Economic Evaluation of New Models of Care: Does the Decision Change Between Cost-Utility Analysis and Multi-Criteria Decision Analysis?

OBJECTIVES: To experiment with new approaches of collaboration in healthcare delivery, local authorities implement new models of care. Regarding the local decision context of these models, multi-criteria decision analysis (MCDA) may be of added value to cost-utility analysis (CUA), because it covers a wider range of outcomes. This study compares the 2 methods using a side-by-side application. METHODS: A new Dutch model of care, Primary Care Plus (PC+), was used as a case study to compare the results of CUA and MCDA. Data of patients referred to PC+ or care-as-usual were retrieved by questionnaires and administrative databases with a 3-month follow-up. Propensity score matching together with generalized linear regression models was used to reduce confounding. Univariate and probabilistic sensitivity analyses were performed to explore uncertainty in the results. RESULTS: Although both methods indicated PC+ as the dominant alternative, complementary differences were observed. MCDA provided additional evidence that PC+ improved access to care (standardized performance score of 0.742 vs 0.670) and that improvement in health-related quality of life was driven by the psychological well-being component (standardized performance score of 0.710 vs 0.704). Furthermore, MCDA estimated the budget required for PC+ to be affordable in addition to preferable (€521.42 per patient). Additionally, MCDA was less sensitive to the utility measures used. CONCLUSIONS: MCDA may facilitate an auditable and transparent evaluation of new models of care by providing additional information on a wider range of outcomes and incorporating affordability. However, more effort is needed to increase the usability of MCDA among local decision makers.

Analyzing Cost-Effectiveness of Allocating Neurointerventionist for Drive and Retrieve System for Patients with Acute Ischemic Stroke.

OBJECTIVES: There are regional disparities in implementation rates of endovascular thrombectomy due to time and resource constraints such as endovascular thrombectomy specialists. In Hokkaido, Japan, Drive and Retrieve System (DRS), where endovascular thrombectomy specialists perform early endovascular thrombectomies by traveling from the facilities where they normally work to facilities closer to the patient. This study analyzed the cost-effectiveness of allocating a endovascular thrombectomy specialist for DRS to treat stroke patients. MATERIALS AND METHODS: he number of ischemic stroke patients expected to receive endovascular thrombectomy in Hokkaido in 2015 was estimated. It was assumed that an additional neutointerventionist was allocated for DRS. The analysis was performed from the government's perspective, which includes medical and nursing-care costs, and the personnel cost for endovascular thrombectomy specialist. The analysis was conducted comparing the current scenario, where patients received endovascular thrombectomy in facilities where endovascular thrombectomy specialists normally work, with the scenario with DRS within 60 min drive distance. Patient transport time was analyzed using geographic information system, and patient severity was estimated from the transport time. The primary outcome was incremental cost-effectiveness ratio (ICER) in each medical area which was calculated from the incremental costs and the incremental quality-adjusted life years (QALYs), estimated from patient severity using published literature. The entire process was repeated 100 times. RESULTS: DRS was most cost-effective in Kamikawachubu area, where the ICER was $14,173±16,802/QALY, significantly lower than the threshold that the Japanese guideline suggested. CONCLUSIONS: Since DRS was cost-effective in Kamikawachubu area, the area should be prioritized when a endovascular thrombectomy specialist for DRS is allocated as a policy.

Economic assessment of changes to an existing medication therapy management program of a large regional health plan.

