Measuring Value in Health Care: The Times, They Are A Changin'.

Policy makers struggle to measure value in health care, and yet there is the recurring question: Is our present system of quality metrics too costly and burdensome? We need to develop measures promoting shared accountability across settings and providers, identify and develop meaningful outcome measures, and reduce the burden on providers of data collection.

A+KIDS, a web-based antipsychotic registry for North Carolina youths: an alternative to prior authorization.

OBJECTIVE: The rise in use of antipsychotics among U.S. children is well documented. Compliance rates with current safety-monitoring guidelines are low. In response, the North Carolina Division of Medical Assistance established the Antipsychotics-Keeping It Documented for Safety (A+KIDS) registry. The initial objectives of the project were to successfully establish a Web-based safety registry and to obtain and evaluate clinical information derived from the registry. METHODS: In April 2011, A+KIDS began asking prescribers of antipsychotics for children age 12 and under to respond to a set of questions regarding dose, indication, and usage history. Antipsychotic registrations were examined by linking North Carolina Medicaid prescription claims to registry entries. Prescribers were classified into different types, and the number of patients and registrations per prescriber were examined. RESULTS: In the initial six months, 730 prescribers registered 5,532 patients, 19% below age seven. By month 6 of the registry, 72% of all fills were registered with the program. Top diagnosis groups for registry patients were unspecified mood disorders, autism spectrum disorders, and disruptive behavior disorders. Top target symptoms were aggression (48%), irritability (19%), and impulsivity (11%). Psychosis accounted for 5% of the target symptoms. Twenty-eight percent of children were receiving no form of psychotherapy. Twenty-five percent of all A+KIDS prescribers were responsible for 81% of the registrations. CONCLUSIONS: The A+KIDS registry initiative has been successful, as measured by rapid uptake, and is providing clinical information not available from claims data alone. Future efforts will allow for detailed examinations of antipsychotic utilization and further safety improvement.

Pharmacist and physician satisfaction and rates of switching to preferred medications associated with an instant prior authorization program for proton pump inhibitors in the North Carolina Medicaid program.

BACKGROUND: Proton pump inhibitors (PPIs) are among the highest expenditure drugs covered by health care plans. During fiscal year 2001-2002, Medicaid programs nationwide spent nearly $2 billion on PPIs. Although the costs of individual PPIs vary widely, there is little variation in therapeutic effectiveness. On June 1, 2007, the North Carolina Medicaid program implemented an "instant approval" option simultaneously with a prior authorization (PA) program for PPIs with the goal of managing costs and maintaining high-quality care. Preferred PPIs included generic omeprazole and Prilosec OTC. This instant approval process (IAP) was expected to impose less administrative burden than is typically associated with PA programs by permitting physician and nonphysician prescribers to either write the PA criteria directly on a prescription form or use "MD Easy," a preprinted form that could be faxed by the prescriber to the dispensing pharmacy. A previous study found that from the prescriber's perspective the IAP reduced practice-related administrative burden and was associated with a reduced gap in PPI therapy when compared with traditional PA. OBJECTIVE: To evaluate the acceptability and effectiveness of this IAP for PPIs as assessed by the outcome measures of (a) pharmacist satisfaction with the IAP; (b) physician and pharmacist satisfaction with the MD Easy form; and (c) utilization rates for preferred PPIs, comparing medical practices that used the MD Easy form with practices that did not. METHODS: A cross-sectional design was used to assess pharmacist and physician satisfaction. A stratified random sample of 240 pharmacies was selected from 1,561 North Carolina pharmacies with claims in the Medicaid claims data file during state fiscal year 2006. Additionally, a stratified random sample of 240 medical practices was selected from 1,045 primary care practices serving Medicaid beneficiaries during 2006. Surveys were administered to pharmacists using either in-person interviews or self-administered questionnaires and to physicians using a mailed questionnaire with follow-up to nonrespondents. An interrupted time series analysis was used to evaluate the effect of the MD Easy form on switching to preferred PPIs using paid Medicaid claims of surveyed practices from calendar year 2007. Practices that reported both using the IAP and receiving the MD Easy form were defined as MD Easy users. Monthly market share data were analyzed using log negative binomial regression models to account for autocorrelation in the time series data. RESULTS: The pharmacy survey was completed by 202 (84.2%) pharmacies selected for participation. Of 198 permanently employed pharmacists, 140 (70.7%) reported experience with the IAP for PPIs. More than two-thirds (68.6%) of the pharmacist respondents with IAP experience indicated that the IAP is better (34.3%) or much better (34.3%) than traditional PA with RESEARCH respect to overall administrative burden of phone calls, faxes, patient interactions, and doctor contacts. Surveys were completed by 171 (71.3%) of selected physician practices, of which 56 (32.7%) reported experience with the MD Easy forms. Of practices that recalled receiving the MD Easy forms, 52 of 56 (92.9%) reported that the forms "very much" or "somewhat" helped prevent gaps in PPI therapy; 54 of 55 (98.2%) reported that they helped identify patients affected by Medicaid PPI PA; and 100% reported that they helped physicians to follow PA requirements. Immediately after implementation of the IAP and MD Easy form, the observed market share of preferred PPIs increased by 4.1 times (95% CI = 3.57-4.62). From May to June 2007, the preferred PPI market share increased by 64.0 percentage points, from 19.3% to 83.3% (P < 0.001), for practices that reported using the IAP and receiving the MD Easy form (n = 56) and by 55.4 percentage points, from 21.8% to 77.2% (P < 0.001), for practices that either (a) reported not receiving the MD Easy form (n = 25) or (b) reported not using the IAP (n = 84) or (c) did not respond to the survey item asking about the MD Easy form (n = 4). The overall increase in preferred PPI market share after implementation of the IAP was 1.29 times higher for practices that used the MD Easy form than for those that did not based on negative binomial regression modeling; this difference approached statistical significance (95% CI = 1.00-1.68; P = 0.053). CONCLUSION: This study suggests that an IAP for PPIs using either handwritten prescriptions or a preprinted form is an effective alternative to traditional PA. The IAP was associated with an increase in market share for preferred PPIs and was perceived by pharmacists as less administratively burdensome than traditional PA. Additional studies are needed to determine sustainability and the applicability to other prescription drugs.

