International Prescription Drug Price Comparisons: Estimates Using 2022 Data.

Understanding the extent to which prescription drug prices are higher in the United States than in other countries-after accounting for differences in the volume and mix of drugs-is useful when developing and targeting policies to address both growth in drug spending and the financial impact of prescription drugs on consumers. This study summarizes findings from comparisons of drug prices in the United States and other high-income countries based on 2022 data and presents results for specific types of drugs, including brand-name originator drugs and unbranded generic drugs, and from sensitivity analyses.

The infant health effects of doulas: Leveraging big data and machine learning to inform cost-effective targeting.

Doula services represent an underutilized maternal and child health intervention with the potential to improve outcomes through the provision of physical, emotional, and informational support. However, there is limited evidence of the infant health effects of doulas despite well-established connections between maternal and infant health. Moreover, because the availability of doulas is limited and often not covered by insurers, existing evidence leaves unclear if or how doula services should be allocated to achieve the greatest improvements in outcomes. We use unique data and machine learning to develop accurate predictive models of infant health and doula service participation. We then combine these predictive models within the double machine learning method to estimate the effects of doula services. We show that while doula services reduce risk on average, the benefits of doula services increase as the risk of negative infant health outcomes increases. We compare these benefits to the costs of doula services under alternative allocation schemes and show that leveraging the risk predictions dramatically increases the cost effectiveness of doula services. Our results show the potential of big data and novel analytic methods to provide cost-effective support to those at greatest risk of poor outcomes.

A Needs Assessment of Women Veterans in Western Pennsylvania: Final Report to Adagio Health.

Women make up an increasingly large share of the U.S. veteran population, and their numbers continue to grow while the overall number of veterans is on the decline. Yet programs designed to support veterans' health and well-being have largely focused on men. Women's military experiences and postservice needs often differ from those of men, and women veterans also differ in significant ways from their nonveteran counterparts. Few studies have explored these variations, and this has translated to potentially missed opportunities to improve support for women during and after their transition from military to civilian life. Adagio Health, a provider of health, wellness, and nutrition services based in Western Pennsylvania, has taken steps to improve care for women veterans in its service area. To identify opportunities to further expand and enhance Adagio Health's efforts to support women veterans' health and wellness, the authors quantitatively and qualitatively assessed the needs of women veterans in the Adagio Health service area. The assessment provides a clearer picture of this often-underserved population, available services and resources, gaps in support, barriers to access, and areas to prioritize to provide the best support possible for the health and well-being of women who served. With the approaches recommended in this assessment, Adagio Health can continue increasing its capacities and capabilities for supporting its women veteran patients and making progress toward its goal of advancing their health and well-being.

Variation in the infant health effects of the women, infants, and children program by predicted risk using novel machine learning methods.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has an extensive literature documenting positive effects on infant health outcomes, specifically preterm birth, low birthweight, small size for gestational age, and infant mortality. However, existing studies focus on average effects for these relatively infrequent outcomes, thus providing no evidence for how WIC affects those at greatest risk of negative infant health outcomes. Our study focuses on documenting how WIC's infant health effects vary by level of risk. In doing so, we leverage a uniquely rich database describing maternal and infant outcomes and risk factors. Additionally, we use high dimensional data to generate predictions of risk and combine these predictions with the novel double machine learning method to stratify the effects of WIC by predicted risk. Our estimates of WIC's average treatment effects align with those in the existing literature. More importantly, we document significant variation in the effects of WIC on infant health by predicted risk level. Our results show that WIC is most beneficial among those at greatest risk of poor outcomes.

Using Claims-Based Estimates of Post-Operative Visits to Revalue Procedures with 10- and 90-Day Global Periods: Updated Results Using Calendar Year 2019 Data.

Medicare payment for many health care procedures covers not only the procedure itself but also most post-operative care over a fixed period of time (the ""global period""). The Centers for Medicare & Medicaid Services (CMS) sets payment rates assuming that a certain number and type of post-operative visits specific to each procedure typically occur. This article describes how CMS might use claims-based data on the number of post-operative visits to adjust valuation for procedures with 10- and 90-day global periods. There are links between the number of bundled post-operative visits and the components of valuation addressed in this study: work, practice expense (PE), and malpractice relative value units (RVUs). There is some ambiguity regarding how a reduction in post-operative visits translates into changes in work RVUs. In contrast, a reduction in post-operative visits has clear implications on physician time and direct PE. Changes in physician work, physician time, and direct PE will, in turn, affect the allocation of pools of PE and malpractice RVUs to individual services. The idiosyncrasies of the resource-based relative value scale system used to determine payment for Medicare services result in some ambiguity about how procedures should be revalued to reflect reductions in post-operative visits. These results may inform further policy development around revaluation for global procedures.

