the best chances of improving job satisfaction. [ABSTRACT FROM AUTHOR]

The article discusses patient-centered medical neighborhood in the U.S. Topics covered include components of the patient-centered speciality practice (PCSP) and the patient-center medical home and the importance of the aligning payments for specialists and primary care physicians in the development of accountable care organizations and the National Committee for Quality Assurance's launch of a PCSP recognition program.

IMPORTANCE Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear. OBJECTIVE To measure associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, one of the earliest and largest multipayer medical home pilots conducted in the United States, and changes in the quality, utilization, and costs of care. DESIGN, SETTING, AND PARTICIPANTS Thirty-two volunteering primary care practices participated in the pilot (conducted from June 1, 2008, to May 31, 2011). We surveyed pilot practices to compare their structural capabilities at the pilot's beginning and end. Using claims data from 4 participating health plans, we compared changes (in each year, relative to before the intervention) in the quality, utilization, and costs of care delivered to 64 243 patients who were attributed to pilot practices and 55 959 patients attributed to 29 comparison practices (selected for size, specialty, and location similar to pilot practices) using a difference-in-differences design. EXPOSURES Pilot practices received disease registries and technical assistance and could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). MAIN OUTCOMES AND MEASURES Practice structural capabilities; performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care. RESULTS Pilot practices successfully achieved NCQA recognition and adopted new structural capabilities such as registries to identify patients overdue for chronic disease services. Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of $92 000 per primary care physician during the 3-year intervention. CONCLUSIONS AND RELEVANCE A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement. [ABSTRACT FROM AUTHOR]

This Viewpoint describes the problem of rising out-of-pocket costs for individuals with employer-sponsored insurance, the causes of this issue, and possible solutions. [ABSTRACT FROM AUTHOR]

Despite the popularity of pay-for-performance (P4P) among health policy makers and private insurers as a tool for improving quality of care, there is little empirical basis for its effectiveness. We use data from published performance reports of physician medical groups contracting with a large network HMO to compare clinical quality before and after the implementation of P4P, relative to a control group. We consider the effect of P4P on both rewarded and unrewarded dimensions of quality. In the end, we fail to find evidence that a large P4P initiative either resulted in major improvement in quality or notable disruption in care. [ABSTRACT FROM AUTHOR]

To decrease the use of oral erectile dysfunction (ED) medications, US Medicaid programmes have implemented prior authorisation (PA) and other cost-containment policies, such as increasing co-payments and restricting monthly dispensing. However, it is unclear how pharmaceutical promotional activities, such as direct-to-consumer advertising (DTCA) and physician detailing, influence the efficacy of these policies. This study sought to estimate the extent to which such policies could reduce the use of ED medication in the face of pharmaceutical promotions. It determined the dates of cost- containment policies in 35 states and the District of Columbia from 2000 through 2005, and used the generalised estimating equation to estimate the impact of pharmaceutical promotions and cost-containment policies on ED medication use. Higher spending on DTCA was associated with increased ED medication utilisation, but the impact of DTCA was less significant when PA policy was in place. The interaction between spending on detailing and PA was however significant, suggesting that higher spending on detailing significantly increases total ED medication utilisation when PA is implemented. PA and dispensing limit policies are associated with a reduction in ED medication utilisation in the Medicaid population in the presence of pharmaceutical promotions, but PA policies are less effective when the medication is heavily promoted to physicians. Policy makers should consider that cost-containment policies may be differentially sensitive to manufacturers' promotional strategies. [ABSTRACT FROM AUTHOR]

In this article, the authors express their views on issues related to health care reform in the U.S. in 2009, focusing on the effectiveness of the Prometheus Payment Model as a fee-for-service payment scheme. The health care reform is expected to promote accountability for the improvement of quality and cost control. The sustainability of the delivery structures is expected to reward medical professionals for the quality of their services.

The article presents the author's views on health care reforms that would produce lower costs to patients while providing high quality medical care. The author explores how consumer cost sharing and providing information and support for consumer decision making effect the cost and quality of care. The impact of payment incentives, public reporting of provider performance, and price increases are also discussed.

