Engaging health plans to prioritize HPV vaccination and initiate at age 9

Health plans can influence pediatric and primary care providers and patients to understand HPV vaccination coverage and increase HPV vaccination uptake. By initiating vaccination at age nine, health plans can lay the groundwork for on-time HPV cancer prevention by age 13. In 2022, the American Cancer Society engaged 28 health plans in a 12-month HPV vaccination learning collaborative in which plans set their own quality improvement targets, implemented multi-pronged interventions, and joined quarterly best-practice sharing calls. Twenty-five of the 28 plans reported including a focus on ages 9 to 10. Preliminary pre-intervention data illustrate that vaccination rates from participating plans follow national trends and reaffirm existing gaps for HPV vaccination. Health plan interventions to address HPV vaccination are consistent with best practices but could be maximized to target initiation at ages 9-10 by using provider and patient reminders, targeted provider education, and dose-specific provider pay for performance and patient incentive programs. Health plans should explore future capacity to analyze non-HEDIS required data, including HPV initiation and HPV vaccination data for adolescents below age 13.

Role of prices in driving the variation in spending across medical groups

OBJECTIVE

To understand the relative role of prices versus utilization in the variation in total spending per patient across medical groups.

DATA SOURCES

We conducted a cross-sectional analysis of medical claims for commercially insured adults from a large national insurer in 2018.

STUDY DESIGN

After assigning patients to a medical group based on primary care visits in 2018, we calculated total medical spending for each patient in that year. Total spending included care provided by clinicians within the medical group and care provided by other providers, including hospitals. It did not include drug spending. We estimated the case mix adjusted spending per patient for each medical group. Within each market, we categorized medical groups into quartiles based on the group's spending per patient. To decompose spending variation into price versus utilization, we compared spending differences between highest and lowest quartile medical groups under two scenarios: (1) using actual prices (2) using a standardized price (same price used for a given service across the nation).

PRINCIPAL FINDINGS

In total, 3,921,736 patients were assigned to 7284 medical groups. Per-patient spending in the highest quartile of spending medical groups was $1813 higher than per-patient spending in the lowest spending quartile of medical groups (50% higher relative spending). This overall difference was primarily driven by differences in inpatient care, imaging, and specialty care. In the scenario where we used standardized prices, the difference in spending between medical groups in the top and bottom quartiles decreased to $1425, implying that 79% of the $1813 difference in spending between the top and bottom quartile groups is explained by utilization and the remaining 21% by prices. The likely explanation for the modest impact of prices is that patients cared for by a given medical group receive care across a wide range of providers.

CONCLUSIONS

Prices explained a modest fraction of the differences in spending between medical groups.

Considerations When Aggregating Data to Measure Performance Across Levels of the Health Care System

BACKGROUND

Measuring quality at varying levels of the health care system requires attribution, a process of determining the patients and services for which each level is responsible. However, it is important to ensure that attribution approaches are equitable; otherwise, individuals may be assigned differentially based upon social determinants of health.

METHODS

First, we used Medicaid claims (2010-2018) from Michigan to assess the proportion of children with sickle cell anemia who had less than 12 months enrollment within a single Medicaid health plan and could therefore not be attributed to a specific health plan. Second, we used the Medicaid Analytic eXtract data (2008-2009) from 26 states to simulate adapting the 30-Day Pediatric All-Condition Readmission measure to the Accountable Care Organization (ACO) level and examined the proportion of readmissions that could not be attributed.

RESULTS

For the sickle cell measure, an average of 300 children with sickle cell anemia were enrolled in Michigan Medicaid each year. The proportion of children that could not be attributed to a Medicaid health plan ranged from 12.2% to 89.0% across years. For the readmissions measure, of the 1,051,365 index admissions, 22% were excluded in the ACO-level analysis because of being unable to attribute the patient to a health plan for the 30 days post discharge.

CONCLUSIONS

When applying attribution models, it is essential to consider the potential to induce health disparities. Differential attribution may have unintentional consequences that deepen health disparities, particularly when considering incentive programs for health plans to improve the quality of care.

