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The American Journal of Accountable Care December 2018
The Cost of Not Taking Our Medicine: The Complex Causes and Effects of Low Medication Adherence
Ellen Harrison, MBA, RN, vice president, HMS
Analysis of 2016 Connecticut ACO Medicare Shared Savings Program Data to Identify Opportunities for Population Health Pharmacist Services
Kathryn Steckowych, PharmD; Marie Smith, PharmD; and Yan Zhuang, PhD
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Cost of Delivering Centralized and Decentralized Reminder/Recall for Vaccinations to Children and Adolescents in an ACO
Melanie D. Whittington, PhD; Dennis Gurfinkel, MPH; Laura P. Hurley, MD; Steven Lockhart, MPH; Brenda Beaty, MSPH; Miriam Dickinson, PhD; Heather Roth, MA; and Allison Kempe, MD, MPH
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Douglas Thornton, PharmD, PhD; Nilanjana Dwibedi, PhD; Virginia Scott, PhD; Charles D. Ponte, PharmD; Xi Tan, PharmD, PhD; Douglas Ziedonis, MD; and Usha Sambamoorthi, PhD
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Christina Mattina, BS
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Joshua Sclar, MD, MPH, Chief Medical Officer, BioIQ
The Blueprint for Complex Care: Laying the Groundwork to Build a Field Across Sectors
National Center for Complex Health and Social Needs; Center for Health Care Strategies; and Institute for Healthcare Improvement

Cost of Delivering Centralized and Decentralized Reminder/Recall for Vaccinations to Children and Adolescents in an ACO

Melanie D. Whittington, PhD; Dennis Gurfinkel, MPH; Laura P. Hurley, MD; Steven Lockhart, MPH; Brenda Beaty, MSPH; Miriam Dickinson, PhD; Heather Roth, MA; and Allison Kempe, MD, MPH
Centralized reminder/recall (R/R) is less costly to deliver than decentralized R/R for both children and adolescents when implemented for patients within an accountable care organization.
ABSTRACT

Objectives: Within an accountable care organization (ACO), we compare the investment needed to deliver reminder/recall (R/R) for childhood and adolescent vaccinations via 2 approaches: (1) centralized R/R with messages delivered to all patients of the ACO by a single organization versus (2) decentralized R/R with messages delivered to ACO patients by their primary practice.

Study Design: A cost analysis was conducted to calculate the total cost of initiating and implementing centralized and decentralized R/R.

Methods: Domains of resource use included collaboration, training, and recall. Personnel time was monetized using standardized federal wage rates for each occupation. Nonpersonnel resources were calculated using invoices for R/R activities. Start-up and implementation costs were stratified by approach (centralized and decentralized) and population (child and adolescent).

Results: Of the 11 practices that agreed to participate in decentralized R/R for children at their practice, just 1 conducted R/R. Similarly, of the 15 practices that agreed to participate in decentralized R/R for adolescents at their practice, just 5 conducted R/R. This study found that start-up costs for R/R were similar across approaches ($1366 for centralized and $1300 for decentralized), but implementation costs differed. For R/R in children, implementation costs were more than twice as much for decentralized R/R ($3.92 per child recalled) than for centralized R/R ($1.78 per child recalled). Similarly, the cost of R/R for adolescents was $1.37 per adolescent recalled in decentralized R/R and $0.78 per adolescent recalled in centralized R/R.

Conclusions: Centralized R/R within an ACO was less costly than decentralized R/R and resulted in more patients being reached.

