Centers for Medicare & Medicaid Services provides reimbursement through Hierarchical Condition Category (HCC) coding. Medical systems strive toward risk adjustment optimization, often implementing costly chart review processes. Previously, our organization implementing countermeasures through workflows was complex and performed in silos. Our goal was to put in place HCC-Risk Adjustment Factor (RAF) improvement tools to optimize HCC-RAF management in Population Health using rapid process improvement methods. In this quality improvement analysis (IRB#806198), we used Lean methodology to develop tools and implement streamlined processes for providers to manage, document, and code high-risk HCC conditions. Rather than applying costly countermeasures, Transformational Healthcare conducted a Rapid Process Improvement Workshop (RPIW), with workgroups implementing proposed changes, to improve processes. Each of these tools was embedded in standard work, for teams to use in practice. Tools included the development of RPIW-inspired work groups, a Provider Education website, tip sheets, clinical champions, trainings, audits, practice alerts, smart phrases, schedule view tools, severity scores, reports, dashboards, on-screen decision-support tools, coding expertise, and HCC standard work. Quantitatively, Year 1 showed enterprise HCC-RAF scores improved by 4.1%. We were able to develop tools for providers and team members to allow for more optimized pathways. Although quantitatively we realized an improvement in enterprise HCC-RAF score, our overall aim was to improve process flow and limit waste. Leveraging Lean improvement methods for the collective design of tools has supported culture change. In the end, we found that providers are indeed willing to adopt these newly built tools. These tools have optimized operations, allowing providers to work smarter, not harder.

Composite health indicators are valuable tools to assess population health over time and identify areas for intervention. This scoping review (ScR) aimed to map the literature describing comprehensive health-related metrics used to assess community health. The Arksey and O'Malley framework was used to conduct the ScR, using the following steps: identifying the research question, identifying relevant studies, charting the data, collating and reporting results. United States-based studies that developed/utilized a composite health index using geographic information system (GIS) mapping capabilities to assess community health at the county level or more granular were identified through literature searches conducted in PubMed and EMBASE databases. Literature searches identified 5112 articles; of these, 8 studies describing composite health indices were included. The number of indicators used in each index ranged from 4 to 75 (median: 22). Health outcomes, health behaviors, education, and economics were incorporated into most indices. High school graduation rate ( = 6 indices), health insurance status ( = 5), commute time, median household income, unemployment, and obesity rates ( = 4 each) were the most common indicators across indices. All indicators were derived from publicly available data sources, such as the American Community Survey and US Census Bureau. Although a limited number of community health indices were identified in the ScR, the indices included a broad range of indicators covering both health outcomes and factors contributing to health vulnerabilities. The public data sources and GIS integration of the indices provide potential for broad, insightful applications to various contexts across the United States.

There is a global mental health crisis: mental illness is underrecognized, underdiagnosed, and undertreated with adverse effects on mental, physical, and social health. In the United States, there is an insufficient number of traditional psychiatric and psychological resources to provide the mental health care needed to solve this crisis. Community-based interventions could be an important adjunct to traditional mental health care. An evaluation of peer-reviewed articles was performed describing community-based interventions and identified 3 approaches with some evidence of effectiveness: (1) interventions that enhance community mental health literacy to improve recognition of early signs of mental illness for early engagement and provide community, family, and peer support; (2) community clinics providing social, medical, and mental health care and support to transition-age youth (15-25 years); and (3) social networking activities to enhance interactions among elders suffering from social isolation and loneliness. Multisector, multidisciplinary, and multicomponent interventions involving health care providers and community-based organizations had the best evidence of effectiveness and should target transition-age youth and elders.

Despite focusing on drivers of health, or social determinants of health, for more than a decade, health care organizations have made minimal progress in improving these factors and associated health outcomes. This data- and theory-driven analysis looks at (1) why that is the case and (2) how organizational leaders and operators can go about correcting it. The authors' research finds that lack of progress is often due to ill-fit, entrenched business models that were optimized for a fee-for-service environment and cannot easily pivot to focus on drivers of health. Additionally, leaders are often unclear about what to change and overwhelmed by how to do it. The authors propose a 5-step strategy and execution process to address these challenges, laying out an end-to-end road map that enables health care leaders to meaningfully improve drivers of health and associated health outcomes for their patients and communities.