Mobile Fotonovelas Within a Text Message Outreach: An Innovative Tool to Build Health Literacy and Influence Behaviors in Response to the COVID-19 Pandemic

With all 50 US states reporting cases of coronavirus disease (COVID-19), people around the country are adapting and stepping up to the challenges of the pandemic; however, they are also frightened, anxious, and confused about what they can do to avoid exposure to the disease. Usual habits have been interrupted as a result of the crisis, and consumers are open to suggestions and strategies to help them change long-standing attitudes and behaviors. In response, a novel and innovative mobile communication capability was developed to present health messages in English and Spanish with links to fotonovelas (visual stories) that are accessible, easy to understand across literacy levels, and compelling to a diverse audience. While SMS text message outreach has been used to build health literacy and provide social support, few studies have explored the benefits of SMS text messaging combined with visual stories to influence health behaviors and build knowledge and self-efficacy. In particular, this approach can be used to provide vital information, resources, empathy, and support to the most vulnerable populations. This also allows providers and health plans to quickly reach out to their patients and members without any additional resource demands at a time when the health care system is severely overburdened.

Variations in Health Care Utilization Patterns Among Inflammatory Bowel Disease Patients at Risk for High Medical Service Utilization Enrolled in High Deductible Health Plans

BACKGROUND

High-deductible health plans (HDHPs) are increasing in prevalence as a cost control device for slowing health care cost growth by reducing nonessential medical service utilization. High cost-sharing associated with HDHPs can lead to significant financial distress and worse disease outcomes. We hypothesize that chronic disease patients are delaying or foregoing necessary medical care due to health care costs.

METHODS

A retrospective cohort analysis of IBD patients at risk for high medical service utilization with continuous enrollment in either an HDHP or THP from 2009 to 2016 were identified using the MarketScan database. Health care costs were compared between insurance plan groups by Kruskal-Wallis test. Temporal trends in office visits, colonoscopies, emergency department (ED) visits, and hospitalizations were evaluated using additive decomposition time series analysis.

RESULTS

Of 605,862 patients with a diagnosis of IBD, we identified 13,052 eligible patients. Annual out-of-pocket costs were higher in the HDHP group (n = 524) than the THP group (n = 12,458) ($2870 vs $1,864; P < 0.001) without any difference in total health care expenses ($23,029 vs $23,794; P = 0.583). Enrollment in an HDHP influenced colonoscopy, ED visit, and hospitalization utilization timing. Colonoscopies peaked in the fourth quarter, ED visits peaked in the first quarter, and hospitalizations peaked in the third and fourth quarter.

CONCLUSIONS

High-deductible health plan enrollment does not change the cost of care; however, it shifts health care costs onto patients and changes the timing of the care they receive. High-deductible health plans are incentivizing delays in obtaining health care with a potential to cause worse disease outcomes and financial distress. Further evaluation is warranted.

Cattle and sheep farmers' opinions on the provision and use of abattoir rejection data in the United Kingdom

BACKGROUND

Communication between farmers and veterinary surgeons is reported to differ when involving abattoir rejection data on cattle or sheep.

METHODS

Using surveys, distributed online and on paper at livestock markets, this study describes the interest and positive opinion of a sample of UK cattle and sheep farmers in receiving abattoir data.

RESULTS

Forty-nine per cent of respondents always received abattoir data (n=37/76). Over 80 per cent of respondents were interested in all suggested rejection conditions and particularly liver fluke and respiratory conditions. Eighty-two per cent of farmers were willing to share data with their veterinary surgeon as the information could be used to inform health plans.

CONCLUSION

The study findings indicate that having an accurate and consistent data system, which is easily accessible to farmers and veterinary surgeons, appears an essential next step to improve the use of existing abattoir data and enhance animal health, welfare and production.

Direct-to-member mailed colorectal cancer screening outreach for Medicaid and Medicare enrollees: Implementation and effectiveness outcomes from the BeneFIT study

Background

Colorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. To the authors' knowledge, little is known regarding the effectiveness of direct‐to‐member outreach by Medicaid health insurance plans to raise colorectal cancer screening use, nor how best to deliver such outreach.

Methods

BeneFIT is a hybrid implementation‐effectiveness study of 2 program models that health plans developed for a mailed fecal immunochemical test (FIT) intervention. The programs differed with regard to whether they used a centralized approach (Health Plan Washington) or collaborated with health centers (Health Plan Oregon). The primary implementation outcome of the current study was the percentage of eligible enrollees to whom the plans delivered each intervention component. The primary effectiveness outcome was the rate of FIT completion within 6 months of mailing of the introductory letter.