BACKGROUND: Although medication therapy management (MTM) has specific eligibility criteria and is mandated for specific Medicare Part D enrollees, some health plans have expanded MTM eligibility beyond the minimum criteria to include other Medicare Part D enrollees, Medicaid, and commercial health plan patients. Differences exist in the mode of delivery, location of services, type of personnel involved in managing the service, and the subsequent outcomes. The type and intensity of MTM services delivered have evolved with time to more streamlined and robust interventions, necessitating ongoing evaluation of the effect on clinical and economic outcomes. OBJECTIVE: To assess the effect of changes to an existing MTM program on cost of care, utilization, and medication adherence. METHODS: UPMC Health Plan made changes to an existing MTM program by expanding eligibility (customized by the type of health plan), intervention types, pharmacist involvement, and patient followup contacts. After matching our intervention cohort (identified January 2017-June 2018) with the pre-2016 MTM historical controls (patients identified January 2014-June 2015 who would have been eligible if we used the intervention cohort eligibility criteria), we estimated that the effect of the program changes with a difference-in-difference model (preintervention [2014-2016] and postintervention [2017-2019]). Outcomes of interest included cost (total cost of care including medical, pharmacy, and unplanned care [i.e., unscheduled health care use such as emergency department visits] in 2017 U.S. dollars); utilization; medication adherence (proportion of days covered); and return on investment (ROI). Target population included continuously enrolled patients aged ≥ 21 years in the commercial, Medicare, and Medicaid health plans. RESULTS: Total propensity score-matched members was 10,747, 55% of which were in the historic control group. The average (SD) ages after matching the groups were similar (historical control group: 57.08 years [14.23], intervention group: 56.79 years [14.21]) and the majority was female (57%). Comorbidities identified most for patients included hypertension (77%), dyslipidemia (70%), and diabetes (52%). Forty-one percent were in the commercial, 37% in the Medicaid, and 23% in the Medicare health plans. Proportion of care activities undertaken in the intervention period compared with the control period were significantly different: "sent letter to physician" (67% vs. 87%), "sent letter to member" (15% vs. 0%), "pharmacist phone call to physician" (15% vs. 0.1%), and "pharmacist phone call to member" (13% vs. 7%). There were statistically significant reductions in unplanned care across all health plans especially in the Medicare population, in total cost of care, and increases in medication adherence in 4 therapeutic classes: anticoagulants (OR = 1.25, P = 0.005), cardiac medications (OR = 1.20, P < 0.001), statins (OR = 1.21, P < 0.001), and antidepressants (OR = 1.15, P < 0.001). There was a positive ROI of $18.50 per dollar spent, which equated to a cumulative net savings of $11 million over 24 months. CONCLUSIONS: In a large health plan, expanding MTM eligibility, intensifying patient follow-up contact and pharmacist involvement, and improving provider awareness had favorable clinical and economic benefits. DISCLOSURES: There was no funding for this project except employees' time. All authors are employees of UPMC and have no conflicts of interest to report.

Budget Impact of Enzalutamide for Nonmetastatic Castration-Resistant Prostate Cancer.

BACKGROUND: Prostate cancer is the most common cancer and second-leading cause of cancer death among men in the United States. Prostate cancer poses a large economic burden, which increases with progression from localized to metastatic disease. Newly approved treatments for non-metastatic castration-resistant prostate cancer (nmCRPC) delay disease progression and reduce the risk of metastatic disease. Quantifying the potential budget impact of these new treatments is of interest to health care decision makers. OBJECTIVE: To estimate the budget impact of enzalutamide for the treatment of patients with nmCRPC in the United States over a 3-year time horizon. METHODS: An Excel-based model was developed to estimate the budget impact to a U.S. health plan of enzalutamide, a second-generation antiandrogen, as an add-on to androgen deprivation therapy (ADT) for the treatment of high-risk nmCRPC patients (prostate-specific antigen doubling time of ≤ 10 months). Comparators include apalutamide + ADT, bicalutamide + ADT, and ADT only. The analysis includes treatment costs for nmCRPC and for treatment after progression to metastatic castration-resistant prostate cancer (mCRPC). The treated population size was estimated from epidemiological data and literature. Dosing, duration of therapy, and adverse event rates were based on package inserts and pivotal studies. RED BOOK, Centers for Medicare & Medicaid Services fee schedules, and literature were used to obtain costs of drugs, adverse events, and health care visits. Market shares were estimated for each comparator before and after enzalutamide adoption. A 1-way sensitivity analysis was performed to quantify the impact of parameter uncertainty. RESULTS: In a hypothetical 1-million-member plan with 3% annual growth, it was estimated that there would be approximately 19 eligible incident nmCRPC patients in year 1, increasing to 20 eligible incident patients in year 3. With an assumed market share of approximately 6% for enzalutamide in year 1, the budget impact would be $106,074 ($0.009 per member per month [PMPM]). With a 26% enzalutamide share in year 3, the budget impact would be $632,729 ($0.048 PMPM). Cumulative budget impact to the health plan over 3 years is estimated to be $1,082,095 ($0.028 PMPM). The increased cost of the treatment regimen is partly offset by reduced postprogression costs. CONCLUSIONS: Treatment of nmCRPC patients with enzalutamide has a modest budget impact that is partly offset by delaying progression to mCRPC. DISCLOSURES: This research was sponsored by Astellas Pharma and Pfizer, the codevelopers of enzalutamide. All authors contributed to the development of the manuscript and maintained control over the final content. Schultz is employed by Astellas Pharma and owns stock in Gilead Sciences and Shire. O'Day and Sugarman are employees of Xcenda, which received consultancy fees from Astellas Pharma. Ramaswamy is employed by Pfizer. A synopsis of the current study was presented in poster format at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2019, in San Diego, CA, on March 25-28, 2019.

