Whaley C, Sood S, Chernew M, Vu L, Metcalfe L, and Mehrotra A. 3/2019. “
Paying Patients to Switch: Impact of a Rewards Program on Choice of Providers, Prices, and Utilization.” Health Aff (Millwood) , 38, 3, Pp. 440-447.
Abstract
Employers and insurers are experimenting with benefit strategies that encourage patients to switch to lower-price providers. One increasingly popular strategy is to financially reward patients who receive care from such providers. We evaluated the impact of a rewards programimplemented in 2017 by twenty-nine employers with 269,875 eligible employees and dependents. For 131 elective services, patients who received care from a designated lower-price provider received a check ranging from $25 to $500, depending on the provider's price and service. In the first twelve months of the program we found a 2.1 percent reduction in prices paid for services targeted by the rewardsprogram. The reductions in price resulted in savings of $2.3 million, or roughly $8 per person, per year. These effects were primarily seen in magnetic resonance imaging and ultrasounds, with no observed price reduction among surgical procedures.
Gourevitch RA, Mehrotra A, Galvin G, Plough AC, and Shah NT. 2/1/2019. “
Does comparing cesarean delivery rates influence women's choice of obstetric hospital?” AM J Manag Care , 25, 2, Pp. e33-e38.
AbstractOBJECTIVES:
Despite public reporting of wide variation in hospital cesarean delivery rates, few women access this information when deciding where to deliver. We hypothesized that making cesarean delivery rate data more easily accessible and understandable would increase the likelihood of women selecting a hospital with a low cesarean delivery rate.
STUDY DESIGN:
We conducted a randomized controlled trial of 18,293 users of the Ovia Health mobile apps in 2016-2017. All enrollees were given an explanation of cesarean delivery rate data, and those randomized to the intervention group were also given an interactive tool that presented those data for the 10 closest hospitals with obstetric services. Our outcome measures were enrollees' self-reported deliveryhospital and views on cesarean delivery rates.
METHODS:
Intent-to-treat analysis using 2-sided Pearson's χ2 tests.
RESULTS:
There was no significant difference across the experimental groups in the proportion of women who selected hospitals with low cesarean delivery rates (7.0% control vs 6.8% intervention; P = .54). Women in the intervention group were more likely to believe that hospitals in their community had differing cesarean delivery rates (66.9% vs 55.9%; P <.001) and to report that they looked at cesareandelivery rates when choosing their hospital (44.5% vs 33.9%; P <.001).
CONCLUSIONS:
Providing women with an interactive tool to compare cesarean delivery rates across hospitals in their community improved women's familiarity with variation in cesarean delivery rates but did not increase their likelihood of selecting hospitals with lower rates.
Sinaiko A and Mehrotra A. 2/2019. “
Why Aren’t More Employers Implementing Reference-Based Pricing Benefit Design?” American Journal of Managed Care , 25, 2, Pp. 85-88.
AbstractOBJECTIVES:
There is robust evidence that implementation of reference-based pricing (RBP) benefit design decreases spending. This paper investigates employer adoption of RBP as a strategy to improve the value of patients' healthcare choices, as well as facilitators and barriers to the adoption of RBP by employers.
STUDY DESIGN:
We conducted a qualitative study using 12 in-depth interviews with human resources executives or their representatives at large- or medium-sized self-insured employers.
METHODS:
Interviews were conducted and recorded over the phone between March 2017 and May 2017. Interviewees were asked about their adoption of RBP and facilitators and barriers to adoption. We applied thematic analysis to the transcripts.
RESULTS:
Despite broad employer awareness of RBP's potential for cost savings, few employers are including RBP in their benefit design. The major barriers to RBP adoption were the complexity of RBP benefit design, concern that employees could face catastrophic out-of-pocket costs, lack of a business case for implementation, and concern that RBP could hurt the employer's competitiveness in the labor market. The few employers that have adopted RBP have implemented extensive, year-round employee education campaigns and invested in multipronged and proactive decision support to help employees navigate their choices.
CONCLUSIONS:
Unless several fundamental barriers are addressed, uptake of RBP will likely continue to be low. Our findings suggest that simplifying benefit design, providing employees protection against very high out-of-pocket costs, understanding which decision-support strategies are most effective, and enhancing the business case could facilitate wider employer adoption of RBP.
Barnett Ml, Wilcock A, McWilliams JM, Epstein AM, Joynt Maddox KE, Orav EJ, Grabowski DC, and Mehrotra A. 1/17/2019. “
Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement.” N Engl J Med , 380, 3, Pp. 252-262.
AbstractBACKGROUND:
In 2016, Medicare implemented Comprehensive Care for Joint Replacement (CJR), a national mandatory bundled-payment model for hip or knee replacement in randomly selected metropolitan statistical areas. Hospitals in such areas receive bonuses or pay penalties based on Medicare spending per hip- or knee-replacement episode (defined as the hospitalization plus 90 days after discharge).