Disparities in access to and quality of health care along racial and ethnic lines are an important national problem. Health care purchasers and payers have a potentially important role to play in alleviating this problem. Using national surveys of 609 employers and 252 health plans with HMO products in 41 U.S. markets, we examined awareness of racial and ethnic disparities in health care access and quality, perceptions of employer and health plan role in addressing disparities, and reported efforts to measure and reduce disparities. Our findings suggest that most health plans and many employers are aware of the existence of substantial disparities and that health plans, but not employers, have taken steps to examine and influence patterns of care by race and ethnicity among their members. [ABSTRACT FROM AUTHOR]

The author reflects on the need for medical care payment reform in the United States. She suggests that increasing costs and the growing imbalance between primary and specialty care in the U.S. have increased the urgency of calls for fundamental reform of the health care payment system. She argues that despite the fact that several payment reform plans have been suggested, none of them are actually new and are instead only new combinations of old ideas.

The article focuses on an increase in interest which has been seen in wellness programs in the work place. A discussion of the relationship between wellness programs and the cost of health benefits in the work place is presented. The legal complications associated with wellness programs, and work place discrimination which could result from them, are discussed. U.S. federal laws which are concerned with wellness programs, including the Health Insurance Portability and Accountability Act, are examined.

We compare and contrast the labor market and distributional impact of three common approaches to state and federal health insurance expansion: public insurance expansions, refundable tax credits for low income people, and employer and individual mandates. We draw on existing estimates from the literature and individual-level data on the non-institutionalized population aged 64 and younger from the 2005 Current Population Survey to estimate how each approach affects (1) the number of people insured; (2) private and public health spending; (3) employment and wages; and (4) the distribution of subsidies across families based on income in relation to the federal poverty level and work status of adult family members. Employer mandates expand coverage to the largest number of previously insured relative to public insurance expansions and individual tax credits, but with potentially negative labor market consequences. Medicaid expansions could achieve moderate reductions in the share of the uninsured with neutral labor market consequences, and by definition, they expand coverage to the poorest groups regardless of work status. Tax credits extend coverage to relatively few uninsured, but with neutral effects on the labor market. Both Medicaid expansions and tax credits offer moderate redistribution to previously insured individuals who are poor or near-poor. None of the three policies significantly expand insurance coverage among poor working families. Our findings suggest that no single approach helps the working poor in exactly the ways policy makers might hope. To the extent that states are motivated to help the uninsured in poor working families, health reforms must find ways to include those unlikely to take up optional policies, and states must address the challenge of the many uninsured likely to be excluded from policies based on part-time work status, firm size, or immigration status. [ABSTRACT FROM AUTHOR]

The article presents information on a study which determines a new typology of organizational and contractual arrangements for the purchasing and delivery of behavioral health care. The study finds that financing and organization of mental health services in the United States has been dramatically altered in the past decade.

The release of clarified Food and Drug Administration (FDA) guidelines and independent changes in consumer behavior provide an opportunity to study the effects of direct-to-consumer advertising (DTCA) in the prescription drug market alongside the effects of various physician-oriented promotions. We examine the effects of DTCA and detailing for brands in five therapeutic classes of drugs, using monthly aggregate U.S. data from August 1996 through December 1999. In terms of impact of DTCA on demand, we provide evidence on two issues: (1) do increases in DTCA increase the market size of an entire therapeutic class? and (2) does DTCA increase within-class market share of advertised drugs? Our findings suggest that, for these classes of drugs, DTCA has been effective primarily through increasing the size of the entire class. Overall, we estimate that 13 to 22 percent of the recent growth in prescription drug spending is attributable to the effects of DTCA. [ABSTRACT FROM AUTHOR]

Analyzes the economic impacts of the master settlement agreement (MSA), under which tobacco companies in the United States agreed to compensate most states for Medicaid expenses. Changes in the volume of cigarettes consumed; Estimated MSA payments to the states; Reduction in Medicaid spending.