A physician-friendly alternative to prior authorization for prescription drugs.

OBJECTIVE: To determine if the instant approval (IA) process differs from the traditional prior authorization (PA) process in preferred drug channeling, resultant gaps in therapy, and provider dissatisfaction. STUDY DESIGN: An interrupted time series analysis using pharmacy claims and a retrospective cohort study. METHODS: The study assessed changes in preferred drug use and subsequent cost reductions. A retrospective cohort study determined if the IA process produced fewer gaps in therapy than the PA process. Provider acceptance of the IA process was assessed using a brief survey of 240 randomly selected primary care practices. RESULTS: Market share for preferred proton pump inhibitors quadrupled from a range of 17.6% to 19.3% at baseline to 76% in the first month after implementation of the new IA policy. Most practices (81.1%) reported reduced administrative burden with the IA process. The median gaps between medication fills for patients using IA were approximately one-half those of patients using PA (P <.001) and were one-fourth in a subset of highly adherent, regularly filling patients (P <.001). CONCLUSIONS: Instant approval may be more patient friendly and prescriber friendly than PA as assessed by a proxy measure for access (gap in therapy) and physician-reported acceptance. Despite its ease of use, IA does not seem to reduce switching to preferred drugs.

The medical home--improving quality of primary care for children.

The concept of a medical home appears to be a key driver for enhancing the value of health services as care systems are transitioned to meet the ongoing challenges of improving quality and containing costs. This article provides an overview of the challenges faced in United States health care delivery systems that affect child health, explains how the medical home might address them, describes methods for measuring quality in medical homes, and identifies barriers to implementation of the model.

Estimated savings from paid telephone consultations between subspecialists and primary care physicians.

OBJECTIVES: Pediatric subspecialists are not routinely reimbursed by Medicaid or insurance payers for telephone consultations. Generally, access to pediatric subspecialists is limited because of the small number of providers, their concentration in academic medical centers, and increasing demand for their services. Little is known about the nature of such consults, the time required to provide them, or whether there is a positive economic impact for payers. METHODS: Between March and October of 2007, pediatric subspecialists from 6 academic medical centers in North Carolina completed consultation reimbursement-request forms to prospectively track their telephone consultations with primary care physicians for the care of Medicaid patients<22 years of age. Data collected included the amount of time required per consult and consult outcomes in terms of service use and quality of care. Medicaid claims records and primary care physician surveys were used to validate the pediatric subspecialist consultation outcomes. RESULTS: A total of 47 pediatric subspecialists provided 306 consults regarding the care of 292 Medicaid-insured children over the 8 study months. Telephone consults were generally <15 minutes in length and exceeded 30 minutes in <7% of calls. Pediatric subspecialists reported that telephone consults led to avoidance of specialist visits (n=98), hospital transfers (n=35), hospital admissions (n=14), and emergency department visits (n=14). Medicaid claims data supported these reports; matched primary care physician surveys suggested even higher levels of service avoidance. After adjusting for the reimbursed costs of providing telephone consults, an estimated $477274 was saved ($39 per dollar spent). CONCLUSIONS: Telephone consultations with pediatric subspecialists provide a valuable service to primary care physicians providing medical homes to Medicaid patients. Rewarding physicians for telephone consults seems to be cost-effective because of reduced use of costly services and reported improvements in quality of care.