Tackling Persistent and Large Disparities in Birth Outcomes in Allegheny County, Pennsylvania.

OBJECTIVES: Based in Allegheny County, a coalition of local stakeholders took note of the region's infant mortality rates, particularly the stark disparities observed by race, and established a vision to reduce infant mortality in the region. The group undertook a multi-faceted effort to (1) develop predictive models of infant mortality risk; (2) evaluate the effectiveness of available interventions; and (3) combine these tools in order to tailor intervention referrals based on maternal risk profiles. With this effort, the coalition sought to address the apparent disconnect between the region's robust maternal and child health care system and relatively poor birth and infant outcomes and racial disparities. METHODS: The effort started with the integration of data from a variety of sources into an integrated database built specifically for this research effort covering the period 2003 to 2013. With the database, researchers linked each individual's data across multiple data sources, including the Allegheny County Health Department, the University of Pittsburgh Medical Center, the Allegheny County Department of Human Services Data Warehouse, and individual programs. With these data, we used a standard method for comparing outcomes and measuring the racial disparity between Black and white infants that involved calculating a ratio by dividing the rate or percentage for Black infants by the rate or percentage for white infants. RESULTS: Overall, the results showed that between 2003 and 2013 in Allegheny County disparities were more pronounced for infant mortality (3.25) than low birthweight (1.88) or preterm birth (1.49). Among the different potential causes of infant mortality, the most pronounced disparity was for SIDS (1.78). Among maternal health factors, pre-pregnancy obesity and gestational diabetes had the highest infant mortality disparity. The low birthweight disparity was similar and lower than the infant mortality disparity across all of the maternal health factors, while the preterm birth disparity was even lower. For the maternal behavioral and contextual factors, the infant mortality disparity ranged from 1.5 to 2.3. CONCLUSION: The 11-year span of data reported in the IMPreSIv database and the breadth of intervention data included allowed us to report granular information on birth outcomes within Allegheny County over this time period. The database also allowed us to summarize the various factors associated with the range of birth outcomes and describe the participation rates in the medical and community setting interventions. Against this backdrop of pronounced disparities in birth outcomes across a range of factors, we examined the effectiveness of interventions for women with different risk factors (e.g. substance use disorders) in order to develop a tool to facilitate individualized referrals to the interventions that will help the most for a specific risk profile.

Patterns of Postoperative Visits Among Medicare Fee-for-service Beneficiaries.

OBJECTIVE: To describe patterns of postoperative visits reported for Medicare fee-for-service (FFS) patients. BACKGROUND: Payment for most surgical procedures bundles postoperative visits within a global period of either 10 or 90 days after a procedure. There is concern that payments for some procedures are excessive because the number of postoperative visits provided is less than the number of postoperative visits used to help determine payment. To obtain data to inform this concern, Medicare required select surgeons to report on their postoperative visits starting July 1, 2017. METHODS: We analyzed Medicare FFS claims data from surgeons who billed Medicare for 1 or more of the 293 common procedure codes between July 1, 2017 and December 31, 2017 in the 9 states where surgeons were required to report postoperative visits. We examined the share of procedures with any reported postoperative visits and the proportion of expected postoperative visits provided. To address concerns about underreporting, we also examined procedures performed by a subset of surgeons actively reporting postoperative visits. RESULTS: We linked 663,681 procedures to 422,432 postoperative visits. The share of procedures with any postoperative visits was higher for procedures with 90-day global periods (70.1%) than for procedures with 10-day global periods (3.7%). The proportions of expected postoperative visits provided for 90-day global and 10-day global periods were 0.37 and 0.04 respectively. Among surgeons actively reporting postoperative visits, the proportions of expected postoperative visits provided were modestly higher (procedures with 90-day global periods=0.46 and 10-day global periods=0.16). CONCLUSIONS: The proportion of expected postoperative visits that were provided is low. These results support the need for a reassessment of payment for surgical procedures.

Evaluation Design Recommendations for the Certified Community Behavioral Health Clinic Demonstration Program.

