Measuring Value in Health Care: The Times, They Are A Changin'.

Policy makers struggle to measure value in health care, and yet there is the recurring question: Is our present system of quality metrics too costly and burdensome? We need to develop measures promoting shared accountability across settings and providers, identify and develop meaningful outcome measures, and reduce the burden on providers of data collection.

Nursing Intervention Aimed at Improving Self-Managementfor Persons with Chronic Kidney Disease in North Carolina Medicaid: A Pilot Project.

This pilot project aimed to improve knowledge and self-management among Medicaid beneficiaries with Stage 3b and 4 chronic kidney disease who were identified using a population-based approach. Participants received up to six in-person educational sessions delivered by a nurse practitioner. Increases in knowledge and self-reported behavior changes were generally observed among participants.

A+KIDS, a web-based antipsychotic registry for North Carolina youths: an alternative to prior authorization.

Objective: The rise in use of antipsychotics among U.S. children is well documented.

Evaluation of a novel web-based prior approval application for palivizumab prophylaxis of respiratory syncytial virus in a state Medicaid program.

Background: Recent disproportionate increases in use of specialty medications, such as palivizumab (Synagis), compared with steady utilization of traditional medication use, have prompted complex utilization management strategies that require frequent evaluation to facilitate cost-effectiveness while preserving patient access. Clinical criteria utilized by North Carolina (NC) Medicaid for use of palivizumab for respiratory syncytial virus (RSV) prophylaxis are consistent with the most recent guidelines published in the Red Book: Report of the Committee on Infectious Diseases. Prior to the 2011-2012 RSV season, prior approval (PA) requests were submitted by facsimile using the NC Medicaid Synagis PA form.

Use of a tool to determine perceived barriers to children's healthy eating and physical activity and relationships to health behaviors.

This pilot investigation assesses whether barriers to children's healthy eating and physical activity reported by parents on a newly developed brief pediatric obesity screening and counseling tool are related to healthy eating and physical activity behaviors. The sample included parents of 115 Medicaid-enrolled children in a general pediatric clinic. Of 10 barriers, 7 were statistically associated with parent-reported behaviors with odds ratios (ORs) ranging from 0.

Use of a pediatrician toolkit to address parental perception of children's weight status, nutrition, and activity behaviors.

Background: Communication of children's weight status and targeted counseling by pediatricians may change parental perceptions or child dietary and physical activity behaviors. The aim of this study was to determine whether accuracy of parental perception of children's weight status and reports of related behaviors changed following a brief pediatrics resident intervention.

Methods: Parents (N = 115) of children aged 4 to 12 years enrolled in Medicaid completed baseline questionnaires with providers about prior communication of weight status and/or body mass index (BMI), perceptions of their children's weight, and children's dietary and physical activity behaviors, and children were weighed and measured.

Pharmacist and physician satisfaction and rates of switching to preferred medications associated with an instant prior authorization program for proton pump inhibitors in the North Carolina Medicaid program.

Background: Proton pump inhibitors (PPIs) are among the highest expenditure drugs covered by health care plans. During fiscal year 2001-2002, Medicaid programs nationwide spent nearly $2 billion on PPIs. Although the costs of individual PPIs vary widely, there is little variation in therapeutic effectiveness.

A physician-friendly alternative to prior authorization for prescription drugs.

Objective: To determine if the instant approval (IA) process differs from the traditional prior authorization (PA) process in preferred drug channeling, resultant gaps in therapy, and provider dissatisfaction.

Study Design: An interrupted time series analysis using pharmacy claims and a retrospective cohort study.

Methods: The study assessed changes in preferred drug use and subsequent cost reductions.

The medical home--improving quality of primary care for children.

The concept of a medical home appears to be a key driver for enhancing the value of health services as care systems are transitioned to meet the ongoing challenges of improving quality and containing costs. This article provides an overview of the challenges faced in United States health care delivery systems that affect child health, explains how the medical home might address them, describes methods for measuring quality in medical homes, and identifies barriers to implementation of the model.

Estimated savings from paid telephone consultations between subspecialists and primary care physicians.

Objectives: Pediatric subspecialists are not routinely reimbursed by Medicaid or insurance payers for telephone consultations. Generally, access to pediatric subspecialists is limited because of the small number of providers, their concentration in academic medical centers, and increasing demand for their services. Little is known about the nature of such consults, the time required to provide them, or whether there is a positive economic impact for payers.

Bolstering confidence in obesity prevention and treatment counseling for resident and community pediatricians.

