Health Care Spending Effectiveness: Estimates Suggest That Spending Improved US Health From 1996 To 2016.

Health care spending effectiveness is the ratio of an increase in spending per case of illness or injury to an increase in disability-adjusted life-years (DALYs) averted per case. We report US spending-effectiveness ratios, using comprehensive estimates of health care spending from the Disease Expenditure Project and DALYs from the Global Burden of Disease Study 2017. We decomposed changes over time to estimate spending per case and DALYs averted per case, controlling for changes in population size, age-sex structure, and incidence or prevalence of cases.

Health spending expenditures for commercial plans are predominantly concentrated among a small population of high-intensity consumers across settings of care.

Rising health care spending has sparked new efforts to constrain health care expenditures. To explore how health care spending is distributed across consumers and how utilization patterns compare across health care resource expenditures (eg, hospital, outpatient care). Using the IQVIA PharMetrics Plus database, we conducted a retrospective claims analysis for the 2018 plan year to examine commercial health care spending and utilization across 5 settings of care: ambulatory services, inpatient services, office visits, pharmacy services, and additional services.

Stakeholders find that step therapy should be evidence-based, flexible, and transparent: assessing appropriateness using a consensus approach.

Step therapy, one approach to utilization management, is used by health plans to ensure safe and clinically appropriate care while managing cost. Several patient and provider groups have each developed principles to guide the appropriate use of step therapy; however, no comprehensive multistakeholder informed set of criteria exist. To assess multistakeholder consensus on criteria for the development and implementation of step therapy for pharmaceutical therapies.

Are ACOs Ready to be Accountable for Medication Use?

Accountable care organizations (ACOs) have the potential to lower costs and improve quality through incentives and coordinated care. However, the design brings with it many new challenges. One such challenge is the optimal use of pharmaceuticals.

Do Patient Preferences Align With Value Frameworks? A Discrete-Choice Experiment of Patients With Breast Cancer.

Assess patient preferences for aspects of breast cancer treatments to evaluate and inform the usual assumptions in scoring rubrics for value frameworks. A discrete-choice experiment (DCE) was designed and implemented to collect quantitative evidence on preferences from 100 adult female patients with a self-reported physician diagnosis of stage 3 or stage 4 breast cancer. Respondents were asked to evaluate some of the treatment aspects currently considered in value frameworks.

Are Value-Based Arrangements the Answer We've Been Waiting for?

In response to rising healthcare costs, value-based arrangements (VBAs) have emerged as a mechanism for transforming how we pay for high-cost therapies. As we think about how VBAs fit into the larger effort of the United States healthcare system to transition to value-based payment, it is important to consider the strengths and limitations associated with this model and to set appropriate expectations for what VBAs can realistically achieve. For example, for VBAs to meaningfully affect overall healthcare spending, there needs to be a sufficient number of products that meet the ideal criteria for a value-based contract.

As Value Assessment Frameworks Evolve, Are They Finally Ready for Prime Time?

Background: Value assessment frameworks have emerged as tools to assist healthcare decision makers in the United States in assessing the relative value of healthcare services and treatments. As more healthcare decision makers in the United States-including state government agencies, pharmacy benefit managers, employers, and health plans-publicly consider the adoption of value frameworks, it is increasingly important to critically evaluate their ability to accurately measure value and reliably inform decision making.

Objective: To examine the evolution of the value assessment landscape in the past two years, including new entrants and updated frameworks, and assess if these changes successfully advance the field of value assessment.

Reconciling the Seemingly Irreconcilable: How Much Are We Spending on Drugs?

Background: Estimates of drug spending are often central to the public policy debate on how to manage healthcare spending in the United States. Nevertheless, common estimates of prescription drug spending vary substantially by source, which can inhibit productive policy dialogue.

Objectives: To review publicly reported estimates of drug spending and uncover the underlying methodological inputs that drive the substantial variation in estimates of prescription drug spending.