This article provides information and recommendations regarding the evaluation design of the Certified Community Behavioral Health Clinic (CCBHC) demonstration. Mandated by Congress in Section 223 of the Protecting Access to Medicare Act of 2014, the CCBHC is a new model of specialty behavioral health clinic, designed to provide comprehensive and integrated care for adults with mental health or substance-use disorders and children with serious emotional distress. Certification criteria for the CCBHCs have been specified by Substance Abuse and Mental Health Services Administration covering six core areas: staffing; accessibility; care coordination; scope of services; quality and other reporting; and organizational authority, governance, and accreditation. In addition, services provided to Medicaid enrollees in CCBHCs will be reimbursed through one of two alternative prospective payment systems. At present, 24 states have been awarded grants to begin the planning process for implementing CCBHCs. Of these states, eight will be selected to participate in the demonstration project beginning in January 2017. Results from the evaluation will inform mandated reports to Congress over the two-year demonstration period and the three years following the end of the demonstration, providing information to policymakers on the program's impact and value. In addition, the results can inform the direction of future efforts at integration of behavioral health into the health care system at this critical time of transformation.

Episode-Based Approaches to Measuring Health Care Quality.

Most currently available quality measures reflect point-in-time provider tasks, providing a limited and fragmented assessment of care. The concept of episodes of care could be used to develop quality measurement approaches that reflect longer periods of care. With input from clinical experts, we constructed episode-of-care frameworks for six illustrative conditions and identified potential gaps and measure development priority areas. Episode-based measures could assess changes in health outcomes ("delta measures"), the amount of time during an episode in which a patient has suboptimal health status ("integral measures"), quality contingent upon events occurring previously ("contingent measures"), and composites of measures throughout the episode. This article identifies a number of challenges that will need to be addressed to advance operationalization of episode-based quality measurement.

Acupuncture for Major Depressive Disorder: A Systematic Review.

Major depressive disorder (MDD) is a prevalent condition associated with significant burden in terms of reduced quality of life, lower productivity, increased prevalence of other conditions and increased health care costs. We conducted a systematic review and qualitative summary of randomized controlled trials (RCTs) that assessed the effectiveness and safety of acupuncture for the treatment of MDD. We searched the databases PubMed, CINAHL, PsycINFO, Web of Science, Embase, CDSR, CENTRAL, clinicaltrials.gov, DARE, and PILOTS for English-language RCTs published through January 2015. Two independent reviewers screened the identified literature against inclusion and exclusion criteria, abstracted study level data, and assessed the risk of bias and methodological quality of included studies. The quality of the evidence was assessed using GRADE. Eighteen studies met inclusion criteria. Eleven assessed acupuncture as monotherapy, seven as adjunct depression treatment. Intervention approaches and comparators varied. Evidence on the effectiveness and comparative effectiveness of acupuncture to treat MDD for the outcomes depression improvement, measured as scale score differences and the number of responders, is very weak. Acupuncture may be superior to waitlist (low quality of evidence) but findings for effect estimates compared to other comparators are inconclusive. Few studies reported on patients achieving remission. The effect of acupuncture on relapse rates could not be determined. Too few studies assessed quality of life to estimate treatment effects. Reported adverse events were typically mild in nature, but the assessment lacked rigor and studies were not designed to detect rare events.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

Authorities and Mechanisms for Purchased Care at the Department of Veterans Affairs.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the authorities and mechanisms by which the Department of Veterans Affairs (VA) pays for health care services from non-VA providers. Purchased care accounted for 10 percent, or around $5.6 billion, of VA's health care budget in fiscal year 2014, and the amount of care purchased from outside VA is growing rapidly. VA purchases non-VA care through an array of programs, each with different payment processes and eligibility requirements for veterans and outside providers. A review and analysis of statutes, regulations, legislation, and literature on VA purchased care, along with interviews with expert stakeholders, a survey of VA medical facilities, and an evaluation of local-level policy documents revealed that VA's purchased care system is complex and decentralized. Inconsistencies in procedures, unclear goals, and a lack of cohesive strategy for purchased care could have ramifications for veterans' access to care. Adding to the complexity of VA's purchased care system is a lack of systematic data collection on access to and quality of care provided through VA's purchased care programs. The analysis also explored concepts of "episodes of care" and their implications for purchased care by VA.

Specialty Payment Model Opportunities and Assessment: Gastroenterology and Cardiology Model Design Report.

