Publications by authors named "Anna D Sinaiko"

66 Publications

In New England, Partisan Differences In ACA Marketplace Participation And Potential Financial Harm.

Health Aff (Millwood) 2021 09;40(9):1420-1429

Alison A. Galbraith is an associate professor of population medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute.

Political orientation can be a powerful motivator of certain health care decisions. This study examines how political orientation was associated with decisions to use the Affordable Care Act Marketplaces to enroll in nongroup health insurance plans and whether it was also associated with adverse financial consequences. We used administrative records and surveys of nongroup Marketplace enrollees from a large insurer in New England. Enrollees were categorized as Republican, Democrat, or independent through self-identification or were assigned to one of the political parties after responding to a political preference question. Republican enrollees were less likely than Democratic enrollees of comparable subsidy eligibility to enroll through the Marketplaces and receive subsidies. Among income-eligible enrollees, Republican subscribers received $66 per month less in premium subsidies than Democratic subscribers, equivalent to roughly $800 per year. However, this result varied by subgroups in the parties, and our results suggest that party effects on decision making may inversely relate to the magnitude of the financial consequence. Navigating the ongoing political polarization in the United States requires optimizing public policies, as well as the associated education and outreach, to ensure maximal efficacy regardless of political orientation.
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http://dx.doi.org/10.1377/hlthaff.2021.00624DOI Listing
September 2021

Out-of-Pocket Spending for Asthma-Related Care Among Commercially Insured Patients, 2004-2016.

J Allergy Clin Immunol Pract 2021 12 1;9(12):4324-4331.e7. Epub 2021 Sep 1.

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass.

Background: Out-of-pocket (OOP) health care costs can cause financial burden and deferred care for many Americans. Little is known about OOP spending for asthma-related care among the commercially insured.

Objectives: To analyze OOP spending for asthma-related care overall, across types of care, and by income.

Methods: Using enrollment, claims, and geocoded census tract data on income from a large US commercial health plan from 2004 to 2016, we measured inflation-adjusted OOP spending for individuals with asthma ages 4 to 64 years (n = 1,986,769). We estimated annual asthma-related OOP spending over time, and average total, asthma-related, asthma type of care, and asthma medication spending by income. We measured trends in median OOP cost per medication. Linear regression models were adjusted for patient covariates and deductible level.

Results: Asthma-related OOP spending decreased over time both for patients enrolled in high-deductible health plans and for those in traditional plans. High-deductible plan enrollment increased from 7% to 54%. Compared with patients living in high-income areas, patients in the lowest-income areas had similar annual total and asthma-related OOP spending, but spent 30% less on controller medications and a higher proportion of their asthma-related OOP spending on inpatient and emergency care (10% vs 3%; P < .001). Asthma-related OOP spending represented a higher proportion of household income for patients in lower-income areas.

Conclusions: Patients with asthma living in the lowest-income areas have greater cost burden, lower spending on controller medications, and greater spending on high-acuity care than higher-income counterparts.
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http://dx.doi.org/10.1016/j.jaip.2021.07.054DOI Listing
December 2021

Patterns of Use of a Price Transparency Tool for Childbirth Among Pregnant Individuals With Commercial Insurance.

JAMA Netw Open 2021 08 2;4(8):e2121410. Epub 2021 Aug 2.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: When introduced a decade ago, patient-facing price transparency tools had low use rates and were largely not associated with changes in spending. Little is known about how such tools are used by pregnant individuals in anticipation of childbirth, a shoppable service with increasing out-of-pocket spending.

Objective: To measure changes over time in the patterns and characteristics of use of a price transparency tool by pregnant individuals, and to identify the association between price transparency tool use, coinsurance, and childbirth spending.

Design, Setting, And Participants: This descriptive cross-sectional study of 2 cohorts used data from a US commercial health insurance company that launched a web-based price transparency tool in 2010. Data on all price transparency tool queries for 2 periods (January 1, 2011, to December 31, 2012, and January 1, 2015, to December 31, 2016) were obtained. The sample included enrollees aged 19 to 45 years who had a delivery episode during 2 periods (November 1, 2011, to December 31, 2012, or November 1, 2015, to December 31, 2016) and were continuously enrolled for the 10 months prior to delivery (N = 253 606).

Exposures: Access to a web-based price transparency tool that provided individualized out-of-pocket price estimates for vaginal and cesarean deliveries.

Main Outcomes And Measures: The primary outcomes were searches on the price transparency tool by delivery mode (vaginal or cesarean), timing (first, second, or third trimester), and individual characteristics (age at childbirth, rurality, pregnancy risk status, coinsurance exposure, area educational attainment, and area median household income). Another outcome was the association of out-of-pocket childbirth spending with price transparency tool use.