US care pathways: continued focus on oncology and outstanding challenges.

Objectives: To update an ongoing assessment of care pathway development, implementation, and evaluation, and to evaluate the emerging relationship between care pathways and other components of value-based care.

Study Design: Targeted literature review followed by an online survey and in-depth interviews.

Methods: The PubMed/Cochrane databases and gray literature were searched for publications on care pathways (January 1, 2014, to March 3, 2017); a supplemental targeted search was completed in October 2017.

Value-based arrangements may be more prevalent than assumed.

Objectives: To better understand the prevalence of US value-based payment arrangements (VBAs), their characteristics, and the factors that facilitate their success or act as barriers to their implementation.

Study Design: Surveys were administered to a convenience sample of subject matter experts who were senior representatives from payer organizations and biopharmaceutical manufacturers. These data were supplemented with qualitative interviews in a subsample of survey respondents.

What's Been The Bang For The Buck? Cost-Effectiveness Of Health Care Spending Across Selected Conditions In The US.

The continued rise in health care spending has led to an intense debate among policy makers and other health care stakeholders on how to best manage increasing costs, leading to a focus on cost increases with little consideration of the associated change in outcomes. We identified the extent to which increased medical intervention spending on seven prevalent chronic conditions in the US over a twenty-year period has been a good investment. The results provide disease-level cost-effectiveness ratios for comparing changes in medical care spending to changes in health outcomes for patients diagnosed with one of the conditions.

Utilization of High-Cost Interventions for Targeted Clinical Conditions During the Early Stages of ACO Development in a Commercially Insured Population.

This study compared utilization patterns of high-cost services and medications for patients receiving care from Accountable Care Organization (ACO)-participating physicians and those receiving care from non-ACO physicians during the initial phases of ACO development in a commercially insured environment. Patients ≥18 years (≥40 years for chronic obstructive pulmonary disease [COPD]) with prevalent rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, type 2 diabetes, COPD, or chronic low back pain between January 1, 2012, and August 31, 2014 were identified in the HealthCore Integrated Research Database. Patients were assigned to the ACO cohort if their primary treating physician was contracted to the health plan through an ACO agreement.

Evaluation of person-level heterogeneity of treatment effects in published multiperson N-of-1 studies: systematic review and reanalysis.

Objective: Individual patients with the same condition may respond differently to similar treatments. Our aim is to summarise the reporting of person-level heterogeneity of treatment effects (HTE) in multiperson N-of-1 studies and to examine the evidence for person-level HTE through reanalysis.

Study Design: Systematic review and reanalysis of multiperson N-of-1 studies.

PEER-REVIEWED JOURNAL EDITORS' VIEWS ON REAL-WORLD EVIDENCE.

Objectives: Peer-review publication is a critical step to the translation and dissemination of research results into clinical practice guidelines, health technology assessment (HTA) and payment policies, and clinical care. The objective of this study was to examine current views of journal editors regarding: (i) The value of real-world evidence (RWE) and how it compares with other types of studies; (ii) Education and/or resources journal editors provide to their peer reviewers or perceive as needed for authors, reviewers, and editors related to RWE.

Methods: Journal editors' views on the value of RWE and editorial procedures for RWE manuscripts were obtained through telephone interviews, a survey, and in-person, roundtable discussion.

Why Value Framework Assessments Arrive at Different Conclusions: A Multiple Myeloma Case Study.

Unlabelled: As the United States transitions from a volume-based health care system to one that rewards value, new frameworks are emerging to help patients, providers, and payers assess the value of medical services and biopharmaceutical products. These value assessment frameworks are intended to support various types of health care decision making. They have the potential to substantially affect patients, whether as tools for shared decision making with their doctors, as an input to care pathways used by providers, or through payer use of the frameworks to make coverage or reimbursement decisions.