Gastroenterology and cardiology services are common and costly among Medicare beneficiaries. Episode-based payment, which aims to create incentives for high-quality, low-cost care, has been identified as a promising alternative payment model. This article describes research related to the design of episode-based payment models for ambulatory gastroenterology and cardiology services for possible testing by the Center for Medicare and Medicaid Innovation at the Centers for Medicare and Medicaid Services (CMS). The authors analyzed Medicare claims data to describe the frequency and characteristics of gastroenterology and cardiology index procedures, the practices that delivered index procedures, and the patients that received index procedures. The results of these analyses can help inform CMS decisions about the definition of episodes in an episode-based payment model; payment adjustments for service setting, multiple procedures, or other factors; and eligibility for the payment model.

A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations.

This study evaluated how the Perfecting Patient Care (PPC) University, a quality improvement (QI) training program for health care leaders and clinicians, affected the ability of organizations to improve the health care they provide. This training program teaches improvement methods based on Lean concepts and principles of the Toyota Production System and is offered in several formats. A retrospective evaluation was performed that gathered data on training, other process factors, and outcomes after staff completed the PPC training. A majority of respondents reported gaining QI competencies and cultural achievements from the training. Organizations had high average scores for the success measures of "outcomes improved" and "sustainable monitoring" but lower scores for diffusion of QI efforts. Total training dosage was significantly associated with the measures of QI success. This evaluation provides evidence that organizations gained the PPC competencies and cultural achievements and that training dosage is a driver of QI success.

Measuring Success in Health Care Value-Based Purchasing Programs: Findings from an Environmental Scan, Literature Review, and Expert Panel Discussions.

Value-based purchasing (VBP) refers to a broad set of performance-based payment strategies that link financial incentives to health care providers' performance on a set of defined measures in an effort to achieve better value. The U.S. Department of Health and Human Services is advancing the implementation of VBP across an array of health care settings in the Medicare program in response to requirements in the 2010 Patient Protection and Affordable Care Act, and policymakers are grappling with many decisions about how best to design and implement VBP programs so that they are successful in achieving stated goals. This article summarizes the current state of knowledge about VBP based on a review of the published literature, a review of publicly available documentation from VBP programs, and discussions with an expert panel composed of VBP program sponsors, health care providers and health systems, and academic researchers with VBP evaluation expertise. Three types of VBP models were the focus of the review: (1) pay-for-performance programs, (2) accountable care organizations, and (3) bundled payment programs. The authors report on VBP program goals and what constitutes success; the evidence on the impact of these programs; factors that characterize high- and low-performing providers in VBP programs; the measures, incentive structures, and benchmarks used by VBP programs; evidence on spillover effects and unintended consequences; and gaps in the knowledge base.

Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Grant Program: Final Report.

Excess morbidity and mortality in persons with serious mental illness is a public health crisis. Numerous factors contribute to this health disparity, including illness and treatment-related factors, socioeconomic and lifestyle-related factors, and limited access to and poor quality of general medical care. Primary and Behavioral Health Care Integration (PBHCI), one of the Substance Abuse and Mental Health Services Administration's service grant programs, is intended to improve the overall wellness and physical health status of people with serious mental illness, including individuals with co-occurring substance use disorders, by making available an array of coordinated primary care services in community mental health and other community-based behavioral health settings where the population already receives care. This article describes the results of a RAND Corporation evaluation of the PBHCI grants program. The evaluation was designed to understand PBHCI implementation strategies and processes, whether the program leads to improvements in outcomes, and which program models and/or model features lead to better program processes and consumer outcomes. Results of the evaluation showed that PBHCI grantee programs were diverse, varying in their structures, procedures, and the extent to which primary and behavioral health care was integrated at the program level. Overall, PBHCI programs also served many consumers with high rates of physical health care needs, although total program enrollment was lower than expected. The results of a small, comparative effectiveness study showed that consumers served at PBHCI clinics (compared to those served at matched control clinics) showed improvements on some (e.g., markers of dyslipidemia, hypertension, diabetes) but not all of the physical health indicators studied (e.g., smoking, weight). Finally, we found that program features, such as clinic hours, regular staff meetings, and the degree of service integration, increased consumer access to integrated care, but that access to integrated care was not directly associated with improvements in physical health. Implications of the study results for programs and the broader field, plus options for future PBHCI-related research are discussed.

Evaluation of a center of excellence program for spine surgery.