Results: The sample included 253 606 pregnant individuals, of whom 131 224 (51.7%) were in the 2011 to 2012 cohort and 122 382 (48.3%) were in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, the mean (SD) age was 31 years (5.2 years) and most individuals had coinsurance for delivery (94 251 [77.0%]). Price searching increased from 5.9% in the 2011 to 2012 cohort to 13.0% in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, 43.9% of searchers' first price query was in their first trimester. The adjusted probability of searching was lower for individuals with a high-risk pregnancy due to a previous cesarean delivery (11.5%; 95% CI, 11.0%-12.1%) vs individuals with low-risk pregnancy (13.4%; 95% CI, 12.9%-14.0%). Use increased monotonically with coinsurance, from 9.2% (95% CI, 8.7%-9.8%) among individuals with no coinsurance to 15.0% (95% CI, 14.4%-15.5%) among individuals with 11% or higher coinsurance. After adjusting for covariates, searching was positively associated with out-of-pocket delivery episode spending. Among patients with 11% coinsurance or higher, early and late searchers spent more out of pocket ($59.57 [95% CI, $33.44-$85.96] and $73.33 [95% CI, $32.04-$115.29], respectively), compared with never searchers.

Conclusions And Relevance: The results of this cross-sectional study indicate that the proportion of pregnant individuals who sought price information before childbirth more than doubled within the first 6 years of availability of a price transparency tool. These findings suggest that price information may help individuals anticipate their out-of-pocket childbirth costs.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.21410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8374613PMC
August 2021

Declines in contraceptive visits in the United States during the COVID-19 pandemic.

Contraception 2021 12 14;104(6):593-599. Epub 2021 Aug 14.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States.

Objective: To document the change in contraceptive visits in the United States during the COVID-19 pandemic.

Study Design: Using a nationwide sample of claims we analyzed the immediate and sustained changes in contraceptive visits during the pandemic by calculating the percentage change in number of visits between May 2019 and April 2020 and between December 2019 and December 2020, respectively. We examined these changes by contraceptive method, region, age, and use of telehealth, and separately for postpartum individuals.

Results: Relative to May 2019, in April 2020, visits for tubal ligation declined by 65% (95% CI, -65.5, -64.1), LARCs by 46% (95% CI, -47.0, -45.6), pill, patch, or ring by 45% (95% CI, -45.8, -44.5), and injectables by 16% (95% CI -17.2, -15.4). The sustained change in visits in December 2020 was larger for tubal ligation (-18%, 95% CI, -19.1, -16.8) and injectable (-11%, 95% CI, -11.4, -9.6) visits than for LARC (-6%, 95% CI, -6.6, -4.4) and pill, patch, and ring (-5%, 95% CI, -5.7, -3.7) visits. The immediate decline was highest in the Northeast and Midwest regions. Declines among postpartum individuals were smaller but still substantial.

Conclusions: There were large declines in contraceptive visits at the start of the COVID-19 pandemic and visit numbers remained below pre-pandemic levels through the end of 2020.

Implications: Declines in contraceptive visits during the pandemic suggest that many people faced difficulties accessing this essential health service during the COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.contraception.2021.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8570647PMC
December 2021

Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration.

Med Care Res Rev 2021 Jun 16:10775587211024796. Epub 2021 Jun 16.

Stanford University, Stanford, CA, USA.

More is known about the structural features of health system integration than the social features-elements of normative integration (alignment of norms) and interpersonal integration (collaboration among professionals and with patients). We surveyed practice managers and 1,360 staff and physicians at 59 practice sites within 17 health systems (828 responses; 61%). Building on prior theory, we developed and established the psychometric properties of survey measures describing normative and interpersonal integration. Normative and interpersonal integration were both consistently related to better provider experience, perceived care quality, and clinical integration (e.g., a 1-point increase in a practice's normative integration was associated with 0.53-point higher job satisfaction and 0.77-point higher perceived care quality in the practice, measured on 1 to 5 scales, < .01). Variation in social features of integration may help explain why some health systems better integrate care, pointing to normative and interpersonal integration as potential resources for improvement.
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http://dx.doi.org/10.1177/10775587211024796DOI Listing
June 2021

Spending and Out-of-Pocket Prices for Brand-Name Drugs Among Commercially Insured Individuals in Massachusetts, 2015-2017.

JAMA Netw Open 2021 03 1;4(3):e213252. Epub 2021 Mar 1.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.3252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994951PMC
March 2021

Mammographic Surveillance in Older Women With Breast Cancer in Canada and the United States: Are We Choosing Wisely?

