5 Findings From the December 2018 Issue of AJMC®

As 2018 draws to a close, the articles in the December issue of The American Journal of Managed Care^® (AJMC^®) touch on some of the timeliest topics of the year, including the value of innovative immuno-oncology (I-O) treatments, results of practice transformation initiatives, and much more. Here are 5 findings from the research published in the issue.

1. Medicare Advantage plans try to control postacute care costs through authorization requirements

In 154 interviews with staff at Medicare Advantage (MA) plans, hospitals, and skilled nursing facilities (SNFs), researchers gleaned a better understanding of how these plans attempt to control spending on postacute care. Most commonly, MA plans would provide patients with a list of covered SNFs and authorize stays for a certain number of days.

While these restrictions make financial sense for the plans, they often provoke frustration among the hospitals and SNFs. The facilities described receiving no guidance from plans on how to achieve length of stay (LOS) goals and experiencing “a burdensome process of appealing for longer LOS.” The authors wrote that SNFs may avoid working with MA plans they perceive as too authoritative, which could adversely affect patients.

2. Introducing behavioral screening in emergency setting is feasible and indicates high prevalence of symptoms

Integrating a nonclinician into emergency department (ED) idle times to screen patients for behavioral health symptoms is feasible, according to an observational study conducted in an integrated healthcare system’s ED. What’s more, the prevalence of the self-reported behavioral symptoms found by screening was higher than that recorded in electronic health records.

The study authors noted that this screening may be valuable for reaching patients whose only contact with the healthcare system is during ED visits. “Opportunities exist in the idle times that patients experience during ED visits to expand screening to more occult behavioral health problems without disrupting workflow,” they concluded.

3. New I-O treatments yield significant value to society via survival gains

Much excitement has surrounded the clinical promise of I-O treatments, but their economic value is not well understood. A new analysis quantified the value of survival gains with I-O treatments versus the existing standard of care for 2 cancers and compared the societal value of these gains with the pharmaceutical manufacturer’s profits.

The results indicated that survival gains are estimated at $465,000 per patient with ipilimumab for melanoma and $381,000 with nivolumab for non—small cell lung cancer, using a full income of $200,000 per year. Further, pharmaceutical profits constitute 28.4% and 11.8% of total social value for ipilimumab and nivolumab, respectively. According to the authors, these findings “suggest that novel I-O treatments have strong potential to yield not only favorable prognoses but also good value.”

4. Primary care practice transformation did not alter patient experience

Results of patient satisfaction surveys conducted in primary care practices after the 4-year Comprehensive Primary Care (CPC) initiative indicate no significant changes in patient experience, although CPC did have positive effects on measures of follow-up care after hospitalizations and ED visits.

The study is a follow-up to one published in the March 2017 issue of AJMC^® that examined patient experience midway through the CPC initiative and found slightly better patient experience ratings for some items in CPC practices. In the new study, the authors suggested that “the lack of favorable findings raises questions about how future efforts in primary care can succeed in improving patient experience.”

5. Hospital Compare grades and readmission penalties send mixed messages to consumers

An analysis delved into discrepancies between hospitals’ grades for readmissions on the Hospital Compare website and the readmission penalties they incur under the Hospital Readmissions Reduction Program. Many hospitals were penalized despite being publicly graded as “no different” than the national rate.

For instance, 92% of hospitals were graded as “no different” than the national rate for heart failure readmissions, but 86% were penalized for their overall readmissions. The authors raised concerns that these discordant systems send an ambiguous value signal and “highlight persistent uncertainty in how best to identify and link value to payment.”