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Value-based payment programs adjust payments to providers based on spending, quality, or health outcomes. Concern that these programs penalize providers disproportionately serving vulnerable patients prompted calls to adjust performance measures for social risk factors. We reviewed fourteen studies of social risk adjustment in Medicare's Hospital Readmissions Reduction Program (HRRP), a value-based payment model that initially did not adjust for social risk factors but subsequently began to do so. Seven studies found that adding social risk factors to the program's base risk-adjustment model (which adjusts only for age, sex, and comorbidities) reduced differences in risk-adjusted readmissions and penalties between safety-net hospitals and other hospitals. Three studies found that peer grouping, the HRRP's current approach to social risk adjustment, reduced penalties among safety-net hospitals. Two studies found that differences in risk-adjusted readmissions and penalties were further narrowed when augmentation of the base model was combined with peer grouping. Two studies showed that it is possible to adjust for social risk factors without obscuring quality differences between hospitals. These findings support the use of social risk adjustment to improve provider payment equity and highlight opportunities to enhance social risk adjustment in value-based payment programs.

Medication nonadherence in the United States contributes to 125,000 deaths and 10% of hospitalizations annually. The pain of preventable deaths and the personal costs of nonadherence are borne disproportionately by Black, Latino, and other minority groups because nonadherence is higher in these groups due to a variety of factors. These factors include socioeconomic challenges, issues with prescription affordability and convenience of filling and refilling them, lack of access to pharmacies and primary care services, difficulty taking advantage of patient engagement opportunities, health literacy limitations, and lack of trust due to historical and structural discrimination outside of and within the medical system. Solutions to address the drivers of lower medication adherence, specifically in minority populations, are needed to improve population outcomes and reduce inequities. While various solutions have shown some traction, these solutions have tended to be challenging to scale for wider impact. We propose that integrated medical and pharmacy plans are well positioned to address racial and ethnic health disparities related to medication adherence.

BACKGROUND: Medicare Part B pharmaceutical spending has increased rapidly, more than doubling in 2006-2017. Yet, it is unclear whether this increase was driven by increased utilization or increased cost per claim. OBJECTIVE: To evaluate the relative impact of changes in drug utilization and cost per claim on changes in Medicare Part B pharmaceutical spending in 2008-2016 overall, by drug type (specialty and nonspecialty) and therapeutic category. METHODS: In this retrospective descriptive study, we extracted all claims in 2008-2016 for separately payable Part B drugs from a 5% random sample of Medicare beneficiaries. Our study included 3 outcomes calculated annually for all included drugs: (1) spending, defined as the sum of total payments; (2) utilization, defined as total number of claims; and (3) cost per claim, defined as spending divided by the number of claims. Estimates of spending and utilization were expressed per beneficiary-year. Spending and cost per claim were adjusted for inflation. For each outcome, we calculated relative changes in 2008-2016. We repeated analyses stratifying by drug type (specialty and nonspecialty) and therapeutic class. RESULTS: Pharmaceutical spending in Medicare Part B increased by 34% from 2008-2016, driven by a 53% increase in the cost per claim. Utilization decreased by 12%. Spending on specialty drugs increased by 56%, driven by a 48% increase in the cost per claim and a 6% utilization increase. Spending on nonspecialty drugs decreased by 32% driven by an 18% reduction in the cost per claim and a 17% reduction in utilization. Spending on ophthalmic preparations increased by 281%, driven by a 238% utilization increase and a 13% increase in the cost per claim. Spending on antiarthritic and immunologic agents increased by 159%, driven by a 117% increase in the cost per claim and a 19% utilization increase. CONCLUSIONS: Medicare Part B pharmaceutical spending grew in recent years, despite decreased utilization, driven by an overall increase in the cost per claim. This was a product of rising drug prices and increased utilization of more expensive specialty drugs. These findings support the development of policies that aim to spur competition and control price growth of provider-administered drugs. DISCLOSURES: The authors acknowledge funding from the Myers Family Foundation. Hernandez was funded by the National Heart, Lung and Blood Institute (grant number K01HL142847). Shrank is an employee of Humana. Good is an employee of the UPMC Health Plan Insurance Services Division. There are no other potential conflicts of interest to disclose.

Objectives To compare outcomes and costs following skilled nursing facility (SNF) discharge for patients within a Medicare Advantage (MA) organization vs traditional Medicare (TM). Study design Retrospective analysis of adults with a postacute SNF admission identified from MA claims (MA cohort: n = 56,228) and the Medicare 5% Limited Data Sets (TM cohort: n = 67,859). Methods Outcomes included hospitalization, proportion of days at home, and total medical costs during the 180 days post SNF discharge, and successful community discharge. Regression models accounted for patient characteristics and health care utilization in the 180 days prior to the proximal hospitalization and characteristics of the proximal hospitalization using backward variable selection and fixed effects for MA enrollment. To control for observable differences between individuals who selected MA vs TM, inverse probability of treatment weighting (IPTW) was conducted. Results The MA cohort was younger than the TM cohort (median age, 77 vs 81 years), more likely to have qualified for Medicare based on disability (29% vs 20%), and less likely to have dual Medicare/Medicaid eligibility (16% vs 23%). After adjustment, MA was associated with 22% decreased odds of hospitalization during the 180 days post SNF discharge, 19% increased odds of successful community discharge, a 4% increase in the proportion of days at home (equating to 6.7 additional days), and a 24% decrease in medical costs post SNF discharge. Results using IPTW were similar. Conclusions MA was associated with better outcomes and lower costs post SNF discharge, suggesting efficiencies in care for SNF patients with MA. Further research is needed to evaluate specific MA features that may lead to better value.

