Racial Bias in Clinical and Population Health Algorithms: A Critical Review of Current Debates.

Among health care researchers, there is increasing debate over how best to assess and ensure the fairness of algorithms used for clinical decision support and population health, particularly concerning potential racial bias. Here we first distill concerns over the fairness of health care algorithms into four broad categories: () the explicit inclusion (or, conversely, the exclusion) of race and ethnicity in algorithms, () unequal algorithm decision rates across groups, () unequal error rates across groups, and () potential bias in the target variable used in prediction. With this taxonomy, we critically examine seven prominent and controversial health care algorithms.

Increasing screening for breast cancer using a randomized evaluation of electronic health record nudges: Design and rationale of the I-screen clinical trial.

Background: Routine mammogram screening is critical for early detection of breast cancer. However, screening rates are below national targets, with persistent disparities among sub-populations. The purpose of this trial is to examine the effectiveness of a multi-component nudge intervention to increase breast cancer screening among eligible primary care patients.

Behavioural economics to improve and motivate vaccination in primary care using nudges through the electronic health record: rationale and design of the BE IMMUNE randomised clinical trial.

Introduction: Annual influenza vaccination reduces disease burden but vaccination rates are suboptimal, with persistent disparities among subpopulations. The purpose of this trial is to evaluate multicomponent behavioural economic nudge interventions to clinicians and patients to increase influenza vaccination. This trial also includes an intensification nudge to reduce disparities in vaccination among older adult, primary care patients.

Association of Participation in Medicare's Oncology Care Model With Spending, Utilization, and Quality Outcomes Among Commercially Insured and Medicare Advantage Members.

Purpose: The Oncology Care Model (OCM), a value-based payment model for traditional Medicare beneficiaries with cancer, yielded total spending reductions that were outweighed by incentive payments, resulting in net losses to the Centers for Medicare & Medicaid Services. We studied whether the OCM yielded spillover effects in total episode spending, utilization, and quality among commercially insured and Medicare Advantage (MA) members, who were not targeted by the program.

Patients And Methods: This observational study used administrative claims from a large national payer, yielding 157,189 total patients with commercial insurance or MA with solid malignancies who initiated 229,376 systemic anticancer therapy episodes before (2012-2015) and during (2016-2021) the OCM at 125 OCM-participating practices (a subset of total OCM practices) and a 1:10 propensity-matched set of 860 non-OCM practices.

Association between mandatory bundled payments and changes in socioeconomic disparities for joint replacement outcomes.

Objective: To determine whether mandatory participation by hospitals in bundled payments for lower extremity joint replacement (LEJR) was associated with changes in outcome disparities for patients dually eligible for Medicare and Medicaid.

Data Sources And Study Setting: We used Medicare claims data for beneficiaries undergoing LEJR in the United States between 2011 and 2017.

Study Design: We conducted a retrospective observational study using a differences-in-differences method to compare changes in outcome disparities between dual-eligible and non-dual eligible beneficiaries after hospital participation in the Comprehensive Care for Joint Replacement (CJR) program.

Hospice Administrators' and Providers' Perspectives on Providing Upstream Palliative Care: Facilitators, Barriers, and Policy Prescriptions.

Among patients with serious illness, palliative care before hospice enrollment is associated with improved quality of life, reduced symptom burden, and earlier transitions to hospice. However, fewer than half of eligible patients receive specialty palliative care referrals. As most hospice clinicians and administrators have experience in specialty palliative care, several emerging programs propose engaging hospice clinicians to provide early palliative care.

The COVID-19 Pandemic Led To A Large Decline In Physician Gross Revenue Across All Specialties In 2020.

US health care use declined during the initial phase of the COVID-19 pandemic in 2020. Although utilization is known to have recovered in 2021 and 2022, it is unknown how revenue in 2020-22 varied by physician specialty and practice setting. This study linked medical claims from a large national federation of commercial health plans to physician and practice data to estimate pandemic-associated impacts on physician revenue (defined as payments to eligible physicians) by specialty and practice characteristics.

Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations.

Background: Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations.

Objective: Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced).

Clinician Perspectives on Virtual Specialty Palliative Care for Patients With Advanced Illnesses.

Patients with serious illnesses have unmet symptom and psychosocial needs. Specialty palliative care could address many of these needs; however, access varies by geography and health system. Virtual visits and automated referrals could increase access and lead to improved quality of life, health outcomes, and patient-centered care for patients with serious illness.

Eliminating Algorithmic Racial Bias in Clinical Decision Support Algorithms: Use Cases from the Veterans Health Administration.

The Veterans Health Administration uses equity- and evidence-based principles to examine, correct, and eliminate use of potentially biased clinical equations and predictive models. We discuss the processes, successes, challenges, and next steps in four examples. We detail elimination of the race modifier for estimated kidney function and discuss steps to achieve more equitable pulmonary function testing measurement.

The role of payment and financing in achieving health equity.

Objective: The aim was to identify healthcare payment and financing reforms to promote health equity and ways that the Agency for Healthcare Research and Quality (AHRQ) may promote those reforms.

Data Sources And Study Setting: AHRQ convened a payment and financing workgroup-the authors of this paper-as part of its Health Equity Summit held in July 2022. This workgroup drew from its collective experience with healthcare payment and financing reform, as well as feedback from participants in a session at the Health Equity Summit, to identify the evidence base and promising paths for reforms to promote health equity.

Spending patterns among commercially insured individuals during the COVID-19 pandemic.

Objectives: To describe trends in US health care spending in a large, national, and commercially insured population during the COVID-19 pandemic.

Study Design: Cross-sectional study of commercially insured members enrolled between May 1, 2018, and December 31, 2021.

Methods: The study utilized a population-based sample of continuously enrolled members in a geographically diverse federation of Blue Cross Blue Shield plans across the United States.

Pneumonia is not just pneumonia: Differences in utilization and costs with common comorbidities.

We sought to explore the heterogeneity among patients hospitalized with pneumonia, a condition targeted in payment reform. In a retrospective cohort study of Medicare beneficiaries hospitalized for pneumonia, we compared postacute care utilization and costs of 90-day episodes of care among patients with and without comorbidities of chronic obstructive pulmonary disease (COPD) and/or heart failure. Of the 1,926,674 discharges, 28.

Association of High-Deductible Health Plans With Health Care Use and Costs for Patients With Cardiovascular Disease.

Background By increasing cost sharing, high-deductible health plans (HDHPs) aim to reduce low-value health care use. The association of HDHPs with health care use and costs in patients with chronic cardiovascular disease is unknown. Methods and Results This longitudinal cohort study analyzed 57 690 privately insured patients, aged 18 to 64 years, from a large commercial claims database with chronic cardiovascular disease from 2011 to 2019.

Association Between a Bundled Payment Program for Lower Extremity Joint Replacement and Patient Outcomes Among Medicare Advantage Beneficiaries.

Importance: Much of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality.

Objective: To evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery.

Growth of Medicare Advantage After Plan Payment Reductions.

Importance: Various policy proposals would reduce federal payments to Medicare Advantage (MA) plans. However, it is unclear whether payment reductions would compromise beneficiary access to the MA program.

Objective: To quantify the association between MA payment reductions under the Affordable Care Act (ACA) and MA enrollment growth.

How Physician Self-Perceptions Affect the Impact of Peer Comparison Feedback on Opioid Prescribing.

Peer comparison feedback is a promising strategy for reducing opioid prescribing and opioid-related harms. Such comparisons may be particularly impactful among underestimating clinicians who do not perceive themselves as high prescribers relative to their peers. But peer comparisons could also unintentionally increase prescribing among overestimating clinicians who do not perceive themselves as lower prescribers than peers.