Results

The health plans identified 12,000 eligible enrollees (8551 in Health Plan Washington and 3449 in Health Plan Oregon). Health Plan Washington mailed an introductory letter and FIT kit to 8551 enrollees (100%) and delivered a reminder call to 839 (10.3% of the 8132 attempted). Health Plan Oregon mailed an introductory letter, and a letter and FIT kit plus a reminder postcard to 2812 enrollees (81.5%) and 2650 enrollees (76.8%), respectively. FIT completion rates were 18.2% (1557 of 8551 enrollees) in Health Plan Washington. In Health Plan Oregon, completion rates were 17.4% (488 of 2812 enrollees) among enrollees who were mailed an introductory letter and 18.3% (484 of 2650 enrollees) among enrollees who also were mailed a FIT kit plus reminder postcard.

Conclusions

The implementation of mailed FIT outreach by health plans may be effective and could reach many individuals at risk of developing colorectal cancer.

Colorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. The implementation of mailed fecal immunochemical test outreach among health plans may be effective and could reach many individuals at risk of developing colorectal cancer.

Does health plan type influence receipt of an annual influenza vaccination?

BACKGROUND

The influenza virus caused 48.8 million people to fall ill and 79 400 deaths during the 2017-2018 influenza season, yet less than 50% of US adults receive an annual flu vaccination (AFV). Having health insurance coverage influences whether individuals receive an AFV. The current study aims to determine if an association exists between an individual's health plan type (HPT) and their receipt of an AFV.

METHODS

Data from the 2017 Behavioral Risk Factor Surveillance System and the optional 'Health Care Access' module were used for this study. The final study sample size was 35 684. Multivariable weighted and adjusted logistic regression models were conducted to investigate the association between HPT and AFV.

RESULTS

Medicare coverage was significantly associated with an increase in AFV for both men (adjusted OR (AOR) 1.62 (95% CI 1.28 to 2.06)) and women (AOR 1.28 (95% CI 1.00 to 1.53)). For men, other sources of coverage were also significantly positively associated with AFV (AOR 1.67 (95% CI 1.27 to 2.19)), while for women obtaining coverage on their own was significantly negatively associated with AFV (AOR 0.75 (95% CI 0.59 to 0.97)).

CONCLUSION

These findings are of interest to health policy makers as these show there are HPTs which are effective at improving vaccination rates. Adopting methods used by these HPTs could help the USA reach its Healthy People 2020 AFV coverage goal of 70%.

How Do Private Health Plans Manage Specialty Behavioral Health Treatment Entry and Continuing Care?

OBJECTIVE

This study examined private health plans' arrangements for accessing and continuing specialty behavioral health treatment in 2010 as federal health reforms were being implemented. These management practices have historically been stricter in behavioral health care than in general medical care; however, the Mental Health Parity and Addiction Equity Act of 2010 required parity in management policies.

METHODS

The data source was a nationally representative survey of private health plans' behavioral health treatment management approaches in 2010. Health plan executives were asked about activities for their plan's three products with highest enrollment (weighted N=8,427, 88% response rate).

RESULTS

Prior authorization for outpatient behavioral health care was rarely required (4.7% of products), but 75% of products required authorization for ongoing care and over 90% required prior authorization for other levels of care. The most common medical necessity criteria were self-developed and American Society of Addiction Medicine criteria. Nearly all products had formal standards to limit waiting time for routine and urgent treatment, but almost 30% lacked such standards for detoxification services. A range of wait time-monitoring approaches was used.

CONCLUSIONS

Health plans used a variety of methods to influence behavioral health treatment entry and continuing care. Few relied on prior authorization for outpatient care, but the use of other approaches to influence, manage, or facilitate access was common. Results provide a baseline for understanding the current management environment for specialty behavioral health care. Tracking health plans' approaches over time will be important to ensure that access to behavioral health care is not prohibitively restrictive.

