CA7-04: Costs of Care for Persons with Opioid Dependence in Two Integrated Health Systems

Background/Aims Opioid dependence is a growing public health concern and results in high costs to individuals, health care systems, and society. Recent legislation allowing expansion of buprenorphine for replacement therapy use in general medical care settings may increase access to care for opioid dependence, but little is known about its impact on services utilization and commercial health systems costs. In this retrospective cohort study, we examined how the introduction of buprenorphine affected the pattern of medical care and addiction medicine (AM) services provided to patients with opioid dependence and associated costs. Methods Using electronic health records, we identified individuals with two or more diagnoses of opioid dependence per year from 2000 through 2008 in two large non-profit, integrated health systems (System A: N=4,425; System B: N=7122) and assessed health system utilization and costs. Results In both health systems and across the study period, the number of opioid-dependent persons increased considerably and the use of buprenorphine for opioid dependence treatment increased steadily. In System A, those receiving buprenorphine plus AM counseling had significantly higher costs than those receiving methadone plus AM counseling (Z= -9.22, p<.001), and significantly lower costs than those with little or no AM counseling (Z=2.81, p=.005). There were no differences in costs between those receiving buprenorphine plus AM counseling and those with AM counseling only (Z=1.30, p=.192). The treatment group by period interaction (?2 = 9.66, df=3, p=.022) was significant, with costs decreasing over time in the buprenorphine plus AM counseling group and increasing over time in all other groups. In System B, costs were significantly lower for the buprenorphine plus AM counseling group than for the group with little or no AM counseling (Z= -5.14, p<.001) and higher than for the group with AM counseling only (Z=5.56, p=.001). The treatment group by period interaction was not significant (?2 =1.23, df=2, p=.540). Discussion Buprenorphine treatment is emerging as a viable alternative to other AM treatment approaches for persons with opioid dependence. Results of this study provide further evidence that buprenorphine treatment can be provided at a similar cost to alternative strategies in private integrated health systems.     

Health status of populations as a measure of health system performance

This article describes the assessment of self-reported health status as one indicator of the performance of health care delivery systems. This work took place in the context of a larger effort to measure performance in health care. The Consortium Research on Indicators of System Performance (CRISP) project is developing measures of the performance of integrated health care systems, rather than plans or providers. The system focus leads to measurement of the health status of defined populations and an analysis of health care episodes and processes extending beyond the physician's office or hospital that relate directly to patient outcomes and satisfaction. This focus provides opportunities for application of performance measures to quality improvement efforts, since outcomes can be logically linked to identifiable and measurable processes. After a discussion of the purpose and the history of CRISP and how populations were defined within the systems, some preliminary data on the health status of populations are presented.     

Epidemiologic trends and costs of fragmentation

The data that were reviewed in this article documented that in health systems, which manage behavioral health disorders independently from general medical disorders, the estimated 10% to 30% of patients with behavioral health service needs can expect (1) poor access or barriers to medical or mental health care; (2) when services are available, most provided will not meet minimum standards for expected outcome change; and (3) as a consequence of (1) and (2), medical and behavioral disorders will be more persistent with increased complications, will be associated with greater disability, and will lead to higher total health care and disability costs than will treatment of patients who do not have behavioral health disorders. This article proposes that these health system deficiencies will persist unless behavioral health services become an integral part of medical care (ie, integrated). By doing so, it creates a win-win situation for virtually all parties involved. Complex patients will receive coordinated general medical and behavioral health care that leads to improved outcomes. Clinicians and the hospitals that support integrated programs will be less encumbered by cross-disciplinary roadblocks as they deliver services that augment patient outcomes. Health plans (insurers) will be able to decrease administrative and claims costs because the complex patients who generate more than 80% of service use will have less complicated claims adjudication and better clinical outcomes. As a result, purchaser premiums, whether government programs, employers, or individuals, will decrease and the impact on national budgets will improve. Ongoing research will be important to assure that application of the best clinical and administrative practices are used to achieve these outcomes.     