It is likely that 2021 will be a dynamic year for US health care policy. There is pressing need and opportunity for health reform that helps achieve better access, affordability, and equity. In this commentary, which is part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we draw on our collective backgrounds in health financing, delivery, and innovation to offer consensus-based policy recommendations focused on health costs and financing. We organize our recommendations around five policy priorities: expanding insurance coverage, accelerating the transition to value-based care, advancing home-based care, improving the affordability of drugs and other therapeutics, and developing a high-value workforce. Within each priority we provide recommendations for key elected officials and political appointees that could be used as starting points for evidence-based policy making that supports a more effective, efficient, and equitable health system in the US.

BACKGROUND: As healthcare reimbursement shifts from being volume to value-focused, new delivery models aim to coordinate care and improve quality. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. We aim to describe economic, utilization, quality, clinical, and patient satisfaction outcomes resulting from PCMH interventions operating within integrated delivery and finance systems (IDFS), government systems including Veterans Administration, and non-integrated delivery systems. METHODS: We searched PubMed, the Cochrane Library, and Embase from 2004 to 2017. Observational studies and clinical trials occurring within the USA that met PCMH criteria (as defined by the Agency for Healthcare Research and Quality), addressed ambulatory adults, and reported utilization, economic, clinical, processes and quality of care, or patient satisfaction outcomes. RESULTS: Sixty-four studies were included. Twenty-four percent were within IDFS, 29% were within government systems, and 47% were within non-IDFS. IDFS studies reported decreased emergency department use, primary care use, and cost relative to other systems after PCMH implementation. Government systems reported increased primary care use relative to other systems after PCMH implementation. Clinical outcomes, processes and quality of care, and patient satisfaction were assessed heterogeneously or infrequently. DISCUSSION: Published articles assessing PCMH interventions generally report improved outcomes related to utilization and cost. IDFS and government systems exhibit different outcomes relative to non-integrated systems, demonstrating that different health systems and populations may be particularly sensitive to PCMH interventions. Both the definition of PCMH interventions and outcomes measured are heterogeneous, limiting the ability to perform direct comparisons or meta-analysis. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05594-3) contains supplementary material, which is available to authorized users.

ImportancePayers are increasingly using approaches to risk adjustment that incorporate community-level measures of social risk with the goal of better aligning value-based payment models with improvements in health equity.ObjectiveTo examine the association between community-level social risk and health care spending and explore how incorporating community-level social risk influences risk adjustment for Medicare beneficiaries.Design, Setting, and ParticipantsUsing data from a Medicare Advantage plan linked with survey data on self-reported social needs, this cross-sectional study estimated health care spending health care spending was estimated as a function of demographics and clinical characteristics, with and without the inclusion of Area Deprivation Index (ADI), a measure of community-level social risk. The study period was January to December 2019. All analyses were conducted from December 2021 to August 2022.ExposuresCensus block group–level ADI.Main Outcomes and MeasuresRegression models estimated total health care spending in 2019 and approximated different approaches to social risk adjustment. Model performance was assessed with overall model calibration (adjusted R2) and predictive accuracy (ratio of predicted to actual spending) for subgroups of potentially vulnerable beneficiaries.ResultsAmong a final study population of 61 469 beneficiaries (mean [SD] age, 70.7 [8.9] years; 35 801 [58.2%] female; 48 514 [78.9%] White; 6680 [10.9%] with Medicare-Medicaid dual eligibility; median [IQR] ADI, 61 [42-79]), ADI was weakly correlated with self-reported social needs (r = 0.16) and explained only 0.02% of the observed variation in spending. Conditional on demographic and clinical characteristics, every percentile increase in the ADI (ie, more disadvantage) was associated with a $11.08 decrease in annual spending. Directly incorporating ADI into a risk-adjustment model that used demographics and clinical characteristics did not meaningfully improve model calibration (adjusted R2 = 7.90% vs 7.93%) and did not significantly reduce payment inequities for rural beneficiaries and those with a high burden of self-reported social needs. A postestimation adjustment of predicted spending for dual-eligible beneficiaries residing in high ADI areas also did not significantly reduce payment inequities for rural beneficiaries or beneficiaries with self-reported social needs.Conclusions and RelevanceIn this cross-sectional study of Medicare beneficiaries, the ADI explained little variation in health care spending, was negatively correlated with spending conditional on demographic and clinical characteristics, and was poorly correlated with self-reported social risk factors. This prompts caution and nuance when using community-level measures of social risk such as the ADI for social risk adjustment within Medicare value-based payment programs.

DISCLOSURES: No funding supported this commentary. The authors are employed by Humana, Inc. Shrank reports board of directors work for GetWell Network and NCQA. The other authors have nothing to di...

BACKGROUND Home health use is rising rapidly in the United States as the population ages, the prevalence of chronic disease increases, and older Americans express their desire to age at home. Enrollment in Medicare Advantage (MA) plans rather than Traditional Medicare (TM) has grown as well, from 13% of total Medicare enrollment in 2004 to 39% in 2020. Despite these shifts, little is known about outcomes and costs following home health in MA as compared with TM. OBJECTIVE The objective of this study was to measure the association of MA enrollment with outcomes and costs for patients using home health. DESIGN This was a retrospective cohort study. PARTICIPANTS Patients enrolled in plans offered by 1 large, national MA organization and patients enrolled in TM, with at least 1 home health visit between January 1, 2017, and June 30, 2018. EXPOSURE MA enrollment. MAIN MEASURES We compared the intensity of home health services and types of care delivered. The main outcome measures were hospitalization, the proportion of days in the home, and total allowed costs during the 180-day period following the first qualifying home health visit during the study period. KEY RESULTS Among patients who used home health, our models demonstrated enrollment in MA was associated with 14%, and 6% decreased odds of 60- and 180-day hospitalization, respectively, a 12.8% and 14.7% decrease in medical costs exclusive and inclusive of home health costs, respectively, and a 0.27% increase in the proportion of days at home during the 180-day follow-up, equivalent to an additional half-day at home. There were few differences in home health care delivered for MA and TM [mean number of visits in the first episode of care (17.1 vs. 17.3) and mean visits per week (3.2 vs. 3.3)]. The mean number of visits by visit type and percent of patients with each type was similar between MA and TM as well. CONCLUSIONS Compared with enrollment in TM, enrollment in MA was associated with improved patient-centered outcomes and lower cost and utilization, despite few differences in the way home health was delivered. These findings might be explained by structural components of MA that encourage better care management, but further investigation is needed to clarify the mechanisms by which MA enrollment may lead to higher value home health care.