Impact of Oxycodone HCl Extended-release Formulary Restrictions on Extended-release Opioid Market Share, Healthcare Resource Utilization and Costs in Commercial and Medicare Plans

Background: Previous research demonstrated that utilization management (UM) such as prior authorization (PA) or non-formulary (NF) restrictions may reduce pharmacy costs when designed and applied appropriately to certain drug classes. However, such access barriers may also have unintended consequences. Few studies systemically analyzed the impact of major UM strategies to extended-release (ER) opioids on different types of health plans. Objective: This study evaluated, from payer perspective, the impact of formulary restrictions (PA, NF, or step therapy [ST]) for branded oxycodone HCl extended release (OER) on market share, and healthcare resource utilization/costs in ER opioids patients for multiple types of health plans in the United States. Methods: This retrospective, longitudinal case-control study analyzed prescription and outpatient medical claims data (2012 to 2015) for adult ER opioid patients from US plans (commercial,/Medicare, national/regional) that instituted OER PA, NF, or ST. Patients from each restricted plan (cases) were matched to patients in an unrestricted plan (controls) on key patient characteristics. ER opioid market share and healthcare resource utilization/costs for both cases and controls were evaluated for the 6-month period before and after the formulary restriction dates. A difference-in-differences (DiD) approach was utilized to evaluate change in the total per patient per month (PPPM) healthcare utilization and costs. Results: The study comprised 1622 (national commercial PA), 2020 (regional commercial PA), 34 703 (national commercial ST), and 4372 (national Medicare NF) cases and equivalent number of controls. OER market share decreased after the formulary restrictions, with the national Medicare NF plan showing the greatest decrease (9.2%). DiD analyses indicated that PPPM office visit change in the PA and NF plans were non-significant (decreased by 0.1 and 0.2, P>0.05), but significant in the ST plan (increased by 0.1, P=0.0001). For most plans, no significant total monthly cost change was observed; PPPM costs decreased by $48.74 and $59.87 in ST and regional PA plans and increased by $37.90 in national NF plans (all P>0.05). Conclusions: This study observed that despite reducing the market share of OER, OER formulary restrictions had negligible impact on overall ER opioid utilization, and did not result in substantial pharmacy/medical cost savings.

Documentation of person-centred health plans for patients with acute coronary syndrome

BACKGROUND

Personalised care planning is argued for but there is a need to know more about what the plans actually contain.

AIM

To describe the content of person-centred health, plans documented at three healthcare levels for patients with acute coronary syndrome.

DESIGN

Patients with acute coronary syndrome aged under 75 years and admitted to two coronary care units at a university hospital were enrolled in the study. This retrospective descriptive study documented 89 person-centred health plans at three healthcare levels: hospital, outpatient and primary care. In total, 267 health plans were reviewed and a quantitative content analysis conducted. The health plans included commonly formulated goals, patients' own resources and support needed.

RESULTS

The health plan goals were divided into three categories: lifestyle changes, illness management and relational activities. The most frequently reported goal for better health was increased physical activity, followed by social life/leisure activities and return to paid professional work. In order to reach the goals, patients identified three ways: own resources, family and social support and healthcare system, in total three categories. The most frequently reported own capability was self-motivation. Spouses and children were important sources of family and social support. The most frequently reported healthcare support was cardiac rehabilitation.

CONCLUSION

In traditional care and treatment plans devised by health professionals, patient goals often comprise behavioural changes. When patients identify their own goals and resources with the help of professionals, they include maintaining social relations and being able to return to important activities such as work.

Examining the Value of Subsidies of Health Plans and Cost-Sharing for Prescription Drugs in the Health Insurance Marketplace

BACKGROUND

The Affordable Care Act (ACA) initiated federally and state-run health insurance exchanges, or marketplaces, with health plans offering subsidies for plan members as well as coverage for essential health benefits, to help individuals, families, and small businesses find health plans that fit their specific needs. A recent study found that the value of these healthcare subsidies varied with the number of health plans in the different geographic rating areas, but that study only examined the premiums and the deductibles of those health plans.

OBJECTIVES

To examine the value of subsidies of health plans, including cost-sharing for prescription drugs in the health insurance marketplace.

METHODS

We have used publicly available health plan data from HealthCare.gov and from county population data obtained from the US Census Bureau in June 2015. The average-weighted premium; medical deductible; medical maximum out-of-pocket spending; and cost-sharing for generic drugs, preferred and nonpreferred brand-name drugs, and specialty drugs were calculated for the second lowest-cost silver plan in each geographic rating area. These were then compared across geographic areas with different numbers of plans to determine the value of the subsidies. We also compared the difference between the cost of the average silver plan and the second lowest-cost silver plan for each area to determine the cost to enrollees if they selected the average silver plan.