METHODS:
We conducted difference-in-differences analyses using Medicare claims from 2015 through 2017, encompassing the first 2 years of bundled payments in the CJR program. We evaluated hip- or knee-replacement episodes in 75 metropolitan statistical areas randomly assigned to mandatory participation in the CJR program (bundled-payment metropolitan statistical areas, hereafter referred to as "treatment" areas) as compared with those in 121 control areas, before and after implementation of the CJR model. The primary outcomes were institutional spending per hip- or knee-replacement episode (i.e., Medicare payments to institutions, primarily to hospitals and post-acute care facilities), rates of postsurgical complications, and the percentage of "high-risk" patients (i.e., patients for whom there was an elevated risk of spending - a measure of patient selection). Analyses were adjusted for the hospital and characteristics of the patients and procedures.
RESULTS:
From 2015 through 2017, there were 280,161 hip- or knee-replacement procedures in 803 hospitals in treatment areas and 377,278 procedures in 962 hospitals in control areas. After the initiation of the CJR model, there were greater decreases in institutional spending per joint-replacement episode in treatment areas than in control areas (differential change [i.e., the between-group difference in the change from the period before the CJR model], -$812, or a -3.1% differential decrease relative to the treatment-group baseline; P<0.001). The differential reduction was driven largely by a 5.9% relative decrease in the percentage of episodes in which patients were discharged to post-acute care facilities. The CJR program did not have a significant differential effect on the composite rate of complications (P=0.67) or on the percentage of joint-replacement procedures performed in high-risk patients (P=0.81).
CONCLUSIONS:
In the first 2 years of the CJR program, there was a modest reduction in spending per hip- or knee-replacement episode, without an increase in rates of complications. (Funded by the Commonwealth Fund and the National Institute on Aging of the National Institutes of Health.).
Ray KN, Shi Z, Poon SJ, Uscher-Pines L, and Mehrotra A. 1/10/2019. “
Use of Commercial Direct-to-Consumer Telemedicine by Children.” Acad Pediatr, S1876-2859, 18, Pp. 30517-5.
AbstractOBJECTIVE:
In commercial direct-to-consumer (DTC) telemedicine, physicians outside of the medical home treat common, acute complaints through real-time, audio-visual conferencing using telephones and personal computers. There has been little examination of the use of DTC telemedicine by children. We describe trends in DTC telemedicine use and DTC telemedicine visit characteristics.
METHODS:
Using 2011-2016 claims from a large national health plan, we identified pediatric acute visits to DTC telemedicine and to primary care providers (PCPs). We examined DTC telemedicine visit trends and compared DTC telemedicine and acute PCP visit diagnoses and patient characteristics.
RESULTS:
From 2011 through 2016, pediatric DTC telemedicine visits increased from 38 to 24,409 visits annually. In 2015 and 2016, the most common primary diagnoses for DTC telemedicine visits (n = 42,072) were infections of the nose/sinuses (24%), mouth/throat (16%), and ear (9%), which were also the most common diagnoses for acute PCP visits (n = 6,917,976). Odds of DTC telemedicine use were higher for children in non-metropolitan communities (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.40-1.51) and children without preventive visits (OR, 1.08; 95% CI, 1.06-1.11). Compared to children receiving acute PCP care, children with DTC telemedicine visits were also more likely to have had urgent care (17% vs 10%; P < .001) and emergency department visits (21% vs 19%; P < .001) during the study period.
CONCLUSIONS:
The use of commercial DTC telemedicine visits for children is growing rapidly, primarily for acute respiratory infections. Compared to children who did not use DTC telemedicine for acute care, children using DTC telemedicine were also more likely to use other venues for acute care outside of the medical home.
Qureshi N, Mehrotra A, Rudin RS, and Fischer SH. 1/9/2019. “
Common Laboratory Results Frequently Misunderstood by a Sample of Mechanical Turk Users.” Appl Clin Inform, 10, 2, Pp. 175-179.
AbstractOBJECTIVES:
More patients are receiving their test results via patient portals. Given test results are written using medical jargon, there has been concern that patients may misinterpret these results. Using sample colonoscopy and Pap smear results, our objective was to assess how frequently people can identify the correct diagnosis and when a patient should follow up with a provider.
METHODS:
We used Mechanical Turk-a crowdsourcing tool run by Amazon that enables easy and fast gathering of users to perform tasks like answering questions or identifying objects-to survey individuals who were shown six sample test results (three colonoscopy, three Pap smear) ranging in complexity. For each case, respondents answered multiple choice questions on the correct diagnosis and recommended return time.
RESULTS:
Among the three colonoscopy cases (n = 642) and three Pap smear cases (n = 642), 63% (95% confidence interval [CI]: 60-67%) and 53% (95% CI: 49-57%) of the respondents chose the correct diagnosis, respectively. For the most complex colonoscopy and Pap smear cases, only 29% (95% CI: 23-35%) and 9% (95% CI: 5-13%) chose the correct diagnosis.