Objective: To assess whether equipping resident pediatricians and community pediatricians with both training and practical tools improves their perceived confidence, ease, and frequency of obesity-related counseling to patients.

Methods: In 2005-2006, resident pediatricians (n = 49) and community pediatricians (n = 18) received training regarding three evidence-based obesity prevention/treatment tools and responded to pre- and post-intervention questionnaires. We analyzed changes in reported mean confidence, ease, and frequency of dietary, physical activity, and weight status counseling.

A medical home for children with insulin-dependent diabetes: comanagement by primary and subspecialty physicians--convergence and divergence of opinions.

Objective: The purpose of this work was to examine pediatricians' and endocrinologists' views about management for routine preventive and acute care, diabetes-specific care, and family education and care coordination for children with insulin-dependent diabetes.

Methods: We conducted a mixed-mode survey of all of the pediatricians in 1 medicaid managed care network and all of the pediatric and adult endocrinologists who treat children with diabetes in North Carolina.

Results: Of the 201 pediatricians surveyed, 132 responded (65%).

Reliability of medicaid claims versus medical record data: in a cost analysis of palivizumab.

Background: Palivizumab is one of the most costly paediatric medications for Medicaid and other health plans. It is uncertain whether the costs of palivizumab administration are justified in specific risk groups. Ongoing investigations of palivizumab require identification of reliable data sources.

Effectiveness of a practice-based, multimodal quality improvement intervention for gastroenteritis within a Medicaid managed care network.

Objective: Acute gastroenteritis results in 220,000 hospitalizations yearly in the United States. The substantial geographic variation in gastroenteritis care, coupled with the evidence of effective treatment of dehydration in nonhospital settings, suggests that the majority of these hospitalizations are avoidable. We sought to decrease hospitalizations for gastroenteritis by using practice-based, multimodal quality improvement methods that target multiple care processes to make them consistent with evidence-based guidelines.

High-deductible health plans and the new risks of consumer-driven health insurance products.

Consumer-driven health care is the most noteworthy development in health insurance since the widespread adoption of health maintenance organizations and preferred provider organizations in the 1980s. The most common consumer-driven health plan is the high-deductible health plan, which is essentially a catastrophic health insurance plan, often linked with tax-advantaged spending accounts, with very high deductibles, fewer benefits, and higher cost-sharing than conventional health maintenance organization or preferred provider organization plans. The financial risks are significant under high-deductible health plans, especially for low- to moderate-income families and for families whose children have special health care needs.

Evaluation of product switching after a state Medicaid program began covering loratadine OTC 1 year after market availability.

Objective: The conversion of loratadine from prescription (Rx)-only to over-the-counter (OTC) status on November 27, 2002, brought about the question of how OTC products may influence utilization of both OTC and Rx-only low-sedating antihistamines (LSAs) simultaneously. North Carolina (NC) Medicaid initially did not cover loratadine OTC but subsequently changed the policy 1 year after OTC conversion, on November 23, 2003. The objective of this study was to determine patterns of LSA utilization in relation to changes in OTC availability and Medicaid coverage policy and to assess the rate of product switching associated with these policies.

Pharmacist response to alerts generated from Medicaid pharmacy claims in a long-term care setting: results from the North Carolina polypharmacy initiative.

Objective: In response to burgeoning drug costs, North Carolina (NC) Medicaid encouraged pharmacists and prescribers to develop collaborative programs to reduce drug expenditures. One of these programs, the North Carolina Polypharmacy Initiative, was a focused drug therapy management intervention aimed at reducing polypharmacy in nursing homes. This intervention targeted patients with more than 18 prescription fills in 90 days, beginning in November 2002.

A pharmacy management intervention for optimizing drug therapy for nursing home patients.

Background: A drug therapy management service was designed to reduce polypharmacy among Medicaid recipients. This service selectively focused on patients who were high users of prescription drugs and had potential drug therapy problems (PDTPs).

Objectives: This article reports the results of the first phase of the North Carolina Polypharmacy Initiative.

Direct cost analyses of palivizumab treatment in a cohort of at-risk children: evidence from the North Carolina Medicaid Program.

Objective: Use of palivizumab prophylactic therapy reduces the occurrence of hospitalizations for serious respiratory syncytial virus (RSV) lower respiratory tract infections in at-risk infants. The direct cost-benefit of palivizumab prophylaxis for infants who are born at 32 to 35 weeks' estimated gestational age (EGA) during their first year of life has not been systematically examined. The objective of this study was to compare the direct costs of palivizumab prophylaxis and RSV treatment in infants who were born at 32 to 35 weeks EGA and received and did not receive palivizumab.