ImportanceMedicare beneficiaries with co-occurring chronic conditions and complex care needs experience high rates of acute care utilization and poor outcomes. These patterns are well described among traditional Medicare (TM) beneficiaries, but less is known about outcomes among Medicare Advantage (MA) beneficiaries. Compared with TM, MA plans have additional levers to potentially address beneficiary needs, such as network design, care management, supplemental benefits, and value-based contracting.ObjectiveTo compare health care utilization for MA and TM beneficiaries with complex care needs.Design, Setting, and ParticipantsThis cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. Beneficiaries were segmented into the following cohorts: frail elderly, major complex chronic, and minor complex chronic. Regression models estimated the association between MA enrollment and health care utilization in 2018, using inverse probability of treatment weighting to balance the MA and TM cohorts on observable characteristics. The study period was January 1, 2017, through December 31, 2018. All analyses were conducted from December 2020 to August 2022.ExposuresEnrollment in MA vs TM.Main Outcomes and MeasuresHospital stays (inpatient admissions and observation stays), emergency department (ED) visits, and 30-day readmissions.ResultsAmong a study population of 1 844 326 Medicare beneficiaries (mean [SD] age, 75.6 [7.1] years; 1 021 479 [55.4%] women; 1 524 458 [82.7%] White; 223 377 [12.1%] with Medicare-Medicaid dual eligibility), 1 177 896 (63.9%) were enrolled in MA and 666 430 (36.1%) in TM. Beneficiary distribution across cohorts was as follows: frail elderly, 116 047 with MA (10.0% of the MA sample) and 104 036 with TM (15.6% of the TM sample); major complex chronic, 320 954 (27.2%) and 158 811 (23.8%), respectively; and minor complex chronic, 740 895 (62.9%) and 403 583 (60.6%), respectively. Beneficiaries enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions. The largest relative differences were observed for hospital stays, which ranged from −9.3% (95% CI, −10.9% to −7.7%) for the frail elderly cohort to −11.9% (95% CI, −13.2% to −10.7%) for the major complex chronic cohort.Conclusions and RelevanceIn this cross-sectional study of Medicare beneficiaries with complex care needs, those enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions than similar beneficiaries enrolled in TM, suggesting that managed care activities in MA may influence the nature and quality of care provided to these beneficiaries.

This study uses Medicare data to assess physician practice interruptions during the 2019-2020 period of the COVID-19 pandemic and provides preliminary evidence on whether those interruptions suggest early retirements or exit from medical practice.

In 2012, Medicare incorporated medication adherence targeting oral antidiabetic medications, renin-angiotensin system (RAS) antagonists, and statins as highly weighted components in its Star Ratings Program. In the same year, health plans began receiving quality bonus payments for higher star ratings.We aimed to assess how these policy changes affected adherence to targeted and other chronic disease medications in the United States.We performed interrupted time series analyses to assess monthly changes in medication adherence from 2010 to 2016 using health plans' Medicare claims submitted to a large pharmacy benefits manager. We conducted 2 sets of analyses. The first examined whether policy changes affected adherence to the 3 targeted therapy classes, and the second assessed the association between policy changes and adherence to 5 chronic disease classes not targeted by star ratings. For the second analysis, we further compared adherence between members who concomitantly used and did not use targeted medications.For star-ratings analyses, we studied 240 811 members on oral antidiabetic medications, 500 958 on RAS antagonists, and 471 135 on statins. Adherence for all star rating-targeted and nontargeted medications increased after 2012 (P.001). Oral antidiabetic, statin, and RAS antagonist adherence was, respectively, 11.2%, 3.7%, and 8.1% higher than adherence without policy changes (P.001). Nontargeted antihypertensive and antihyperlipidemic adherence trends were higher among those concomitantly on star rating-targeted medications compared with those who were not (P.001).As policy makers strive to identify optimal quality measures for improving healthcare delivery, it is important to consider that incentives can promote improved performance in both targeted measures and related outcomes.

The shift to a value-based health care system has incentivized providers to implement strategies that improve population health outcomes while minimizing downstream costs. Given their accessibility and expanded clinical care models, community pharmacists are well positioned to join interdisciplinary care teams to advance efforts in effectively managing the health of populations. In this Viewpoints article, we discuss the expanded role of community pharmacists and potential barriers limiting the uptake of these services. We then explore strategies to integrate, leverage, and sustain these services in a value-based economy. Although community pharmacists have great potential to improve population health outcomes because of their accessibility and clinical interventions that have demonstrated improved outcomes, pharmacists are not recognized as merit-based incentive eligible providers and, as a result, may be underutilized in this role. Additional barriers include lack of formal billing codes, which limits patient access to services such as hormonal contraception; fragmentation of Medicare, which prevents alignment of medical and pharmaceutical costs; and continued fee-for-service payment models, which do not incentivize quality. Despite these barriers, there are several opportunities for continued pharmacist involvement in new care models such as patient-centered medical homes (PCMH), accountable care organizations, and other value-based payment models. Community pharmacists integrated within PCMHs have demonstrated improved hemoglobin A1c, blood pressure control, and immunization rates. Likewise, other integrated, value-based models that used community pharmacists to provide medication therapy management services have reported a positive return on investment in overall health care costs. To uphold these efforts and effectively leverage community pharmacist services, we recommend the following: (a) recognition of pharmacists as providers to facilitate full participation in performance-based models, (b) increased integration of pharmacists in emerging delivery and payment models with rapid cycle testing to further clarify the role and value of pharmacists, and (c) enhanced collaborative relationships between pharmacists and other providers to improve interdisciplinary care. DISCLOSURES: This article was funded by the National Association of Chain Drug Stores. The authors have no potential conflicts of interest to report.