CONCLUSION:
People frequently misinterpret colonoscopy and Pap smear test results. Greater emphasis needs to be placed on assisting patients in interpretation.
Poon SJ, Vu L, Baker O, Mehrotra A, and Schuur JD. 1/9/2019. “
The Impact of Conversion From an Urgent Care Center to a Freestanding Emergency Department on Patient Population, Conditions Managed, and Reimbursement.” J Emerg Med, S0736-4679, 18, Pp. 31202-2.
AbstractBACKGROUND:
Freestanding emergency departments (FSEDs), EDs not attached to acute care hospitals, are expanding. One key question is whether FSEDs are more similar to higher-cost hospital-based EDs or to lower-cost urgent care centers (UCCs).
OBJECTIVE:
Our aim was to determine whether there was a change in patient population, conditions managed, and reimbursement among three facilities that converted from a UCC to an FSED.
METHODS:
Using insurance claims from Blue Cross Blue Shield of Texas, we compared outcomes of interest for three facilities that converted from a UCC to an FSED for 1 year before and after conversion.
RESULTS:
There was no significant change in age, sex, and comorbidities among patients treated after conversion. Conditions were similar after conversion, though there was a small increase in visits for potentially more severe conditions. For example, the most common diagnoses before and after conversion were upper respiratory infections (42.8% of UCC visits, 26.0% of FSED visits), while chest pain increased from rank 30 to 10 (0.5% of UCC visits, 2.3% of FSED visits). Yearly number of visits decreased after conversion, while median reimbursement per visit increased (facility A: $148 to $2,153; facility B: $137 to $1,466; and facility C: $131 to $1,925) and total revenue increased (facility A: $1,389,590 to $1,486,203; facility B: $896,591 to $4,294,636; and facility C: $637,585 to $8,429,828).
CONCLUSIONS:
After three UCCs converted to FSEDs, patient volume decreased and reimbursement per visit increased, despite no change in patient characteristics and little change in conditions managed. These case studies suggest that some FSEDs are similar to UCCs in patient mix and conditions treated.
Poon SJ, Vu L, Metcalfe L, Baker O, Mehrotra A, and Schuur JD. 1/9/2019. “
The Impact of Conversion From an Urgent Care Center to a Freestanding Emergency Department on Patient Population, Conditions Managed, and Reimbursement.” J Emerg Med, S0736-4679, 18, Pp. 31202-2.
AbstractBACKGROUND:
Freestanding emergency departments (FSEDs), EDs not attached to acute care hospitals, are expanding. One key question is whether FSEDs are more similar to higher-cost hospital-based EDs or to lower-cost urgent care centers (UCCs).
OBJECTIVE:
Our aim was to determine whether there was a change in patient population, conditions managed, and reimbursement among three facilities that converted from a UCC to an FSED.
METHODS:
Using insurance claims from Blue Cross Blue Shield of Texas, we compared outcomes of interest for three facilities that converted from a UCC to an FSED for 1 year before and after conversion.
RESULTS:
There was no significant change in age, sex, and comorbidities among patients treated after conversion. Conditions were similar after conversion, though there was a small increase in visits for potentially more severe conditions. For example, the most common diagnoses before and after conversion were upper respiratory infections (42.8% of UCC visits, 26.0% of FSED visits), while chest pain increased from rank 30 to 10 (0.5% of UCC visits, 2.3% of FSED visits). Yearly number of visits decreased after conversion, while median reimbursement per visit increased (facility A: $148 to $2,153; facility B: $137 to $1,466; and facility C: $131 to $1,925) and total revenue increased (facility A: $1,389,590 to $1,486,203; facility B: $896,591 to $4,294,636; and facility C: $637,585 to $8,429,828).
CONCLUSIONS:
After three UCCs converted to FSEDs, patient volume decreased and reimbursement per visit increased, despite no change in patient characteristics and little change in conditions managed. These case studies suggest that some FSEDs are similar to UCCs in patient mix and conditions treated.
Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, and Mehrotra A. 2019. “
Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits.” Pediatrics , 143, 5, Pp. e20190631.
AbstractBACKGROUND AND OBJECTIVES:
Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office.
METHODS:
In a retrospective cohort study using 2015-2016 claims data from a large national commercial health plan, we identified ARI visitsby children (0-17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management.
RESULTS:
There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the matched sample. Antibioticprescribing was higher for DTC telemedicine visits than for other settings (52% of DTC telemedicine visits versus 42% urgent care and 31% PCP visits; P < .001 for both comparisons). Guideline-concordant antibiotic management was lower at DTC telemedicine visits than at other settings (59% of DTC telemedicine visits versus 67% urgent care and 78% PCP visits; P < .001 for both comparisons).
CONCLUSIONS:
At DTC telemedicine visits, children with ARIs were more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management compared to children at PCP visits and urgent care visits.