Does a One-Size-Fits-All Cost-Sharing Approach Incentivize Appropriate Medication Use? A Roundtable on the Fairness and Ethics Associated with Variable Cost Sharing.

Background: Tiered formularies, in which patients pay copays or coinsurance out-of-pocket (OOP), are used to manage costs and encourage more efficient health care resource use. Formulary tiers are typically based on the cost of treatment rather than the medical appropriateness for the patient. Cost sharing may have unintended consequences on treatment adherence and health outcomes.

Improving Oncology Quality Measurement in Accountable Care: Filling Gaps with Cross-Cutting Measures.

Unlabelled: Payment for health care services, including oncology services, is shifting from volume-based fee-for-service to value-based accountable care. The objective of accountable care is to support providers with flexibility and resources to reform care delivery, accompanied by accountability for maintaining or improving outcomes while lowering costs. These changes depend on health care payers, systems, physicians, and patients having meaningful measures to assess care delivery and outcomes and to balance financial incentives for lowering costs while providing greater value.

Employer, Insurer, and Industry Perspectives on Patient-Centered Comparative Effectiveness Research: Final Report.

The Patient-Centered Outcomes Research Institute (PCORI) is an independent, nonprofit, nongovernmental organization authorized under the Affordable Care Act of 2010 and funded by Congress to help close the gaps in research needed to improve key health outcomes. To do this, PCORI identifies critical research questions, funds patient-centered comparative effectiveness research (CER), and strives to disseminate the results in ways that stakeholders, including patients, providers, health insurance purchasers, payers, and industry, will find useful. PCORI commissioned RAND and the National Pharmaceutical Council to conduct an independent study of the health-related decisions, information needs, understanding and use of CER, and opportunities for involvement of these three stakeholder communities in CER.

The Central Role of Physician Leadership for Driving Change in Value-Based Care Environments.

Background: In 2013, it was reported that about 1 of every 3 U.S. adults has hypertension.

Evaluating the Importance of Heterogeneity of Treatment Effect: Variation in Patient Utilities Can Influence Choice of the "Optimal" Oral Anticoagulant for Atrial Fibrillation.

Objectives: To investigate heterogeneity of treatment effect (HTE) for anticoagulants in atrial fibrillation across subgroups defined by 1) clinical characteristics and 2) variation in patient utilities for benefits and harms of treatment.

Methods: We reanalyzed aggregate data from a published network meta-analysis that compared four anticoagulants for atrial fibrillation (apixaban, dabigatran, edoxaban, and rivaroxaban) as well as warfarin. Event rates for stroke/systemic embolism (SE) and major bleeding were generated for each agent across seven subgroups, and rankings were developed on the basis of clinical performance.

No improvement in the reporting of clinical trial subgroup effects in high-impact general medical journals.

Background: When subgroup analyses are not correctly analyzed and reported, incorrect conclusions may be drawn, and inappropriate treatments provided. Despite the increased recognition of the importance of subgroup analysis, little information exists regarding the prevalence, appropriateness, and study characteristics that influence subgroup analysis. The objective of this study is to determine (1) if the use of subgroup analyses and multivariable risk indices has increased, (2) whether statistical methodology has improved over time, and (3) which study characteristics predict subgroup analysis.

What Contributes Most to High Health Care Costs? Health Care Spending in High Resource Patients.

Background: U.S. health care spending nearly doubled in the decade from 2000-2010.

Using an Electronic Medication Refill System to Improve Provider Productivity in an Accountable Care Setting.

Background: Even within fully integrated health care systems, primary care providers (PCPs) often lack support for medication management. Because challenges with conducting medication reconciliation, improving adherence, and achieving optimal patient outcomes continue to be prevalent nationally, it is critical that PCPs are provided the resources and support they need to provide high-quality, patient-centered care in an accountable care environment.

Program Description: Sharp Rees-Stealy Medical Group uses a fully electronic medication refill system that allows for a centralized team to manage all incoming requests.