Care Coordination for Patients With Complex Health Profiles in Inpatient and Outpatient Settings

Patients with the most complex health profiles consume a disproportionate percentage of health care expenditures, yet often receive fragmented, suboptimal care. Since 2003, Wisconsin-based Gundersen Health has improved the quality of life and reduced the cost burden of patients with complex health profiles with an integrated care coordination program. Those results are consistent with data from the most successful care coordination demonstration projects funded by the Centers for Medicare and Medicaid Services. Specifically, Gundersen's program has been associated with reduced hospital stays, lower costs for inpatients, less use of inpatient services, and increased patient satisfaction. Gundersen's success is rooted in its team-based approach to coordinated care. Teams, led by a subspecialty-trained nurse, have regular, face-to-face contact with patients and their physicians in both inpatient and outpatient settings; involve patients deeply in care-related decisions; access a system-wide electronic medical record database that tracks patients' care; and take a macrolevel view of care-related factors and costs. Gundersen's model offers specific take-home lessons for institutions interested in coordinated care as they design programs aimed at improving quality and lowering costs. This institutional case study provides a window into well-executed care coordination at a large health care system in an era when major changes in health care provision and reimbursement mechanisms are on the horizon.     

Social networks and best practices in public health: the example of regional billing groups

OBJECTIVE: Rising health care costs, increased demand for clinical services, and reimbursement difficulties created a funding shortage among local health departments in the state of Kansas. This intervention established regional billing groups to provide professional support and increase third-party reimbursement. DESIGN: Through feedback sessions, billing clerks provided qualitative responses about training needs. These informed the process of establishing billing groups in each state health district. SAMPLE: All billing clerks in the state's 6 regional health districts were invited to participate, as were insurance and billing software representatives. INTERVENTION: Between April 2002 and September 2004, 6 collaborative groups were established. Billing clerks received professional support and training from peers, insurance representatives, and software providers. An interagency billing advisory team was established to coordinate training activities between groups. RESULTS: These groups have allowed local health departments to increase reimbursement revenue by 50%-75%, allowing for the provision of expanded health services to client populations. CONCLUSIONS: These methods can serve as a model for other states, particularly those with considerable rural populations or decentralized health care systems. Still, funding shortages persist, and public health billing clerks will continue to need ongoing training in the most current and effective billing methods.     

Indigenous community participation: how does it relate to student centered learning and embrace primary health care philosophies?

The health and well-being of Indigenous Australians has been identified as a critical problem with high levels of chronic illness, morbidity and mortality compared to other Australian population groups. However, as health professionals we continue to discuss and theorise components of Indigenous health addressing issues in a piecemeal way. The concept of primary health care has been shown to have an independent effect on improving the health status of populations and having the ability to reduce health inequalities. Countries with well developed primary care systems have healthier populations and reduced health care costs (Macinko et al., 2003, p. 407). Primary health care combined with a community holistic approach and the defined use of student centered learning in Indigenous education has the potential to provide optimal health care and thus be an effective way to improve Indigenous Community health (McMurray, 2003, p. 296).     

Transitional care services and chronicity: oncology as a case in point

Fragmentation in care is of primary concern to nurses and other individuals involved in the provision of health services. Currently, fragmentation is related to the changes that have occurred in health delivery systems, increased emphasis on cost containment, the appropriate and effective delivery of nursing care, and the increasing prevalence of chronicity in populations requiring health services. This paper examines the fragmentation of care that results under current health care delivery structures for individuals with the diagnosis of cancer and their families. Transitional care, which the clinical nurse specialist is prepared uniquely to implement, is discussed for its potential to impact positively the elements of care rendered to individuals and families living with the realities of cancer.     

Health care information systems. Patient-centered integration is the key

In today's cost-constrained health care delivery environment, hospitals are recognizing the need to optimize their care operations to improve the efficiency, efficacy, and service quality of primary health care providers, particularly the medical staff and nursing services, which comprise about 50% of the hospital's total personnel. Because health care institutions are in the business of caring for patients (not for accounts or departments), and because health care delivery largely is a personnel-intensive information industry, operations optimization is supported best by information systems that fully integrate all information concerning the patient. The goal of this is to simplify the job duties of direct care providers. The benefits of an integrated, patient-centered approach include demonstrable improvements in over-all patient care quality and staff satisfaction as well as a significant reduction in costs.     

