A scoping review of US insurers' use of patient-reported outcomes.

OBJECTIVES: To complete a scoping review of US health insurers' use of health-related quality of life (HRQOL) patient-reported outcome measures (PROMs). STUDY DESIGN: Literature review. METHODS: A literature search was constructed for articles that contained an insurer-related term and an HRQOL-related term between 1999 and 2019 using the MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, EconLit, and Business Source Complete databases. RESULTS: The search identified 14,253 unduplicated records, of which 2340 passed abstract screening and 350 were included in the review. The populations addressed in these studies included both populations with specific health conditions (eg, diabetes) and an entire member population. The most common purpose of the article was to evaluate a policy or program (n = 255; 72.9%); the range of interventions evaluated included federal policy, subgroup management strategies, and identification of individual patients. The most common insurance mechanism was Medicare (n = 205; 58.6%). The most common source of data was collected specifically for a research project (n = 172; 49.1%), and the least common source of data was collected by providers at the point of care (n = 34; 9.7%). The most commonly addressed age group was 65 years and older (n = 262; 74.9%), and the least commonly addressed was younger than 18 years (n = 36; 10.3%). The most commonly used PROMs were single-item self-rated health (n = 138; 47.1%) and activities of daily living (n = 88; 30.0%), with validated depression questionnaires (n = 56; 19.1%) being the most common disease-focused questionnaire. CONCLUSIONS: This review found a wide variety of articles across insurance providers, health conditions, and uses of PROMs. There is a noted paucity of data in pediatric populations and little information about the use of data collected within health care settings that is transmitted to health insurers.

Professional agency vs consumer directed care workers: Outcomes in managed care.

Direct care workers are a major part of the long-term services and supports (LTSS) needed to address the health of individuals and accounted for $112 billion in United States spending in 2015. Direct care workers are hired within professional agency models (PAMs) or consumer-directed models (CDMs) where workers (including family) are contracted by the individual to obtain services. We sought to identify differences in cost and utilisation outcomes between PAM and CDM participants. Data were obtained from the University of Pittsburgh Medical Center (UPMC) Insurance Services Division from the participants enrolled in UPMC Community HealthChoices in Pennsylvania during 2018. A retrospective, observational cohort study design was performed using claims data. Utilisation outcomes were assessed using multivariate logistic regression and cost outcomes by linear regression. The 3,232 participants met the inclusion criteria. Of these, 69% (N = 2,217) were in a PAM, 23% (N = 752) were in a CDM, and 8% (N = 263) used a combination of services. PAM groups were older (mean 62.4 years vs 54.1 years), more likely to be women (69.0% vs 62.8%), and had more healthcare needs. Hospital utilisation was the same among groups. However, total cost was lower in CDM groups due to differences in LTSS costs between CDM and PAM services. Among dually eligible Medicare and Medicaid beneficiaries receiving LTSS, there are significant differences in age, gender, race and health needs. While hospital utilisation was not different between groups, CDM groups had lower total costs of care compared to PAM. These findings have implications for families, policymakers and insurers in helping to govern community LTSS while supporting member autonomy.

A Systematic Review of Health Outcomes Associated With Provision of Representative Payee Services.

OBJECTIVE: The Social Security Administration's Representative Payment Program appoints payees as financial managers for individuals determined incapable of managing their funds. The aim is to afford stability and increase clients' ability to meet health and behavioral priorities. This systematic review examined literature on the effect of representative payee services on identified outcomes. METHODS: A search of academic databases and gray literature was conducted in November 2015 and repeated in December 2017. Included studies had a comparison group; excluded studies examined services other than representative payee. Primary outcomes included substance use, symptoms of mental illness, housing stability, quality of life, and other health-specific outcomes. Secondary outcomes included the client-payee relationship and client satisfaction with services. RESULTS: Eighteen articles met inclusion criteria. Studies assessing primary outcomes found several positive and few negative effects of representative payee services. Studies examining secondary outcomes indicated that receipt of such services may affect the client-provider relationship, increase conflict and violence, and increase clients' perceptions of financial leverage (i.e., a payee's use of control over funds to encourage, incentivize, or otherwise coerce certain behaviors). Most studies were of poor or moderate quality. Studies spanned nearly two decades, and results may have been confounded by the evolution of service delivery modalities. CONCLUSIONS: Representative payee services are largely beneficial or neutral in terms of health and behavior outcomes. Negative findings mainly involved the client-payee relationship. Given that more than five million individuals have a representative payee, assessing the impact of these services with more rigorous research designs is worthwhile.

