5 Findings From the October 2018 Issue of AJMC®

The October 2018 issue of The American Journal of Managed Care^® includes studies on diabetes outcomes, the effect of feedback reports on physician behavior, accountable care organization (ACO) performance, and more. Here are 5 findings from the research published in the issue.

1. Gatekeeping in health maintenance organizations may curb specialist visits

A multipayer analysis of insured adults in Massachusetts compared outpatient utilization and spending patterns within preferred provider organization (PPO) and health maintenance organization (HMO) plans. Investigators led by Michael L. Barnett, MD, MS, found that those with HMO insurance had fewer new specialist visits and lower specialist spending than those with PPO insurance. When the HMO patients had specialist visits, they were more likely to be with a specialist in the same health system as the patient’s primary care physician (PCP).

The authors attribute the reduced specialist utilization to the “gatekeeping” policies of HMOs that require PCPs to approve referrals to specialists. Gatekeeping may represent another avenue for cost control as an alternative to patient-facing cost sharing imposed in high-deductible health plans, they write.

2. Early ACO joiners had more capabilities but still room for improvement

A study from Stephen M. Shortell, PhD, MPH, MBA, and coauthors examined the characteristics of physician practices that intended to join Medicare ACOs in 2012 and compared them with those that did not intend to join. Those jumping into the ACO game had greater capabilities in health information technology, care management processes, and quality improvement methods than their more hesitant counterparts, but they still used half or less of the recommended capabilities, showing substantial room for improvement.

Pointing out that these retrospective findings can inform ACO policies going forward, the researchers suggested that “catch-up” policies may be necessary to help the practices that have fewer resources to invest in such capabilities, lest these practices fall further behind and worsen health disparities among patients.

3. Message forwarding through EHR linked to worse diabetes outcomes

Sending messages through the electronic health record (EHR) is a key method of communicating in today’s practices, but an article found that too much indirect communication, measured through message forwarding, is associated with worse diabetes outcomes, including increased hospital visits and higher medical costs. Spending increased by $226 per patient per 6 months for each 1-percentage-point increase in indirect EHR communication.

According to authors Marlon P. Mundt, PhD, and Larissa I. Zakletskaia, MA, the extent of message forwarding may be a marker of care team functioning, as teams that deliver information face-to-face or directly to particular colleagues seem to have more efficient communication processes that are associated with better patient care.

4. Providing feedback to physicians on resource use can change their ordering patterns

Showing PCPs their peers’ patterns of resource use in tailored feedback reports can help them change their ordering patterns of costly services, especially among those with less experience, although the direction of those changes varied. In research based on a resource stewardship initiative, Eva Chang, PhD, MPH, and coauthors found that ordering rates of high-end imaging decreased, but laboratory tests and prescriptions increased, after PCPs received annual feedback reports comparing their own ordering rates with those of their peers.

The observation of greater changes in PCPs with 10 or fewer years of experience may indicate that they are more flexible in their practice patterns and willing to learn from their more experienced colleagues. Despite the mixed results of this feedback program, the authors suggest that increased transparency among physicians will be essential for encouraging high-value care.

5. Conservatively managing low back pain without imaging yields huge savings for Medicare

The common problem of low back pain is also a costly one, as initial evaluations of the condition have increasingly been using diagnostic imaging like magnetic resonance imaging (MRI) or computed tomography (CT) when no red-flag signs are present, even though the accepted best practice is to delay imaging in favor of a physical examination. According to an analysis of Medicare claims data, patients with low back pain receiving an early MRI scan accrued $2500 more in Medicare expenditures, and those receiving early CT accrued $19,900 more, than patients who were conservatively managed.

The authors, led by Alan M. Garber, MD, PhD, extrapolated these figures to find that Medicare spending could be reduced by $362 million each year if all cases of newly diagnosed low back pain were managed without using MRI or CT imaging, per clinical guidelines. Strategies to move away from unnecessary imaging toward conservative management must be accompanied by patient education on the risks and minimal usefulness of imaging, the researchers emphasized.

You can access other articles from the issue here.