Trends in mental health: implications for advanced practice nurses

PURPOSE: To examine current trends in mental health care for vulnerable populations and suggest how advanced practice nurses (APNs) can incorporate mental health care into primary care practice. DATA SOURCES: Original research and evidence-based clinical articles, government publications, and professional practice guidelines. CONCLUSIONS: Vulnerable populations, such as racial and ethnic minorities, adults with chronic mental illness, the elderly, the incarcerated, and those living in rural areas have long been ignored as recipients of quality, integrated health care services. There is a compelling need for APNs to participate in the integrated delivery of physical and mental health care to all Americans, especially to vulnerable populations. IMPLICATIONS FOR PRACTICE: Under the umbrella of advanced practice nursing, a variety of nurse practitioners (NPs) and clinical nurse specialists (CNSs) can offer a holistic approach to the provision of evidence-based health care in a wide variety of settings to an array of vulnerable and underserved people. By serving on provider panels, partnering with consumer groups, and advocating for the unmet health needs of vulnerable populations, APNs can have a positive impact on the health care delivery system.     

Interdisciplinary shared governance: a partnership model for high performance in a managed care environment

Today's managed care environment is forcing hospitals to seek new and innovative ways to deliver a seamless continuum of high-quality care and services to defined populations at lower costs. Many are striving to achieve this goal through the implementation of shared governance models that support point-of-service decision making, interdisciplinary partnerships, and the integration of work across clinical settings and along the service delivery continuum. The authors describe the key processes and strategies used to facilitate the design and successful implementation of an interdisciplinary shared governance model at The University Hospital, Cincinnati, Ohio. Implementation costs and initial benefits obtained over a 2-year period also are identified.     

Evaluation of the Washington State Workers' Compensation Managed Care Pilot Project II: medical and disability costs.

OBJECTIVES: This study examined the effect of managed care on medical and disability costs as part of an evaluation of the Washington State Workers' Compensation Managed Care Pilot (MCP). METHODS: One hundred twenty firms (7,041 employees) agreed to have their injured workers treated in managed care plans. Managed care introduced two changes from the fee-for-service (FFS) delivery system currently used by injured workers in Washington State: experience- rated capitation and a primary occupational medicine delivery network. The FFS control group included injured workers employed at 392 firms (12,000 employees). Medical and disability costs were compared for 1,058 injuries in the managed care group and 1,159 injuries in the FFS group occurring between April 1995 and June 1996. Univariate and multivariate statistical methods were used to analyze the effects of managed care on medical and disability costs. RESULTS: The mean unadjusted medical cost per injury ($587) for the managed care group was 21.5% lower (P = 0.06) than for the FFS group ($748). Adjustment for differences in worker and firm-level characteristics through multivariate analysis had little effect on the unadjusted results, except that the difference in costs between managed care and FFS groups became statistically significant (P<0.01). The major cost differences were for outpatient surgery (cost per surgery) and ancillary services (pharmacy, x-ray, physical therapy, and all other costs). In addition, disability costs, particularly percent on time loss and time-loss cost per injury, were significantly lower (P<0.01) in the managed care group. CONCLUSIONS: The results from the MCP suggest that substantial savings in workers' compensation medical and disability costs may be realized using the type of managed care intervention designed for this study. Delivering occupational health services through managed care arrangements whose design is based on an integrated, occupational health-centered delivery model may offer a viable approach for improving delivery systems, reducing costs and encouraging greater attention to disability prevention.     

Priori outcomes: oxymoron or practice plan

This assessment helped shape the practice of a nurse administered mobile clinic serving three rural communities. Needed services were identified and existing services were customized to improve the overall health of the communities. With the dynamic state of health care systems, each practice is subject to influence by managed care and populations who, in turn, respond with changes in need, resources, and adaptation to the system dynamics. Nurse practitioners struggling to match resources and patient needs could use a similar research design to assess their practice, discover significant relationships, and redesign practice plans to fit specific practice settings.     

A future perspective on patient/health education in Canada

The current climate of health care redefinition and reform in Canada has prompted the need to review services and resources with a view to reducing costs, refocusing emphasis and maintaining the level of health care services of which Canadians are proud This paper reviews the process of patient/health education using the PRECEDE model This model encompasses the behavioural and non-behavioural aspects of targeted health problems and their populations at risk, and three sets of strategic factors affecting educators and their clients The paper examines the particular challenges implicit in each of the process components which are suggested by current trends and their implications for the future     

Does supplementary prenatal nursing and home visitation reduce healthcare costs in the year after childbirth?

