Integrated personalized diabetes management goes Europe: A multi-disciplinary approach to innovating type 2 diabetes care in Europe

Type 2 diabetes mellitus represents a multi-dimensional challenge for European and global societies alike. Building on an iterative six-step disease management process that leverages feedback loops and utilizes commodity digital tools, the PDM-ProValue study program demonstrated that integrated personalized diabetes management, or iPDM, can improve the standard of care for persons living with diabetes in a sustainable way. The novel “iPDM Goes Europe” consortium strives to advance iPDM adoption by (1) implementing the concept in a value-based healthcare setting for the treatment of persons living with type 2 diabetes, (2) providing tools to assess the patient’s physical and mental health status, and (3) exploring new avenues to take advantage of emerging big data resources.     

Patients’ expectations for and experiences with primary healthcare services received from a patient centered medical home

ObjectiveExpectations for and experiences with healthcare services are summarized for 1143 patients receiving care in a statewide demonstration of Patient Centered Medical Homes (PCMH).MethodsPatients were recruited from 91 primary care clinics for semi-structured interviews to determine what patients expect, what they plan to do and how they intend to execute their plans in partnership with their healthcare team.ResultsThe majority (78%) of patients defined the patient-team partnership as a collaborative and problem-solving effort. Overall, 68% defined responsibility for own health as a personal responsibility; 55% defined listening to patient’s concerns and answering questions as a responsibility of their healthcare team. Diet and exercise came up most frequently whether as a personal responsibility, issues for receiving additional help from their clinic, or plans for personal change.ConclusionPatients’ preferred a collaborative, problem-solving healthcare team partnership but also had boundaries for what additional services they wanted from this team.Practice Implications: Patients’ expectations for a collaborative partnership, acceptance of personal responsibility and interest in diet and exercise expands opportunities for patient education and teamwork. Clinics’ engagement with broader resources would be needed to address patients’ many and varied challenges to taking care of their health.     

Reasons for underutilization of bariatric surgery: The role of insurance benefit design

Despite the effectiveness of bariatric surgery, both with respect to weight loss and improvements in obesity-related co-morbidities, it remains underused. Only 1% of the currently eligible population undergoes surgical treatment for obesity, with roughly 228,000 individuals receiving bariatric surgery in the United States each year. Several barriers to bariatric surgery have been identified, including limited patient and referring physician knowledge and attitudes regarding the effectiveness and safety of bariatric surgery. However, the role of insurance coverage and benefit design as a barrier to access to care has received less attention to date. Bariatric surgery is cost-effective compared with nonsurgical treatments among individuals with extreme obesity and type 2 diabetes. While it may not result in cost savings among all bariatric surgery eligible patients, for certain patient subgroups, bariatric surgery may be cost neutral compared with traditional treatment options. In addition, longer-term outcomes of bariatric surgery suggest decreased or stable costs in the long run. The purpose of this review paper was to synthesize the existing knowledge on why bariatric surgery remains largely underused in the United States with a focus on health insurance benefits and design. In addition, the review discusses the applicability of value-based insurance design to bariatric surgery. Value-based insurance design has been previously applied to bariatric surgery coverage with use of incentive-based cost-sharing adjustments. Its application could be further extended because the postoperative clinical outcomes and costs vary among the different subgroups of bariatric surgery eligible patients.     

Determinants of price negotiations for new drugs. The experience of the Italian Medicines Agency

ObjectivesThe aim of this paper is to investigate the determinants of the difference between the price proposal submitted by the industry and the final negotiated price. We used Italy as a case-study.MethodsData were gathered through the information system used by Italian Medicines Agency. The time-frame for this analysis is 2013–2017. Factors influencing the delta price were analyzed through a regression analysis.Results44 orphan drugs and 89 new other molecular entities obtained reimbursement in the last five years. Following the negotiation process, prices were lowered by 25.1% and 28.6% on average for orphan drugs and other molecules respectively. The price reduction was higher for innovative drugs (-32.2%). Statistically significant determinants associated to higher price reduction were: i) the implementation of a product specific monitoring registry, ii) the negotiation of a financial-based Managed Entry Agreement, iii) a target population larger than 20,000 patients, iv) an expected National Health Service expenditure larger than €200 million.DiscussionThe impact of some variables on the delta price was predictable (e.g. for drugs with an expected higher budget impact and a larger population target), others were more surprising (e.g. a significant price reduction for “innovative” drugs). The implementation of financial-based agreements, which often rely on confidential arrangements, was one of the determinants with higher impact on price reduction.     

Value-Based Healthcare in Urology: A Collaborative Review

ContextIn response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated.ObjectiveTo systematically review the literature regarding the implementation and impact of value-based healthcare in urology.Evidence acquisitionA systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion.Evidence synthesisReorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms.ConclusionsFew studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented.Patient summaryWhile few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.     

Barriers to payment reform: Experiences from nine Dutch population health management sites

Population health management (PHM) initiatives aim for better population health, quality of care and reduction of expenditure growth by integrating and optimizing services across domains. Reforms shifting payment of providers from traditional fee-for-service towards value-based payment models may support PHM. We aimed to gain insight into payment reform in nine Dutch PHM sites. Specifically, we investigated 1) the type of payment models implemented, and 2) the experienced barriers towards payment reform. Between October 2016 and February 2017, we conducted 36 (semi-)structured interviews with program managers, hospitals, insurers and primary care representatives of the sites. We addressed the structure of payment models and barriers to payment reform in general. After three years of PHM, we found that four shared savings models for pharmaceutical care and five extensions of existing (bundled) payment models adding providers into the model were implemented. Interviewees stated that reluctance to shift financial accountability to providers was partly due to information asymmetry, a lack of trust and conflicting incentives between providers and insurers, and last but not least a lack of a sense of urgency. Small steps to payment reform have been taken in the Dutch PHM sites, which is in line with other international PHM initiatives. While acknowledging the autonomy of PHM sites, governmental stewardship (e.g. long-term vision, supporting knowledge development) can further stimulate value-based payment reforms.     

El modelo Clinical outcomes,healthcare resource utilization,and related costs (COHERENT). Aplicación en pacientes con insuficiencia cardiaca

Introduction and objectivesComposite endpoints are widely used but have several limitations. The Clinical outcomes, healthcare resource utilization and related costs (COHERENT) model is a new approach for visually displaying and comparing composite endpoints including all their components (incidence, timing, duration) and related costs. We aimed to assess the validity of the COHERENT model in a patient cohort.MethodsA color graphic system displaying the percentage of patients in each clinical situation (vital status and location: at home, emergency department [ED] or hospital) and related costs at each time point during follow-up was created based on a list of mutually exclusive clinical situations coded in a hierarchical fashion. The system was tested in a cohort of 1126 patients with acute heart failure from 25 hospitals. The system calculated and displayed the time spent in each clinical situation and health care resource utilization-related costs over 30 days.ResultsThe model illustrated the times spent over 30 days (2.12% in ED, 23.6% in index hospitalization, 2.7% in readmissions, 65.5% alive at home, and 6.02% dead), showing significant differences between patient groups, hospitals, and health care systems. The tool calculated and displayed the daily and cumulative health care-related costs over time (total, €4 895 070; mean, €144.91 per patient/d).ConclusionsThe COHERENT model is a new, easy-to-interpret, visual display of composite endpoints, enabling comparisons between patient groups and cohorts, including related costs. The model may constitute a useful new approach for clinical trials or observational studies, and a tool for benchmarking, and value-based health care implementation.