Effects of a Commercial Insurance Policy Restriction on Lumbar Fusion in North Carolina and the Implications for National Adoption.
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ABSTRACT: An analysis of the State Inpatient Database of North Carolina, 2005 to 2012, and the Nationwide Inpatient Sample, including all inpatient lumbar fusion admissions from nonfederal hospitals.The aim of the study was to examine the influence of a major commercial policy change that restricted lumbar fusion for certain indications and to forecast the potential impact if the policy were adopted nationally.Few studies have examined the effects of recent changes in commercial coverage policies that restrict the use of lumbar fusion.We included adults undergoing elective lumbar fusion or re-fusion operations in North Carolina. We aggregated data into a monthly time series to report changes in the rates and volume of lumbar fusion operations for disc herniation or degeneration, spinal stenosis, spondylolisthesis, or revision fusions. Time series regression models were used to test for significant changes in the use of fusion operation following a major commercial coverage policy change initiated on January 1, 2011.There was a substantial decline in the use of lumbar fusion for disc herniation or degeneration following the policy change on January 1, 2011. Overall rates of elective lumbar fusion operations in North Carolina (per 100,000 residents) increased from 103.2 in 2005 to 120.4 in 2009, before declining to 101.9 by 2012. The population rate (per 100,000 residents) of fusion among those under age 65 increased from 89.5 in 2005 to 101.2 in 2009, followed by a sharp decline to 76.8 by 2012. There was no acceleration in the already increasing rate of fusion for spinal stenosis, spondylolisthesis, or revision procedures, but there was a coincident increase in decompression without fusion.This commercial insurance policy change had its intended effect of reducing fusion operations for indications with less evidence of effectiveness without changing rates for other indications or resulting in an overall reduction in spine surgery. Nevertheless, broader adoption of the policy could significantly reduce the national rates of fusion operations and associated costs.3.
<h4>Study design</h4>An analysis of the State Inpatient Database of North Carolina, 2005 to 2012, and the Nationwide Inpatient Sample, including all inpatient lumbar fusion admissions from nonfederal hospitals.<h4>Objective</h4>The aim of the study was to examine the influence of a major commercial policy change that restricted lumbar fusion for certain indications and to forecast the potential impact if the policy were adopted nationally.<h4>Summary of background data</h4>Few studies have exami ...[more]
Project description:Purpose: The emergence of the COVID-19 pandemic led health care systems and providers worldwide to rapidly adopt telehealth solutions to minimize risk and comply with isolation mandates. This article explores telehealth utilization trends in North Carolina (NC) free and charitable clinics—an ambulatory health care delivery setting where traditional third-party reimbursement policies are not a primary consideration. Methods: We surveyed NC free and charitable clinic administrators regarding clinic decisions to adopt an externally sponsored telehealth system, what services are provided by telehealth, clinic implementation processes, which populations used telehealth, how telehealth was incorporated into current clinic workflows, and perceptions of telehealth outcomes. Findings: Telehealth was rapidly adopted among free and charitable clinics after the COVID-19 outbreak. Reasons for implementing telehealth included the ability to continue providing services during a public health emergency and to increase access to patients. However, clinics report that telehealth utilization has dropped significantly since the initial pandemic surge. Patient and provider preferences for in-person services are a common reason cited for this drop. Free and charitable clinics report a strong interest in continuing to deliver services through telehealth. The majority reported continuing to offer telehealth services, but primarily as a supplement to in-person visits rather than as a replacement. They perceive that implementing telehealth has increased access to care but are less certain about the impact on cost of care and patient satisfaction. However, clinic administrators believe improvements in interoperability with other data systems, workflows, scheduling, and care delivery approaches are needed to achieve telehealth's fullest utilization. Conclusion: Telehealth can play a significant role in expanding access to services in the free and charitable clinic setting. However, continued refinements in the technology to facilitate integration with other systems and workflow processes are needed to reach its full potential.
Project description:ObjectiveTo evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America.MethodsAn anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics.ResultsA total of 105 responses were entered with complete data available on 70. Sixty percent of the respondents (n = 42) were considered compliant with NASS guidelines. NASS-discordant responses did not differ between surgeons who stated that they include the NASS guidelines in their decision-making algorithm (5.10 ± 1.96) and those that did not (4.68 ± 2.09) (p = 0.395). The greatest number of NASS-discordant answers in the United States. was in the South (5.75 ± 2.09), with the lowest number in the Northeast (3.84 ± 1.70) (p < 0.01). For 5 survey items, rates of NASS-discordant answers were ≥ 40%, with the greatest number of NASS-discordant responses observed in relation to indications for fusion in spinal deformity (80%). Spine surgeons utilizing a NASS-concordant approach had a significant lower number of NASS-discordant answers for synovial cysts (p = 0.03), axial low back pain (p < 0.01), adjacent level disease (p < 0.01), recurrent stenosis (p < 0.01), recurrent disc herniation (p = 0.01), and foraminal stenosis (p < 0.01).ConclusionThis study serves an important role in clarifying the rates of uptake of clinical practice guidelines in spine surgery as well as to identify barriers to their implementation.