Cost-Effectiveness of Exploratory Laparotomy in a Regional Referral Hospital in Eastern Uganda.

BACKGROUND: Surgical disease increasingly contributes to global mortality and morbidity. The Lancet Commission on Global Surgery found that global cost-effectiveness data are lacking for a wide range of essential surgical procedures. This study helps to address this gap by defining the cost-effectiveness of exploratory laparotomies in a regional referral hospital in Uganda. MATERIALS AND METHODS: A time-and-motion analysis was utilized to calculate operating theater personnel costs per case. Ward personnel, administrative, medication, and supply costs were recorded and calculated using a microcosting approach. The cost in 2018 US Dollars (USD, $) per disability-adjusted life year (DALY) averted was calculated based on age-specific life expectancies for otherwise fatal cases. RESULTS: Data for 103 surgical patients requiring exploratory laparotomy at the Soroti Regional Referral Hospital were collected over 8 mo. The most common cause for laparotomy was small bowel obstruction (32% of total cases). The average cost per patient was $75.50. The postoperative mortality was 11.7%, and 7.8% of patients had complications. The average number of DALYs averted per patient was 18.51. The cost in USD per DALY averted was $4.08. CONCLUSIONS: This investigation provides evidence that exploratory laparotomy is cost-effective compared with other public health interventions. Relative cost-effectiveness includes a comparison with bed nets for malaria prevention ($6.48-22.04/DALY averted), tuberculosis, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY averted). Given that the total burden of surgically treatable conditions in DALYs is more than that of malaria, tuberculosis, and HIV combined, our findings strengthen the argument for greater investment in primary surgical capacity in low- and middle-income countries.

Cost Effectiveness of Drive and Retrieve System in Hokkaido for Acute Ischemic Stroke Patient Treatment Using Geographic Information System.

BACKGROUND AND PURPOSE: Although endovascular thrombectomy combined with recombinant tissue-type plasminogen activator is effective for treatment of acute ischemic stroke, regional disparities in implementation rates of those treatments have been reported. Drive and retrieve system, where a qualified neurointerventionist travels to another primary stroke center for endovascular thrombectomy, has been practiced in parts of Hokkaido, Japan. This study aims to simulate the cost effectiveness of the drive and retrieve system, which can be a method to enhance equality and cost effectiveness of treatments for acute ischemic stroke. MATERIALS AND METHODS: The number of patients who had acute ischemic stroke in 2015 is estimated. Those patients are generated according to the population distribution, and thereafter patient transport time is analyzed in the 3 scenarios (1) 60-minute drive scenario, (2) 90-minute drive scenario, in which the drive and retrieve system operates within 60-minute or 90-minute driving distance (3) without the system, using geographic information system. Incremental cost-effectiveness rate, quality-adjusted life years, and medical and nursing care costs are estimated from the analyzed transport time. FINDINGS: The incremental cost-effectiveness rate by implementing the system was dominant. Cost reductions of $213,190 in 60-minute drive scenario, and $247,274 in the 90-minute scenario were expected, respectively. Such benefits are the most significant in Soya, Emmon, Rumoi, and Kamikawahokubu medical areas. CONCLUSIONS: The drive and retrieve system could enhance regional equality and cost effectiveness of ischemic stroke treatments in Hokkaido, which can be achieved using existing resources. Further studies are required to clarify its cost effectiveness from hospital perspective.

