A time series analysis of immune checkpoint inhibitor use in the United States Medicare population: 2014-2019.

BACKGROUND: The adoption of immune checkpoint inhibitors (ICIs) has dramatically transformed the treatment of numerous cancers. Medicare is the largest payer in the US and pays for physician-administered drugs through its medical Part B benefit. The aim of this study was to describe trends in ICI utilization and corresponding government expenditures within the US Medicare population. METHODS: We analyzed Medicare data to describe trends in total number of claims, total annual expenditures, expenditures per patient, and expenditures per claim for ICIs from January 2014 to December 2019. RESULTS: From 2014 to 2019, utilization rates for each of the seven market approved ICIs in the US increased. Over this time period, total Medicare expenditure on ICIs increased 1916% from $285,506,498 to $5,755,319,571. Concurrently, overall Medicare Part B drug expenditure increased 57% from $23,679,547,748 to $37,271,080,631. Expenditures on ICIs accounted for 40% of the increase in total Medicare Part B drug spending over this time period. CONCLUSIONS: The rapid increase in utilization of ICIs has accounted for a disproportionate share of government drug spending growth in the United States. Policymakers can potentially curb spending growth by linking payments to patient outcomes.

Quantifying the Financial Value of Clinical Specialty Choice and Its Association With Competitiveness of Admissions.

Background The factors influencing medical student clinical specialty choice have important implications for the future composition of the US physician workforce. The objective of this study was to determine the career net present values (NPVs) of US medical students' clinical specialty choices and identify any relationships between a specialty's NPV and competitiveness of admissions as measured by the US Medical Licensing Examination (USMLE) Step 1 scores. Methodology NPVs were calculated using the results of the 2019 Doximity Physician Compensation report, a survey of 90,000 physicians. Mean USMLE Step 1 scores for matched US allopathic seniors in the 2018 National Resident Matching Program were used as a measure of clinical specialties' competitiveness of admissions. We calculated a composite measure of NPV and annual work-hours by dividing each specialty's NPV by the reported average number of hours worked per year. Results In our analysis, orthopedic surgery had the highest NPV ($10,308,868), whereas family medicine had the lowest NPV ($5,274,546). Dermatology and plastic surgery had the highest mean USMLE Step 1 scores (249 for both), whereas family medicine had the lowest (220). Clinical specialties' NPVs were positively associated with mean USMLE Step 1 scores (Pearson's r = 0.82; p < 0.001). Conclusions In this study, we describe associations suggesting that medical students respond to financial incentives in choosing clinical specialties and that these decisions are mediated by USMLE Step 1 scores. This underscores the importance of titrating and aligning incentives to improve the allocation of medical students into clinical specialties.

Variability in asthma quality and costs in children with different Medicaid insurance plans in Maricopa County.

OBJECTIVE: To describe the variation in asthma quality and costs among children with different Medicaid insurance plans. METHODS: We used 2013 data from the Center for Health Information and Research, which houses a database that includes individuals who have Medicaid insurance in Arizona. We analyzed children ages 2-17 years-old who lived in Maricopa County, Arizona. Asthma medication ratio (AMR, a measure of appropriate asthma medication use), outpatient follow-up within 2 weeks after asthma-related hospitalization (a measure of continuity of care), asthma-related hospitalizations, and all emergency department (ED) visits were the primary quality metrics. Direct costs were reported in 2013 $US dollars. We used one-way analysis of variance to compare the health plans for AMR and per member cost (total, ER, and hospital), and the chi-squared test for the outpatient follow-up measure. We used coefficient of variation to identify variation of each measure across all individuals in the study. RESULTS: In 2013, 90,652 children in Maricopa County were identified as having asthma. The average patient-weighted AMR for children with persistent asthma was 0.35, well short of the goal of ≥0.70, and only 36% of hospitalized asthma patients had outpatient follow-up within 2 weeks of hospitalization. AMR, total costs, and ED costs varied significantly (p <.0001) when comparing health plans while hospital costs and outpatient follow-up showed no significant variation. CONCLUSIONS: Targeting appropriate medication use for asthma may help reduce variation, improve outcomes, and increase healthcare value for children with asthma and Medicaid insurance in the US.

The Affordable Care Act: a case study for understanding and applying complexity concepts to health care reform.

RATIONALE, AIMS AND OBJECTIVES: The current health system in the United States is the result of a history of patchwork policy decisions and cultural assumptions that have led to persistent contradictions in practice, gaps in coverage, unsustainable costs, and inconsistent outcomes. In working toward a more efficient health system, understanding and applying complexity science concepts will allow for policy that better promotes desired outcomes and minimizes the effects of unintended consequences. METHODS: This paper will consider three applied complexity science concepts in the context of the Patient Protection and Affordable Care Act (PPACA): developing a shared vision around reimbursement for value, creating an environment for emergence through simple rules, and embracing transformational leadership at all levels. RESULTS AND CONCLUSIONS: Transforming the US health system, or any other health system, will be neither easy nor quick. Applying complexity concepts to health reform efforts, however, will facilitate long-term change in all levels, leading to health systems that are more effective, efficient, and equitable.

