Tag Archives: Bruce Pyenson

The high cost of heart failure for the Medicare population: An actuarial cost analysis

Major efforts to improve the care and reduce the cost of heart failure patients have recently been implemented. Despite these efforts, however, the rate of heart failure is rising and only small improvements in survival have been realized. The lack of novel therapies and limited improvement in medical management highlight the need for more focus on heart failure, especially among the Medicare population. Milliman consultants Bruce Pyenson, Kate Fitch, and Pamela Pelizzari provide some perspective in this report.

Evaluating opportunity in the CMMI BPCI program: Comparison of PAC utilization to benchmarks

The opportunity to reduce Medicare claims cost in the Bundled Payment for Care Improvement Initiative (BPCI) of the Center for Medicare and Medicaid Innovation (CMMI) is typically in the post-acute care (PAC) period. Analyzing the opportunity to reduce Medicare PAC spending requires providers to adopt a payor state of mind—payor tools and approaches will be very helpful. Benchmarking to best practices is one of those tools.

Milliman has developed nationwide average and well-managed (WM) benchmarks for PAC periods of one to 30, 31 to 60, and 61 to 90 days. Milliman’s Bruce Pyenson, Kate Fitch, Michele Barrios, and Tyler Engel provide perspective in this healthcare reform paper.

2014 individual exchange policies in four states: An early look for patients with blood cancer

It will be easier for people with blood cancer and other serious conditions to get healthcare coverage under the Patient Protection and Affordable Care Act (ACA). However, the ACA permits variation among exchange plans, which could mean significant differences in services to people with blood cancer.

This report by Bruce Pyenson and Jane Suh provides an early look at the 2014 individual benefit designs and premiums for policies sold on state exchanges in California, New York, Florida, and Texas. The report also reviews which drugs, cancer centers, and transplant centers are covered and discusses the role of out-of-pocket limits, as blood cancer treatment can be expensive and out-of-pocket limits will not apply to non-covered treatments and treatment centers.

Healthcare reform and hepatitis C: A convergence of risk and opportunity

Changes from the Patient Protection and Affordable Care Act (ACA) are dominating the healthcare landscape. These changes are very important for people infected with the hepatitis C virus (HCV). Last year there was an increased federal public health effort aimed at diagnosing people with HCV. Baby Boomers, the generation with the most HCV-infected people, has started to become eligible for Medicare.

Further, new treatments for HCV are under development. Undiagnosed individuals and uninsured individuals may represent a population that payors and stakeholders have not yet experienced. This paper discusses how increased diagnosis, increased Medicare eligibility, and newly insured individuals with HCV will affect the U.S. healthcare system.

Economic impact of community-acquired pneumonia in the employed population

Community-acquired pneumonia (CAP) is frequently associated with the very young and the elderly but is a largely under-recognized burden among working-age adults. Although the burden of CAP among the elderly has been established, there are limited data on the economic burden of CAP in the employed population.

This study assesses the economic impact of CAP in the United States in working-age adults from an employer perspective by estimating the incidence rate and costs of healthcare, sick time, and short-term disability for this patient population and recommends prevention strategies that may reduce the morbidity and costs associated with CAP among working-age adults, especially those with comorbidities.

This research was first published in American Health & Drug Benefits, Vol. 6, No. 8 (September/October 2013).

Comparing episode of cancer care costs in different settings: An actuarial analysis of patients receiving chemotherapy

Cancer patients receiving active treatment with chemotherapy incur four times the costs of cancer patients not receiving chemotherapy. The cost of patients receiving chemotherapy has been reported to vary by site of service, with higher costs when treatment is delivered in a hospital outpatient setting (HOP) versus a physician office visit (POV). Recent reports indicate an increasing portion of chemotherapy is being delivered in HOP settings and less in POV settings, which can increase costs for payors and/or employers.

This study provides new information by examining Truven MarketScan® commercial claims data (index years 2009 and 2010) to calculate the episode cost of chemotherapy delivered in the HOP versus POV settings for specific disease states. HOP costs were 28% to 53% higher than the POV costs depending on the cancer and adjuvant or metastatic stage. In particular, we noted significantly higher per-episode cost for chemotherapy drugs, radiation oncology, imaging (CT, MRI, and PET scans) and laboratory services in the HOP setting.

This report was commissioned by Genentech.