Cardiovascular disease (CVD) is a leading cause of premature mortality among patients with severe mental illness (SMI). Effective care delivery models are needed to address this mortality gap. This study examines the impact of an enhanced primary care (PC) program that specializes in the treatment of patients with SMI, called Medicine in Psychiatry Service-Primary Care (MIPS-PC). Using multipayer claims data in Western New York from January 1, 2016 to December 31, 2021, patients with SMI and CVD were identified using International Classification of Diseases, Tenth Revision codes. National Provider Identification numbers of MIPS-PC providers were then used to identify those patients who were treated by MIPS-PC during the period. These MIPS-PC-treated patients were compared against a cohort of one-to-one propensity score matched contemporaneous comparison group (ie, patients receiving PC from providers unaffiliated with MIPS-PC). A difference-in-difference approach was used to identify the treatment effects of MIPS-PC on all-cause emergency department (ED) visits and hospitalization rates. The MIPS-PC group was associated with a downtrend in the acute care utilization rates over a 3-year period following the index date (ie, date of first MIPS-PC or other PC provider encounter), specifically a lower hospitalization rate in the first year since the index date (25%; < 0.001). ED visit rate reduction was significant in the third-year period (18%; = 0.021). In summary, MIPS-PC treatment is associated with a decreasing trend in acute care utilization. Prospective studies are needed to validate this effect of enhanced PC in patients with SMI and CVD.

Recombinant zoster vaccine has been recommended by the US Advisory Committee on Immunization Practices (ACIP) for the prevention of herpes zoster (HZ) in immunocompetent adults aged at least 50 years since 2018. In January 2022, this was extended to immunodeficient/immunosuppressed adults aged at least 19 years. Key study objectives were to assess specialists' knowledge of the ACIP HZ vaccination recommendations, their attitudes toward HZ vaccination, and HZ vaccination practices/barriers. This cross-sectional, web-based survey (conducted in March 2022) included US dermatologists, gastroenterologists, infectious disease specialists, oncologists, and rheumatologists who treat patients with psoriasis, inflammatory bowel disease, human immunodeficiency syndrome, solid tumors/hematological malignancies, and rheumatoid arthritis, respectively. Although most of the 613 specialists correctly identified the ACIP HZ vaccination recommendations for adults aged at least 50 years (84%) and immunodeficient/immunosuppressed adults aged at least 19 years (67%), only 29% knew that recombinant zoster vaccine is recommended for individuals who have previously received zoster vaccine live, and only 18% knew all current ACIP recommendations. For patients with the diseases listed, 84% of specialists thought that HZ is a serious risk, 75% that HZ vaccination is extremely/very important, and 69% were extremely/very likely to recommend HZ vaccination. Only 36% administer vaccines themselves, mainly because patients receive vaccinations from others. Barriers to vaccination included more urgent/acute issues, insufficient time, and lack of patient motivation/willingness. Full knowledge of the ACIP HZ vaccination recommendations among the surveyed specialists was low. There may be a need to educate specialists to improve adherence to these recommendations. [Figure: see text].

In the aftermath of the US withdrawal from Afghanistan, over 100,000 individuals were evacuated to the United States, primarily arriving through Philadelphia International Airport and Dulles International Airport under Operation Allies Welcome. In Philadelphia, evacuees were greeted at the airport by a medical triage unit (MTU) that was rapidly assembled to provide on-site medical care. The MTU triaged emergent medical complaints, handled minor complaints on-site to reduce impact on local health care systems, distributed patients who did require a higher level of care among area hospitals, and ensured appropriate follow-up care for individuals with ongoing needs. Although there are regional and federal entities whose purview is the establishment and coordination of such responses, these entities were not mobilized to respond immediately when planes began to arrive carrying the first wave of evacuees as this event was not a designated disaster. The MTU was a grassroots effort initiated by local health care providers in coordination with the local Medical Reserve Corps and Department of Public Health. This article presents a framework for similar operations, anticipating an ongoing need for planning for sudden arrivals of large numbers of displaced persons, particularly via air travel, in a time of increasing mass displacement events, as well as a rationale for establishing more robust networks of local medical professionals willing to respond in the case of an emergency and involving them in the emergency planning processes to ensure preexisting protocols are practical.

HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention for HIV infections. PrEP persistence is critical to achieving optimal protection against HIV infection. However, little is known about PrEP persistence in the United States. This study utilized the Connecticut All-Payer Claims Database (APCD) to identify PrEP persistence among patients who filled their PrEP prescriptions in the state. The authors identified 1,576 PrEP patients who picked up PrEP prescriptions and extracted medical and pharmacy claims to evaluate a longitudinal cohort during 2012-2018 based on the Connecticut APCD. Patients who did not pick up medication for one consecutive month (ie, 30 days) were defined as discontinuing PrEP. Kaplan-Meier Survival Curve and proportional hazard regression were used to describe PrEP persistence. Of the 1,576 patients who picked up PrEP prescriptions, the median age was 32.0 (interquartile range [IQR]: 22.0-44.0). The majority were male individuals (93%). Of 1,040 patients who discontinued PrEP, 702 (67.5%) restarted PrEP at least once. The median time of PrEP persistence was 3 months (IQR: 1-6 months) for initial PrEP use. The median time on PrEP was also around 3 months in the following episodes of PrEP use. Being female, being on parent's insurance, and having high co-pays were associated with shorter periods of PrEP persistence. PrEP persistence was low among patients who picked up PrEP prescriptions. Although many patients restarted PrEP, persistence remained low during follow-up PrEP use and possibly led to periods of increased HIV risk. Effective interventions are needed to improve PrEP persistence and reduce HIV incidence.

The authors describe a rapid implementation of medication treatment for substance use disorders in a value-based organization, delivered in the community-based, interdisciplinary primary care of Medicaid and dual-eligible members. The determinants of increased need are reviewed, as well as the growing opportunity to improve access to treatments, and a template for implementation is shared.

This cross-sectional study assessed hepatitis C virus (HCV) antibody and RNA test results performed from 2016 to 2021 at a large US clinical reference laboratory. When individual patient factors (ie, income, education, and race/ethnicity) were not available, estimates from the US Census were linked to the residential zip code. The final analytic cohort comprised 19,543,908 individuals with 23,233,827 HCV antibody and RNA test results. An analysis of progressively increasing poverty quintiles demonstrated an increasing trend in both HCV antibody positivity (from 2.6% in the lowest quintile to 6.9% in the highest, < 0.001 for trend) and HCV RNA positivity (from 1.0% to 3.6%, < 0.001 for trend). Increasing levels of education were associated with a decreasing trend in both HCV antibody positivity (from 8.4% in the least educated quintile to 3.0% in the most, < 0.001 for trend) and HCV RNA positivity (from 4.7% to 1.2%, < 0.001 for trend). Persistent differences in positivity rates by these social determinants were observed over time. HCV antibody and RNA positivity rates were nearly identical in predominantly Black non-Hispanic, Hispanic, and White non-Hispanic zip codes. However, after adjustment for all other factors in the study, residents of predominantly Black non-Hispanic and Hispanic zip codes were significantly less likely to test positive for HCV RNA (adjusted odds ratios [AOR]: 0.51, 95% confidence interval [CI]: 0.51-0.52; AOR: 0.46, 95% CI: 0.46-0.46, respectively). These findings may benefit targeted intervention initiatives by public health agencies.