We estimate the increment in Massachusetts Medicaid program costs attributable to smoking from December 20, 1991 to 1998. We describe how our methods improve upon earlier estimates of analogous costs at the national level. Current costs to the Massachusetts Medicaid program approximate the payments to Massachusetts under the tobacco settlement of November 1998. Whether these payments are viewed as appropriate compensation for Medicaid costs over time depends upon the rate of increase in future health care costs, the rate of decline in smoking, the proportion of smoking that should be attributed to the actions of the tobacco companies and the likelihood the state would have prevailed at trial. The costs to the Medicaid program are dwarfed by the internal costs to smokers themselves. [ABSTRACT FROM AUTHOR]

With the Merit-Based Incentive Payment System, Medicare shifts from payment based on macroeconomic indicators to relying on physician- or group-level indicators of cost and quality--and could create a large fee differential between high- and low-performing physicians. [ABSTRACT FROM AUTHOR]

Background: Healthcare payers in the United States are increasingly tying provider payments to quality and value using pay-for-performance policies. Cost-effectiveness analysis quantifies value in healthcare but is not currently used to design or prioritize pay-for-performance strategies or metrics. Acute ischemic stroke care provides a useful application to demonstrate how simulation modeling can be used to determine cost-effective levels of financial incentives used in pay-for-performance policies and associated challenges with this approach.Methods and Results: Our framework requires a simulation model that can estimate quality-adjusted life years and costs resulting from improvements in a quality metric. A monetary level of incentives can then be back-calculated using the lifetime discounted quality-adjusted life year (which includes effectiveness of quality improvement) and cost (which includes incentive payments and cost offsets from quality improvements) outputs from the model. We applied this framework to an acute ischemic stroke microsimulation model to calculate the difference in population-level net monetary benefit (willingness-to-pay of $50 000 to $150 000/quality-adjusted life year) accrued under current Medicare policy (stroke payment not adjusted for performance) compared with various hypothetical pay-for-performance policies. Performance measurement was based on time-to-thrombolytic treatment with tPA (tissue-type plasminogen activator). Compared with current payment, equivalent population-level net monetary benefit was achieved in pay-for-performance policies with 10-minute door-to-needle time reductions (5057 more acute ischemic stroke cases/y in the 0-3-hour window) incentivized by increasing tPA payment by as much as 18% to 44% depending on willingness-to-pay for health.Conclusions: Cost-effectiveness modeling can be used to determine the upper bound of financial incentives used in pay-for-performance policies, although currently, this approach is limited due to data requirements and modeling assumptions. For tPA payments in acute ischemic stroke, our model-based results suggest financial incentives leading to a 10-minute decrease in door-to-needle time should be implemented but not exceed 18% to 44% of current tPA payment. In general, the optimal level of financial incentives will depend on willingness-to-pay for health and other modeling assumptions around parameter uncertainty and the relationship between quality improvements and long-run quality-adjusted life expectancy and costs. [ABSTRACT FROM AUTHOR]

Vertical integration in health care has recently garnered scrutiny by antitrust authorities and state regulators. We examined trends, geographic variation, and price effects of vertical integration and joint contracting between physicians and hospitals, using physician affiliations and all-payer claims data from Massachusetts from the period 2013-17. Vertical integration and joint contracting with small and medium health systems rose from 19.5 percent in 2013 to 32.8 percent in 2017 for primary care physicians and from 26.1 percent to 37.8 percent for specialists. Vertical integration and joint contracting with large health systems slightly declined, whereas geographic variation in these physician affiliations rose. We found that vertical integration and joint contracting led to price increases from 2013 to 2017, from 2.1 percent to 12.0 percent for primary care physicians and from 0.7 percent to 6.0 percent for specialists, with the greatest increases seen in large health systems. These findings can inform policy makers seeking to limit growth in health care prices. [ABSTRACT FROM AUTHOR]