AIM: This paper reports the costs of a programme of supplementary prenatal care, including healthcare costs, in the year following childbirth. BACKGROUND: Publicly funded healthcare systems have provided pregnant women with adequate medical care, but access to resources to address their non-medical needs is still an issue. To improve women's access to pregnancy-related resources, a community-based, prenatal programme involving consultations with a specialist nurse, or nurse plus a home visitor was evaluated. METHOD: A sample of 284 women who had participated in a randomized controlled trial of the prenatal care programme participated in this partial economic analysis. Women had been randomized to one of three trial arms: (1) standard care, (2) standard care plus consultations with a specialist prenatal care nurse, or (3) standard care plus nurse consultations and a home visitor. For the economic study, each woman was asked about her and her baby's use of healthcare services in the 12 months after the baby's birth. Health service utilization was multiplied by the unit cost of each service and summed to arrive at the total cost of services used. The study was undertaken in 2004. RESULTS: Supplementary prenatal care neither increased the use of health services nor resulted in savings in health spending. Compared with standard care, women in the two intervention groups made more use of family physicians and less use of paediatricians, but no significant differences in the overall costs of health care were noted. CONCLUSION: While supplementary prenatal care had no impact on costs, some benefits occurred for those at greatest risk of not accessing services. However, it would be premature to draw widespread recommendations for policy from the results of a single study. Further investment in prenatal care should continue to be accompanied by rigorous evaluation of its costs and the value that women place on the service provided.     

Integrating reproductive health into emergency response assessments and primary health care

War-affected populations often are displaced for years. When primary health care is focused on the acute conditions that often present in the emergency phase of a complex emergency, insufficient attention often is directed towards other evolving needs of the population. Their reproductive health, psychosocial health, and problems with chronic diseases may be overlooked even after the situation stabilizes. This article examines currently available resources for conducting rapid assessments of health needs and services during complex emergencies. Their respective strengths and weaknesses are discussed, particularly for assessing a population's reproductive health needs, and for fostering the integration of reproductive health and primary health-care services, and for designing health services delivery. When more specific indicators are included in a needs assessment tool, the likelihood that the assessment results will influence the design and scope of the health program is increased. Needs assessments for primary health care that incorporate reproductive health indicators will assist health officials to integrate these services, and thus, use staff and facilities more efficiently, and will highlight areas of opportunity for providing services.     

Health services research and quality of care. Assignments for the 1990s

The unabated rise in health care costs is bringing health services research into center stage as an applied science to help guide health care managers, purchasers, and regulators. To be equal to the task, health services research must pursue at least four intellectual agendas: the study of efficacy (knowing what works), the study of appropriateness (using what works), the study of the execution of care (doing well what works), and the study of the purposes of care (the values that underlie action). The responsibility for the financing and conduct of the research agendas varies with the level of aggregation of data and effort needed for each topic. All four topics must be pursued effectively if health care quality is to be successfully defined, measured, and protected.     

Structured headache services as the solution to the ill-health burden of headache. 2. Modelling effectiveness and cost-effectiveness of implementation in Europe: methodology

BackgroundHealth economic evaluations support health-care decision-making by providing information on the costs and consequences of health interventions. No universally accepted methodology exists for modelling effectiveness and cost-effectiveness of interventions designed to close treatment gaps for headache disorders in countries of Europe (or elsewhere). Our aim here, within the European Brain Council’s Value-of-Treatment project, was to develop headache-type-specific analytical models to be applied to implementation of structured headache services in Europe as the health-care solution to headache.MethodsWe developed three headache-type-specific decision-analytical models using the WHO-CHOICE framework and adapted these for three European Region country settings (Luxembourg, Russia and Spain), diverse in geographical location, population size, income level and health-care systems and for which we had population-based data. Each model compared current (suboptimal) care vs target care (delivered in accordance with the structured headache services model). Epidemiological and economic data were drawn from studies conducted by the Global Campaign against Headache; data on efficacy of treatments were taken from published randomized controlled trials; assumptions on uptake of treatments, and those made for Healthy Life Year (HLY) calculations and target-care benefits, were agreed with experts. We made annual and 5-year cost estimates from health-care provider (main analyses) and societal (secondary analyses) perspectives (2020 figures, euros).ResultsThe analytical models were successfully developed and applied to each country setting. Headache-related costs (including use of health-care resources and lost productivity) and health outcomes (HLYs) were mapped across populations. The same calculations were repeated for each alternative (current vs target care). Analyses of the differences in costs and health outcomes between alternatives and the incremental cost-effectiveness ratios are presented elsewhere.ConclusionsThis study presents the first headache-type-specific analytical models to evaluate effectiveness and cost-effectiveness of implementing structured headache services in countries in the European Region. The models are robust, and can assist policy makers in allocating health budgets between interventions to maximize the health of populations.