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The American Journal of Managed Care September 2018
Food Insecurity, Healthcare Utilization, and High Cost: A Longitudinal Cohort Study
Seth A. Berkowitz, MD, MPH; Hilary K. Seligman, MD, MAS; James B. Meigs, MD, MPH; and Sanjay Basu, MD, PhD
Language Barriers and LDL-C/SBP Control Among Latinos With Diabetes
Alicia Fernandez, MD; E. Margaret Warton, MPH; Dean Schillinger, MD; Howard H. Moffet, MPH; Jenna Kruger, MPH; Nancy Adler, PhD; and Andrew J. Karter, PhD
Hepatitis C Care Cascade Among Persons Born 1945-1965: 3 Medical Centers
Joanne E. Brady, PhD; Claudia Vellozzi, MD, MPH; Susan Hariri, PhD; Danielle L. Kruger, BA; David R. Nerenz, PhD; Kimberly Ann Brown, MD; Alex D. Federman, MD, MPH; Katherine Krauskopf, MD, MPH; Natalie Kil, MPH; Omar I. Massoud, MD; Jenni M. Wise, RN, MSN; Toni Ann Seay, MPH, MA; Bryce D. Smith, PhD; Anthony K. Yartel, MPH; and David B. Rein, PhD
“Precision Health” for High-Need, High-Cost Patients
Dhruv Khullar, MD, MPP, and Rainu Kaushal, MD, MPH
From the Editorial Board: A. Mark Fendrick, MD
A. Mark Fendrick, MD
Health Literacy, Preventive Health Screening, and Medication Adherence Behaviors of Older African Americans at a PCMH
Anil N.F. Aranha, PhD, and Pragnesh J. Patel, MD
Early Experiences With the Acute Community Care Program in Eastern Massachusetts
Lisa I. Iezzoni, MD, MSc; Amy J. Wint, MSc; W. Scott Cluett III; Toyin Ajayi, MD, MPhil; Matthew Goudreau, BS; Bonnie B. Blanchfield, CPA, SM, ScD; Joseph Palmisano, MA, MPH; and Yorghos Tripodis, PhD
Currently Reading
Economic Evaluation of Patient-Centered Care Among Long-Term Cancer Survivors
JaeJin An, BPharm, PhD, and Adrian Lau, PharmD
High-Touch Care Leads to Better Outcomes and Lower Costs in a Senior Population
Reyan Ghany, MD; Leonardo Tamariz, MD, MPH; Gordon Chen, MD; Elissa Dawkins, MS; Alina Ghany, MD; Emancia Forbes, RDCS; Thiago Tajiri, MBA; and Ana Palacio, MD, MPH
Adjusting Medicare Advantage Star Ratings for Socioeconomic Status and Disability
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; Cheryl L. Damberg, PhD; Ann Haas, MS, MPH; Mallika Kommareddi, MPH; Anagha Tolpadi, MS; Megan Mathews, MA; and Marc N. Elliott, PhD

Economic Evaluation of Patient-Centered Care Among Long-Term Cancer Survivors

JaeJin An, BPharm, PhD, and Adrian Lau, PharmD
Providing patient-centered comprehensive care to long-term cancer survivors may lead to reduced total healthcare expenditures.
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The findings of this study suggest that providing patient-centered comprehensive care may mitigate total healthcare utilization and subsequently reduce total healthcare expenditures among long-term cancer survivors in the United States. In the overall analysis, although there were no significant differences in healthcare utilization, there were significant reductions in adjusted mean healthcare expenditures at follow-up between the PCC group and the non-PCC group. Subgroup analyses suggest that the majority of the benefits of PCC were seen in the elderly population. In the subgroup of those 65 years and older, cancer survivors in the PCC group had 19% lower odds of hospitalization compared with the non-PCC group, and the savings were mostly from hospitalization-related healthcare expenditures. In the subgroup of those younger than 65 years, the benefits stemmed from reductions in prescription-related healthcare expenditures. These findings suggest that providing patient-centered comprehensive care might be more effective in the elderly population of cancer survivors than in the younger population. Elderly patients usually have more comorbidities and are likely to experience more hospitalizations or ED visits; therefore, patient-centered comprehensive care may play a bigger role in reducing overall healthcare costs. In this study, the population 65 years and older had a higher number of hospitalizations and ED visits compared with the population younger than 65 years, which might have driven our findings. These findings are also supported by previous literature that has suggested that reduction of hospital readmission rates and lowering of inpatient expenditures were more pertinent to the older adult population.26,36 However, this study was not able to further explain the reasoning behind these findings.

The secondary analysis performed in this study revealed that of the 3 hallmark attributes of a PCMH, the whole-person orientation attribute contributed the most to the reduction in total healthcare expenditures in long-term cancer survivors, whereas the comprehensive care and accessible care attributes were not associated with savings. This may be due to a ceiling effect for the comprehensive care and accessible care attributes, because their positive responses reached 98.3% and 93.7%, respectively, making it more difficult to assess if they impacted the economic outcomes.