The approval of new oral disease-modifying drugs (DMDs), such as fingolimod, dimethyl fumarate (DMF), and teriflunamide, has considerably expanded treatment options for relapsing forms of multiple sclerosis (MS). However, data describing the use of these agents in routine clinical practice are limited.To describe time trends and identify factors associated with oral DMD treatment initiation and switching among individuals with MS.Using data from a large sample of commercially insured patients, we evaluated changes over time in the proportion of MS patients who initiated treatment with an oral DMD and who switched from an injectable DMD to an oral DMD between 2009 and 2014 in the United States. We evaluated predictors of oral DMD use using conditional logistic regression in 2 groups matched on calendar time: oral DMD initiators matched to injectable DMDs initiators and oral DMD switchers matched to those who switched to a second injectable DMD.Our cohort included 7,576 individuals who initiated a DMD and 1,342 who switched DMDs, of which oral DMDs accounted for 6% and 39%, respectively. Oral DMD initiation and switching steadily increased from 5% to 16% and 35% to 84%, respectively, between 2011 and 2014, with DMF being the most commonly used agent. Of the potential predictors with clinical significance, a recent neurologist consultation (OR = 1.60; 95% CI = 1.20-2.15) and emergency department visit (OR = 1.43; 95% CI = 1.01-2.01) were significantly associated with oral DMD initiation. History of depression was noted to be a potential predictor of oral DMD initiation; however, the estimate for this predictor did not reach statistical significance (OR = 1.35; 95% CI = 0.99-1.84). No clinically relevant factors measured in our data were associated with switching to an oral DMD.Oral DMDs were found to be routinely used as second-line treatment. However, we identified few factors predictive of oral DMD initiation or switching, which implies that their selection is driven by patient and/or physician preferences.This study was funded by CVS Caremark through an unrestricted research grant to Brigham and Women's Hospital. Shrank and Matlin were employees of, and shareholders in, CVS Health at the time of the study; they report no financial interests in products or services that are related to the subject of this study. Spettell is an employee of, and shareholder in, Aetna. Chitnis serves on clinical trial advisory boards for Novartis and Genzyme-Sanofi; has consulted for Bayer, Biogen Idec, Celgene, Novartis, Merck-Serono, and Genentech-Roche; and has received research support from NIH, National Multiple Sclerosis Society, Peabody Foundation, Consortium for MS Centers, Guthy Jackson Charitable Foundation, EMD-Serono, Novartis Biogen, and Verily. Desai reports receiving a research grant from Merck for unrelated work. Gagne is principal investigator of a research grant from Novartis Pharmaceuticals Corporation to the Brigham and Women's Hospital and has received grant support from Eli Lilly, all for unrelated work. He is also a consultant to Aetion and Optum. Minden reports grants from Biogen and other fees from Genentech, EMD Serano, Avanir, and Novartis, unrelated to this study. The other authors have no conflicts to report. This study was presented as a poster at the International Society for Pharmacoepidemiology 32nd Annual Meeting; August 25-28, 2016; Dublin, Ireland.

It is unknown to what extent rising drug costs are due to inflation in the prices of existing drugs versus the entry of new products. We used pricing data from First Databank and pharmacy claims from UPMC Health Plan to quantify the contribution of new versus existing drugs to the changes in costs of oral and injectable drugs used in the outpatient setting in 2008-16. The costs of oral and injectable brand-name drugs increased annually by 9.2 percent and 15.1 percent, respectively, largely driven by existing drugs. For oral and injectable specialty drugs, costs increased 20.6 percent and 12.5 percent, respectively, with 71.1 percent and 52.4 percent of these increases attributable to new drugs. Costs of oral and injectable generics increased by 4.4 percent and 7.3 percent, respectively, driven by new drug entry. The rising costs of generic and specialty drugs were mostly driven by new product entry, whereas the rising costs of brand-name drugs were due to existing drug price inflation.

Low-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care.To compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care.This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022.Enrollment in MA vs TM.Low-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries.Among a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements.In this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.

There is increased focus on identifying and addressing health-related social needs (HRSNs). Understanding how different HRSNs relate to different health outcomes can inform targeted, evidence-based policies, investments, and innovations to address HRSNs.To examine the association between self-reported HRSNs and acute care utilization among older adults enrolled in Medicare Advantage.This cross-sectional study used data from a large, national survey of Medicare Advantage beneficiaries to identify the presence of HRSNs. Survey data were linked to medical claims, and regression models were used to estimate the association between HRSNs and rates of acute care utilization from January 1, 2019, through December 31, 2019.Self-reported HRSNs, including food insecurity, financial strain, loneliness, unreliable transportation, utility insecurity, housing insecurity, and poor housing quality.All-cause hospital stays (inpatient admissions and observation stays), avoidable hospital stays, all-cause emergency department (ED) visits, avoidable ED visits, and 30-day readmissions.Among a final study population of 56 155 Medicare Advantage beneficiaries (mean [SD] age, 74.0 [5.8] years; 32 779 [58.4%] women; 44 278 [78.8%] White; and 7634 [13.6%] dual eligible for Medicaid), 27 676 (49.3%) reported 1 or more HRSNs. Health-related social needs were associated with statistically significantly higher rates of all utilization measures, with the largest association observed for avoidable hospital stays (incident rate ratio for any HRSN, 1.53; 95% CI, 1.35-1.74;In this cross-sectional study of older adults enrolled in Medicare Advantage, self-reported HRSNs were common and associated with statistically significantly increased rates of acute care utilization, with variation in which HRSNs were associated with different utilization measures. These findings provide evidence of the unique association between certain HRSNs and different types of acute care utilization, which could help refine the development and targeting of efforts to address HRSNs.