Project description:ImportanceInsurers have increasingly adopted policies to reduce emergency department (ED) visits that they consider unnecessary. One common approach is to retrospectively deny coverage if the ED discharge diagnosis is determined by the insurer to be nonemergent.ObjectiveTo characterize ED visits that may be denied coverage if the ED coverage denial policy of a large national insurer, Anthem, Inc, is widely adopted.Design, setting, and participantsA cross-sectional analysis of probability-sampled ED visits from the nationally representative National Hospital Ambulatory Medical Care Survey ED subsample occurring from January 1, 2011, to December 31, 2015, was conducted. Visits by commercially insured patients aged 15 to 64 years were examined. Those with ED discharge diagnoses defined by Anthem's policy as nonemergent and therefore subject to possible denial of coverage were classified as denial diagnosis visits. The primary presenting symptoms among denial diagnosis visits were identified, and all visits by commercially insured adults presenting with these primary symptoms were classified as denial symptom visits.Main outcomes and measuresEach visit cohort as a weighted proportion of commercially insured adult ED visits. The proportion of each visit cohort that received ED-level care, defined as visits where patients were triaged as urgent or emergent, received 2 or more diagnostic tests, or were admitted or transferred, was also examined.ResultsFrom 2011 to 2015, 15.7% (95% CI, 15.0%-16.4%) of commercially insured adult ED visits (4440 of 28 304) were denial diagnosis visits (mean [SD] patient age, 36.6 [14.0] years; 2592 [58.7%] female and 2962 [63.5%] white). Among these visits, 39.7% (95% CI, 37.1%-42.3%) received ED-level care: 24.5% (95% CI, 21.7%-27.4%) were initially triaged as urgent or emergent and 26.0% (95% CI, 23.8%-28.3%) received 2 or more diagnostic tests. These denial diagnosis visits shared the same presenting symptoms as 87.9% (95% CI, 87.3%-88.4%) of commercially insured adult ED visits (24 882 of 28 304) (mean [SD] patient age, 38.5 [14.1] years; 14 362 [57.9%] female and 17 483 [68.7%] white). Among these denial symptom visits, 65.1% (95% CI, 63.4%-66.9%) received ED-level care: 43.2% (95% CI, 40.2%-46.4%) were triaged as urgent or emergent, 51.9% (95% CI, 50.0%-53.9%) received 2 or more diagnostic tests, and 9.7% (95% CI, 8.8%-10.6%) were admitted or transferred.Conclusions and relevanceAnthem's nonemergent ED discharge diagnoses were not associated with identification of unnecessary ED visits when assessed from the patient's perspective. This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial.
Project description:Salmonellosis originating from poultry poses a significant threat to human health. Surveillance within production is thus needed to minimize risk. The objectives of this work were to investigate the distribution of Salmonella spp. from a commercial turkey operation and describe the animal movement patterns to investigate the association between contact network structure and Salmonella infection status. Four years of routine growout farm samples along with data on facility location, time since barns were built, production style, and bird movement data were utilized. From all of the surveillance samples collected, Salmonella serotyping was performed on positive samples and results showed that the most represented groups were C1 (28.67%), B (24.37%) and C2 (17.13%). The serovar Infantis (26.44%) was the most highly represented, followed by Senftenberg (12.76%) and Albany (10.93%). Results illustrated the seasonality of Salmonella presence with a higher number of positive samples being collected in the second half of each calendar year. We also demonstrated that Salmonella was more likely to occur in samples from older farms compared to farms built more recently. The contact network connectivity was low, although a few highly connected farms were identified. Results of the contact network showed that the farms which tested positive for Salmonella were not clustered within the network, suggesting that even though Salmonella dissemination occurs via transferring infected birds, for this study case it is unlikely the most important route of transmission. In conclusion, this study identified seasonality of Salmonella with significantly more cases in the second half of each year and also uncovered the role of between-farm movement of birds as not a major mode of Salmonella transmission.
Project description:Provider payment reforms, such as capitation, are very contentious. Such reforms can drop off the policy agenda due to political and contextual resistance. Using the Shiffman and Smith (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007; 370 1370-9) framework, this study explains why Ghana's National Health Insurance capitation payment policy that rose onto the policy agenda in 2012, dropped off the agenda in 2017 during its pilot implementation in the Ashanti region. We conducted a retrospective qualitative policy analysis by collecting field data in December 2019 in the Ashanti region through 18 interviews with regional and district level policy actors and four focus group discussions with community-level policy beneficiaries. The thematically analysed field data were triangulated with media reports on the policy. We discovered that technically framing capitation as a cost-containment strategy with less attention on portraying its health benefits resulted in a politically negative reframing of the policy as a strategy to punish fraudulent providers and opposition party electorates. At the level of policy actors, pilot implementation was constrained by a regional level anti-policy community, weak civil society mobilization and low trust in the then political leadership. Anti-policy campaigners drew on highly contentious and poorly implemented characteristics of the policy to demand cancellation of the policy. A change in government in 2017 created the needed political window for the suspension of the policy. While it was technically justified to pilot the policy in the stronghold of the main opposition party, this decision carried political risks. Other low- and middle-income countries considering capitation reforms should note that piloting potentially controversial policies such as capitation within a politically sensitive location can attract unanticipated partisan political interest in the policy. Such partisan interest can potentially lead to a decline in political attention for the policy in the event of a change in government.