The impact of the whole-person orientation attribute on reducing healthcare utilization and expenditures may be explained by the idea that as clinicians empower cancer survivors to become more engaged in the decision-making process of their own care, the patients become more responsible and adherent to those treatments. As a result, unnecessary healthcare expenditures stemming from treatment nonadherence are reduced. This finding was supported by further evaluating the whole-person orientation attribute in the secondary analysis, which showed significant decreases in total healthcare utilization, specifically in the odds of ED visits, in addition to decreases in ED visit–related healthcare expenditures and total healthcare expenditures.

The significant reductions in total healthcare expenditures and total healthcare utilization among the PCC group in this study, especially the reduced odds of hospitalization and reductions in hospitalization-related expenditures, were mostly consistent with findings from other similarly designed studies evaluating PCMHs. Findings of a study by Cuellar and colleagues suggested that a PCMH model, by the third year of its inception, resulted in lower rates of healthcare utilization and subsequently lower observed total healthcare expenditures.37 Likewise, a study by Cole and colleagues found diminished healthcare expenditures, as well as fewer hospitalizations, among Louisiana primary care clinics that have adopted the PCMH model in the management of their chronically ill patients.38 One study by Kohler and colleagues reached a different conclusion and found that patients with breast cancer in North Carolina actively receiving treatment in a PCMH model had higher total healthcare expenditures after initial diagnosis via increased total healthcare utilization, possibly due to greater access to their primary and specialty care teams compared with those who were not in a PCMH model.39

However, it is important to note that our study findings should be understood as the economic benefits associated with patient perceptions of their care instead of direct effects of implementation of a structured PCMH model. The definition of PCC relied on cancer survivors’ self-reported data; cancer survivors were considered to have received patient-centered comprehensive care if they provided positive responses to statements correlated with common characteristics of a PCMH model, rather than actual enrollment in a PCMH program. This patient perception may be affected by various factors, including characteristics of patients, individual physicians, or the practices in which patients received care. Although this study does not provide direct evidence from the implementation of a PCMH model, the indirect method of measurement may provide an advantage because it allows us to examine unique patient perspectives and compare each of the 3 hallmark attributes of the PCMH model and how each attribute can affect overall economic outcomes.

Limitations and Strengths

This study has several limitations. The PCMH attributes were potentially determined by both primary care and oncology care because the survey respondents did not specify whether their USC was their primary care provider or an oncologist. Therefore, study findings may not serve as evidence of patient perception of oncology care. Another limitation of this study is possible bias from unobserved confounding variables, as commonly seen with other observational studies. In this study, unobserved confounding variables, such as disease severity, may have affected the study findings rather than the PCC. However, observed confounding variables were adjusted with a PS model to maintain balance between the PCC group and the non-PCC group of cancer survivors. Other possible limitations of this study are nonresponse bias or recall bias, which are common in survey-type studies. Therefore, the analysis had to utilize only data that were readily available.

Despite these limitations, this study also has various strengths. To date, there have been a limited number of studies on the effects of implementing a PCMH model for patients with cancer and even fewer studies examining its effects on long-term cancer survivors. The findings derived from this study may be useful in the development of clinical programs for the care of long-term cancer survivors or in aiding the design of future PCMH models for managing other costly chronic conditions. In addition, this study utilized panel data to investigate the association between patient perceptions of PCMH characteristics at year 1 and economic outcomes at year 2, thereby minimizing limitations that would arise from a cross-sectional study when evaluating outcomes. In addition, a majority of cancer survivors (80%) did not change their responses to the questions on having received care attributable to PCMH characteristics at year 2, which suggests a continuation of similar types of care provided throughout the year. Furthermore, the unique patient perspectives obtained from a nationally representative sample may allow the results to be further applied and generalized to the broader US population.

CONCLUSIONS

The positive patient perception of PCMH characteristics was associated with reductions in mean total healthcare utilization and mean total healthcare expenditures among long-term cancer survivors. Future studies should further investigate the economic benefits of implementing a PCMH model for long-term cancer survivors through an interventional study design, in order to gain a better understanding of the origins of cost savings.

Author Affiliations: Department of Pharmacy Practice and Administration, Western University of Health Sciences College of Pharmacy (JA, AL), Pomona, CA.

Source of Funding: None.

Prior Presentation: Part of the study findings were presented as a poster at the Academy of Managed Care Pharmacy Managed Care & Specialty Pharmacy Annual Meeting 2017, Denver, Colorado, March 27-31, 2017.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JA); acquisition of data (JA); analysis and interpretation of data (JA, AL); drafting of the manuscript (JA, AL); critical revision of the manuscript for important intellectual content (JA, AL); statistical analysis (JA); provision of patients or study materials (JA); administrative, technical, or logistic support (JA); and supervision (JA).

Address Correspondence to: JaeJin An, BPharm, PhD, Department of Pharmacy Practice and Administration, Western University of Health Sciences College of Pharmacy, 309 E Second St, Pomona, CA 91766. Email: jan@westernu.edu.
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