Pract Radiat Oncol 2021 Jul-Aug;11(4):e384-e394. Epub 2021 Mar 19.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Purpose: Guidelines on mammographic surveillance after breast cancer treatment have been disseminated internationally and incorporated into Choosing Wisely recommendations to reduce low-value care. However, adherence within different countries before their publication is unknown.

Methods And Materials: Low-value mammography, defined as "short-interval" (within 6 months of radiation) or "high-frequency" (>1 within 12 months of radiation), was compared in Medicare fee-for-service in the United States and Ontario, Canada. Women ≥65 years diagnosed with breast cancer who underwent breast-conserving therapy with a minimum of 24 months of follow-up were included (n = 19,715 United States; 6479 Ontario). Secondary outcomes were patient and physician characteristics associated with discordance.

Results: Short-interval mammography was higher in the United States than in Ontario (55.9% vs 38.0%, P < .001), as was high-frequency (39.6% vs 7.9%, P < .001). In Ontario, younger age (42% ≥85 vs 58% <74 years, P < .001) and chemotherapy (69% vs 51%, P < .001) were associated with short-interval mammography; in the United States, age, earlier diagnosis year, stage, chemotherapy, rurality, and academic center treatment were associated with greater use. Chemotherapy was associated with high-frequency mammography in both countries (13% vs 7% in Ontario, P < .001; 69% vs 51% in United States, P = .02); younger age, earlier diagnosis year, stage, and nonacademic center treatment were associated in the United States. In both countries, radiation oncologists had the highest proportion of providers ordering low-value mammograms.

Conclusions: Despite significant evidence guiding surveillance mammography recommendations, there are high rates of short-interval mammography in both the United States and Ontario, and high rates of high-frequency mammography in the United States. Further international efforts, such as Choosing Wisely, are needed to reduce low-value mammography.
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http://dx.doi.org/10.1016/j.prro.2021.03.003DOI Listing
September 2021

Understanding Consumer Experiences and Insurance Outcomes Following Plan Disenrollment in the Nongroup Insurance Market.

Med Care Res Rev 2022 Feb 16;79(1):36-45. Epub 2021 Mar 16.

Harvard Pilgrim Health Care Institute, Boston, MA, USA.

Disenrollment from health plans purchased on Affordable Care Act (ACA) Marketplaces is frequent; little is known whether disenrollment from off-Marketplace plans is as common or about the experiences and consequences of disenrollment. Using longitudinal administrative data on 2017-2018 nongroup plan enrollment linked with survey data, we analyze plan disenrollment in one regional insurance carrier servicing three states. Overall, 71% of enrollees disenrolled from their 2017 plan. Disenrollment was associated with purchasing through an ACA Marketplace, the carrier making significant changes to an enrollee's plan benefit design, being healthier, being younger, and paying a higher premium for their 2017 plan in 2018. Experiencing financial burden or poor access to preferred providers was not associated with disenrollment. Most disenrollees (93.2%) enrolled in other coverage, often at a lower premium, but lacked confidence that they could afford needed care. These results can inform policy to support enrollees through coverage transitions and foster stability in the nongroup market.
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http://dx.doi.org/10.1177/1077558721998910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8443667PMC
February 2022

Medicaid Payments For Immediate Postpartum Long-Acting Reversible Contraception: Evidence From South Carolina.

Health Aff (Millwood) 2021 02;40(2):334-342

Jessica L. Cohen is the Bruce A. Beal, Robert L. Beal, and Alexander S. Beal Associate Professor of Global Health in the Department of Global Health and Population, Harvard T. H. Chan School of Public Health.

In 2012 South Carolina's Medicaid program was the first state Medicaid program to separate payment for the immediate postpartum placement of long-acting reversible contraception (intrauterine devices and contraceptive implants) from its global maternity payment. Examining data on all Medicaid-insured South Carolina women giving birth from 2010 to 2014, we found that the new policy achieved its explicit goal: increasing the availability of immediate postpartum long-acting reversible contraception. Among adolescents, for whom most pregnancies are unintended, this represented new use of long-acting reversible options, rather than substitution for sterilization or for short-acting reversible methods. Therefore, the new policy also significantly increased use of highly effective postpartum contraception in an age group that is particularly vulnerable to closely spaced, higher-risk repeat pregnancies. However, fewer than half of facilities began to offer immediate postpartum long-acting reversible contraceptives after the policy change. Additional policy approaches may be needed to achieve widespread availability of this option.
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http://dx.doi.org/10.1377/hlthaff.2020.00254DOI Listing
February 2021

Care integration within and outside health system boundaries.