Preparing for an Aging World: Engaging Biogerontologists, Geriatricians, and the Society.

Although the demographic revolution has produced hundreds of millions people aged 65 and older, a substantial segment of that population is not enjoying the benefits of extended healthspan. Many live with multiple chronic conditions and disabilities that erode the quality of life. The consequences are also costly for society. In the United States, the most costly 5% of Medicare beneficiaries account for approximately 50% of Medicare's expenditures. This perspective summarizes a recent workshop on biomedical approaches to best extend healthspan as way to reduce age-related dysfunction and disability. We further specify the action items necessary to unite health professionals, scientists, and the society to partner around the exciting and palpable opportunities to extend healthspan.

Teamwork in health care.

It is becoming increasingly clear that maintaining and improving the health of the population, and doing so in a financially sustainable manner, requires the coordination of acute medical care with long-term care, and social support services, that is, team-based care. Despite a growing body of evidence on the benefits of team-based care, the health care ecosystem remains "resistant" to a broader implementation of such care models. This resistance is a function of both system-wide and organizational barriers, which result primarily from fragmentation in reimbursement for health care services, regulatory restrictions, and the siloed nature of health professional education. To promote the broader adoption of team-based care models, the health care system must transition to pay for value reimbursement, as well as break down the educational silos and move toward team-based and value-based education of health professionals.

Regulatory and reimbursement innovation.

Coverage with evidence development and parallel review for molecular diagnostics aid regulation and reimbursement.

Prospects for change.

This chapter addresses the prospects for change in health care delivery. The focus is on value - high quality, affordable care for everyone. We consider three domains that participate in the flow of value and the nature of the interfaces among these domains. We also discuss strategic priorities that should align in various ways with these domains. Finally, we address the business transformations needed to enable the provision of value by enterprises that are viable and successful.

Health care reform: why we cannot afford to fail.

Under the auspices of the Mayo Clinic Health Policy Center, the authors of this Perspective participated in a two-year consensus-building process among more than 2,000 health care stakeholders. The result was agreement on reforming U.S. health care along four key principles: improving health care quality and value; undertaking payment reform; vastly improving coordination of care; and providing insurance coverage for all. The authors expand on these ideas and make additional recommendations for how health care financing and delivery should be transformed as soon as possible.

Putting the needs of the patient first: Mayo Clinic's core value, institutional culture, and professionalism covenant.

From its inception more than a century ago, Mayo Clinic's founders instilled the core value, the needs of the patient come first, into the institution's culture. Today, this core value of professionalism continues to guide the clinic's leadership practices, management strategies, and daily activities. Members of the Mayo Clinic staff embrace and reinforce this core value and regard it as a professionalism covenant: a collective, tacit agreement that everyone will earnestly collaborate to put the needs and welfare of patients first. This covenant is articulated for patients and learners in two key documents, both crafted in 2001--the Mayo Clinic Model of Care, and the Mayo Clinic Model of Education--and is reaffirmed through Mayo Clinic's mission to provide the best outcomes, service, and value in health care to every patient, every day. Mayo's value-based culture serves as a powerful, positive hidden curriculum that facilitates the accomplishment of desired practice and educational outcomes and fosters the development of health care professionals with the highest standards of professionalism. The profound allegiance of Mayo Clinic staff and students to its patient-centered culture connects all to the purpose and meaning of their work, elicits collaboration and voluntary efforts, and fosters an environment that is committed to excellence and continuous improvement. In the context of contemporary challenges and competing commitments facing academic health centers, the authors discuss key initiatives that Mayo Clinic has implemented to preserve the institution's culture, honor the professionalism covenant, and enable faculty, staff, and learners to align their behaviors, work activities, and resources to accomplish the institution's mission.

Managing conflict of interest in clinical practice.

Conflict of interest, even the appearance of potential conflict, has long been a concern for physicians and scientists. Conflict of interest arises when an activity is accompanied by a divergence between personal or institutional benefit when compared to the responsibilities to patients and to society; it arises in the context of research, purchasing, leadership, and investments. Conflict of interest is of concern because it compromises the trust of the patient and of society in the individual physician or the medical center.

Taking steps toward integration.

If patients are to be at the center of health care, then providers should work diligently to better organize the delivery system. In this Perspective, two Mayo Clinic leaders provide their views on why it is necessary for physicians and hospitals to set aside their differences and work together for the good of their patients. They cite successful enterprises nationwide that combine hospital and physician control. Many of them have been recognized as examples.