Connected Care: improving outcomes for adults with serious mental illness.

OBJECTIVES: To evaluate the effectiveness of Connected Care-a care coordination effort of physical and behavioral health managed care partners in Pennsylvania-on acute service use among adult Medicaid beneficiaries with serious mental illness (SMI). STUDY DESIGN: We examined changes in service utilization using a difference-in-differences model, comparing study group with a comparison group, and conducted key informant interviews to better understand aspects of program implementation. METHODS: We compared the difference in service use rates between baseline year and 2-year intervention period for the Connected Care group (n = 8633) with the difference in rates for the comparison group (n = 10,514), confirming results using a regression adjustment. RESULTS: Mental health hospitalizations (per 1000 members per month) decreased for the Connected Care group from 41.1 to 39.6, while increasing for the comparison group from 33.8 to 37.2 (P = .04). All-cause readmissions within 30 days decreased nearly 10% for Connected Care while increasing slightly for the comparison group (P < .01), with a similar pattern observed for 60- and 90-day all-cause readmissions. No differences were observed in physical health hospitalizations, drug and alcohol admissions, or ED use. Data from qualitative stakeholder interviews illuminated facilitators and barriers of implementing Connected Care. CONCLUSIONS: Payer-level healthcare information sharing can help identify members who could benefit from care coordination services, inform care management activities, and assist with pharmacy management. Results can inform state, health plan, and provider efforts around integration of care for individuals with SMI and improve care efficiencies and quality, which is especially important in this time of Medicaid expansion.

Evidence of Syndemics and Sexuality-Related Discrimination Among Young Sexual-Minority Women.

PURPOSE: Syndemics, or the co-occurrence and interaction of health problems, have been examined extensively among young men who have sex with men, but their existence remain unexamined, to our knowledge, among sexual-minority (i.e., lesbian, gay, and bisexual) women. Thus, we investigated if syndemics were present among young sexual-minority women, and if sexual-orientation discrimination was an independent variable of syndemic production. METHODS: A total of 467 sexual-minority women between the ages of 18 and 24 completed a cross-sectional online survey regarding their substance use, mental health, sexual behaviors, height, weight, and experiences of discrimination. We used structural equation modeling to investigate the presence of syndemics and their relationship to sexual-orientation discrimination. RESULTS: Heavy episodic drinking, marijuana use, ecstasy use, hallucinogen use, depressive symptoms, multiple sexual partners, and history of sexually transmitted infections (STIs) comprised syndemics in this population (chi-square=24.989, P=.201; comparative fit index [CFI]=0.946; root mean square error of approximation [RMSEA]=0.023). Sexual-orientation discrimination is significantly and positively associated with the latent syndemic variable (unstandardized coefficient=0.095, P<.05), and this model fit the data well (chi-square=33.558, P=.059; CFI=0.914; RMSEA=0.029). The reverse causal model showed syndemics is not an independent variable of sexual-orientation discrimination (unstandardized coefficient=0.602, P>.05). CONCLUSIONS: Syndemics appear to be present and associated with sexual-orientation discrimination among young sexual-minority women. Interventions aimed at reducing discrimination or increasing healthy coping may help reduce substance use, depressive symptoms, and sexual risk behaviors in this population.