Health plans and risk-bearing provider organizations seek information sources to inform proactive interventions for patients at risk of adverse health events. Interventions should take into account the strong relationship between social context and health. This retrospective cohort study of a Medicare Advantage population examined whether a change in self-reported health-related quality of life (HRQOL) signals a subsequent change in healthcare needs.A retrospective longitudinal analysis of administrative claims data was conducted for participants in a Medicare Advantage plan with prescription drug coverage (MAPD) who responded to 2 administrations of the Centers for Disease Control and Prevention 4-item Healthy Days survey within 6-18 months during 2015-2018. Changes in HRQOL, as measured by the Healthy Days instrument, were compared with changes in utilization and costs, which were considered to be a reflection of change in healthcare needs.A total of 48,841 individuals met inclusion criteria. Declining HRQOL was followed by increases in utilization and costs. An adjusted analysis showed that every additional unhealthy day reported one year after baseline was accompanied by an $8 increase in monthly healthcare costs in the subsequent six months for the average patient.Declining HRQOL signaled subsequent increases in healthcare needs and utilization.Findings suggest that HRQOL assessments in general, and the Healthy Days instrument in particular, could serve as a leading indicator of the need for interventions designed to mitigate poor health outcomes and rising healthcare costs.III.

It is likely that 2021 will be a dynamic year for US health care policy. There is pressing need and opportunity for health reform that helps achieve better access, affordability, and equity. In this commentary, which is part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we draw on our collective backgrounds in health financing, delivery, and innovation to offer consensus-based policy recommendations focused on health costs and financing. We organize our recommendations around five policy priorities: expanding insurance coverage, accelerating the transition to value-based care, advancing home-based care, improving the affordability of drugs and other therapeutics, and developing a high-value workforce. Within each priority we provide recommendations for key elected officials and political appointees that could be used as starting points for evidence-based policy making that supports a more effective, efficient, and equitable health system in the US.

OBJECTIVE: To review the evidence of the association between performance in eight indicators of diabetes care and a patient's race/ethnicity and socioeconomic characteristics. DATA SOURCE: Studies of adult patients with type 2 diabetes in MEDLINE published between January 1, 2000, and December 31, 2018. STUDY DESIGN: Systematic review and meta‐analysis of regression‐based studies including race/ethnicity and income or education as explanatory variables. Meta‐analysis was used to quantify differences in performance associated with patient race/ethnicity or socioeconomic characteristics. The systematic review was used to identify potential mechanisms of disparities. DATA COLLECTION: Two coauthors separately conducted abstract screening, study exclusions, data extraction, and scoring of retained studies. Estimates in retained studies were extracted and, where applicable, were standardized and converted to odds ratios and standard errors. PRINCIPAL FINDINGS: Performance in intermediate outcomes and process measures frequently exhibited differences by race/ethnicity even after adjustment for socioeconomic, lifestyle, and health factors. Meta‐analyses showed black patients had lower odds of HbA1c and blood pressure (BP) control (OR range: 0.67‐0.68, P

Clinical and Social Risk Adjustment Adopting methods that account for all factors that influence patients’ risk, and those factors’ interdependence, could help create a more equitable health care p...

Background We studied whether integrating the US Department of Health and Human Services’ myHealthfinder tool, an interactive tool that recommends preventive services, into CVS Health's digital platforms could increase preventive service uptake at its retail clinic, MinuteClinic. Methods We used a quasi-experimental, pre-post, difference-in-differences design. In a web-based campaign, consumers in “exposed” states visiting CVS pharmacy and MinuteClinic websites could view and use the myHealthfinder tool. Consumers in “unexposed” states could not. A September 26, 2015 email campaign to registered MinuteClinic patients in exposed states described and included links to the myhealthfinder tool. We assessed consumer engagement with the myHealthfinder tool via number of website visits, myHealthfinder sessions, and myHealthfinder recommendations delivered. Using the difference-in-differences approach, we assessed mean changes in influenza, pneumococcal, and/or hepatitis A vaccine uptake, as well as other preventive services, per clinic, per month at MinuteClinics. Results In exposed states, 39,225 (1.6%) website visits included myhealthfinder use, and 13,688 personalized recommendations for preventive services were delivered. The web-based campaign was associated with an increase in mean pneumococcal vaccines (1.19 vaccines per clinic per month; 95% CI, 0.11–2.28). The email campaign resulted in a 5% increase in influenza vaccines (74.83 vaccines per clinic per month; 1.65–148.02). The myhealthfinder campaigns did not significantly change preventive service uptake for any of the other services at MinuteClinics. Conclusions Our findings highlight the potential role of personalized patient education tools and public-private partnerships to communicate about preventive care. Getting patients to act on these recommendations was more difficult.

Efforts at predicting long-term adherence to medications have been focused on patients filling typical month-long supplies of medication. However, prediction remains difficult for patients filling longer initial supplies, a practice that is becoming increasingly common as a method to enhance medication adherence.To (a) extend methods involving short-term filling behaviors and (b) develop novel variables to predict adherence in a cohort of patients receiving longer initial prescriptions.In this retrospective cohort study, we used claims from a large national insurer to identify patients initiating a 90-day supply of oral medications for diabetes, hypertension, and hyperlipidemia (i.e., statins). Patients were included in the cohort if they had continuous database enrollment in the 180 days before and 365 days after medication initiation. Adherence was measured in the subsequent 12 months using the proportion of days covered metric. In total, 125 demographic, clinical, and medication characteristics at baseline and in the first 30-120 days after initiation were used to predict adherence using logistic regression models. We used 10-fold cross-validation to assess predictive accuracy by discrimination (c-statistic) measures.In total, 32,249 patients met the inclusion criteria, including 14,930 patients initiating statins, 12,887 patients initiating antihypertensives, and 4,432 patients initiating oral hypoglycemics. Prediction using only baseline variables was relatively poor (cross-validated c-statistic = 0.644). Including indicators of acute clinical conditions, health resource utilization, and short-term medication filling in the first 120 days greatly improved predictive ability (0.823). A model that incorporated all baseline characteristics and predictors within the first 120 days after medication initiation more accurately predicted future adherence (0.832). The best performing model that included all 125 baseline and postbaseline characteristics had strong predictive ability (0.837), suggesting the utility of measuring these novel postbaseline variables in this population.We demonstrate that long-term, 12-month adherence in patients filling longer supplies of medication can be strongly predicted using a combination of clinical, health resource utilization, and medication filling characteristics before and after treatment initiation.This work was supported by an unrestricted grant from CVS Health to Brigham and Women's Hospital. Shrank and Matlin were employees and shareholders at CVS Health at the time of this study; they report no financial interests in products or services that are related to this subject. Spettell is an employee of, and shareholder in, Aetna. This research was previously presented at the 2016 Annual Conference of the International Society for Pharmacoepidemiology; August 25-28, 2016; Dublin, Ireland.