Objective: To understand variation in enrollment in tiered network health plans (TNPs) and the local provider market characteristics associated with TNP penetration. Data Sources and Study Setting: We used 2013–2017 Massachusetts three‐digit ZIP code level employer‐sponsored health insurance enrollment data, data on physician horizontal and vertical affiliations from the Massachusetts Provider Database, state hospital reports in 2013, 2015, and 2017, and the 2013–2017 Massachusetts All‐Payer Claims database. Study Design: Linear regressions were used to estimate associations between TNP and local provider market characteristics. Data Extraction: We constructed measures of TNP penetration and local provider market characteristics and linked these data using three‐digit ZIP code. Principal Findings: TNP penetration was at least 10% in all employer market sectors and highest among jumbo sized employers. All state employee health plan enrollees were in a tiered network health plan. Among enrollees not in the state employee health plan, TNP penetration varied from 6.0% to 19.6% across three‐digit ZIP codes in Massachusetts. TNP penetration was higher in areas with less horizontal and vertical physician market concentration. Conclusions: Market competition, rather than the absolute quantity of physicians in an area, is associated with TNP penetration. [ABSTRACT FROM AUTHOR]

Background Disease-modifying therapies benefit individuals with relapsing forms of multiple sclerosis, but their utility remains unclear for those without relapses. Objective To determine disease-modifying therapy use and costs in 2009, compare use in 2009 and 2000, and examine compliance with evidence-based guidelines. Methods We determined the extent and characteristics of disease-modifying therapy use by participants in the Sonya Slifka Longitudinal Multiple Sclerosis Study (Slifka) in 2000 (n=2156) and 2009 (n=2361) and estimated out-of-pocket and total (payer) costs for 2009. Two multivariable logistic regressions predicted disease-modifying therapy use. Results Disease-modifying therapy use increased from 55.3% in 2000 to 61.5% in 2009. In 2009, disease-modifying therapy use was reported by 76.5% of participants with relapsing-remitting multiple sclerosis, 73.2% with progressive-relapsing multiple sclerosis, 62.5% with secondary progressive multiple sclerosis, and 41.8% with primary progressive multiple sclerosis. Use was significantly associated with relapsing-remitting multiple sclerosis, shorter duration of illness, one to two relapses per year, non-ambulatory symptoms, using a cane, younger age, higher family income, and having health insurance. Average annual costs in 2009 were US$939–3101 for patients and US$16,302–18,928 for payers. Conclusion Use rates were highest for individuals with relapsing-remitting multiple sclerosis, but substantial for those with progressive courses although clinical trials have not demonstrated significant benefits for them. [ABSTRACT FROM AUTHOR]

Background: In the United States (U.S.), large price increases for selected generic drugs have elicited public outrage. Recent legislative proposals aim to increase price transparency and identify outlier drug "price spikes." It is unknown how many and what types of products would be highlighted by such efforts. Methods: IQVIA Health Incorporated's National Sales Perspectives™ provided sales, use and price data for all generic prescription products (unique molecule-manufacturer-formulation combinations) sold in the U.S. We estimated annual prescription price levels and changes between 2013 and 2014. We identify drugs with annual prescription price increases in excess of the medical consumer price index (CPI), and in excess of 15% or 20%, per legislative proposals. We reported annualized inflation-adjusted mean, standard deviation (SD), median, and 95th percentile prescription price increases and percentage of products exceeding the growth in the medical CPI. We fitted logistic regression models to identify characteristics of drugs associated with each category of price increase. Results: We analyzed data for 6,182 generic products. The mean inflation-adjusted price increase among all generic products was 38% (SD 1,053%), the median, 2%; the 95th percentile, 135%; and the mean price level, $29.69 (SD $378.44). Approximately half of all products experienced price increases in excess of the growth in the medical CPI; 28% had price increases greater than 15% and 23% had price increases greater than 20%. Drugs exceeding outlier thresholds exhibited lower baseline price levels than the mean price level observed among all generic drugs. The most consistent characteristic predicting whether a product would exceed "price spike" thresholds proposed in legislation is the being supplied by only one manufacturer. Conclusions: "Price spikes" among generic drugs in 2014 were more common than newspaper stories and legislative hearings suggest. While the cross-sectional association between an indicator of being sold by only a single manufacturer and the probability of meeting specific price growth thresholds is suggestive of an economically intuitive causal story, future work should delve more deeply into whether decreases in generic competition explain the dramatic price increases that have captured the public's attention in recent years. [ABSTRACT FROM AUTHOR]