Health Serv Res 2020 12;55 Suppl 3:1033-1048

RAND Corporation, Santa Monica, California, USA.

Objective: Examine care integration-efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them-to understand whether and at which organizational level health systems impact care quality and staff experience.

Data Sources: Surveys administered to one practice manager (56/59) and up to 26 staff (828/1360) in 59 practice sites within 24 physician organizations within 17 health systems in four states (2017-2019).

Study Design: We developed manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. We analyzed data using descriptive statistics and regression.

Principal Findings: Managers and staff perceived opportunity for improvement across most types of care integration and organizational levels. Managers/staff perceived little variation in care integration across health systems. They perceived better care integration within practice sites than within physician organizations, health systems, and outside health systems-up to 38 percentage points (pp) lower (P < .001) outside health systems compared to within practice sites. Of nine clinical process integration measures, one standard deviation (SD) (7.2-pp) increase in use of evidence-based care related to 6.4-pp and 8.9-pp increases in perceived quality of care by practice sites and health systems, respectively, and a 4.5-pp increase in staff job satisfaction; one SD (9.7-pp) increase in integration of social services and community resources related to a 7.0-pp increase in perceived quality of care by health systems; one SD (6.9-pp) increase in patient engagement related to a 6.4-pp increase in job satisfaction and a 4.6-pp decrease in burnout; and one SD (10.6-pp) increase in integration of diabetic eye examinations related to a 5.5-pp increase in job satisfaction (all P < .05).

Conclusions: Measures of clinical process integration related to higher staff ratings of quality and experience. Action is needed to improve care integration within and outside health systems.
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http://dx.doi.org/10.1111/1475-6773.13578DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720712PMC
December 2020

Association of Peer Comparison Emails With Electronic Health Record Documentation of Cancer Stage by Oncologists.

JAMA Netw Open 2020 10 1;3(10):e2015935. Epub 2020 Oct 1.

Division of Hematology and Oncology, Department of Medicine, General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts.

Importance: Systematically capturing cancer stage is essential for any serious effort by health systems to monitor outcomes and quality of care in oncology. However, oncologists do not routinely record cancer stage in machine-readable structured fields in electronic health records (EHRs).

Objective: To evaluate whether a peer comparison email intervention that communicates an oncologist's performance on documenting cancer stage relative to that of peer physicians was associated with increased likelihood that stage was documented in the EHR.

Design, Setting, And Participants: This 12-month, randomized quality improvement pilot study aimed to increase oncologist staging documentation in the EHR. The pilot study was performed at Massachusetts General Hospital Cancer Center from October 1, 2018, to September 30, 2019. Participants included 56 oncologists across 3 practice sites who treated patients in the ambulatory setting and focused on diseases that use standardized staging systems. Data were analyzed from July 2, 2019, to March 5, 2020.

Interventions: Peer comparison intervention with as many as 3 emails to oncologists during 6 months that displayed the oncologist's staging documentation rate relative to all oncologists in the study sample.

Main Outcomes And Measures: The primary outcome was patient-level documentation of cancer stage, defined as the likelihood that a patient's stage of disease was documented in the EHR after the patient's first (eg, index) ambulatory visit during the pilot period.

Results: Among the 56 oncologists participating (32 men [57%]), receipt of emails with peer comparison data was associated with increased likelihood of documentation of cancer stage using the structured field in the EHR (23.2% vs 13.0% of patient index visits). In adjusted analyses, this difference represented an increase of 9.0 (95% CI, 4.4-13.5) percentage points (P = .002) in the probability that a patient's cancer stage was documented, a relative increase of 69% compared with oncologists who did not receive peer comparison emails. The association increased with each email that was sent, ranging from a nonsignificant 4.0 (95% CI, -0.8 to 8.8) percentage points (P = .09) after the first email to a statistically significant 11.2 (95% CI, 4.9-17.4) percentage points (P = .003) after the third email . The association was concentrated among an oncologist's new patients (increase of 11.8 [95% CI, 6.2-17.4] percentage points; P = .001) compared with established patients (increase of 1.6 [95% CI, -2.9 to 6.1] percentage points; P = .44) and persisted for 7 months after the email communications stopped.

Conclusions And Relevance: In a quality improvement pilot trial, peer comparison emails were associated with a substantial increase in oncologist use of the structured field in the EHR to document stage of disease.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.15935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539129PMC
October 2020

Let's talk costs: Out-of-pocket cost discussions and shared decision making.