Lei n. 141/2012 e seus aspectos: Aplicação de Recursos dos Estados, DF e Municípios

Foi publicada no dia 13 de janeiro de 2012 a Lei Complementar n. 141, que regulamenta a Emenda Constitucional n. 29, com a definição sobre a aplicação de recursos em ações e serviços de saúde por parte da União, estados e Distrito Federal, e municípios brasileiros. Ela também esclarece critérios de rateio de recursos e transferências para a saúde, assim como para fiscalização, avaliação e controle das despesas nas três esferas de governo e revoga dispositivos das leis n. 8.080, de setembro de 1990, e n. 8.698, de julho de 1993. Tendo em vista a importância da Lei para a gestão do SUS, o CONASS promoveu uma reunião ampliada entre a sua Câmara Técnica de Gestão e Financiamento (CTGF), o Ministério da Saúde e especialistas em orçamento público, no dia 6 de março de 2012, em Brasília/DF.

What drives variation in spending for breast cancer patients within geographic regions?

OBJECTIVE: To estimate and describe factors driving variation in spending for breast cancer patients within geographic region. DATA SOURCE: Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 2009-2013. STUDY DESIGN: The proportion of variation in monthly medical spending within geographic region attributed to patient and physician factors was estimated using multilevel regression models with individual patient and physician random effects. Using sequential models, we estimated the contribution of differences in patient and disease characteristics or use of cancer treatment modalities to patient-level and physician-level variance in spending. Services associated with high spending physicians were estimated using linear regression. DATA EXTRACTION METHOD: A total of 20 818 women with a breast cancer diagnosis in 2010-2011. PRINCIPAL FINDINGS: We observed substantial between-patient and between-provider variation in spending following diagnosis and at the end-of-life. Immediately following diagnosis, 48% of between-patient and 31% of between-physician variation were driven by differences in delivery of cancer treatment modalities to similar patients. At the end-of-life, patients of high spending physicians had twice as many inpatient days, double the chemotherapy spending, and slightly more hospice days. CONCLUSIONS: Similar patients receive very different treatments, which yield significant differences in spending. Efforts to reduce unwanted variation may need to target treatment choices within patient-doctor discussions.

Advantages and disadvantages of channeling Gavi's health system strengthening funds through health partners, a case study.

INTRODUCTION: Following a period of interruption of Gavi's funds for health system strengthening (HSS) in Cameroon and Chad, the two countries reprogramed their HSS grants. To implement the reprogrammed HSS, Chad committed to better management of the funds. Cameroon chose to channel the HSS funds through one of the health partners. This process is new to Gavi's HSS grants, and little is known about its effectiveness or characteristics. We investigated the advantages and disadvantages of this process to inform the global health community about the added value of this solution. MATERIALS AND METHODS: We retrospectively evaluated Gavi's HSS programs in Cameroon and Chad through a mixed methodology. To explore the pros and cons of channeling the funds through a health partner, we triangulated data from document review, key informant interviews (KIIs), field visits, and financial analysis of HSS expenditures in both countries. RESULTS: Data triangulated from multiple sources showed that channeling HSS funds thorugh a health partner in Cameroon allowed compliance with budget, the development of a stronger accounting system at the Ministry of Health (MOH), and a rigid monitoring system. However, this mechanism delayed implementation by six months, accounted for 15% of the total cost, and created a tension around roles between MOH and the health partner. Achievement of program's output indicators was average. In Chad, expenditures complied with budget as well. However, implementation was delayed longer causing a second reprogramming of the funds. While the program had fewer output indicators in Chad, these were minimally achieved. DISCUSSION: To our knowledge, this is the first study of channeling Gavi HSS funds through a health partner. This new process contributed to a higher level of implementation, stronger monitoring, and strengthened accountability in Cameroon. Recipient countries of Gavi HSS grants who lack the financial management capacity can benefit from a similar process.

Regional initiatives for malaria elimination: Building and maintaining partnerships.

Andrew Lover and colleagues discuss regional malaria initiatives, the strengths and challenges.

The health regionalization process from the perspective of the transation cost theory. / O processo de regionalização da saúde sob a ótica da teoria dos custos de transação.