RESULTS

The monetary value of the subsidies provided by health plans was lower in areas with a larger number of plans, because the second lowest-cost silver plans in these areas tended to have lower premiums and higher deductibles. For the most common type of cost-sharing for generic and for preferred brand-name drugs, plan enrollees would likely have a lower or similar copayment if they selected the average-cost silver plan instead of the second lowest-cost silver plan. However, they may end up paying approximately $8 less in copayment for nonpreferred branded drugs and approximately 4% less for coinsurance after a deductible for specialty drugs if they resided in a geographic area with fewer than 11 plans.

CONCLUSION

The value of subsidies provided by the ACA-initiated health plans in the healthcare marketplace, including cost-sharing for prescription drugs, varies across geographic areas with different numbers of health plans. This suggests that potential enrollees should consider cost-sharing for prescription drugs in addition to health plans' premiums and deductibles when choosing their health plan.

Value of the Pharmacist in the Medication Reconciliation Process

Involving pharmacists in the process of comparing the medications that should be ordered for a patient with the new medications that are currently ordered and resolving differences improves accuracy, decreases mortality, and improves transitions of care.

The Pioneering Role of the Vaccine Safety Datalink Project (VSD) to Advance Collaborative Research and Distributed Data Networks

Introduction:

Large-scale distributed data networks consisting of diverse stakeholders including providers, patients, and payers are changing health research in terms of methods, speed and efficiency. The Vaccine Safety Datalink (VSD) set the stage for expanded involvement of health plans in collaborative research.

Expanding Surveillance Capacity and Progress Toward a Learning Health System:

From an initial collaboration of four integrated health systems with fewer than 10 million covered lives to 16 diverse health plans with nearly 100 million lives now in the FDA Sentinel, the expanded engagement of health plan researchers has been essential to increase the value and impact of these efforts. The collaborative structure of the VSD established a pathway toward research efforts that successfully engage all stakeholders in a cohesive rather than competitive manner. The scientific expertise and methodology developed through the VSD such as rapid cycle analysis (RCA) to conduct near real-time safety surveillance allowed for the development of the expanded surveillance systems that now exist.

Building on Success and Lessons Learned:

These networks have learned from and built on the knowledge base and infrastructure created by the VSD investigators. This shared technical knowledge and experience expedited the development of systems like the FDA’s Mini-Sentinel and the Patient Centered Outcomes Research Institute (PCORI)’s PCORnet

Conclusion:

This narrative reviews the evolution of the VSD, its contribution to other collaborative research networks, longer-term sustainability of this type of distributed research, and how knowledge gained from the earlier efforts can contribute to a continually learning health system.

Essential contractual language for medical necessity in children

The previous policy statement from the American Academy of Pediatrics, "Model Language for Medical Necessity in Children," was published in July 2005. Since that time, there have been new and emerging delivery and payment models. The relationship established between health care providers and health plans should promote arrangements that are beneficial to all who are affected by these contractual arrangements. Pediatricians play an important role in ensuring that the needs of children are addressed in these emerging systems. It is important to recognize that health care plans designed for adults may not meet the needs of children. Language in health care contracts should reflect the health care needs of children and families. Informed pediatricians can make a difference in the care of children and influence the role of primary care physicians in the new paradigms. This policy highlights many of the important elements pediatricians should assess as providers develop a role in emerging care models.

Using the Bayesian Improved Surname Geocoding Method (BISG) to create a working classification of race and ethnicity in a diverse managed care population: a validation study

OBJECTIVE

To validate classification of race/ethnicity based on the Bayesian Improved Surname Geocoding method (BISG) and assess variations in validity by gender and age.

DATA SOURCES/STUDY SETTING

Secondary data on members of Kaiser Permanente Georgia, an integrated managed care organization, through 2010.

STUDY DESIGN

For 191,494 members with self-reported race/ethnicity, probabilities for belonging to each of six race/ethnicity categories predicted from the BISG algorithm were used to assign individuals to a race/ethnicity category over a range of cutoffs greater than a probability of 0.50. Overall as well as gender- and age-stratified sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Receiver operating characteristic (ROC) curves were generated and used to identify optimal cutoffs for race/ethnicity assignment.