Key Points Question Are food insecurity interventions associated with improvements in food insecurity status, health outcomes, or health care utilization? Findings In this systematic review and meta-analysis of 39 randomized and observational studies, including 170 605 participants, direct provision of food and monetary assistance were associated with statistically significant reductions in the prevalence of food insecurity. Health and health care utilization outcomes were reported in less than half of studies with mixed results that were not statistically significant in pooled analyses. Meaning For individuals with food insecurity, interventions that directly address their needs with food or monetary assistance are associated with improvements in food insecurity status, but further work is needed to understand the association with health outcomes and health care utilization., Importance Inadequate access to food is a risk factor for poor health and the effectiveness of federal programs targeting food insecurity, such as the Supplemental Nutrition Assistance Program (SNAP), are well-documented. The associations between other types of interventions to provide adequate food access and food insecurity status, health outcomes, and health care utilization, however, are unclear. Objective To review evidence on the association between food insecurity interventions and food insecurity status, clinically-relevant health outcomes, and health care utilization among adults, excluding SNAP. Data Sources A systematic search for English-language literature was performed in PubMed Central and Cochrane Trials databases (inception to January 23, 2020), the Social Interventions Research and Evaluation Network database (December 10, 2019); and the gray literature using Google (February 1, 2021). Study Selection Studies of any design that assessed the association between food insecurity interventions for adult participants and food insecurity status, health outcomes, and health care utilization were screened for inclusion. Studies of interventions that described addressing participants’ food needs or reporting food insecurity as an outcome were included. Interventions were categorized as home-delivered food, food offered at a secondary site, monetary assistance in the form of subsidies or income supplements, food desert interventions, and miscellaneous. Data Extraction and Synthesis Data extraction was performed independently by 3 reviewers. Study quality was assessed using the Cochrane Risk of Bias Tool, the ROBINS-I (Risk of Bias in Non-Randomized Studies of Interventions) tool, and a modified version of the National Institutes of Health’s Quality Assessment Tool for Before-After Studies With No Control. The certainty of evidence was based on GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria and supplemented with mechanistic and parallel evidence. For outcomes within intervention categories with at least 3 studies, random effects meta-analysis was performed. Main Outcomes and Measures Food insecurity (measured through surveys; eg, the 2-item Hunger Vital Sign), health outcomes (eg, hemoglobin A1c), and health care utilization (eg, hospitalizations, costs). Results A total of 39 studies comprising 170 605 participants were included (8 randomized clinical trials and 31 observational studies). Of these, 14 studies provided high-certainty evidence of an association between offering food and reduced food insecurity (pooled random effects; adjusted odds ratio, 0.53; 95% CI, 0.33-0.67). Ten studies provided moderate-certainty evidence of an association between offering monetary assistance and reduced food insecurity (pooled random effects; adjusted odds ratio, 0.64; 95% CI, 0.49-0.84). There were fewer studies of the associations between interventions and health outcomes or health care utilization, and the evidence in these areas was of low or very low certainty that any food insecurity interventions were associated with changes in either. Conclusions and Relevance This systematic review with meta-analysis found that providing food and monetary assistance was associated with improved food insecurity measures; however, whether it translated to better health outcomes or reduced health care utilization was unclear., This systematic review with meta-analysis examines 39 randomized and observational studies for associations between food insecurity interventions and insecurity status, health outcomes, and health care use among adults.

Americans are increasingly demanding the same level of service in healthcare that they receive in other services and products that they buy. This rise in consumerism poses challenges for primary care physicians as they attempt to transform their practices to succeed in a value-based reimbursement landscape, where they are rewarded for managing costs and improving the health of populations. In this paper, three examples of consumer-riven trends are described: retail healthcare, direct and concierge care, and home-based diagnostics and care. For each, the intersection of consumer-driven care and the goals of value-based primary care are explored. If the correct payment and connectivity enablers are in place, some examples of consumer-driven care are well-positioned to support primary care physicians in their mission to deliver high-quality, efficient care for the populations they serve. However, concerns about access and equity make other trends less consistent with that mission.

To mark the 25th anniversary of the journal, each issue in 2020 will include an interview with a health care thought leader. The November issue features a conversation with William H. Shrank, MD, MSHS, chief medical officer of Humana.

National-level demonstration projects and real-world studies continue to inform health care transformation efforts and catalyze implementation of value-based service delivery and payment models, though evidence generation and diffusion of learnings often occurs at a relatively slow pace. Rapid-cycle learning models, however, can help individual organizations to more quickly adapt health care innovations to meet the challenges and demands of a rapidly changing health care landscape. Integrated delivery and financing systems (IDFSs) offer a unique platform for rapid-cycle learning and innovation. Since both the provider and payer benefit from delivering care that enhances the patient experience, improves quality, and reduces cost, incentives are aligned to experiment with value-based models, enhance learning about what works and why, and contribute to solutions that can accelerate transformation. In this article, we describe how the UPMC Insurance Services Division, as part of a large IDFS, uses its Business, Innovation, Learning, and Dissemination (BuILD) model to prioritize, design, test, and refine health care innovations and accelerate learning. We provide examples of how the BuILD model offers an approach for quickly assessing the impact and value of health care transformation efforts. Lessons learned through the BuILD process will offer insights and guidance for a wide range of stakeholders whether an IDFS or independent payer-provider collaborators.