Patient Educ Couns 2020 11 27;103(11):2388-2390. Epub 2020 Apr 27.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, USA.

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http://dx.doi.org/10.1016/j.pec.2020.04.022DOI Listing
November 2020

Association of a national insurer's reference-based pricing program and choice of imaging facility, spending, and utilization.

Health Serv Res 2020 06 10;55(3):348-356. Epub 2020 Mar 10.

Harvard Medical School, Boston, Massachusetts.

Objective: To examine the association of a national insurer's reference-based pricing (RBP), program for outpatient advanced imaging-a benefit design to encourage patients to choose lower-price facilities.

Data Source/study Setting: Administrative and medical claims data for three self-insured employers that introduced RBP and a comparison group without RBP.

Study Design: Difference-in-difference comparison of pre-RBP (2014) and post-RBP (2015-6) care between intervention and comparison groups.

Data Collection/extraction Method: We identified 137 680 imaging procedures (4602 intervention group; 133 078 comparison group) in 2014-2016.

Principal Findings: In the first post-RBP year (2015), there was no change in choice of facility; by the second year, RBP-exposed enrollees were 21.9 pp (95% CI: 18.5, 25.3) more likely to choose a lower-priced facility and net prices were $101.05 (95% CI: -$130.65, -$71.46), a difference of 8.1 percent lower. RBP was associated with higher patient out-of-pocket spending in the first post-RBP year ($31.82; 95% CI: $10.91, $52.73). There was no change in utilization, and higher-priced providers did not lower prices in the postperiod. Net savings represented 0.3 percent of outpatient spending.

Conclusions: Reference-based pricing for advanced imaging was associated with a shift to lower-priced facilities, but net impact on outpatient spending was modest. Patients paid increased out-of-pocket costs, though the amount declined after the first year of the program.
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http://dx.doi.org/10.1111/1475-6773.13279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240778PMC
June 2020

Physician and facility drivers of spending variation in locoregional prostate cancer.

Cancer 2020 04 24;126(8):1622-1631. Epub 2020 Jan 24.

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

Background: Prostate cancer is the most common male cancer, with a wide range of treatment options. Payment reform to reduce unnecessary spending variation is an important strategy for reducing waste, but its magnitude and drivers within prostate cancer are unknown.

Methods: In total, 38,971 men aged ≥66 years with localized prostate cancer who were enrolled in Medicare fee-for-service and were included in the Surveillance, Epidemiology, and End Results-Medicare database from 2009 to 2014 were included. Multilevel linear regression with physician and facility random effects was used to examine the contributions of urologists, radiation oncologists, and their affiliated facilities to variation in total patient spending in the year after diagnosis within geographic region. The authors assessed whether spending variation was driven by patient characteristics, disease risk, or treatments. Physicians and facilities were sorted into quintiles of adjusted patient-level spending, and differences between those that were high-spending and low-spending were examined.

Results: Substantial variation in spending was driven by physician and facility factors. Differences in cancer treatment modalities drove more variation across physicians than differences in patient and disease characteristics (72% vs 2% for urologists, 20% vs 18% for radiation oncologists). The highest spending physicians spent 46% more than the lowest and had more imaging tests, inpatient care, and radiotherapy spending. There were no differences across spending quintiles in the use of robotic surgery by urologists or the use of brachytherapy by radiation oncologists.

Conclusions: Significant differences were observed for patients with similar demographics and disease characteristics. This variation across both physicians and facilities suggests that efforts to reduce unnecessary spending must address decision making at both levels.
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http://dx.doi.org/10.1002/cncr.32719DOI Listing
April 2020

What Is the Value of Market-Wide Health Care Price Transparency?

Authors:
Anna D Sinaiko

JAMA 2019 Oct;322(15):1449-1450

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2019.11578DOI Listing
October 2019

Marketwide Price Transparency Suggests Significant Opportunities For Value-Based Purchasing.

Health Aff (Millwood) 2019 09;38(9):1514-1522

Meredith B. Rosenthal is the C. Boyden Gray Professor of Health Economics and Policy in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health.

The extent of price variation across a local market has important implications for value-based purchasing. Using a new data set containing health care prices for nearly every insurer-provider-service triad across a large local market, we comprehensively examined variation in fee-for-service paid commercial prices in Massachusetts for 291 predominantly outpatient medical services. Prices varied considerably across hospital service areas. Prices for medical services at acute hospitals were, on average, 76 percent higher than at all other providers. The service categories with the widest price variation were ambulance/transportation services, physical/occupational therapy, and laboratory/pathology testing. In this market, simulations suggested that steering patients toward lower-price providers or setting price ceilings could generate potential savings of 9.0-12.8 percent. Marketwide price information at the insurer-provider-service level could help target policy interventions to reduce health care spending.
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http://dx.doi.org/10.1377/hlthaff.2018.05315DOI Listing
September 2019

What are the potential savings from steering patients to lower-priced providers? a static analysis.