This study analyzes the incidence of transaction costs in the regionalization process of health policies in the Brazilian federal system. In this work, regionalized health actions contracted and agreed between federal agencies have assumed a transactional nature. A conceptual theoretical essay of reflective nature was prepared with the purpose of questioning and proposing new approaches to improve the health regionalization process. The main considerations suggest that institutional management tools proposed by the standards and regulations of the Unified Health System have a low potential to reduce transaction costs, especially due to hardships in reconciling common goals among the entities, environment surrounded by uncertainty, asymmetries and incomplete information, bounded rationality and conflict of interest. However, regionalization can reduce the incidence of social and/or operational costs, through improved access to health and the construction of more efficient governance models.

O processo de regionalização da saúde sob a ótica da teoria dos custos de transação / The health regionalization process from the perspective of the transation cost theory

Resumo O estudo analisa a incidência dos custos de transação no processo de regionalização das políticas de atenção à saúde no sistema federativo brasileiro. As ações de saúde regionalizadas, contratadas e pactuadas entre os entes federados assumiram neste trabalho o caráter de transação. Foi elaborado um ensaio teórico conceitual de natureza reflexiva com o propósito de problematizar e propor novas abordagens para as melhorias no processo de regionalização da saúde. As principais considerações apontam que os instrumentos institucionais de gestão propostos pelas normativas e regulamentações do Sistema Único de Saúde apresentam baixo potencial para reduzir os custos de transação, especialmente devido a dificuldades na conciliação de objetivos comuns entre os entes, ambientes cercados de incertezas, assimetrias e informações incompletas, racionalidade limitada e conflito de interesses. Entretanto, o processo de regionalização pode reduzir a incidência de custos sociais e/ou operacionais, através do melhoramento do acesso à saúde e na construção de modelos de governança mais eficientes.

Abstract This study analyzes the incidence of transaction costs in the regionalization process of health policies in the Brazilian federal system. In this work, regionalized health actions contracted and agreed between federal agencies have assumed a transactional nature. A conceptual theoretical essay of reflective nature was prepared with the purpose of questioning and proposing new approaches to improve the health regionalization process. The main considerations suggest that institutional management tools proposed by the standards and regulations of the Unified Health System have a low potential to reduce transaction costs, especially due to hardships in reconciling common goals among the entities, environment surrounded by uncertainty, asymmetries and incomplete information, bounded rationality and conflict of interest. However, regionalization can reduce the incidence of social and/or operational costs, through improved access to health and the construction of more efficient governance models.

Possible consequences of regionally based bundled payments for diabetic amputations for safety net hospitals in Texas.

OBJECTIVE: Ongoing health reform in the United States encourages quality-based reimbursement methods such as bundled payments for surgery. The effect of such changes on high-risk procedures is unknown, especially at safety net hospitals. This study quantified the burden of diabetes-related amputation and the potential financial effect of bundled payments at safety net hospitals in Texas. METHODS: We performed a cross-sectional analysis of diabetic amputation burden and charges using publically available data from Centers for Medicare and Medicaid and the Texas Department of Health from 2008 to 2012. Using hospital referral region (HRR)-level analysis, we categorized the proportion of safety net hospitals within each region as very low (0%-9%), low (10%-20%), average (20%-33%), and high (>33%) and compared amputation rates across regions using nonparametric tests of trend. We then used charge data to create reimbursement rates based on HRR to estimate financial losses. RESULTS: We identified 51 adult hospitals as safety nets in Texas. Regions varied in the proportion of safety net hospitals from 0% in Victoria to 65% in Harlingen. Among beneficiaries aged >65, amputation rates correlated to the proportion of safety net hospitals in each region; for example, patients in the lowest quartile of safety net had a yearly rate of 300 amputations per 100,000 beneficiaries, whereas those in the highest quartile had a yearly rate of 472 per 100,000 (P = .007). Charges for diabetic amputation-related admissions varied almost 200-fold, from $5000 to $1.4 million. Using reimbursement based on HRR to estimate a bundled payment, we noted net losses would be higher at safety net vs nonsafety net hospitals ($180 million vs $163 million), representing a per-hospital loss of $1.6 million at safety nets vs $700,000 at nonsafety nets (P < .001). CONCLUSIONS: Regions with a high proportion of safety net hospitals perform almost half of the diabetic amputations in Texas. Changes to traditional payment models should account for the disproportionate burden of high-risk procedures performed by these hospitals.