Am J Accountable Care. 2018;6(4):19-25
Accountable care organizations (ACOs) are groups of healthcare providers and facilities that unite to share the responsibility of providing medical care to a set of patients.1 There are now more than 600 ACOs in the United States.2 These entities are held accountable by healthcare payers for the quality and cost of care delivered to their patients.1 Although the design of ACOs varies due to different provider configurations and payment models, some features are generally common to all ACOs.1 These commonalities include that they are provider-led with a foundation in primary care, they are held accountable for the quality and cost of care for their patients, they link payments to quality improvements that reduce cost, and they integrate sophisticated performance measurements to demonstrate savings through improved care.1 ACOs are thus incentivized to improve the quality and efficiency of care provided to their patients and to demonstrate the value of the healthcare they deliver.2

Vaccination represents one of the most valuable health interventions available. It can prevent the direct and indirect costs associated with treating and managing vaccine-preventable diseases.3 Research has estimated that for every dollar spent on vaccines, there are savings of $3 to the payer and $10 to society.3 ACOs should be encouraged to increase vaccination coverage for their patients to improve patient health outcomes by reducing the number of preventable infectious diseases and to promote efficient healthcare by providing healthcare interventions proven to generate cost savings.

Evidence suggests that reminder/recall (R/R) is associated with an increase in vaccination coverage by notifying patients of vaccinations that are due soon (reminders) or are overdue (recall) via mailed postcard, phone call, text message, or some combination of these.4,5 Recent studies have evaluated different approaches to R/R, including centralized and decentralized approaches. Centralized R/R approaches refer to R/R messages sent by a single entity (eg, state health department6,7 or managed care organization8) to health systems or entire counties using centralized patient data from a state or jurisdictional Immunization Information System (IIS). A decentralized approach refers to R/R conducted by individual practices using administrative, electronic health record, or IIS data to reach out to their own patients. Although both approaches are effective at increasing vaccination coverage, their adoption by state health departments, managed care organizations, and individual practices has been limited. Centralized R/R has only recently been described and has not been broadly adopted by state health departments or managed care organizations. Decentralized R/R is conducted by less than 20% of practices9 due to time constraints, financial barriers, and lack of technical support.9,10 Because ACOs generally include a group of practices, they could use either approach to increase vaccination coverage for their patient population.

The objective of this analysis was to calculate the investment needed to deliver R/R to the child and adolescent populations of an ACO via both centralized and decentralized approaches, in order to inform ACOs of the approach that is least costly.

METHODS

Centralized Versus Decentralized Approaches to R/R

This study calculated the total cost of delivering 2 R/R approaches: centralized R/R and decentralized R/R. Both approaches used a state immunization registry, the Colorado Immunization Information System (CIIS), to identify patients who belonged to the ACO and needed at least 1 vaccine. The CIIS receives patient and immunization data through live entry into the web-enabled application and through electronic transfers from data sources maintained by providers and insurers. The CIIS includes historical data about immunizations given outside of the state, if data were entered by a provider within the state. Participating provider practices can access the CIIS via a web application to view and update a patient’s immunization and demographic information. A report can be run by authorized users, including ACOs and practices, to identify patients in need of at least 1 vaccine.

In the centralized R/R approach, the Colorado state health department led the R/R efforts for the ACO patients. ACO patients in need of at least 1 vaccine were sent up to 2 automated phone messages followed by 1 postcard; reminders were sent approximately 6 weeks apart. If patients did not have a phone number in the CIIS or the phone number was determined to be incorrect, the patient received a postcard instead of a phone call for each subsequent reminder. A toll-free number and an email address were included in the R/R message to allow the patient to opt out of receiving further messages. If a patient became up-to-date on their vaccines after the first or second R/R message or chose to opt out of future messages, they did not receive subsequent messages.

In the decentralized R/R approach, participating practices led the R/R efforts for their subset of patients, and each practice was compensated $0.80 by the ACO per message sent out. The practices were offered training on using the CIIS to run R/R and could choose which format in which to send the messages (eg, postcard, phone call, text message). Practices could also elect to conduct a chart audit of the patient list generated in the CIIS to identify any patients within the CIIS who were no longer patients of their practice (eg, patients who had moved or gone to another practice). A scenario analysis was conducted to estimate the practice-level costs for a practice that elected to do a chart audit prior to sending the R/R messages to patients on the list.


 
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