BACKGROUND: The Centers for Medicare and Medicaid Services and many private health plans are encouraging patients to seek orthopedic care at hospitals designated as centers of excellence. No evaluations have been conducted to compare patient outcomes and costs at centers of excellence versus other hospitals. The objective of our study was to assess whether hospitals designated as spine surgery centers of excellence by a group of over 25 health plans provided higher quality care. METHODS: Claims representing approximately 54 million commercially insured individuals were used to identify individuals aged 18-64 years with 1 of 3 types of spine surgery in 2007-2009: 1-level or 2-level cervical fusion (referred to as cervical simple fusion), 1-level or 2-level lumbar fusion (referred to as lumbar simple fusion), or lumbar discectomy and/or decompression without fusion. The primary outcomes were any complication (7 complications were captured) and 30-day readmission. The multivariate models controlled for differences in age, sex, and comorbidities between the 2 sets of hospitals. RESULTS: A total of 29,295 cervical simple fusions, 27,214 lumbar simple fusions, and 28,911 lumbar discectomy/decompressions were identified, of which 42%, 42%, and 47%, respectively, were performed at a hospital designated as a spine surgery center of excellence. Designated hospitals had a larger number of beds and were more likely to be an academic center. Across the 3 types of spine surgery (cervical fusions, lumbar fusions, or lumbar discectomies/decompressions), there was no difference in the composite complication rate [OR 0.90 (95% CI, 0.72-1.12); OR 0.98 (95% CI, 0.85-1.13); OR 0.95 (95% CI, 0.82-1.07), respectively] or readmission rate [OR 1.03 (95% CI, 0.87-1.21); OR 1.01 (95% CI, 0.89-1.13); OR 0.91 (95%, CI 0.79-1.04), respectively] at designated hospitals compared with other hospitals. CONCLUSIONS: On average, spine surgery centers of excellence had similar complication rates and readmission rates compared with other hospitals. These results highlight the importance of empirical evaluations of centers of excellence programs.

Evaluation of centers of excellence program for knee and hip replacement.

BACKGROUND: Medicare and private plans are encouraging individuals to seek care at hospitals that are designated as centers of excellence. Few evaluations of such programs have been conducted. This study examines a large national initiative that designated hospitals as centers of excellence for knee and hip replacement. OBJECTIVE: Comparison of outcomes and costs associated with knee and hip replacement at designated hospitals and other hospitals. RESEARCH DESIGN: Retrospective claims analysis of approximately 54 million enrollees. STUDY POPULATION: Individuals with insurance from one of the sponsors of this centers of excellence program who underwent a primary knee or hip replacement in 2007-2009. OUTCOMES: Primary outcomes were any complication within 30 days of discharge and costs within 90 days after the procedure. RESULTS: A total of 80,931 patients had a knee replacement and 39,532 patients had a hip replacement of which 52.2% and 56.5%, respectively, were performed at a designated hospital. Designated hospitals had a larger number of beds and were more likely to be an academic center. Patients with a knee replacement at designated hospitals did not have a statistically significantly lower overall complication rate with an odds ratio of 0.90 (P=0.08). Patients with hip replacement treated at designated hospitals had a statistically significant lower risk of complications with an odds ratio of 0.80 (P=0.002). There was no significant difference in 90-day costs for either procedure. CONCLUSIONS: Hospitals designated as joint replacement centers of excellence had lower rates of complications for hip replacement, but there was no statistically significant difference for knee replacement. It is important to validate the criteria used to designate centers of excellence.

CMS Innovation Center Health Care Innovation Awards: Evaluation Plan.

The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.

Measuring success for health care quality improvement interventions.

BACKGROUND: The lack of a standard measure of quality improvement (QI) success and the use of subjective or self-reported measures of QI success has constrained efforts to formally evaluate QI programs and to understand how the various contextual factors impact QI success. OBJECTIVES: The objective of this study was to assess how best to measure "QI success" by comparing self-reported and externally rated measures of QI success. RESEARCH DESIGN: We performed a retrospective evaluation that analyzed data on different measures of QI success for organizations after their staff completed the QI training. SUBJECTS: The sample included 30 organizations whose staff had received QI training during 2006-2008, and who had used this training to carry out at least some subsequent QI initiative in their organizations. MEASURES: We developed 2 measures of self-reported QI success based on survey responses and 4 externally rated measures of QI success based on outcome data provided by the participating organizations in addition to qualitative data generated from the interviews. RESULTS: We found some variation in the mean scores of the different QI success measures and only moderate to small correlations between the self-report and externally rated QI measures. CONCLUSIONS: This study confirms that there are important differences between self-reported and externally rated measures of QI success and provides researchers with a methodology and criteria to externally rate measures of QI success.