PRINCIPAL FINDINGS

The overall cutoffs for assignment that optimized sensitivity and specificity ranged from 0.50 to 0.57 for the four main racial/ethnic categories (White, Black, Asian/Pacific Islander, Hispanic). Corresponding sensitivity, specificity, PPV, and NPV ranged from 64.4 to 81.4 percent, 80.8 to 99.7 percent, 75.0 to 91.6 percent, and 79.4 to 98.0 percent, respectively. Accuracy of assignment was better among males and individuals of 65 years or older.

CONCLUSIONS

BISG may be useful for classifying race/ethnicity of health plan members when needed for health care studies.

Characteristics of practitioners in a private managed behavioral health plan

BACKGROUND

Little is known about the practitioners in managed behavioral healthcare organization (MBHO) networks who are treating mental and substance use disorders among privately insured patients in the United States. It is likely that the role of the private sector in treating behavioral health will increase due to the recent implementation of federal parity legislation and the inclusion of behavioral health as a required service in the insurance exchange plans created under healthcare reform. Further, the healthcare reform legislation has highlighted the need to ensure a qualified workforce in order to improve access to quality healthcare, and provides an additional focus on the behavioral health workforce. To expand understanding of treatment of mental and substance use disorders among privately insured patients, this study examines practitioner types, experience, specialized expertise, and demographics of in-network practitioners providing outpatient care in one large national MBHO.

METHODS

Descriptive analyses used 2004 practitioner credentialing and other administrative data for one MBHO. The sample included 28,897 practitioners who submitted at least one outpatient claim in 2004. Chi-square and t-tests were used to compare findings across types of practitioners.

RESULTS

About half of practitioners were female, 12% were bilingual, and mean age was 53, with significant variation by practitioner type. On average, practitioners report 15.3 years of experience (SD = 9.4), also with significant variation by practitioner type. Many practitioners reported specialized expertise, with about 40% reporting expertise for treating children and about 60% for treating adolescents.

CONCLUSIONS

Overall, these results based on self-report indicate that the practitioner network in this large MBHO is experienced and has specialized training, but echo concerns about the aging of this workforce. These data should provide us with a baseline of practitioner characteristics as we enter an era that anticipates great change in the behavioral health workforce.

Accessing specialty behavioral health treatment in private health plans

Connecting people to mental health and substance abuse services is critical, given the extent of unmet need. The way health plans structure access to care can play a role. This study examined treatment entry procedures for specialty behavioral health care in private health plans and their relationship with behavioral health contracting arrangements, focusing primarily on initial entry into outpatient treatment. The data source was a nationally representative health plan survey on behavioral health services in 2003 (N = 368 plans with 767 managed care products; 83% response rate). Most health plan products initially authorized six or more outpatient visits if authorization was required, did not routinely conduct telephonic clinical assessment, had standards for timely access, and monitored wait time. Products with carve-outs differed on several treatment entry dimensions. Findings suggest that health plans focus on timely access and typically do not heavily manage initial entry into outpatient treatment.

Changes in how health plans provide behavioral health services

Health plans appear to be moving toward less stringent management, but it is not known whether behavioral health care arrangements mirror the overall trend. To improve access to and quality of behavioral health services, it is critical to track plans' delivery of these services. This study examined plans' behavioral health care arrangements and changes over time using a nationally representative health plan survey regarding alcohol, drug abuse, and mental health services in 1999 (N = 434, 92% response) and 2003 (N = 368, 83% response). Findings indicate health plans' behavioral health service provision changed significantly since 1999, including a large increase in contracting with managed behavioral health care organizations. Some evidence of loosening administrative controls such as prior authorization implies easier access to services. However, increased prevalence of higher levels of cost sharing suggests financial barriers have grown. These changes have important implications for enrollees seeking care and for providers working to meet patients' needs.

A new method for estimating race/ethnicity and associated disparities where administrative records lack self-reported race/ethnicity

OBJECTIVE

To efficiently estimate race/ethnicity using administrative records to facilitate health care organizations' efforts to address disparities when self-reported race/ethnicity data are unavailable.

DATA SOURCE

Surname, geocoded residential address, and self-reported race/ethnicity from 1,973,362 enrollees of a national health plan.