Regionalization: What Have We Learned?

Regionalization is arguably the most significant health reform in Canada since medicare. Although a majority of provinces continue to have regionalized systems in Canada, the policy is more contested today than it was a decade ago. Since Ontario's implementation of local health integration networks (LHINs) in 2006 and Alberta's elimination of regional health authorities (RHAs) in favour of Alberta Health Services in 2008, Canada has had differing approaches to regionalization. However, due to the centralization of physician budgets in provincial health ministries, primary care has not been integrated into any regionalization model in Canada. This factor has severely constrained the performance of RHAs and their ability to meet their respective legislative mandates. Moreover, the lack of research on regionalization has meant that provincial governments are working from an extremely limited evidence base on which to make critical decisions on the structuring of health systems in Canada.

Regionalization Lessons from Denmark.

Denmark is a small Northern European country with an extensive welfare state and a strong commitment to maintaining a universal healthcare system. Like the other countries in the Nordic region, Denmark has a long tradition of democratically governed local and regional governments with extensive responsibilities in organizing welfare state services. The Danish healthcare system has demonstrated an ability to increase productivity, while at the same time maintaining a high level of patient satisfaction. Ongoing reforms have contributed to these results, as well as a firm commitment to innovation and coordination. Regions and municipalities in Denmark are governed by directly elected democratic councils. The Danish case is thus an example of democratic decentralization, but within a framework of national coordination and fiscal control. In spite of the difference in size and historical traditions there are also many similarities between Canada and Denmark, particularly in terms of health and social policy goals and aspirations, and in terms of the commitment to a comprehensive, universal healthcare system. These similarities provide interesting opportunities for comparison.

Health System Regionalization - the New Zealand Experience.

New Zealand's health system has many similarities with Canada, and also has longstanding experience with regionalization of healthcare services. Since 2001, the most important change has been the development of regional primary healthcare organizations funded according to population characteristics. This significant change has created the potential for a more integrated health system. However, barriers remain in realizing this potential. The key challenges include dealing with inter-organizational complexity and finding the right balance between hierarchical and collaborative relationships between the state and non-government providers. Although New Zealand governments have greater capacity to make changes to organizational and policy changes, professional interests retain considerable capacity to shape policy outcomes through implementation.

The Politics of Regionalization.

Regardless of their policy outcomes, strategies of regionalization are prevalent because they are politically useful. They permit governments to be seen addressing serious systemic problems in the healthcare system without fundamentally upsetting the face-to-face relationship between physicians and patients. They shift the responsibility for unpopular policies, including the consolidation of services, away from provincial governments. They can be part of a larger process of decentralizing power that is undertaken for larger, non-health-related reasons. They can also serve as a strategy of disruption that destabilizes the bases of influence enjoyed by specific stakeholder groups. For epistemological reasons, it is difficult to determine with any certainty what the specific outcomes of regionalization are. Thus, to mitigate the utilization of regionalization for politically advantageous reasons, it is useful not only to catalogue the outcomes of policies of regionalization, but also to identify whose interests are furthered, and whose are hindered, within a strategy of regionalization.

Oregon's Coordinated Care Organizations Increased Timely Prenatal Care Initiation And Decreased Disparities.

Policies at the state and federal levels affect access to health services, including prenatal care. In 2012 the State of Oregon implemented a major reform of its Medicaid program. The new model, called a coordinated care organization (CCO), is designed to improve the coordination of care for Medicaid beneficiaries. This reform effort provides an ideal opportunity to evaluate the impact of broad financing and delivery reforms on prenatal care use. Using birth certificate data from Oregon and Washington State, we evaluated the effect of CCO implementation on the probability of early prenatal care initiation, prenatal care adequacy, and disparities in prenatal care use by type of insurance. Following CCO implementation, we found significant increases in early prenatal care initiation and a reduction in disparities across insurance types but no difference in overall prenatal care adequacy. Oregon's reforms could serve as a model for other Medicaid and commercial health plans seeking to improve prenatal care quality and reduce disparities.