Project description:Although screening is effective in reducing incidence, mortality, and costs of treating colorectal cancer (CRC), it remains underutilized, in part due to limited insurance access. We used microsimulation to estimate the health and financial effects of insurance expansion and reduction scenarios in North Carolina (NC). We simulated the full lifetime of a simulated population of 3,298,265 residents age-eligible for CRC screening (ages 50-75) during a 5-year period starting January 1, 2018, including polyp incidence and progression and CRC screening, diagnosis, treatment, and mortality. Insurance scenarios included: status quo, which in NC includes access to the Health Insurance Exchange (HIE) under the Affordable Care Act (ACA); no ACA; NC Medicaid expansion, and Medicare-for-all. The insurance expansion scenarios would increase percent up-to-date with screening by 0.3 and 7.1 percentage points for Medicaid expansion and Medicare-for-all, respectively, while insurance reduction would reduce percent up-to-date by 1.1 percentage points, compared to the status quo (51.7% up-to-date), at the end of the 5-year period. Throughout these individuals' lifetimes, this change in CRC screening/testing results in an estimated 498 CRC cases averted with Medicaid expansion and 6031 averted with Medicare-for-all, and an additional 1782 cases if health insurance gains associated with ACA are lost. Estimated cost savings - balancing increased CRC screening/testing costs against decreased cancer treatment costs - are approximately $30 M and $970 M for Medicaid expansion and Medicare-for-all scenarios, respectively, compared to status quo. Insurance expansion is likely to improve CRC screening both overall and in underserved populations while saving money, with the largest savings realized by Medicare.
Project description:Seafood mislabeling occurs in a wide range of seafood products worldwide, resulting in public distrust, economic fraud, and health risks for consumers. We quantified the extent of shrimp mislabeling in coastal and inland North Carolina. We used standard DNA barcoding procedures to determine the species identity of 106 shrimp sold as "local" by 60 vendors across North Carolina. Thirty-four percent of the purchased shrimp was mislabeled, and surprisingly the percentage did not differ significantly between coastal and inland counties. One third of product incorrectly marketed as "local" was in fact whiteleg shrimp: an imported and globally farmed species native to the eastern Pacific, not found in North Carolina waters. In addition to the negative ecosystem consequences of shrimp farming (e.g., the loss of mangrove forests and the coastal buffering they provide), North Carolina fishers-as with local fishers elsewhere-are negatively impacted when vendors label farmed, frozen, and imported shrimp as local, fresh, and wild-caught.
Project description:Ghana's National Health Insurance Scheme (NHIS), established by an Act of Parliament (Act 650), in 2003 and since replaced by Act 852 of 2012 remains, in African terms, unprecedented in terms of growth and coverage. As a result, the scheme has received praise for its associated legal reforms, clinical audit mechanisms and for serving as a hub for knowledge sharing and learning within the context of South-South cooperation. The scheme continues to shape national health insurance thinking in Africa. While the success, especially in coverage and financial access has been highlighted by many authors, insufficient attention has been paid to critical and context-specific factors. This paper seeks to fill that gap.Based on an empirical qualitative case study of stakeholders' views on challenges and success factors in four mutual schemes (district offices) located in two regions of Ghana, the study uses the concept of policy translation to assess whether the Ghana scheme could provide useful lessons to other African and developing countries in their quest to implement social/NHISs.In the study, interviewees referred to both 'hard and soft' elements as driving the "success" of the Ghana scheme. The main 'hard elements' include bureaucratic and legal enforcement capacities; IT; financing; governance, administration and management; regulating membership of the scheme; and service provision and coverage capabilities. The 'soft' elements identified relate to: the background/context of the health insurance scheme; innovative ways of funding the NHIS, the hybrid nature of the Ghana scheme; political will, commitment by government, stakeholders and public cooperation; social structure of Ghana (solidarity); and ownership and participation.Other developing countries can expect to translate rather than re-assemble a national health insurance programme in an incomplete and highly modified form over a period of years, amounting to a process best conceived as germination as opposed to emulation. The Ghana experience illustrates that in adopting health financing systems that function well, countries need to customise systems (policy customisation) to suit their socio-economic, political and administrative settings. Home-grown health financing systems that resonate with social values will also need to be found in the process of translation.