The objective was to examine Medical Advantage (MA) organizations' commitment toward addressing social determinants of health (SDOH) through their health-related social benefit offerings, and the perceived impact of providing supplemental benefits associated with SDOH in their plans. Public reporting documents were reviewed from six of the largest MA firms: Humana, UnitedHealthcare, Cigna, Elevance Health, CVS Health, and Centene. Public reports were obtained from each company's website (eg, from the "Investor Relations" page). Quarterly reports for Q1 2023, annual reports for 2022, and proxy statements for 2023 for all companies were examined. Content analysis of the public reports was conducted under three constructs: (1) Growth of MA in the company, (2) SDOH-related activities in the company, and (3) SDOH-related activities in the MA plans of the company. Each of the three constructs was further analyzed for recurring themes and elements. The findings from content analysis suggests that plans are providing tailored benefits that may address the social needs of vulnerable and underserved populations. Companies that offered supplemental benefits and value-based arrangements that addressed social needs reported beneficiary clinical outcomes resulting in cost savings and increased revenue. Health insurance companies identify MA as a significant growth opportunity and a strategically important market for overall membership and revenue growth. Moreover, companies providing innovative social benefits through their MA plans reported witnessing increased value propositions by underserved and vulnerable populations, leading to increased revenue and cost containment.

The association between depression and ambulatory care utilization is unclear. The authors sought to determine the association between untreated depression and ambulatory care utilization, including the extent to which care is fragmented, or spread across providers. The authors conducted a longitudinal study using data from the nationwide REasons for Geographic and Racial Differences in Stroke study linked to Medicare fee-for-service claims ( = 1412). They categorized participants into three study groups, based on self-reported depressive symptoms (Center for Epidemiological Studies Depression Scale score ≥ 4) and a medication inventory for antidepressants: Symptomatic Untreated (SU), Symptomatic Treated (ST), and Asymptomatic Treated (AT). The authors used descriptive statistics to characterize ambulatory care patterns by study group. They determined the association between the study group and fragmentation score (with high fragmentation defined as a reversed Bice-Boxerman Index ≥ 0.85) using multivariable logistic regression. All groups had similar numbers of primary care visits, but the SU group had the fewest specialist visits. The SU group had the lowest proportion of participants who received care from a psychiatrist (3.4% vs. 10.7% for ST and 11.9% for AT, pairwise -values < 0.001). The SU group was the least likely to have highly fragmented care (adjusted odds ratio 0.68; 95% confidence interval 0.48, 0.95, compared with the ST group). These results suggest that older adults with untreated depression are not engaged in excess care-seeking behaviors. Rather, the results suggest undertreatment of depression in primary care and underutilization of psychiatric care.

The health care industry is experiencing a transformative shift from traditional fee-for-service models to value-based care (VBC), emphasizing improved patient outcomes, enhanced quality, and reduced costs. While Centers for Medicare & Medicaid Services Innovation Center models focus on financial and quality outcomes, a critical opportunity for reform lies in organizational culture. VBC signifies a cultural and systemic evolution aligned with the quintuple aim of enhancing equitable patient outcomes, improving quality, reducing costs, and prioritizing provider well-being. Cultural impacts play a pivotal role in this transformation.

Screening for social needs has gained traction as an approach to addressing social determinants of health, but it faces challenges regarding standardization, resource allocation, and follow-up care. The year-long study, conducted by the Association of American Medical Colleges, integrated data from conferences, surveys, and key informant interviews to examine the integration of social needs screening into health care services within Academic Health Systems (AHS). The authors' analysis unveiled eight key themes, showcasing AHS's active involvement in targeted social needs screening alongside persistent resource allocation obstacles. AHS are dedicated to efficiently identifying high-risk populations, fostering partnerships with community-based organizations, and embracing technology for closed-loop referrals. However, concerns endure about the utilization of reimbursement codes for social needs and regulatory compliance. AHS confront staffing issues, resource allocation intricacies, and the imperative for seamless integration across clinical and nonclinical departments. Notably, opportunities arise in standardized training, alignment of AHS priorities, exploration of social investment models, and engagement with state-level health information exchanges. Aligning clinical care, research pursuits, and community engagement endeavors holds promise for AHS in effectively addressing social needs.

