Comparing Rural and Urban Cervical and Breast Cancer Screening Rates in a Privately Insured Population.

Low preventive screening varies by region and contributes to poor outcomes for breast and cervical cancer. Previous comparative urban and rural research on preventive screening has focused on government programs. This study quantified and compared rural and urban preventive cancer screening rates for women who were privately insured. National Quality Forum measures were used to calculate rates for women within rural and urban parts of the same Hospital Referral Region (HRR) using claims data. Mammography screening rates for women age 24 to 69 years were 77.1% in 2011 and 76.1% in 2008. Compared to urban women, mammography screening rates for women visiting rural physicians were lower in 42%, higher in 2% and identical in 56% of HRRs. Cervical cancer screening rates for women age 21 to 64 years were 82.9% in 2011 and 83.5% in 2008. Cervical cancer screening rates among women who saw rural physicians were lower in 55%, higher in 4%, and identical in 42% of HRRs. HRRs where rural areas underperformed urban areas increased between 2008 and 2011 for both screenings. Moderate but notable differences in women's preventive screening rates between rural and urban physicians highlight the need for practical solutions that increase use of screening services and reduce barriers to services in rural areas.

A coordinated national model for diabetes prevention: linking health systems to an evidence-based community program.

BACKGROUND: Twenty-six million U.S. adults have diabetes, and 79 million have prediabetes. A 2002 Diabetes Prevention Program research study proved the effectiveness of a lifestyle intervention that yielded a 58% reduction in conversion to type 2 diabetes. However, cost per participant was high, complicating efforts to scale up the program. PURPOSE: UnitedHealth Group (UHG) and the YMCA of the USA, in collaboration with the CDC, sought to develop the infrastructure and business case to scale the congressionally authorized National Diabetes Prevention Program nationwide. Emphasis was placed on developing a model that maintained fidelity to the original 2002 Diabetes Prevention Program research study and could be deployed for a lower cost per participant while yielding similar outcomes. DESIGN: The UHG created the business case and technical and operational infrastructure necessary for nationwide dissemination of the YMCA's Diabetes Prevention Program (YMCA's DPP), as part of the National Diabetes Prevention Program. The YMCA's DPP is a group-based model of 16 core sessions with monthly follow-up delivered by trained lifestyle coaches. SETTING/PARTICIPANTS: A variety of mechanisms were used to identify, screen, and encourage enrollment for people with prediabetes into the YMCA's DPP. INTERVENTION: Substantial investments were made in relationship building, business planning, technology, development, and operational design to deliver an effective and affordable 12-month program. The program intervention was conducted July 2010-December 2011. Data were collected on the participants over a 15-month period between September 2010 and December 2011. Data were analyzed in February 2012. MAIN OUTCOME MEASURES: The main outcome measures were infrastructure (communities involved and personnel trained); engagement (screening and enrollment of people with prediabetes); program outcomes (attendance and weight loss); and service delivery cost of the intervention. RESULTS: In less than 2 years, the YMCA's DPP was effectively scaled to 46 communities in 23 states. More than 500 YMCA Lifestyle Coaches were trained. The program enrolled 2369 participants, and 1723 participants completed the core program at an average service-delivery cost of about $400 each. For those individuals completing the program, average weight loss was about 5%. UHG anticipates that within 3 years, savings from reduced medical spending will outweigh initial costs. CONCLUSIONS: Large-scale prevention efforts can be scalable and sustainable with collaboration, health information technology, community-based delivery of evidence-based interventions, and novel payment structures that incentivize efficiency and outcomes linked to better health and lower future costs.

Growth of molecular diagnostics and genetic testing in the USA, 2008-2011: analysis and implications.

AIMS: Advances in genomics and molecular diagnostic testing are expanding, but national data on which to base clinical, regulatory and reimbursement policies in the USA are lacking. The study objective is to provide current estimates of utilization/spending trends for private and public payers. PATIENTS & METHODS: Healthcare utilization/expenditure claims data for 32 million individuals across the USA in 2008-2011 were analyzed. Genetic testing and molecular diagnostic usage was categorized by major testing groups: infectious disease, cancer and inherited/other acquired conditions. RESULTS: Per-person testing cost grew by 14% per year between 2008 and 2011, primarily resulting from increased utilization. Spending per person for Medicare and Medicaid was higher than for commercially insured patients. Expenditure across the USA was estimated at US$5.5 billion in 2011, up 13% from 2010. DISCUSSION: Greater understanding of usage and technology diffusion requires increased data transparency and granularity. Conclusion & future perspective: The use of genetic testing and molecular diagnostics will grow over the next 5 years, with uncertainty about the precise diffusion trajectory. By strengthening the capacity to capture and analyze trends in this changing area of medicine, we increase our chances of promoting positive change to the benefit of patients.

Health plans' strategies for managing outpatient specialty pharmaceuticals.

Balancing increased spending for specialty pharmaceuticals while providing affordable and equitable coverage for consumers is a key issue for public and private payers. Health plans rely on an array of strategies, including both medical management and those used for more traditional pharmaceuticals. To explore specific management strategies for outpatient specialty pharmaceuticals, a survey was administered to thirty-eight Blue Cross and Blue Shield plans, focused on identifying core strategies. Prior authorization was the most commonly used strategy, implemented by 83.3 percent of respondents. Other frequently implemented management strategies included claims review (82.8 percent), formulary management (76.7 percent), and utilization review (70 percent).

Emergence of a new national health services research alliance.

Although underrepresented to date, PPOs have the potential to become major contributors to health services research. However, policy and health plan decision makers must be informed about the unique features and contributions of PPOs. The authors describe a unique health services research coalition established among 13 Blue Cross and Blue Shield plans nationwide and the Kerr L. White Institute for Health Services Research (Decatur, GA), in collaboration with research institutions and government agencies, that features multiple health plan products within commercial, Medicare, and Medicaid enrollments, but with a specific emphasis on PPOs.

Recent tax changes may assist treatment of obesity.

The U.S. Surgeon General's Call to Action on Overweight and Obesity 2001 proposes inclusion of health care providers in prevention efforts and suggests classification of obesity as a disease category for reimbursement coding. Physician counseling on and referral for physical activity is generally recognized as a component of obesity treatment, but data on the effectiveness of these measures remain inconclusive. Recent changes in the federal tax law may influence physicians' and health plans' roles in promoting physical activity.

Promoting physical activity: a profile of health plan programs and initiatives.

A study was conducted to capture information on health plans' initiatives to promote physical activity among members and in community settings. This investigation was based on a descriptive nationwide study of American Association of Health Plans- and Blue Cross and Blue Shield Association-member plans conducted from October 2001 to February 2002. Sixty individuals with responsibility for health-promotion programs were surveyed, and 24 provided in-depth interviews. The measures used in this evaluation were the number and type of member- and community-based physical activity programs/initiatives offered by health plans, and the types of programs evaluated. Information was captured on more than 373 physical activity initiatives. Thirty-five percent of surveyed health plans responded, representing more than 62 million health plan members; the participation rate for in-depth interviews was 80%. Most health plans integrate physical activity messages into routine services for members (92%) and sponsor community races/walks and health fairs (85%). Physical activity programs are offered to improve member health (92%), increase member satisfaction (80%), and reduce long-term health care costs (62%). Few rigorous evaluations have been conducted on these programs, and return-on-investment data are scarce. Although some health plans currently play a relatively active role in promoting physical fitness to their members and the community, multiple opportunities exist for health plan involvement in various settings with different populations.