Am J Manag Care 2019 07 1;25(7):e204-e210. Epub 2019 Jul 1.

Department of Population Health, NYU School of Medicine, 227 E 30th St, New York, NY 10016. Email:

Objectives: Healthcare payers are increasingly using price transparency and benefit design to encourage patients to choose lower-priced providers. We quantify potential savings from shifting patients to lower-priced providers. If there is limited price variation or if higher-priced providers command little market share, savings could be minimal.

Study Design: Using 2013-2014 commercial claims for 697,381 enrollees in California, we characterized within-market price variation and the relationship between providers' market shares and relative prices for 3 nonemergent, shoppable outpatient services: laboratory tests, imaging services, and durable medical equipment (DME). In a stylized policy simulation that holds provider price and utilization constant, we computed potential savings if patients who visited providers with prices above the median price shifted to the median-priced provider in their geographic market for the same service.

Methods: Observational analyses.

Results: Of the service categories examined, laboratory tests had greatest within-market price variation (median coefficient of variation of 100% vs 87% for imaging services and 43% for DME). Roughly half of services (53%, 47%, and 54% for laboratory tests, imaging services, and DME, respectively) were billed by providers with prices above their market median. Shifting these patients to the median-priced provider in their markets could save 42%, 45%, and 15% of spending on laboratory tests, imaging services, and DME, respectively, together representing savings of 11% of total outpatient spending and 7% of the sum of inpatient and outpatient spending.

Conclusions: Steering patients from higher- to lower-priced providers within geographic markets in targeted service categories could generate substantial healthcare savings.
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July 2019

Decision-Making Experiences Of Consumers Choosing Individual-Market Health Insurance Plans.

Health Aff (Millwood) 2019 03;38(3):464-472

Alison A. Galbraith is an associate professor of population medicine at the Harvard Pilgrim Health Care Institute and Harvard Medical School.

The health insurance Marketplaces established by the Affordable Care Act include features designed to simplify the process of choosing a health plan in the individual, or nongroup, insurance market. While most individual health insurance enrollees purchase plans through the federal and state-based Marketplaces, millions also purchase plans directly from an insurance carrier (off Marketplace). This study was a descriptive comparison of the decision-making processes and shopping experiences of consumers in two states who purchased a health insurance plan from the same large insurer in 2017, either through the federal Marketplaces or off Marketplace. In a survey, those who selected plans through the Marketplaces reported less difficulty finding the best or most affordable plan than did those enrolling off Marketplace. Respondents in families with chronic health conditions who enrolled through the Marketplaces reported better overall experiences than those who enrolled off Marketplace. Respondents with low health insurance literacy reported poor experiences in enrolling both through the Marketplaces and off Marketplace. Access to consumer assistance in the individual health insurance market should target off-Marketplace populations as well as all populations with low health insurance literacy.
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http://dx.doi.org/10.1377/hlthaff.2018.05036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333350PMC
March 2019

Why aren't more employers implementing reference-based pricing benefit design?

Am J Manag Care 2019 02;25(2):85-88

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Room 409, Boston, MA 02115. Email:

Objectives: There is robust evidence that implementation of reference-based pricing (RBP) benefit design decreases spending. This paper investigates employer adoption of RBP as a strategy to improve the value of patients' healthcare choices, as well as facilitators and barriers to the adoption of RBP by employers.

Study Design: We conducted a qualitative study using 12 in-depth interviews with human resources executives or their representatives at large- or medium-sized self-insured employers.

Methods: Interviews were conducted and recorded over the phone between March 2017 and May 2017. Interviewees were asked about their adoption of RBP and facilitators and barriers to adoption. We applied thematic analysis to the transcripts.

Results: Despite broad employer awareness of RBP's potential for cost savings, few employers are including RBP in their benefit design. The major barriers to RBP adoption were the complexity of RBP benefit design, concern that employees could face catastrophic out-of-pocket costs, lack of a business case for implementation, and concern that RBP could hurt the employer's competitiveness in the labor market. The few employers that have adopted RBP have implemented extensive, year-round employee education campaigns and invested in multipronged and proactive decision support to help employees navigate their choices.