This paper describes hospital, insurance, and pharmaceutical price transparency policies and applications in the United States and in selected countries around the world. Many of these policies apply to self-insured employers. So far, the experience in the United States and elsewhere is clear that federal and state price transparency regulations have had little impact on whether employees or dependents search for low-cost or high-quality providers or on the cost and quality of their health care. This is because of weak regulatory oversight, conflicting federal and state reporting requirements, and few economic incentives for providers and insurance companies to supply easily readable or analyzable price information. However, price transparency requirements are here to stay. This paper therefore offers several recommendations to maximize the utility of price transparency tools provided for employees and other insureds, by their employers, providers, commercial insurance carriers, or technology firms. From a policy perspective, coupling reporting requirements with clearer technological guidance and much stronger regulatory oversight would increase the utility of price transparency efforts. For individual employers, the impact of price transparency efforts may increase by coupling price transparency tools with health plan network and design strategies, behavioral economic nudges, and programs designed to improve health, well-being, and quality of care. Many program vendor partners, consultants, and actuarial, technology, and research firms can help make these efforts useful.

Obesity-related comorbidities (ORCs) cause significant economic and clinical burdens for people with obesity and the US health care system. A reduction in weight at the population level may reduce incident ORC diagnoses and associated costs of treatment. The aim of this work is to describe obesity burden in the United States through the prevalence and direct treatment costs of ORCs, as well as the clinical and economic value of 15% weight loss in a population of adults with obesity. The IQVIA Ambulatory US electronic medical record database was used to create a cohort (7,667,023 individuals 20-69 years of age, body mass index of 30-50 kg/m), utilized to characterize the prevalence of 10 ORCs. Direct treatment costs were collected from literature reports. A risk model was leveraged to estimate the number and cost of additional ORC diagnoses over 5 years from baseline through two scenarios: stable weight and 15% lower body weight at baseline for all members of the population. Prevalence, incidence, and cost data were scaled down to a representative subset of 100,000 individuals. In 2022, the annual treatment costs for all 10 ORCs exceeded $918 million for the representative cohort. In a stable-weight scenario, these costs were estimated to increase to ≈$1.4 billion by 2027. With 15% lower body weight at baseline, $221 million in cumulative savings was estimated, corresponding to $2205 in savings/patient over 5 years. Consequently, weight loss in this population may correspond to significantly reduced numbers of incident ORC complications translating to substantial cost savings.

Over 10 million uninsured individuals are eligible for subsidized health insurance coverage through the Affordable Care Act (ACA) marketplaces, and millions more were projected to become eligible with the end of the federal COVID-19 Public Health Emergency in 2023. Individual studies on behaviorally informed interventions designed to encourage enrollment suggest that some are more effective than others. This study summarizes evidence on the efficacy of these interventions and suggests which administrative burdens might be most relevant for potential enrollees. Published and unpublished studies were identified through a systematic review of studies assessing the impact of behaviorally informed interventions on ACA marketplace enrollment from 2014 to 2022. Thirty-four studies comprising over 18 million participants were included (32 randomized controlled trials and 2 quasiexperimental studies). At the time of data extraction, 8 were published. Twenty-seven of the studies qualified for inclusion in a meta-analysis, which found that the average rate of enrollment was about 1 percentage point higher for those who received an intervention (0.009, < 0.001), a 24% increase relative to control households; for every 1000 people who receive an intervention, that would correspond to about 9 additional enrollees. When stratifying by intervention intensity, support-based interventions increased enrollment by 2 percentage points (0.020, = 0.004), while information-based interventions increased enrollment by 0.6 percentage points (0.006, < 0.001). The meta-analysis found that behaviorally informed interventions can increase ACA marketplace enrollment. Interventions aimed at alleviating compliance costs by providing enrollment support were about three times as effective as information alone.