The call for value-based medicine has augmented the role of primary care physicians, potentially exacerbating the already-acknowledged shortage of primary care physicians in the current delivery landscape. Lifetime earnings for primary care physicians are millions lower than those for other specialties, and the burden of medical school debt is increasing at a rate that outpaces inflation. Given the societal value of primary care entry for newly minted physicians, one option is a loan repayment program that shares some of that societal value with the physicians themselves, essentially a subsidy that is continuous and tied to present-day specialty choice. While income-based options exist currently, these are merely a proxy for specialty, and other service-driven options are finite and may impose undue burden on physicians at an early and pressure-laden time in their careers. Value-based repayment reflects the graduate's benefit from physician training while also rewarding the real-time societal value of specialties such as primary care, allowing doctors to put their talents to their best uses while advancing the transformation of the physician workforce necessary to realize value-based, patient-centered, population-oriented care.

Physician satisfaction is associated with patient satisfaction, adherence to treatment recommendations, and quality. However, burnout is prevalent, and physician experience with health plans is likely a key contributor. We explored physician satisfaction with health plans and assessed physician and plan characteristics associated with greater satisfaction.Cross-sectional analysis of physician satisfaction surveys for US health plans in 2016.We assessed the association between health plan/physician characteristics and physician satisfaction domains using multivariable linear regression. The following satisfaction domains were outcomes of interest, measured by 5-point Likert scales: overall health plan rating, finance, utilization/quality management, network/care coordination, pharmacy, call center, provider relations, and recommendation of the plan to others' practices.We analyzed surveys from 3158 physicians on 74 health plans, representing a 12.6% response rate. We observed highest satisfaction in overall plan rating, finance, and call center domains (adjusted means = 3.25) and lowest satisfaction in the pharmacy domain (adjusted mean = 3.02). The largest and smallest plans and vertically integrated plans had the highest satisfaction; 76% and 66% of physicians recommended vertically integrated plans and non-vertically integrated plans, respectively, to others (P.001). Solo practitioners rated overall plan rating, finance, utilization/quality management, and pharmacy domains more favorably than did physicians in larger practices, whereas primary care physicians rated overall plan rating, finance, and utilization/quality management more favorably than did specialists.Our findings demonstrate opportunity to improve physician satisfaction with health plans, specifically in pharmacy/formulary management. As provider satisfaction is increasingly recognized as a critical outcome, our findings highlight intervention targets.

Value-based contracts link medication payments to performance measures with the ultimate goal of lowering costs while improving patient outcomes. Previous multiple sclerosis (MS) value-based contracts have focused on indicators easily collected from claims or electronic health record data as their value-based outcomes, even though numerous other MS clinical indicators of interest exist. Uncertainty remains regarding which MS indicators are most meaningful to all stakeholders affected by a value-based contract.To identify meaningful MS indicators among key stakeholders for the purpose of informing a value-based contract for MS medications.Using a modified Delphi method, we surveyed 26 diverse stakeholders, including 8 patients and caregivers; 9 providers (neurologists, nurses, physician assistants, and specialty pharmacists); 2 pharmaceutical company representatives; 5 payers; and 2 pharmacy benefits managers. A list of 12 MS indicators was created from subject matter expert consultation and a literature review. All stakeholders reported on the meaningfulness and value of these 12 indicators through a 5-point Likert scale and forced selection of the 3 most meaningful indicators. All nonpatient stakeholders were additionally surveyed on collection feasibility of the same 12 indicators using a 5-point Likert scale. We defined consensus as ≥ 75% agreement on the meaningfulness and feasibility of an indicator (Likert scores 4 or 5). We performed a Fisher's exact test to assess differences between nonpatient and patient stakeholder rankings of indicators.Consensus was reached for at least 1 indicator for all questions after 2 rounds. "Worsening physical disability" and "functional impairment" achieved 92% agreement on a Likert-scale question assessing indicator value, and 100% of participants selected "worsening physical disability" when asked to choose the 3 most meaningful indicators. "MS flares requiring an emergency department visit" and "MS flares requiring inpatient admission" were rated as the 2 most feasibly collected indicators (both received 89% agreement).Using the Delphi method, we identified that disability and functional impairment are meaningful MS indicators to diverse stakeholders. These findings support the incorporation of important patient-reported outcomes into value-based contracts for MS medications.This study was supported by a grant from Express Scripts Holding Company, which provided research funding to the UPMC Center for Value-Based Pharmacy Initiatives for work on this study. Swart, Neilson, Good, and Parekh are employed by the UPMC Center for Value-Based Pharmacy Initiatives. Manolis is the Chief Pharmacy Officer of UPMC Health Plan, and Shrank was the Chief Medical Officer of UPMC Insurance Services Division at the time of this study. Henderson is employed by Express Scripts Holding Company.

