5 Findings From the May 2019 Issue of AJMC®

The May issue of The American Journal of Managed Care^® featured research on diabetes drug cost-effectiveness, patient-centered medical homes, and value-based insurance design. Here are 5 findings from research published in the issue.

1. Evaluating heart symptoms in urgent care centers can prevent emergency visits

Patients with chest pain indicating potential acute coronary syndrome are often sent to the emergency department (ED) for evaluation, incurring high costs and resource utilization. A pilot study of a protocol for evaluating such patients in urgent care centers (UCCs) found that most cases could be managed in the outpatient setting without compromising safety.

Of the 802 patients in the pilot, just 72 (9.1%) were referred to or evaluated in the ED within 6 hours of the index UCC visit; an additional 56 (7.6%) were evaluated in the ED within 30 days of their UCC visit. No deaths occurred, and no safety events were observed. Although the study authors did not measure costs, they noted that “it is reasonable to suggest that redirecting even a small portion of our national ED burden to outpatient settings might represent a significant reduction in healthcare expenditures.”

2. Removing cost sharing for primary care preserved access, lowered total spending

An analysis of what happened when a large employer removed cost sharing for primary care visits as part of a value-based insurance design strategy found promising changes in utilization and spending. The group without cost sharing did not experience a significant increase in physician office visits relative to a comparison cohort, but they did see reduced spending on emergency department visits and other outpatient services, contributing to a relative reduction of $12 per member per month in overall spending.

“Preserving and promoting access to care while keeping expenditure trends stable is an attractive outcome for all participants in the healthcare system,” wrote the authors, who recommended testing value-based insurance design principles in populations with different socioeconomic characteristics and levels of access to care.

3. Preventive service use improved in patients with a usual source of care, regardless of medical home status

Patient-centered medical homes (PCMHs) have been touted as an avenue to increase preventive service use, but this cross-sectional study determined that an individual’s having a usual source of care was a stronger predictor of receiving preventive services than whether or not that usual source of care was a PCMH.

There were several significant relationships between prevention and a usual source of care, including higher rates of screening for breast cancer and cervical cancer, but fewer such relationships by PCMH status. “Although evidence is growing that the PCMH model improves patient care, these benefits are not available to patients who cannot access the health system or do not have a USC provider,” wrote the authors, who emphasized the importance of ensuring access to care before pushing toward the adoption of PCMH principles.

4. Diabetes pathway comparison shows cost-effectiveness of brand-name combination therapy

Treatment intensification for diabetes often involves generic sulfonylureas and insulin, but a pathway using newer, brand-name medications is more cost-effective over a lifetime, according to the results of this cost-effectiveness analysis. The model of lifetime outcomes incorporated the cost savings from the newer therapies’ cardiovascular protective effects, which can improve life expectancy and quality of life.

The study authors note this evaluation’s strength of including sequential treatment pathways with multiple intensification steps; nearly all other diabetes cost-effectiveness studies have looked at the costs and benefits of a single intervention. Because the incremental cost-effectiveness ratios found for the branded pathway fall within usual willingness-to-pay thresholds, the findings “thus indicate that it represents good value for money.”

5. Exploring negative experiences among patients with cancer can provide more insight than satisfaction scores alone

While many cancer care centers measure patient-centeredness through satisfaction scores, the authors of this qualitative study used in-depth interviews and survey comments to explore reports of emotionally adverse experiences that can negatively influence patient outcomes. They found that such experiences were rarely reported and that there was wide variation in their causes.

One finding was that prior annoyances and expectations could affect how patients perceived experiences; for instance, repeated instances of canceled appointments accumulated into a negative experience and led a patient to consider finding another cancer center. “Listening to the dissatisfied patient voice in survey comments can help providers and managers alike improve care, even in high-performing systems,” the study authors concluded.