For-profit companies addressing disparities in social determinants of health (SDOH), also known as companies, often lack member-level claims data to evaluate their organizational interventions. Health-related quality of life (HRQOL) measures, such as the Centers for Disease Control and Prevention's Healthy Days Measure, offer a unique proxy metric to evaluate impact. This retrospective study sought to explore the association between self-reported physically and mentally unhealthy days with health care costs among a Medicare Advantage (MA) population. A cross-sectional study of MA members receptive to a companion care program, and thus likely to have unmet social needs, was conducted. The analysis included members with recorded baseline unhealthy days and complete claims data ( = 2,354). Least squares regression analyses were performed to determine the relationship between baseline medical costs, physically unhealthy days, and mentally unhealthy days. A review of Major Diagnostic Categories (MDCs) was also included to elucidate the strength of the Healthy Days Measure as an indicator of the burden of health conditions. Each additional unhealthy day reported was associated with an increase in 30-day medical costs of $60 and $34 for physically and mentally unhealthy days, respectively. Unhealthy days and costs increased with an increasing number of MDCs. Compared with previous studies linking unhealthy days and health care expenditure, these data reveal the potential for even higher savings by reducing the number of unhealthy days in a high-risk population. This evidence supports using unhealthy days as a HRQOL measure and as an important tool for cost estimations.

The evidence that a healthy and safe workforce provides a competitive business advantage is increasingly clear. However, how to obtain this may be unclear to many. This article presents a case study showcasing how one large employer worked toward improving its culture of health and well-being. Measuring progress using an established corporate health assessment tool, results improved 75% over a 5-year period. In addition, site scan culture checks showed annual improvement, exceeding best-in-class scores by the fifth year. Building a culture of health and well-being often requires a few years to implement fully and involves a commitment to plan, deploy, improve, and manage over time. Ultimately, by following approaches taken by best-in-class employers, this can be accomplished with some ease and without missteps along the way.

Chronic kidney disease (CKD) is common, costly, and life-limiting, requiring dialysis and transplantation in advanced stages. Although effective guideline-based therapy exists, the asymptomatic nature of CKD together with low health literacy, adverse social determinants of health, unmet behavioral health needs, and primary care providers' (PCP) limited understanding of CKD result in defects in screening and diagnosis. Care is fragmented between PCPs and specialty nephrologists, with limited time, expertise, and resources to address systemic gaps. In this article, the authors define how they classified defects in care and report the current numbers of patients exposed to these defects, both nationally and in their health system Accountable Care Organization. They describe use of the health system's three-pillar leadership model (believing, belonging, and building) to empower providers to transform CKD care. Believing entailed engaging individuals to believe defects in CKD care could be eliminated and were a collective responsibility. Belonging fostered the creation of learning communities that broke down silos and encouraged open communication and collaboration between PCPs and nephrologists. Building involved constructing a fractal management infrastructure with transparent reporting and shared accountability, which would enable success in innovation and transformation. The result is proactive and relational CKD care organized around the patient's needs in University Hospitals Systems of Excellence. Systems of excellence combine multiple domains of expertise to promote best practice guidelines and integrate care throughout the system. The authors further describe a preliminary pilot of the CKD System of Excellence in primary care.

In 2017, the Certified Community Behavioral Health Clinic (CCBHC) demonstration was implemented in New York State to redesign care delivery and financing for behavioral health services. Although CCBHC primarily targeted Medicaid patients, it was hypothesized that the clinic-level benefits of CCBHC were expected to impact even non-Medicaid patients treated in CCBHCs. To test this hypothesis, this study conducted a health insurance claims data analysis of non-Medicaid (ie, commercial and Medicare) patients with severe mental illnesses, comparing a cohort of CCBHC-treated patients with a propensity score-matched comparison cohort of patients treated by non-CCBHC clinics on rates of mental health service utilization, hospitalization, and emergency department (ED) visits. The data suggested CCBHC was associated with more than 10% increase in outpatient mental health service utilization by the patients' second year of CCBHC exposure, accompanied by similarly significant reductions in the rates of all-cause ED visits and non-psychiatric hospitalization. These findings suggest that for behavioral health clinics that serve a sufficiently large population of Medicaid, the impact of innovative clinical redesign attributable to CCBHC is likely to extend to all patients treated by them.