Conclusions: Unless several fundamental barriers are addressed, uptake of RBP will likely continue to be low. Our findings suggest that simplifying benefit design, providing employees protection against very high out-of-pocket costs, understanding which decision-support strategies are most effective, and enhancing the business case could facilitate wider employer adoption of RBP.
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February 2019

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

Health Serv Res 2019 02 14;54(1):97-105. Epub 2018 Oct 14.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

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.
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http://dx.doi.org/10.1111/1475-6773.13068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6338302PMC
February 2019

Quality Reporting by Payers: A Mixed-Methods Study of Provider Perspectives and Practices.

Qual Manag Health Care 2018 Jul/Sep;27(3):157-164

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (Drs Garabedian, Ross-Degnan, and Wagner); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Dr Sinaiko); and Harvard Pilgrim Health Care, Wellesley, Massachusetts (Mr Abu-Jaber and Mss Hoefer and Oddleifson).

Background: Providers need timely, clinically meaningful, and actionable information to improve quality of care. Payers may play an important role in providing such information in ambulatory care settings. We sought to learn about providers' use and perceptions of quality reports from insurers.

Methods: We employed a mixed-methods study design. We analyzed the performance of 118 provider groups on 21 HEDIS measures included in one New England insurer's quality reporting program and evaluated how a subset of provider groups (n = 55) accessed the reports. We also conducted 14 semistructured interviews with providers and administrators to assess their perspectives about quality reports from insurers in general.

Results: Performance on quality measures varied greatly across provider groups and by metric. Only 20% of provider groups accessed the quality reports during the study period. While providers reported that payer information on quality has the potential to be useful, respondents suggested important reasons why insurer quality reports were not widely accessed, including information overload, conflicts with other sources of information, and the significant provider effort required to make the reports actionable.

Conclusions: Payer-provider collaborations are needed to improve the usefulness of payers' quality measurement reports, and coordination among payers is needed to streamline reported measures.
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http://dx.doi.org/10.1097/QMH.0000000000000179DOI Listing
June 2019

Clinicians and Health Care Price Transparency-Buyers vs Sellers?

Authors:
Anna D Sinaiko

JAMA Intern Med 2018 08;178(8):1133-1135

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2018.1503DOI Listing
August 2018

Promise and Reality of Price Transparency.

N Engl J Med 2018 04;378(14):1348-1354

From Harvard Medical School (A.M., M.E.C.), Beth Israel Deaconess Medical Center (A.M.), and the Harvard T.H. Chan School of Public Health (A.D.S.) - all in Boston.

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http://dx.doi.org/10.1056/NEJMhpr1715229DOI Listing
April 2018

Implications of family risk pooling for individual health insurance markets.

Health Serv Outcomes Res Methodol 2017 Dec 26;17(3-4):219-236. Epub 2017 May 26.

Department of Health Care Policy, Harvard Medical School.

While family purchase of health insurance may benefit insurance markets by pooling individual risk into family groups, the correlation across illness types in families could exacerbate adverse selection. We analyze the impact of family pooling on risk for health insurers to inform policy about family-level insurance plans. Using data on 8,927,918 enrollees in fee-for-service commercial health plans in the 2013 Truven MarketScan database, we compare the distribution of annual individual health spending across four pooling scenarios: (1) "Individual" where there is no pooling into families; (2) "real families" where costs are pooled within families; (3) "random groups" where costs are pooled within randomly generated small groups that mimic families in group size; and (4) "the Sims" where costs are pooled within random small groups which match families in demographics and size. These four simulations allow us to identify the separate contributions of group size, group composition, and family affinity in family risk pooling. Variation in individual spending under family pooling is very similar to that within "simulated families" and to that within random groups, and substantially lower than when there is no family pooling and individuals choose independently (standard deviation $12,526 vs $11,919, $12,521 and $17,890 respectively). Within-family correlations in health status and utilization do not "undo" the gains from family pooling of risks. Family pooling can mitigate selection and improve the functioning of health insurance markets.
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http://dx.doi.org/10.1007/s10742-017-0170-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5796434PMC
December 2017

Consumer Health Insurance Shopping Behavior and Challenges: Lessons From Two State-Based Marketplaces.

Med Care Res Rev 2019 08 5;76(4):403-424. Epub 2017 Jul 5.

