5 Findings From the August 2019 Issue of AJMC®

The August issue of The American Journal of Managed Care^® featured research on surprise medical billing policies, social determinants of health, and the value of chimeric antigen receptor (CAR) T-cell therapies, among other topics. Here are 5 findings from research published in the issue.

1. CAR T-cell treatment delays result in loss of social value

Treatment with CAR T-cell therapy provides significant benefit to patients with 2 types of cancers and results in billions of dollars gained in social value, according to this economic analysis. But without access to treatment, patients lose large chunks of that value: a 6-month delay in treatment results in patients with pediatric acute lymphoblastic leukemia and diffuse large B-cell lymphoma losing 67.3% and 46.0% of social value, respectively.

The study authors wrote that current barriers to CAR T-cell treatment, including lack of coverage and manufacturing challenges, should be eliminated to enable prompt patient access to curative therapies. “Efficient payment mechanisms, sufficient technological capabilities, adequate capital and human capital, and payment policy reform are required to minimize treatment delays for patients,” they concluded.

2. California’s policy to address surprise medical billing affected bargaining dynamics

With the problem of surprise medical billing receiving nationwide attention, a case study used semistructured interviews to delve into California’s experience implementing a policy that sets out-of-network payment standards for nonemergency physician services. In interviews with a wide range of stakeholders, the author found that the new payment standard has shifted leverage in negotiations in favor of payers, who now have an incentive to cancel contracts with rates higher than the standard.

This change in contracting dynamics is accelerating the trend of physician consolidation, interviewees reported, and has prompted concerns about access to care if specialists stop practicing in the state due to lower payments. The author noted that these experiences can inform policy making as several proposals to stop surprise billing are being debated at the federal level.

3. Patients with self-identified social needs have higher odds of hospital readmission

By examining claims data and data collected from a social health surveillance system, the authors of this retrospective observational study found that individuals who reported social needs (eg, food insecurity, transportation needs) were more likely to have an inpatient readmission within 30, 90, and 180 days than individuals without such needs. For instance, individuals with a social service need had 101% higher odds of readmission within 180 days.

The investigators wrote that the social health surveillance function discussed in the study, which is a managed care organization’s call center—based social service referral program, “highlights the potential for nonclinical organizations to support medical and social care integration.” They called for further research on the relationship between social health needs and readmissions.

4. Moving to an area with less access to chiropractic care linked to higher spine care spending

Back pain and neck pain represent a significant source of healthcare visits and costs in the United States, and this retrospective cohort study aimed to determine whether there is a relationship between accessibility of chiropractic care and spine-related spending. When Medicare beneficiaries relocated to an area of higher accessibility, there were associated decreases in spending on spine evaluation and management as well as diagnostic imaging and testing.

Although the savings per person were small, the study authors noted that they could accumulate into significant savings, considering the large volume of older Americans with spine conditions. Because chiropractors deliver more conservative management of back pain, future studies could determine if chiropractic care access “breaks the pathway to care that is discordant with practice guidelines.”

5. Late diagnosis of hepatitis C represents missed opportunities for intervention

Prompt detection and treatment of hepatitis C virus (HCV) is key to achieving improved outcomes, but many infections are not diagnosed until cirrhosis or end-stage liver disease occurs, representing missed opportunities to intervene earlier in the disease process, according to this large cohort study of patients with newly diagnosed HCV infection between 2014 and 2016. Of those 2695 patients, 21.4% had late diagnosis, and the rate of late diagnosis was higher in those born between 1945 and 1965, who represent the baby boomer cohort recommended by the CDC to receive screening.

“This study supports the finding that patients with undiagnosed cirrhosis are being followed in health systems for years prior to receiving a diagnosis of HCV, but waiting until it is clear that severe liver disease is present is a failed strategy for reducing morbidity and health costs,” the authors concluded. They pointed to opportunities for payers and providers to take an active role in facilitating recommended HCV screening in hopes of alleviating the economic and health burdens of late diagnosis.