STUDY DESIGN

We compare the accuracy of a Bayesian approach to combining surname and geocoded information to estimate race/ethnicity to two other indirect methods: a non-Bayesian method that combines surname and geocoded information and geocoded information alone. We assess accuracy with respect to estimating (1) individual race/ethnicity and (2) overall racial/ethnic prevalence in a population.

PRINCIPAL FINDINGS

The Bayesian approach was 74 percent more efficient than geocoding alone in estimating individual race/ethnicity and 56 percent more efficient in estimating the prevalence of racial/ethnic groups, outperforming the non-Bayesian hybrid on both measures. The non-Bayesian hybrid was more efficient than geocoding alone in estimating individual race/ethnicity but less efficient with respect to prevalence (p<.05 for all differences).

CONCLUSIONS

The Bayesian Surname and Geocoding (BSG) method presented here efficiently integrates administrative data, substantially improving upon what is possible with a single source or from other hybrid methods; it offers a powerful tool that can help health care organizations address disparities until self-reported race/ethnicity data are available.

Health plans' disease management programs: extending across the medical and behavioral health spectrum?

Although the disease management industry has expanded rapidly, there is little nationally representative data regarding medical and behavioral health disease management programs at the health plan level. National estimates from a survey of private health plans indicate that 90% of health plan products offered disease management for general medical conditions such as diabetes but only 37% had depression programs. The frequency of specific depression disease management activities varied widely. Program adoption was significantly related to product type and behavioral health contracting. In health plans, disease management has penetrated more slowly into behavioral health and depression program characteristics are highly variable.

Health plan requirements for mental health and substance use screening in primary care

BACKGROUND

Screening for substance abuse and mental health in primary care can improve detection. One way to advance screening is for health plans to require it.

OBJECTIVES

We developed national estimates of the prevalence and type of mental and substance-use condition screening health plans require of primary care practitioners.

DESIGN

In 1999 (N = 434, response rate = 92%) and 2003 (N = 368, response rate = 83%), we conducted a nationally representative health plan survey regarding alcohol, drug, and mental health services, including screening requirements.

PARTICIPANTS

Health plans reported on screening requirements of their top three private insurance products. Products were categorized by type (HMO, POS, or PPO), behavioral health contracting arrangements, tax status, market area population, and region.

MEASUREMENTS

We asked whether primary care practitioners are required to use a general health screening questionnaire (including mental health, alcohol, or drugs items) and/or a screening questionnaire focused on mental health, alcohol, or drug problems.

RESULTS

By 2003, 34% of products had any behavioral health screening requirements. Although there was no increase from 1999 to 2003 in requirements for any kind of behavioral health screening, requirements for using a standard screening instrument declined for mental health but increased for alcohol and drug screening. PPOs showed the largest increase in prevalence of behavioral health screening requirements. Products contracting with managed behavioral health organizations were more likely to require screening.

CONCLUSIONS

Most products do not require behavioral health screening in primary care. More screening could help to improve identification of behavioral health conditions, a first step towards effective treatment.

Hospitals' negotiating leverage with health plans: how and why has it changed?

OBJECTIVE

To describe how hospitals' negotiating leverage with managed care plans changed from 1996 to 2001 and to identify factors that explain any changes.

DATA SOURCES

Primary semistructured interviews, and secondary qualitative (e.g., newspaper articles) and quantitative (i.e., InterStudy, American Hospital Association) data.

STUDY DESIGN

The Community Tracking Study site visits to a nationally representative sample of 12 communities with more than 200,000 people. These 12 markets have been studied since 1996 using a variety of primary and secondary data sources.

DATA COLLECTION METHODS

Semistructured interviews were conducted with a purposive sample of individuals from hospitals, health plans, and knowledgeable market observers. Secondary quantitative data on the 12 markets was also obtained.

PRINCIPAL FINDINGS

Our findings suggest that many hospitals' negotiating leverage significantly increased after years of decline. Today, many hospitals are viewed as having the greatest leverage in local markets. Changes in three areas--the policy and purchasing context, managed care plan market, and hospital market--appear to explain why hospitals' leverage increased, particularly over the last two years (2000-2001).

CONCLUSIONS

Hospitals' increased negotiating leverage contributed to higher payment rates, which in turn are likely to increase managed care plan premiums. This trend raises challenging issues for policymakers, purchasers, plans, and consumers.