Background Chronic disease represents a significant burden to the United States (US) health care system, with approximately 50% of all adults in the US having one or more chronic disease conditions. Pharmacist-led chronic disease management interventions are of special interest since 80% of medical treatments involve the use of prescription drugs. Moreover, community pharmacists are among the most accessible health care professionals to provide care for populations with chronic diseases. The impact of care provided by community pharmacists isn't well defined, with interventions taking on diverse forms with varied effects on outcomes. Objective The purpose of this review is to summarize evidence from secondary literature on community pharmacist-led chronic disease management interventions and the impact on clinical, utilization, and economic outcomes. Methods We conducted a systematic search of systematic reviews, meta-analyses, and narrative reviews using MEDLINE via PubMed, EMBASE.com and Cochrane Library databases published between January 1, 2007 and October 17, 2017. The following data were extracted: citation details, review type, number of primary studies included, disease state, description of the intervention, outcomes assessed, and results. Results Our search strategy retrieved 2296 titles and abstracts of which 15 references met our inclusion criteria. Selected articles covered 7 main diseases —diabetes, asthma, chronic obstructive pulmonary disease (COPD), hypertension, heart failure, hyperlipidemia, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Community pharmacist-led interventions mostly consisted of patient consultations and education. In diabetes, interventions achieved significant reductions in hemoglobin A1c, total cholesterol, and low-density lipoprotein (LDL). Reviews also reported favorable reductions in blood pressure, improved medication adherence and reduced readmission rates in patients with heart failure, improved lung function in patients with respiratory conditions, and increased medication adherence in those with HIV/AIDs. Literature reporting economic and utilization outcomes were limited and mostly focused on pharmacy interventions in diabetes. In some cases, community pharmacy services demonstrated a decrease in medical and health care costs in patients with diabetes. Conclusion We found that community pharmacists can improve clinical outcomes in a wide array of chronic diseases, including diabetes, hyperlipidemia, HIV/AIDS, cardiovascular and respiratory diseases. More robust studies are needed to further assess the impact of specific interventions on economic and utilization outcomes.

Value-based contracts (VBCs) between payers and pharmaceutical manufacturers link drug payments to predefined performance measures and require shared risk between both entities. It is unclear how outcome measures were selected in previously reported VBCs, and many VBCs have focused on surrogate endpoints often used in the conduct of clinical trials, which may not be valued by or of importance to patients.To identify outcome measures that are meaningful to key stakeholders and feasibly measured to inform VBCs for diabetes medications.We conducted a modified Delphi survey to incorporate views from patients (n = 9), endocrinologists (n = 5), primary care physicians (n = 4), payers (n = 3), pharmacy benefit managers (n = 3), and pharmaceutical company representatives (n = 2). A list of 12 diabetes-related outcome measures was generated from the literature and consultations with subject matter experts. Participants rated the importance of each outcome on a 5-point Likert scale and selected the 3 most meaningful outcomes. Nonpatient participants then used a Likert scale to rate the feasibility of collecting each outcome. Consensus was defined as ≥ 75% agreement on the importance and feasibility of an outcome (Likert scores 4 or 5 or selection of an outcome as most meaningful). A 2-sample test of proportions was performed to examine differences between patient and nonpatient stakeholder rankings of outcomes.All 12 outcomes reached consensus for importance on the Likert scale. The measure "reducing risk of heart attacks" was the most meaningful outcome (84%), while "reducing A1c levels" ranked second (68%). The 2 measures rated as most feasibly collected were "reducing A1c levels" and "reducing risk of hospitalizations from diabetes" (93.8% each). The measures "weight loss," "reducing risk of diabetes-related kidney disease," "reducing risk of emergency room visits from diabetes," and "reducing risk of diabetes-related amputations and foot ulcers" also reached consensus for feasibility. There were statistically significant differences between patient and nonpatient stakeholders in the selection of "reducing A1c levels" (37.5% vs. 82.3%, respectively; P = 0.03) and "reducing risk of diabetes-related kidney disease" (50.0% vs. 11.8%, respectively; P = 0.03) as most meaningful outcomes.The measures "reducing risk of heart attacks" and "reducing A1c levels" were identified as top priority diabetes outcome measures.Express Scripts provided research funding for this study to the UPMC Center for Value-Based Pharmacy Initiatives. Henderson is employed by Express Scripts and was involved in the conception and design of the study and manuscript approval. The other authors are employed by the UPMC Center for Value-Based Pharmacy Initiatives and have nothing to disclose.

Polypharmacy has been linked to adverse outcomes including increased risk of hospitalization, falls, and death and contributes to unnecessary healthcare spending. Deprescribing efforts aim to reduce medication burden while improving or maintaining patients' quality of life. While the practice of deprescribing is gaining momentum, quality measurement and provider reimbursement are barriers that must be addressed for deprescribing to achieve widespread adoption. Because many quality measures are focused on medication use and adherence, deprescribing efforts may negatively impact primary care provider and health plan quality ratings and value-based reimbursement. In addressing this conflict, there are opportunities to proactively align the priorities and incentives of patients, providers, and plans to promote deprescribing. In this report, we propose several actionable steps to address quality and reimbursement-based barriers such as facilitating the exclusion of those engaged in deprescribing efforts from quality measures and the development of deprescribing-based quality measures.

Medication adherence is associated with lower health care utilization and savings in specific patient populations; however, few empirical estimates exist at the population level.The main objective of this study was to apply a data-driven approach to obtain population-level estimates of the impact of medication nonadherence among Medicare beneficiaries with chronic conditions.Medicare fee-for-service (FFS) claims data were used to calculate the prevalence of medication nonadherence among individuals with diabetes, heart failure, hypertension, and hyperlipidemia. Per person estimates of avoidable health care utilization and spending associated with medication adherence, adjusted for healthy adherer effects, from prior literature were applied to the number of nonadherent Medicare beneficiaries.A 20% random sample of community-dwelling, continuously enrolled Medicare FFS beneficiaries aged 65 years or older with Part D (N=14,657,735) in 2013.Avoidable health care costs and hospital use from medication nonadherence.Medication nonadherence for diabetes, heart failure, hyperlipidemia, and hypertension resulted in billions of Medicare FFS expenditures, millions in hospital days, and thousands of emergency department visits that could have been avoided. If the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, with over 100,000 emergency department visits and 7 million inpatient hospital days that could be averted.Medication nonadherence places a large resource burden on the Medicare FFS program. Study results provide actionable information for policymakers considering programs to manage chronic conditions. Caution should be used in summing estimates across disease groups, assuming all nonadherent beneficiaries could become adherent, and applying estimates beyond the Medicare FFS population.