4 Harvard Pilgrim Health Care Institute and Harvard Medical School, Landmark Center, Boston, MA, USA.

Selecting a health plan in a health insurance exchange is a critical decision, yet consumers are known to face challenges with health plan choice. We surveyed new enrollees in two state-based exchanges in 2015 to investigate how a nonelderly, primarily low-income population chose their health plans and the implications of shopping behavior for early experiences in their plans. Financial considerations were most important to enrollees. Prior Medicaid enrollees and the uninsured were more likely to have multiple shopping challenges (e.g., difficulty identifying the best or most affordable plan, fair/poor experience, unmet need for help) than enrollees with prior employer coverage (42.9% vs. 32.5% vs. 16.4%, respectively, < .01). Shopping challenges were associated with difficulty finding a doctor, understanding coverage, and getting questions answered. Assistance targeting enrollees who previously had Medicaid or lacked insurance could improve both shopping experiences and downstream outcomes in plans.
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http://dx.doi.org/10.1177/1077558717718625DOI Listing
August 2019

Patients' views on price shopping and price transparency.

Am J Manag Care 2017 Jun 1;23(6):e186-e192. Epub 2017 Jun 1.

Harvard Medical School, 180 Longwood Ave, Boston, MA 02115. E-mail:

Objectives: Driven by the growth of high deductibles and price transparency initiatives, patients are being encouraged to search for prices before seeking care, yet few do so. To understand why this is the case, we interviewed individuals who were offered access to a widely used price transparency website through their employer.

Study Design: Qualitative interviews.

Methods: We interviewed individuals enrolled in a preferred provider organization product through their health plan about their experience using the price transparency tool (if they had done so), their past medical experiences, and their opinions on shopping for care. All interviews were transcribed and manually coded using a thematic coding guide.

Results: In general, respondents expressed frustration with healthcare costs and had a positive opinion of the idea of price shopping in theory, but 2 sets of barriers limited their ability to do so in reality. The first was the salience of searching for price information. For example, respondents recognized that due to their health plan benefits design, they would not save money by switching to a lower-cost provider. Second, other factors were more important than price for respondents when choosing a provider, including quality and loyalty to current providers.

Conclusions: We found a disconnect between respondents' enthusiasm for price shopping and their reported use of a price transparency tool to shop for care. However, many did find the tool useful for other purposes, including checking their claims history. Addressing the barriers to price shopping identified by respondents can help inform ongoing and future price transparency initiatives.
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June 2017

Offering A Price Transparency Tool Did Not Reduce Overall Spending Among California Public Employees And Retirees.

Health Aff (Millwood) 2017 08;36(8):1401-1407

Ateev Mehrotra is an associate professor of health care policy at Harvard Medical School.

Insurers, employers, and states increasingly encourage price transparency so that patients can compare health care prices across providers. However, the evidence on whether price transparency tools encourage patients to receive lower-cost care and reduce overall spending remains limited and mixed. We examined the experience of a large insured population that was offered a price transparency tool, focusing on a set of "shoppable" services (lab tests, office visits, and advanced imaging services). Overall, offering the tool was not associated with lower shoppable services spending. Only 12 percent of employees who were offered the tool used it in the first fifteen months after it was introduced, and use of the tool was not associated with lower prices for lab tests or office visits. The average price paid for imaging services preceded by a price search was 14 percent lower than that paid for imaging services not preceded by a price search. However, only 1 percent of those who received advanced imaging conducted a price search. Simply offering a price transparency tool is not sufficient to meaningfully decrease health care prices or spending.
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http://dx.doi.org/10.1377/hlthaff.2016.1636DOI Listing
August 2017

Americans Support Price Shopping For Health Care, But Few Actually Seek Out Price Information.

Health Aff (Millwood) 2017 08;36(8):1392-1400

Neeraj Sood is a professor and vice dean for research at the Sol Price School of Public Policy and director of research at the Leonard D. Schaeffer Center for Health Policy and Economics, both at the University of Southern California, in Los Angeles.

The growing awareness of the wide variation in health care prices, increased availability of price data, and increased patient cost sharing are expected to drive patients to shop for lower-cost medical services. We conducted a nationally representative survey of 2,996 nonelderly US adults who had received medical care in the previous twelve months to assess how frequently patients are price shopping for care and the barriers they face in doing so. Only 13 percent of respondents who had some out-of-pocket spending in their last health care encounter had sought information about their expected spending before receiving care, and just 3 percent had compared costs across providers before receiving care. The low rates of price shopping do not appear to be driven by opposition to the idea: The majority of respondents believed that price shopping for care is important and did not believe that higher-cost providers were of higher quality. Common barriers to shopping included difficulty obtaining price information and a desire not to disrupt existing provider relationships.
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http://dx.doi.org/10.1377/hlthaff.2016.1471DOI Listing
August 2017

Medical Homes: The Authors Reply.

Health Aff (Millwood) 2017 07;36(7):1347

Brown University School of Public Health Providence, Rhode Island.

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http://dx.doi.org/10.1377/hlthaff.2017.0666DOI Listing
July 2017
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